A TRANSFUSION HIV PREVENTION MODEL FOR PERU
FIRST TAKING A LOOK AT OURSELVES

INTRODUCTION

Many third world countries are being successful in getting good results in their blood safety problem , however having a national blood law , a national blood program and a local ( hospital blood bank ) promotion of the voluntary blood donation haven’t been enough to succeed in Peru.
When 6 neonates in Lima were HIV transfusion infected from a single non-remunerated blood donor who was HIV infectious but non reactive to an HIV fourth generation ELISA test ( Ag. p 24 , Ab. HIV 1 , 2 ) , the Peruvian Minister of Health convoked a National Committee of Experts who confirmed the HIV serum conversion and presented its HIV Blood Safety Peruvian Problem’s Solution which represented a dramatic change in the solution focus used through several years and several governments.
Knowing the scientific world’s blood safety recommendations and the importance of a country’s tailor-made design when applying them , we decided to first take a look at ourselves.What we saw gave us the whole vision of the problem and the list of tasks we had to do.We think it could be interesting for countries like us to learn from our image on the mirror.

PERU’S HIV BLOOD SAFETY FACTS

27 millions of population , 1 % donates blood , only 5.3 % does it voluntarily
Population isn’t massively informed about HIV risk factors or HIV infection through window period
There are 175 blood banks in the country located inside the labs of hospitals of four very different ( budget and functioning ) health systems working in parallel. Almost all of them collect only 50 – 200 blood donations / month/ blood bank.
The National Blood Program has the limited budget of a Ministry of Health’s unit so it has its functions restricted to giving rules and supervision in the expectation that each small hospital blood bank may obey the Program rules by themselves.
The program did succeed in getting all country’s blood units with the Quality Seal ( recommended by the World Health Organization ) put on them after getting negative results in the blood donor’s infectious screening.
There isn’t a center for the national massive promotion of the voluntary blood donation nor one for the centralized production of standardized blood components and none for the national periodical and external HIV Serology Quality Control of tests done in blood banks.

WHAT WE SAW
I
Inspired in Reason 1 and Murphy 2 we adopted the ideas of considering errors and their ways to prevent they could be transferred to the patient , as intrinsic to human activity so we decided to put barriers ( Figure 1 ) to impede the HIV could pass through the holes of the cheese to the transfusion receptor.
When we climbed the mountain to the top to see the whole picture of the valley we found that most of the 21 HIV Transfusion Receptors Protection Barriers ( Table 1 ) Peru should rise were beyond the hospital blood banks responsibilities ( Table 2 ) however being always working under the limited visions of a hospital blood bank , a health institution ( of four ) , a restricted budget National Blood Program or even a too many problems / too small budget Ministry of Health we couldn’t see that our demand was out of focus.What we know now is that rising these barriers requires the participation of the whole nation.

II
been keeping the same structure : 50 – 200 blood donors / month hospital blood banks attending all blood banks functions inside four parallel and very different health institutions.To pretend get them efficiently obeying the National Blood Program norms was like to pretend efficiently driving a stagecoach pull for 4 different horses : a normal one , a race one , an undernourished and a pony.What is more , every organization success requires an order to follow : 1 – objective , 2 – financing , 3 – structure , 4 – organization , 5 – human resources supply , 6 – area supply , 7 - equipment supply , 8 – materials supply , 9 – norms , 10 - standard operating procedures , 11 – human resources training , and 12 – supervision .All of this under a Complete Quality Assurance Program that secures a Continuous Improvement of the organization. We were working only numbers 9 and 11 and skipping numbers 2 and 3 : financing and structure and being of course unsuccessful in the rest of the numbers of the sequence. Furthermore we were wasting money not having a single blood banks system with an standardized and centralized production of blood components.
III
Probably thinking like Kenneth 3 we understood that to rise more HIV prevention barriers ( 2 HIV tests : rapid and non rapid ) only for adapting us to our unsuitable non voluntary blood donor pool was not the solution, in the same sense we understood that to point to a non less than a 100 % for the national voluntary blood donation was even more important for developing nations that for developed ones because our countries can’t afford the each time more numerous and more expensive technologies used to diminish infectious risks in transfusions ( viral inactivation ) but we could certainly diminish them by using cheaper procedures like the quarantine storage opened through the key of the voluntary blood donation.
On the other hand to get a national pool of a 100 % of voluntary blood donors is a huge task that requires a national command , a multidisciplinary group of professionals and a budget hospital blood banks don’t have so it was not real putting the complete burden of this task in the hospital blood banks.We’ve not been using the brain but the centipede’s limbs of the system of national recruitment of voluntary blood donors instead.
We know now that to succeed in National Voluntary Blood Donation doesn’t mean to be congratulated for a successfully one day hospital blood bank campaign , for the donor’s day campaign or for a few blood banks in the country increasing their numbers of voluntary blood donors.It isn’t even enough to succeed in one of the four health institutions we have , it’s necessary to do it in the whole nation.We must get to the point that we don’t need to organize more campaigns to cover our regular blood needs but to the point of getting committed groups of the civil society that voluntarily and periodically donate blood in a repetitive and silent way instead.
IV
Because you need people without HIV infection risk factors to donate blood we became aware of that there won’t be success in voluntary blood donation without success in HIV prevention and that this won’t become true without a massively informed population about this matter so first getting a well HIV informed population is a must of our proposal.The HIV prevention Program is not parallel to the Voluntary Blood Donation Program , it’s its number one task.Furthermore we believe that is more important for countries like us to be exigent in considering getting a 100 % percent of the national blood donor pool as a voluntary and repetitive one as the first goal because to get it opens for us cheaper ways to diminish infection risks ( quarantine storage , Club 25 ) than the each time more numerous and more expensive ways used in developed countries (Viral inactivation ).We just can’t afford this expensive way so we should chase the 100 % medal of the national voluntary blood donation in the first race.
V
We realized that we followed solution ways that didn’t work with us like :
A reactive instead of proactive behavior to face our blood safety problem – this HIV proposal , the National Blood Law and the National Blood Program were launched after the astonish news of HIV transfusion infected patients.
Copying and Pasting good blood safety solutions without first fitting them to the country – our blood laws resembles one proposed by the Pan American Health Organization in May 1995 , it has its same regulations about financing supply ( we never built a way to effectively get it ) , hemoderivatives plants ( we still don’t have one ) and the Quality Seal idea ( we should’ve been very careful before using this procedure without having a national voluntary blood donor pool at the same time ). Even in a developed country , inside a global world with emergent and non emergent infections , there is not such a thing as “Blood Safety” so we believe this didactic term could be misunderstood if we take it out of context like when we expose it to the non scientific world.In the same way , in the scientific world , the didactic term “Quality Seal” means different in a developed country with a repetitive voluntary blood donor pool than in a developing one with a non repetitive voluntary blood donor one so to copy and paste this idea without doing something like the Quarantine Storage to at least cover the HIV infection window period doesn’t mean certainly “Quality Seal ” and not even “ Blood Safety ”.You can take your own conclusions of what it means to the non scientific world to read this phrase in a blood bag.
The same reasoning is valid for the right concepts of “ Hemocenter ” and “ Blood Banks Net ”.They should be specifically adjusted to solve the blood safety problem of the country however even now we have some people that want to establish a National Blood Banks Net by appointing some blood banks inside hospitals as “ centers of standardized production of blood components” and by using an Hemocenter project not specifically planned for our Blood Banks situation.We learned that it’s not enough to copy right concepts , you should copy them in the right way too.

LOOKING TO THE FUTURE

We point to :

Use the South African Model ( Figure 2 ) presented by D. de Coning 4 to get a 100 % voluntary blood donor pool in the first step.
Get a 100 % massively informed population about HIV infection risk factors, HIV window period and the advantages of a voluntary and repetitive blood donation.We think we could have the more modern Hemocenter or the NAT HIV technology in use but both of them wouldn’t impede HIV transfusion transmitted cases in our population given because we didn’t begin for getting a 100 % of the national voluntary blood donor pool as a voluntary and repetitive one.
Use cheaper tools to diminish our transfusion risk factors by reducing the excessive transfusion indications we have ( reducing Transfusion Triggers , monitoring Transfusion Practice , using scientific-approved Transfusion Alternatives like hemodilution , iron , folic acid , blood less surgery techniques or even hemoglobin substitutes ).

We have observed that some countries like us advance not in the slow progressive ascending line of developed ones but sometimes by jumping between intermittent ascending spikes.For example in the field of Immunohematology we jumped from the blood group in the glass plate to the one done in gel cards , skipping the blood group done in tube only because we lacked trained professionals to do it.Because of the high level of HIV in the African population , the African Council has authorized for some specific clinical situations the use of a Bovine Hemoglobin medicine , skipping the necessity of blood units production for those specific cases so it’s possible to think that perhaps developing countries may find their own way to solve their problems.

CONCLUSION

Like Rocío Sapag 5 we certainly believe in the international financing supply and what’s more in the international advice for developing health in the third world countries but both of them won’t help us if we don’t look at ourselves first to construct a situational diagnosis of our blood safety problem , a plausible national plan and an also national strong commitment to execute it.

GRATITUDES

To transfusion Today for permitting us to share not the final numbers of a clinical assay , not even successes but facts , their analisis and the proposal of ideas that form part of our past and hopeful future , maybe the may help.
To the Peruvian Ministry of Health for convoking a National Committee of Experts to get a solution proposal for the Peruvian Blood Safety Problem for the very first time.

This is an specifically prepared version for Transfusion Today – courtesy of Dr. Saditt Ramos – who was the President in charge of the Peruvian Committee of Experts mentioned in this article.
You can find the complete proposal in spanish at http://hivtransfusionalperu.blogspot.com/ .Transfusion Today readers can find an english resumed version of this proposal at http://bloodbanking.blogspot.com/ complemented at http://slidesbb.blogspot.com/ .
Inquiries to mdperu@bonus.com.pe .

BIBLIOGRAPHY

1 - Reason J : Human Error : Models and management. BMJ 2000 , 320 : 768 –70
2 - M.F. Murphy et J.D.S. Kay : Patient identification : problems and potential solutions.
Vox Sanguinis (2004 ) 87 ( Suppl.2 ) , S 197 – S 202
3 - Kenneth A. Clark , MD : Editorial about Predonation testing of potential blood donors
in resource – restricted settings. Transfusion ,Volume ,Issue 2 , page 130 – February
2005
4 – D. de Coning .Finding blood donors : challenges facing donor recruitment in South
Africa. Vox Sanguinis ( 2004 ) 87 ( Suppl. 2 ) , S 168 – S 171
5 – Letter from Rocío Sapag and Jaime Bayona. Learning from low income countries :
what are the lessons ?.BMJ 2004 – 329 : 1186.
http : // bmjjournals.com/cgi/content/full/329/7475/1186