PANOS London: 10 June 1996.

Transmission of HIV through unprotected sex is overwhelmingly the main way in which HIV is spread world-wide. Sex with an infected person, while very risky, does not always lead to infection with HIV, but receiving an infected blood transfusion will almost certainly do so.

`Safe blood' means blood that will not cause harm to the recipient and that has been fully screened and is not contaminated by any blood-borne disease such as HIV, hepatitis, malaria, or syphilis.

Screening involves more than a laboratory blood test.

Blood banks ask people who come forward to donate blood questions about past experiences such as intravenous drug use, prostitution or multiple sexual partners that might have put them at risk of infection. An affirmative answer to questions such as 'have you ever used illegal drugs?' or 'have you ever had sex for money?' means that a donors' blood will not be used for transfusion.

These questions are asked because no laboratory test for HIV is always 100% reliable, particularly in developing countries. This is mostly due to the 'window period', the three months or so after a person becomes infected with HIV but before he or she develops antibodies to HIV. During this time infection cannot be detected with a standard HIV test.

In the industrialised world, receiving a blood transfusion is generally safer due to lower HIV prevalence and the reliance on voluntary blood donors who give blood at regular intervals. However failures of a number of western governments to safeguard blood supplies in the 1980s created political scandals when many recipients of blood productsbecame infected with HIV and died.

In many developing countries, however, the blood supply remains a potential source of HIV infection. Some countries have a fatalistic attitude, believing that a safe blood system is too expensive.

However, South Africa, Zimbabwe and Namibia have all achieved a safe blood supply, financed entirely within country. Uganda has recently declared its blood supply safe following a programme funded by the Commission of the European Community.

The cost of a single transfusion, from recruiting volunteer donors in the community to transfusing it with safe, sterile equipment in a hospital is estimated to be US$20-30. In Zimbabwe and South Africa costs are recovered mostly through medical insurance schemes. Government pays the bill for poorer citizens.

The cost of safe blood can be substantially cut by installing a centralised system for collection and testing. In Zimbabwe, the National Blood Transfusion Service employs mobile teams which collect blood from all over the country every day. A sample of each unit is brought to one of two testing sites. Blood is then distributed to peripheral hospitals around the country.

Many countries including India and Pakistan have hospital-based, decentralised blood banking systems. Such systems are expensive because test kits are often either in short supply or expire before they are used. Quality control is much more difficult to ensure because laboratory technicians are not all trained to the same standard. Partly for this reason, India and Pakistan have had great difficulty implementing safe blood supplies.

Another difficulty in India and Pakistan has been a reliance on paid donors who give blood for money. Many of these people are forced by poverty to sell their blood. Studies carried out in Bombay and Karachi suggest that paid blood donors have particularly high rates of HIV infection, perhaps because they tend to be involved in prostitution or intravenous drug use.

In Pakistan, as many as 12 per cent of new HIV infections in 1992 were the result of infected blood transfusions, and less than half of its blood banks were found to have HIV screening equipment. A new law to prohibit transfusion of untested blood was approved by the federal parliament earlier this year, but has still to go before the four state parliaments and may be difficult to enforce.

In India the Supreme Court has ordered the government to clean up the country's blood transfusion system or face legal consequences. It has given the government two years in which to eliminate paid professional blood donors and one year to ensure that all of the country's one thousand blood banks are licensed.

There are a number of questions facing developing countries who are committed to safeguarding their blood supply:

HIV testing is expensive. Blood testing kits are expensive, they need skills to administer as well as electricity, refrigerators and transport systems that many poor countries may not be able to afford. Some countries rely heavily on foreign financial sources to pay for testing kits, but these funders will not sustain safe blood projects indefinately. Voluntary donor recruitment, as well as testing must be part of every safe blood system. This is to avoid wasting test kits and other resources on blood that contains HIV and must be thrown away.

Encouraging voluntary non-paid donations is the most cost effective mechanism for ensuring a safe blood supply: A cohort of healthy repeat donors whose blood consistently tests negative saves wasted effort, time and test kits.

Donating blood is completely safe and is one of the most valuable, cost-free activities a citizen can perform. About 90 million people give blood each year many of them through the Red Cross and Red Crescent Societies. A voluntary system can be created by investing in public education and recruitment through schools, churches and other groups and through radio and newspaper campaigns.

All blood collection sites need skilled counsellors to discuss risk factors for blood borne diseases, including HIV, with potential donors and to encourage those with a clean bill of health to come back and give blood again.

How many blood transfusions are necessary? . In some developing countries, blood transfusions are given routinely in the belief that they have a beneficial health effect. According to Dr Steve Luby of the Aga Khan University in Pakistan, "we find that fully a third of the transfusions that are given are not medically necessary. So, if we can encourage and empower people not to get so many translations, that that would do a lot of good in reducing the risks of HIV transmission." Reducing the demand for needless blood transfusions is an important priority for health workers.

A universal right?

The World Health Organisation (WHO) has established a Blood Safety Unit, with the aim of setting universal standards for collection and use of blood. Safe blood is, according to WHO, a universal right which can only be guaranteed in the context of a sustained global co-operative effort. HIV is forcing a world-wide review of national policies towards blood supply.

Attempts to improve the quality of the blood supply are under way in Angola, Benin, Cameroon, Congo, Cote d'Ivoire, Guinea Conakry, Lesotho, Madagascar, Mauritius, Mozambique, Zambia, Guyana and Haiti. The European Union is the main international donor on blood safety and has provided over $40 million to blood safety initiatives world-wide.

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