HIV transmission: Why is blood transfusion in India not yet safe?

Nowhere in the world is transfused blood considered 100% safe. This, despite the fact that each unit of blood is mandatorily tested for infection, among other things, before transfusion.

This happens because several infections, such as Hepatitis A, B, C and Human Immunodeficiency Virus, have a window period during which the virus doesn’t show up in a blood test.

So, if a person contracts the HIV today and decides to donate blood the next day, the laboratory that tests the blood will not detect the virus in it. The window period for HIV is usually between three weeks and three months, depending on the technology used at the laboratory.

Even the best-available technology in the market right now – the Nucleic Acid Amplification Test – only reduces the window period to seven days. It does not entirely eliminate the risk.

But India fares poorly

Despite this limitation, many countries have not reported a case of HIV transmission through blood transfusion for years now. Canada has had no transfusion-transmitted HIV cases since 1985. In the US, the last known case of HIV transmission was in 2008 and the risk of disease spreading through transfusion is one in two million donations. In the UK, the last known case of a viral infection, including HIV, transmitted through blood transfusion was in 2005.

In India, on the other hand, at least 2,234 people are reported to have been infected with HIV while getting blood transfusions in the last 17 months. The National Aids Control Organisation had on Wednesday revealed this in response to a Right to Information plea filed by activist Chetan Kothari.

The organisation, however, has maintained that it has not been scientifically corroborated that the infection was indeed transmitted through transfusion. “The data shows the number of self-reported cases of HIV through blood transfusion during post-test counselling of positive clients,” said Dr Shobini Rajan, Assistant Director-General, National Aids Control Organisation. “This is a socially acceptable way of contracting the disease, as opposed to, say, sexual transmission. These are not proven cases of the virus being transmitted through blood transfusion.”

In India, approximately 0.2% of the donated blood units are detected with HIV. These are then removed from the supply. So, any infected blood that remains was ostensibly within the window period at the time of testing and could go on and infect healthy people.

The National Consumer Disputes Redressal Commission recently ordered a hospital in the outskirts of Mumbai to pay Rs 12,000 to a patient who had contracted HIV 20 years ago after blood transfusion. The court held that the blood was transfused without the woman’s “informed consent”, enlisting the risks of blood transfusion.

Blame it on the technology?

At present, most blood banks in the country use the enzyme-linked immunosorbent assay or ELISA to test for HIV and Hepatitis B and C, among other infections. This is the technology mandated by the Central Drug Standards Control Organisation.

How up-to-date the kits are impacts the window period of the infection. “The new kits that are third- or fourth-generation ELISA kits reduce the window period to about three weeks. But not everyone has this technology,” said Vinay Shetty from Think Foundation, which promotes and organises blood donation camps all over Maharashtra. The organisation works with Thalassaemia patients who need to undergo blood transfusions at least once a month.

The Nucleic Acid Amplification Test, in comparison, reduces the window period to about seven days, but it also increases the cost of the blood unit to Rs 2000 to Rs 2500 per unit, Shetty said.

The current policy of the National Aids Control Organisation caps the price at Rs 1,050 per unit of whole blood in a government institution and Rs 1,450 in a private institution.

“Can patients really afford this technology?” asked Shetty. “We need to do a cost-effect analysis and see if it works out for our patients. Blood is not free in our country.” Government hospitals only provide blood free of cost to Thalassaemia, Haemophilia and sickle-cell disease patients who require repeated transfusions.

Still, states such as Karnataka have implemented the Nucleic Acid Amplification Test technology for all their government hospitals. Some others, including Maharashtra, want to follow suit.

Voluntary blood donation

The World Health Organisation defines a voluntary blood donor as someone who donates blood or any of its components on free will and receives no payment, either in cash or in kind. It is widely accepted the world over that the safest blood donors are voluntary, non-remunerated ones from low-risk populations.

The Supreme Court of India, in 1998, banned the system of using professional donors who were remunerated for donating blood.

Till September 2014, 30 lakh units of blood had been collected through National Aids Control Organisation-supported blood banks. The organisation's website states that voluntary blood donation increased from about 54.4% in 2006 to 84% in 2013-14.

This figure, activists believe, is misleading.

Hospitals, even private ones, regularly ask patients in need of blood transfusions to get donors so that they can replenish the stock of blood units. This system, called replacement donation, is not voluntary. This is against the National Blood Policy of the country.

“Every day I get requests of patients’ relatives not for blood, but for donors. I tell them I can arrange for blood from a bank, but they insist on donors. These are patients in big private hospitals,” said Shetty.

The National Aids Control Organisation, in recent years, has started counting family donations as voluntary.

“This goes against the WHO definition completely,” said Rajat Agarwal, from Sankalp India Foundation, which works in the field of voluntary blood donation and with thalassaemia patients in Karnataka and Maharashtra. “No wonder the figures of blood units from voluntary donations have shown a rise.”

There are no penal provisions for blood banks not following the rule of voluntary non-remunerative donations, as yet.

“Unless it is a gross violation, we do not have any punitive provisions yet for banks that do replacement donations,” said Dr Rajan.

No thorough screening process

Often, patients are not screened well before they donate blood. They do not even fill their forms, which ask questions related to recent illness and unsafe sexual activity, among other things, said Shetty.

“In Canada, for instance, patients have to fill their forms themselves and go through lengthy counselling, where they are asked about sexual partners and other parameters, to rule out any infection in the blood. Till recently, homosexual men were not allowed to donate blood,” said Shetty.

In India, there is no counselling for the patient before the test.

Rational use of blood

One of the best ways to reduce the infection is to rationalise blood transfusions, to ensure that it is only done when necessary.

“There are a number of instances when transfusions may not be warranted,” said Dr Rajan. “One needs to follow our guidelines before blood transfusion.”

In dengue cases, particularly, it has been observed that blood plasma is transfused to patients who do not need it.

In the US, the requirement of blood is going down every year. “This is not because they are getting healthier,” said Agarwal. “It is because people are not using blood irrationally. These guidelines are not being implemented. It is well known that using blood increases the number of days a patient is hospitalised and the potential complications.”

A thorough investigation

As the National Aids Control Organisation has said, it has not been proven that the HIV virus was in fact transmitted by blood transfusion in all the more than 2,000 cases.

Therefore, even as there is room for improvement in the blood transfusion policy and its implementation, we also need to ascertain the cause of infection in patients claiming to have contracted HIV via transfusion.

For this, each case should be scientifically investigated. “These cases should be mapped right back to the individual,” said Agarwal. “How can we decide a change in the policy unless we know what the problem is?”

Based on the findings of such an investigation, Agarwal said, the government and other stakeholders should work on a revised policy.