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SAIDS and the Blood Supply The advent of AIDS and HIV infection has raised new concerns about the safety of the blood supply in the United States. Although safety has been a concern since the beginning of the era of transfusion medicine and is not unique to the AIDS epidemic, the stresses that AIDS places on the blood supply pose serious challenges to those charged with protecting that supply. These challenges will require not only the continuing efforts of the blood banking system, which is responsible for protecting the supply, but the intervention of both the biomedical and the social/behavioral research communities to devise strategies that address three major areas of concern: (~) maintaining an adequate supply of safe blood; (2) ensuring the safety of that supply; and (3) encouraging appropriate use of blood and blood components. Infectious diseases are of paramount interest to those responsible for protecting the blood supply, but maintaining an adequate supply of safe blood has become increasingly important as the donors who provide that supply receive more scrutiny. Only a small fraction of the people who may be eligible attempt to give blood, and those who do are requiem to meet increasingly stringent criteria designed to protect blood recipients. If eligibility cr~tena become even more stringent and the donor pool is not enlarged, the supply will inevitably contract. The demand for blood in this country is substantial but not without some flexibility, as noted in the discussion of the appropriate use of blood at the end of this chapter. Each year, more than 4 million patients receive approximately 20 million tin 1986 only a small minority of the age-eligible donors~.6 percentdonated (Linden, Gregorio, and Kalish, 1988); repeat donors constituted an even smaller proportion. 289

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290 ~ AIDS: THE SECOND DECADE transfusions of blood or blood components (red blood cells, platelets, leukocytes, or plasma) prepared from about 12.5 million units2 of blood. Of the 20 million units used, a significant number may be transfused unnecessarily.3 In the era of AIDS, the question of the inappropriate use of blood has come under renewed examination as the balance between supply and demand becomes increasingly precarious. Although maintaining an adequate supply of blood is crucial to the delivery of health care, a great deal of concern has also been expressed about the safety of the blood that is being donated. Technological ad- vances provide increasingly expanded capacities to detect evidence of infectious pathogens in the blood itself, but in the case of AIDS the time lag between acquisition of HIV infection and the production of antibodies highlights the limitations of technology to solve all of the problems AIDS brings to blood. Thus, technological solutions must be augmented by behavioral strategies that focus on donor character~stics- who the donors are and whether they engage in behaviors that may have put them at risk for acquiring HIV infection and emphasize approaches that identify, recruit, and retain only those donors who are least likely to be infected. After 1975, the blood collection system in the United States ceased outright payments, except in a few cases, for the donation of whole blood.4 Studies of viral hepatitis demonstrated that the rate of this infection was greater In recipients of blood from paid donors than In recipients of blood from volunteers (Walsh et al., 1970; Alter, Holland, and Purcell, 1975; Seeff et al., 1975; Alter, 1987~. An all-volunteer system was established to prevent the intrusion of undesirable factors (e.g., financial remuneration) into motivations to donate blood. Yet the question of safety does not stand alone. Indeed, shortages, which have been apparent in some areas of the country for some time, reemerge as a continuing problem that now warrants additional attention. Thus, the issues of adequate supply and safety are integrally connected. In this chapter, the committee looks at how blood is collected, how the balance between supply and demand can be maintained through in- tervention strategies targeting the donors that supply the blood and the physicians that prescribe its use, and behavioral mechanisms to protect 2A unit, which is the standard donation per individual, is generally 450 milliliters, and each unit is, on the average, converted to 1.54 component units (summing et al.? 1989). 3 Christine Parker, National Heart, Lung, and Blood Institute, personal communication, February 15, 1990. 4Donors with rare blood types may be paid to provide a regular supply of this scarce resource, and a few blood collection organizations (e.g., The Mayo Clinic) provide payment for at least a portion of their regular donors, though this practice is being phased out.

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BLOOD SUPPLY ~ 291 the safety of the blood supply. Because of the connection between an adequate and a safe blood supply, the committee has grouped its recom- mendations concerning these issues after its review of related substantive material. BRIEF HISTORY AND OVERVIEW OF THE PROBLEM Early in the epidemic, suspicions arose that AIDS could be transmitted by transfusion (CDC, '982; Curran etal., 1984~. In the spring of 1983, cases of AIDS diagnosed among hemophiliacs were thought to be related to clotting factor concentrates made from contaminated blood (Evatt et al., 19831. Although the etiologic or causative agent of AIDS had not been identified in the early 1980s and no specific diagnostic tests were available, reports of cases among transfusion recipients and hemophiliacs prompted blood banks to institute a variety of procedures to reduce the risk of AIDS associated with blood transfusions. Such procedures included efforts to exclude donors who were members of groups at high risk for the disease, studies of the use of tests that measured factors considered to be surrogate markers of AIDS (e.g., antibody to hepatitis B core antigen, T-lymphocyte ratios), the increased use of autologous donation (providing one's own blood for personal use), and the reduction of unnecessary transfusions of blood and blood components (Nichols, 1986~. After the etiologic agent, HIV, was identified and blood tests for . . antibody to the virus became available in March 1985, blood collec- tion organizations added this serologic test to their screening procedures (CDC, 1985; Ward et al., 1986~. Yet despite the high sensitivity of HIV antibody tests, they do not detect all infected donors (CDC, 1986; Ward et al., 198Sb). A variable length of time elapses between acquisition of the virus and development of a detectable antibody response. Generally, this period is no more than a few months, but in one study virus was isolated from blood samples of 27 men who did not yet exhibit antibod- ies for periods of as long as three years after the initial positive virus culture (Imagawa et al., 19891. Dunng this so-called "window" period, the blood collected from an infected donor may test negative and thus go undetected by the serologic screening mechanisms employed in most blood banks.5 The current incidence of HIV infection from antibody-negative blood in the United States is not known. Estimates vary from a rate of approx- imately one infection for every 40,000-50,000 units transfused (N. D. S Although evidence of infection can be demonstrated among antibody-negative individuals during the window period, the precise risk associated with transmission during this period is not known.

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292 ~ Alas: THE SECOND DECADE Cohen et al., 1989) to one in every 153,000 units transfused (summing et al., 19891.6 Estimates of the prevalence of detectable HIV infection in donors have ranged from 1.3 to 5 per 10,000 (Ward et al., 1988a; Hughes et al., 19891. These rates, however, are not constant across all donor groups, geographic areas, or time. For example, seroprevalence rates are higher among black and Hispanic donors and among younger males (Ward et al., 1988a; Hughes et al., 19891. It also appears that repeat donors, especially females, are less likely to be infected than are first-time donors (summing et al., 1989; Leitman et al., 19891. The proportion of HIV antibody-positive donations has also decreased over time. This decrease is due both to notification and exclusion of donors found to be positive for antibody to HIV and to success in donor self- exclusion measures, donor prescreening, community education efforts, availability of HIV antibody tests in alternative sites for donors who have been using blood collection systems for this service, and a reduction in the incidence of new HIV infections in some populations (Ward et al., 1988a; Hughes et al., 19891.7 Nevertheless, the risk of HIV transmission through transfusion remains (Kleinman and Secord, 1988; N. D. Cohen et al., 1989~. Although HIV antibody tests cannot eliminate all possibility of transfusion-associated HIV infection, Hey have vastly improved the safety of the blood supply. Additional methods to detect infected units, such as those based on recombinant-DNA technology, synthetic peptides, and gene-amplification techniques, are being explored to increase the sen- sitivity of serologic testing (Menitove, 1989~. Other safeguards involving improved donor screening and recruitment are also being evaluated and implemented as described below. 7 THE BLOOD COLLECTION SYSTEM IN THE UNITED STATES hn the United States there are two separate systems that collect blood for various products: (1) a commercial system that pays donors for plasmas 6Cumming and colleagues (1989) report a range of one infection in 88,000 units transfused to one in 300,000. Earlier in the epidemic, Kleinman and Secord (1988) estimated that the risk of infection from blood that tested negative for HIV antibody was between one in 51,000 units to one in 102,000 units. The lower rates of infection associated with antibody-negative donations that have been derived from more recently collected data may reflect diminishing numbers of HIV-positive donors and a changing donor pool that may include more tested donors (Menitove, 1989). 7It should be noted that before testing was available, self-exclusionary and prescreening measures resulted in significant deferral rates among gay men (Wykoff and Halsey, 1986). 8 Plasma is the fluid component of blood that transports water, nutrients, minerals, oxygen, and hor- mones to all cells of the body. It also contains important proteins and other substances vital to the clotting capacity of blood and to maintaining the integrity of the circulation. Plasma collected from

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BLOOD SUPPLY | 293 used by industry to manufacture albumin, antihemophilic factor, gamma globulin, and various protein derivatives; and (2) a voluntary system for whole blood that uses no monetary incentives to motivate donations. This latter system provides whole blood and blood components such as platelets, red blood cells, cryoprecipitate, and plasma for blood trans- fusion services. Plasma that is not used for transfusion is provided to pharmaceutical companies for the manufacture of blood products. This report deals only with the voluntary system for whole blood collection. The volunteer donor system expects healthy individuals to donate blood to meet the needs of their community; those who need blood then receive it at the cost of collection plus processing. Occasionally, individuals make directed donations, donating blood specifically for use by friends or relatives. Before the AIDS epidemic, enough volunteers gave blood to maintain an adequate supply for most parts of the country although only 5 or 6 percent of the adult population donated blood in any given year. Today, however, there is not enough blood available locally in several U.S. communities, and in such cases blood must be acquired from individuals in other locales. The Organization of Blood Collection There are three major blood collection organizations operating at the community level: the Amencan Red Cross, the American Association of Blood Barks (AABB), and the Council of Community Blood Centers (CCBC). The American Red Cross currently collects about half of the blood used in the United States (Kalish, Cable, and Roberts, 1986~. The AABB and the members of the CCBC and independent hospital blood banks collect the remainder. On the United States, approximately 80 percent of donated blood is collected at mobile sites through blood drives that recruit donors from organizations such as high schools, universities, businesses, and corporations of wearying size, as well as the offices of local governments and other public-sector organizations. Equipment to collect blood is brought to the donors, either through a bloodmobile van or in temporary facilities set up at the donors' organization. Blood is also collected at fixed sites (e.g., buildings that house the necessary equipment and staff on a permanent basis). Individuals who come to donate on their own initiative may prefer fixed sites, although few studies link different subpopulations of donors to donation sites. Thus, it is not clear that fixed sites and mobile operations are dealing with the same donor populations. paid donors in the commercial system is treated with detergents or heat to kill infectious pathogens, including viruses (Horowitz, 1987). Thus, the danger of acquiring HIV infection from these products is greatly reduced.

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294 ~ AIDS: THE SECOND DECADE Once the blood has been collected and tested for a variety of infec- tious agents Concluding HIV), those units that pass all safety requirements are distributed to blood banks and organizations that transfuse blood and blood products, such as hospitals and dialysis centers. The shelf life of blood and blood components ranges from 72 hours to 42 days, depending on the specific component. However, frozen products can generally withstand longer periods of storage than fresh ones, although some components (e.g., platelets) cannot be frozen. Exclusionary Procedures Donor deferral measures have two goals: (1) to protect the donor from potential harm and (2) to ensure the safety of the recipient. People are deferred from donation, either temporarily or permanently, for a number of reasons, including fever, anemia, a history of exposure to malaria, recent infection, signs of symptoms of HIV infection, or a history of r~sk-associated behavior. Blood banks have established procedures to assist potential donors in their assessment of whether they may have been exposed to HIV and to discourage those at risk from donat~ng.9 Each donor is given information about the donation process and about infections transmitted by blood, especially HIV, and asked to read it carefully. Those who have signs or symptoms of AIDS or who have engaged in behaviors that put them at risk are asked not to donate (self-defer) and are informed that they may leave the donation site with no explanation required. Potential donors who choose to continue the donation process provide a confidential health history, which is given to or reviewed by a member of the blood collection staff. (Donors are asked a number of health-related questions, including questions about possible exposure to HIV and symptoms consistent with HIV-related illnesses.) Following the health history, donors are asked to attest that they have read and understood the information about risk factors for AIDS. Because some potential donors fee} pressure to donate blood (es- pecially during blood drives) and others may not have been truthful in responding to questions posed during the health history, all donors are offered yet another opportunity to exclude their unit from the blood sup- ply even if they complete the donation process. The donor is asked to choose one of two options for handling the unit of blood indicating either that (1) the blood may be used for transfusion or (2) the blood should not be transfused. Donors select the option in private or using a code so 9Minimum donor guidelines for exclusionary criteria have been established by federal regulatory law, but additional restrictions can be imposed by blood collection organizations (Linden, Gregorio, and Kalish, 1988).

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BLOOD SUPPLY ~ 295 that others in the blood collection facility will not learn of the choice. This step is referred to as confidential unit exclusion, or the CUE. Some centers also use a callback system that permits donors after leaving the site to notify the blood bank that they may be at risk. Regardless of subsequent laboratory test results, all units identified by the donors for exclusion from transfusion are removed from the blood distribution pool. This step allows a donor to go through the entire donation process in the presence of friends and associates without revealing potentially sensitive inflation and without compromising the safety of the blood supply. Exclusionary Procedures: The Organizational Perspective Although donors who may be at risk of acquiring HIV infection are discouraged from donating and are given an opportunity to have their blood discarded through self-exclusion mechanisms, these approaches are by no means fully effective. The majority of donors who are found to be HIV antibody positive do not self-exclude. Thus, continuing efforts are needed to improve approaches for discouraging HTV-infected individuals from giving blood and to educate potential donors more effectively to improve self-exclusion. In this section, the committee looks at how the organization of blood collection might affect donor deferral and proposes structural changes that may improve this process. In a later section of the chapter, the committee reviews the impact of exclusionary measures on donor behavior. Generally, AIDS-related information is only provided to prospective donors when they a:Tive to give blood. It may also be productive to contact individuals before they come to donate and provide specific information about behaviors that exclude donors. This practice would allow prospective donors time to reflect on their risk status and to make decisions regarding donation in private and under conditions of lower social pressure. In setting the tone for such information, blood collection organizations should stress both the factors that motivate donors to give (which are described below) and the altruistic reasons for not donating if at risk. It should be made clear that appropriate self-deferral is a community-spirited act. There are other informational issues that blood collection organiza- tions must consider. In addition to providing AIDS-related information, community blood centers may wish at this time of increasing fear and decreasing supply to increase their efforts to educate the public regarding blood donation in general. Such efforts should tap a broader range of individuals and organizations and make more effective use of coordina- tion. The media can also play an important role in providing messages

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296 ~ AIDS: THE SECOND DECADE about the need for blood, the need for specific individuals to give, the safety and ease of giving, the collective responsibility for the quality and quantity of the blood supply, and the problems associated with alternative collection systems (such as directed and paid donation). One approach to improving self-deferral, albeit a controversial one, has been the use of direct questions concerning intimate personal be- havior. In August 1989, the American Association of Blood Banks took the tradition-breaking position that donors should be asked specific ques- tions regarding risky behaviors during the health history. Although the presumption had been that donors would not be likely to answer such questions honestly, recent studies suggest that direct questioning may be more effective than previously thought in identifying high-nsk donors. Silvergleid, LeParc, and Schmidt (1989) found that 90 percent of donors approved of direct questioningly and that direct (as opposed to indirect) questioning resulted in a fivefold increase in deferrals for participation in high-nsk activities. Although the Food and Drug Administration (FDA), one of the federal institutions responsible for regulating the blood collec- tion system in this county, has provided recommendations concerning the provision of educational materials to donors, to date no guidelines have been developed concerning direct questioning of potential donors during the health history. The use of explicit questions during the donation process can create problems related to loss of privacy and confidentiality if one donor can overhear the questions asked and answers given by another. This problem would be most severe in small bloodmobiles or in an instance in which a donor knows others who are giving blood at the same time. Thus, if interviewing is to be effective in eliciting truthful responses to direct questions on sensitive matters, the physical settings in which interviews take place must take privacy into account. One possible solution might be computer-conducted health history interviews, which afford privacy even when space is limited. Computer questioning may also eliminate embarrassment on the part of both interviewer and interviewee when sensitive topics are covered and might lead to greater honesty in reporting risk behaviors. However, the capacity of donors to understand written material and to use computers must be kept in mind when developing such an interview format. Changes in the "processing" of donors raise staffing issues for blood collection organizations. Increased scrutiny of potential donors involves a more detailed history and currently relies on a face-to-face interview Wholly 1 percent of donors found the questions to be embarrassing, and only 1 percent said Hey would stop donaimg blood because of explicit questioning (Silvergleid, LeParc, and Schmidt, 1989).

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BLOOD SUPPLY ~ 297 concerning behaviors that may be stigmatizing or even illegal. Expe- rience from survey research involving personal interviews shows that adequate interviewer training improves the quality of the data that are collected (Hymen et al., 1975; Fowler, 1989; Fowler and Mangione, 1990; Campbell et al., n.d.~. Studies of sexual behavior have revealed that even experienced interviewers require special training to gather valid data on sensitive topics (Reinisch, Sanders, and Ziemba-Davis, 19881. Blood collection staff who are not professionally trained in discussing sensitive personal issues may fee] uncomfortable and therefore may not be very effective in this area. Specific training may help these staff over- come this battier or identify those who should not be entrusted with this task. Processing donors raises the difficult issue of managing donors who must be deferred. Donors who are temporarily or permanently deferred require careful attention from staff. Donors who are permanently deferred must be made to understand that they should not give blood again. However, donors who are temporarily deferred may be eligible to donate in the future and, in the interest of securing an adequate supply of blood, these donors should be effectively encouraged to return at an appropriate time. Because little is known about the factors associated with successful management of permanent or temporary deferral of donors, this topic could benefit from additional research. Although organizational issues may be important in fine-tuning donor screening to maintain a safe blood supply, other issues must also be addressed. If blood banks are to reconsider how they recruit and retain sufficient numbers of safe donors, several questions need to be answered. What motivates people to donate? What are the banners to donation? What characterizes safe donors? The next section discusses available data on donor demographics and behavior and explores areas in which additional information is needed. MAINTAINING AN ADEQUATE SUPPLY OF SAFE BLOOD Given the increasing restrictions on donors, it is reasonable to question whether the number of donors will be sufficient to maintain a supply of blood that is adequate to meet current and future demands. The American Red Cross estimates that, of 14.8 million donors who presented at blood collection sites between 1986 and 1987, 1.3 million were deferred. Of 13.2 million units collected, 0.7 million were rejected at the time of testing (summing, Schorr, and Wallace, 1987~. The impact of exclusionary policies on the adequacy and safety of the blood supply remains an important area of study, although existing data indicate increasingly lower

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298 AIDS: THE SECOND DECADE rates of HIV antibody-positive donations over time. These data also show significant decreases in the number of high-nsk donors, especially males. As more donors are deferred and as more donations are rejected, the issue of supply shortages will inevitably anse. Periodic shortages are already occurring, arid some regions must ob- ta~n blood from other areas. In deciding whether or not to obtain blood from other areas during periods of shortage, administrators of blood col- lection organizations may balance the cost of more intensive recruitment efforts against the cost of getting blood from another organization. In areas win persistent shortages, management may favor purchasing blood from other areas, as recruitment efforts are very costly and may not result in a supply that will be adequate to meet the demand. Although the precise number of people whose medical or behavioral history excludes them from the pool of potential donors is uncertain, recent research suggests that more than half of the men and women in the United States should be eligible to give blood Gregory and Linden, 1988; Linden, Gregorio, and Kalish, 1988~.~3 Thus, factors other than 11In a New York area study that compared the donor population of 1982 to that of 1983, Pindyck and coworkers (1985) found that male participation in New York City decreased by 6.1 percent; the decrease was particularly striking among 21- to 36-year-old males. Medical screening resulted in rejection of 2 percent of all individuals presenting as donors at the Greater New York Blood Program and the confidential unit of exclusion (CUE) procedure eliminated another 1.4 percent. However, there was an overall increase in blood collections of 1.1 percent, largely due to increases in the participation of women and men from over areas (Pindyck et al., 1985). A review of 818,629 donations collected in three major blood centers in the United States between March 1985 and July 1986 found that 450, or 0.05 percent' were HIV antibody positive (Ward et al., 1988a). Between May 1988 and September 1989, 756 HIV antibody-positive donations (0.029 percent) were found among 2.65 million donations at 19 different blood centers (Council of Community Blood Centers, 1989). 12 Anecdotal infonnation indicates that the Irwin Memorial Blood Bank in San Francisco is encoun- tering the worst shortage of donors in its 50-year history. (See David Perlman, "Major Blood Bank Facing Worst-Ever Shortage of Donors," San Franc~sco Chronicle, February 1, 1989.) For example, normal inventory would include 350 units of type O-positive blood, but on January 31, 1989, only 9 units were available; 60 units were flown in from Milwaukee. However, the cause of this shortage is less than clear, blood bank officials indicated that flu viruses were in part to blame (see George Raine, `'Bay Area Supplies of Blood at Crisis," San Francisco Examiner, February 1, 1989). 13The eligible donor population was estimated by subtracting from the number of 17- to 7S-year-olds identified in the 1980 census the number of individuals meeting American Red Cross exclusion criteria for (1) low hematocrit levels, (2) inadequate body weight, (3) recent pregnancy, (4) heart disease, (5) diabetes requiring insulin, (6) high blood pressure, (7) male homosexual activity since 1977, (8) intravenous drug use, (9) sexual contact with a member of a high-risk group, (10) transfusion within the previous six months, (11) history of cancer, and (12) other factors, including a history of hepatitis, medications, and certain types of foreign travel. (See Linden, Gregorio, and Kalish [1988] for criteria definition, data sources, and estimates of individuals meeting exclusionary criteria as well as estimated overlap across criteria.) The authors estimate that 57 percent of women and 70 percent of men are eligible to donate blood. Screening for hepatitis C (non-A, non-B) virus would further reduce these numbers but only slightly.

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BLOOD SUPPLY ~ 299 eligibility, including willingness to give blood, play an important role in maintaining an adequate blood supply. The current challenge lies in utilizing available information on the characteristics of individuals who donated in the past and on factors that motivate people to participate to devise effective strategies for safe donor recruitment. Who Donates Blood? In the United States most blood is given by donors who have given blood before (American Red Cross Mid-America Regional Blood Services, 1980; Piliavin and Callero, in press). Epidemiological studies find that repeat blood donorsespecially repeat female donors have the lowest rates of infections transmitted through transfusion (Dondero et al., 1987; Cumming et al., 1989~. Consequently, both supply and safety issues highlight the importance of retaining safe donors once they have been identified. Prior to the AIDS epidemic most blood donors were men (Oswalt, 1977~; depending on when and where the data were collected, men constituted between 49 and 91 percent of the donor population (Boe, 1976; American Red Cross Mid-Amer~ca Regional Blood Services, 1980; American Red Cross Blood Services, Los Angeles-Orange Counties Re- gion, 1981; L~ightman, 19811. In a recent survey, ~ percent of men and 5 percent of women in the general population claimed to have given blood in the past year (Dawson, 19891. Among first-time donors, however, fe- males predominate (Mell, 1979; Callero, 19831. Because the majority of AIDS cases have been diagnosed among men, blood drives have looked to women as potential sources of safer blood. Unfortunately, fewer women than men are repeat donors, and gender discrepancies therefore become more apparent with subsequent donations (Mell, 1979; American Red Cross Mid-America Regional Blood Services, 1980; Callero, 1983; American Red Cross Greater Buffalo Chapter, 1985~. Less than a third of blood donors who have given one gallon or more are women (Mell, 1979; Piliavin and Callero, in press). A factor that may be related to the loss of women from the donor pool is low hemoglobin levels and depletion of iron stores, which can lead to temporary deferral. Unfortunately, even temporary discouragement from donation may have permanent effects. One remedy to this problem is routine provision of iron supplements to permit such women to remain regular donors (Gordeuk et al., 19871. In an experiment using "VIP" donors a special group whose members volunteer to donate at least four times a yearadministenng iron supplements to menstruating female

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348 ~ AIDS: THE SECOND DECADE Edwards, P. W., and Zeichner, A. (1985) Blood donor development: Effects of personality, motivational and situational variables. Personality and Individual Differences 6:743-751. Eschbach, J. W., Egne, J. C., Downing, M. R., Browne, J. K., and Adarnson, J. W. (1987) Correction of the anemia of end-stage renal disease with recombinant human erythropoietin: Results of a combined Phase I and II clinical trial. New England Journal of Medicine 316:73-78. Eschbach, J. W., Kelly, M. R., Haley, N. R., Abets, R. I., and Adamson, J. W. (1989) Treatment of the anemia of progressive renal failure with recombinant human erythropoietin. New England Journal of Medicine 321:158-163. Evans, D. E. (1981) Development of intrinsic motivation for voluntary blood donation among first-time donors. Dissertation Abstracts International 42:3777. Evatt, B. L., Francis, D. P., McLane, M. F., Lee, T. H., Cabradilla, C., et al. (1983) Antibodies to human T-cell leukemia virus-associated membrane antigens in hemophiliacs: Evidence for infection before 1980. Lancet 2:698-700. Farrales, F. B., Stevenson, A. R., and Bayer, W. L. (1977) Causes of disqualification in a volunteer blood donor population. Transfusion 17:598~01. Ferrari, J. R., Barone, R. C., Jason, L. A., and Rose, T. (1985a) Effects of a personal phone call prompt on blood donor commitment. Journal of Community Psychology 13:295-298. Ferran, J. R., Barone, R. C., Jason, L. A., and Rose, T. (1985b) The use of incentives to increase blood donations. Journal of Social Psychology 125:791-793. Fischer, A., Pura, L., Smith, L., and Goldfinger, D. (1986) Safety and effectiveness of directed blood donation in a large teaching hospital. Transfusion 26:600(A611. Fishbein, M., and Ajzen, I. (1975) Belief, Attitude, Intention and Behavior: An Introduction to Theory and Research. Reading, Mass.: Addison and Wesley. Fisher, J. D. (1988) Possible effects of reference group-based social influence on AIDS-risk behavior and AIDS prevention. American Psychologist 43:91~920. Foss, R. D. (1983) Community nones and blood donation. Journal of Applied Social Psychology 13:28 1-290. Foss, R. D., and Dempsey, C. B. (1979) Blood donation and the foot-in-the-door technique: A limiting case. Journal of Personality and Social Psychology 37:58~590. Fowler, F. J., Jr. (1989) Evaluating special training and debriefing procedures for pretest interviews. In C. Cannell, L. Oksenberg, G. Kalton, K. Bischoping, and F. J. Fowler, eds., New Techniques for Pretesting Survey Questions. (mimeo). Final Report to the National Center for Health Services Research and Health Care Technology Assessment. Survey Research Center, University of Michigan and Center for Survey Research, University of Massachusetts. Fowler, F. J., and Mar~gione, T. W. (1990) Standardized Survey Interviewing. Newbu~y Park, Calif.: Sage. Freiburger, C. A., and George, W. R. (1988) It's as easy as 1, 2, 3: lst-time donors will come back. Transfusion 28:(Suppl. 61:55S(A551. Gaynor, S., Kessler, D., Berge, P., Andrews, S., and Del Valle, C. (1989a) Risk factors for HIV among New York blood donors in 1988. Presented at the Fifth International Conference on AIDS, Montreal, June =9.

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BLOOD SUPPLY 349 Gaynor, S., Kessler, D., Andrews, S., and Del Valle, C. (1989b) Self-exclusion by HIV antibody positive blood donors. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Gibson, T. (1980) Notes on East Anglian blood donors. Transfusion 20:71~719. Giovanetti, A. M., Parravicini, A., Baroni, L., Riccardi, D., Pizzi, M. N., et al. (1988) Quality assessment of transfusion practice in elective surgery. Transfusion 28:16~169. Goldfinger, D. (1989) Directed blood donations: Pro. Transfusion 29:7(}74. Goodnough, L. T., Kruskall, M., Stehling, L., Johnson, M., Kennedy, M., et al. (1988) A multicenter audit of transfusion practice in coronary artery bypass (CABG) surgery. Blood 72:277a. Gordeuk, V. R., Brittenham, G. M., Bravo, J. A., Hughes, M. A., and Keating, L. J. (1987) Carbonyl iron for short-term supplementation in female blood donors. Transfusion 27:8~85. Grace, H. A. (1957) Blood donor recruitment: A case study in the psychology of communication. Journal of Social Psychology 46:269-276. Greenwalt, T. J., and Jamieson, G. A., eds. (1975) Transmissible Disease and Blood Transfusion. New York: Grune and Stratton. Gregorio, D. L., and Linden, J. V. (1988) Screening prospective blood donors for AIDS risk factors: Will sufficient donors be found? American Journal of Public Health 78: 1468-1471. Grindon, A. J., Winn, L. C., Kastal, P., and Eska, P. (1976) Conversion of professional donors to volunteer donors. Transfusion 1 6: 1 90. Haigh, J. D. (1987) A plan to educate elementary school children, recruit their parents and maintain an adequate blood supply. Transfusion 27:57Q(A69). Hamilton, Frederick, and Schneiders. (1988) Recent trend survey research findings. Memorandum to the American Association of Blood Banks, June 15. Hamilton, Frederick, and Schneiders, Washington, D.C. Handler, S. (1983) Does continuing medical education affect medical care: A study of improved transfusion practices. Minnesota Medicine, March:167-180. Hartz, R. S., Smith, J. A., and Green, D. (1988) Autotransfusion after cardiac operation: Assessment of hemostatic factors. Journal of Thoracic Cardiovascular Surgery 96:178-182. Hayes, T. J., Dwyer, F. R., Greenwalt, T. J., and Coe, N. A. (1984) A comparison of two behavioral influence techniques for improving blood donor recruitment. Transfusion 24:399-403. Heider, F. (1958) The Psychology of Interpersonal Relations. New York: Wiley. Herbert, W. N. P., Owen, H. G., and Collins, M. L. (1988) Autologous blood storage in obstetrics. Obstetrics & Gynecology 72:16~170. Hochschild, A. R. (1983) The Managed Heart: Commercialization of Human Feeling. Berkeley, Calif.: University of California Press. Hocking, B., O'Collins, M., Pulsford, R. L., Woodfield, D. J., Arnold, P., et al. (1974) Blood donor motivation in Papua New Guinea. Medical Journal of Australia 2:67~674. Horowitz, B. (1987) Inactivation of viruses in blood derivatives. In S. B. Moore, ea., Transfusion-Transmitted Viral Diseases. Arlington, Va.: American Association of Blood Banks.

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350 ~ AIDS: THE SECOND DECADE Hughes, M. J., Winter, S. L., Perkins, C. I., Kizer, K. W., Capell, F. J., and Trachtenberg, A. I. (1989) Prevalence of HIV antibody among blood donors in California. New England Journal of Medicine 321 :97i975. Wyman, H. H., Cobb, W. J., Feldman, J. J., Hart, C. W., and Stember, C. H. (1975) Interviewing in Social Research. Chicago, Ill.: The University of Chicago Press. Imagawa, D. T., Lee, M. H., Wolinsky, S. M., Sano, K., Morales, F., et al. (1989) Human immunodeficiency virus Type 1 infection in homosexual men who remain seronegative for prolonged periods. New England Journal of Medicine 320:1458- 1462. Inui, T. S., Yourtee, E. L., and Williamson, J. W. (1976) Improved outcomes in hypertension after physician tutorials: A controlled trial. Annals of Internal Medicine 84:646~51. Jason, L. A., Jackson, K., and Obradovic, J. L. (1986) Behavioral approaches in increasing blood donations. Evaluation and the [health Professions 9:439 448. Jason, L. A., Rose, T., Ferrari, J. R., and Barone, R. (1984) Personal versus impersonal methods for recruiting blood donations. Journal of Social Psychology 123:139- 140. Kalish, R. I., Cable, R. G., and Roberts, S. C. (1986) Voluntary deferral of blood donations and HTLV-III antibody positivity. New England Journal of Medicine 314:1115-1116. Kaloupek, D. G., and Stoupakis, T. (1985) Coping with a stressful medical procedure: Further investigation with volunteer blood donors. Journal of Behavioral Medicine 8:131-148. Kaloupek, D. G., Scott, J. R., and Khatarni, V. (1985) Assessment of coping strategies associated with syncope in blood donors. Journal of Psychosomatic Research 29:207-214. Kaloupek, D. G., White, H., and Wong, M. (1984) Multiple assessment of coping strategies used by volunteer blood donors: Implications for preparatory training. Journal of Behavioral Medicine 7:35-60. Kelley, H. H. (1967) Attribution theory in social psychology. In D. Levine, ea., Nebraska Symposium on Motivation. Lincoln, Neb.: University of Nebraska Press. Kleinman, S., and Secord, K. (1988) Risk of human immunodeficiency virus (HIV) transmission by anti-HIV negative blood: Estimates using the lookback method- ology. Transfusion 28:499-501. Kotler, P., and Roberto, E. L. (1989) Social Marketing: Strategies for Changing Public Behavior. New York: The Free Press. Kramer, D., Ber, R., and Moore, M. (1987) Impact of workshop on students' and physicians' rejecting behaviors in patient interviews. Journal of Medical Education 62:90~909. Kruskall, M. S., Glazer, E. E., Leonard, S. S., Willson, S. C., Pacini, D. G., et al. (1986) Utilization and effectiveness of a hospital autologous preoperative blood donor program. Transfusion 26:335-340. LaQue, C., Bailey, G., Odell, T., Heal, J., and Nusbacher, J. (1982) Hemapheresis donors as volunteer recruiters. Transfusion 22:446(A431. Leibrecht, B. C., Hogan, J. M., Luz, G. A., and Tobias, K. I. (1976) Donor and non-donor motivations. Transfusion 16:182-189.

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352 ~ AIDS: THE SECOND DECADE Moss, A. J. (1976) Blood donor characteristics and types of blood donations. In Vital and Health Statistics. DNEW 7~1533. Series 10, No. 106:1-19. Rockville, Md: National Center for Health Statistics. Murray, C. (1988) Evaluation of on-site cholesterol testing as a donor recruitment tool. Transfusion 28(Suppl. 61:56S(A59~. National Blood Resource Education Program. (1989) Transfusion Alert: Use of Autologous Blood. Ned Publication No. 89-3038. Bethesda, Md.: National Heart, Lung, and Blood Institute. National Blood Resource Education Program. (1990) The use of autologous blood: The national blood resource education program expert panel. Journal of the American Medical Association 263:414~17. National Heart, Lung, and Blood Institute (NHLBI). (1972) Summary report: National Heart, Lung and Blood Institute's resource studies. U.S. Department of Health, Education, and Welfare Publication No. (NIH) 73~16. Bethesda, Md.: U.S. Department of Health, Education, and Welfare. National Heart, Lung, and Blood Institute (NHLBI). (1988) AIDS and blood resources. Presented at the meeting of the Corrunittee on AIDS Research, National Academy of Sciences. Washington, D.C., December 22. Nelson, K. E., Vlahov, D., Margolick, J., and Bernal, M. (1989) Blood and plasma donations among a cohort of IV drug users. Presented at the Fifth International Conference on AIDS, Montreal, June =9. Newman, B. H., Burak, F. Q., McKay-Peters, E. H., and Pothiawala, M. A. (1988) Patient-related blood drives. Transfusion 28:142-144. Nichols? E. K. (1986) Mobilizing Against AIDS: An Unfinished Story of a Virus. Cambridge, Mass.: Harvard University Press. Nusbacher, J., Chiavetta, J., Naiman, R., Buchner, B., Scalia, V., and Herst, R. (1986) Evaluation of a confidential method of excluding blood donors exposed to human immunodeficiency virus. Transfusion 26:539-541. Obome, D. J., Bradley, S., and Lloyd-Griffiths, M. (1978) The anatomy of a volunteer blood donation system. Transfusion 18:458~65. Office of Medical Applications of Research (OMAR), National Institutes of Health. (1985) Consensus Conference: Fresh-frozen plasma indications and risks. Journal of the American Medical Association 253:551-553. Office of Medical Applications of Research (OMAR)? National Institutes of Health. (1987) Consensus Conference: Platelet transfusion therapy. Journal of the Ameri- can Medical Association 257:1777-1780. Office of Medical Applications of Research (OMAR), National Institutes of Health. (1989) Perioperative red cell transfusion: National Institutes of Health Consensus Development Conference. Transfusion Medicine Reviews 3:63-68. Office of Technology Assessment (OTA). (1985) Blood Policy and Technology. Wash- ington, D.C.: Office of Technology Assessment. Oswalt? R. M. (1977) A review of blood donor motivation and recruitment. Transfusion 17:123-135. Oswalt, R. M., and Zaclc, L. A. (1976) The motivation and recruitment of pheresis donors. Presented at the 29th Annual Meeting of the American Association of Blood Banks, San Francisco, October November 5.

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354 ~ AIDS: THE SECOND DECADE Rushton, J. P.9 and Campbell9 A. C. (1977) Modeling vicarious reinforcement and extroversion on blood donating in adults: Immediate and long-term effects. European Journal of Social Psychology 7:297-306. Ryan, T. (1987) Junior high school student blood drive A community education program for non blood donors. Transfusion 27:571(A75~. Rzasa, M., and Gilcher, R. (1988) Cholesterol testing: Incentive or health benefit? Transfusion 28(Suppl. 6~:56S(A60~. Salzman, E. W., Weinstein, M. J., Weintraub, R. M., Ware, J. A., Thurer, R. L., et al. (1986) Treatment with desmopressin acetate to reduce blood loss after cardiac surgery: A double-blind randomized trial. New England Journal of Medicine 314:1402-1406. Schaffner, W., Ray, W. A., Federspiel, C. F., and Miller, W. O. (1983) Improving antibiotic prescribing in the office practice: A controlled trial of three educational methods. Journal of the American Medical Association 250:1728-1732. Schmidt, P. J. (1984) Senior donors. Transfusion 24:445(A38~. Schroeder, C. (1987) Recruiting blacks as blood donors. Transfusion 27:570(A70~. Schroeder, S. A., Myers, L. P., McPhee, S. J., Showstack, J. A., Simborg, D. W., et al. (1984) The failure of physician education as a cost containment strategy: Report of a prospective controlled trial at a university hospital. Journal of the American Medical Association 252:225-230. Schwartz, S. H. (1970) Elicitation of moral obligation and self-sacrificing behavior: An experimental study of volunteering to be a bone marrow donor. Journal of Personality and Social Psychology 15:283-293. Schwartz, S. H. (1973) Normative explanations of helping behavior: A critique, proposal and empirical test. Journal of Experimental Social Psychology 9:349-364. Schwartz, S. H., and Tessler, R. C. (1972) A test of a model for reducing measured attitude-behavior discrepancies. Journal of Personality and Social Psychology 24:225-236. Seage, G. R.' Barry, A., Landers, S., Silvia, A. M., Lamb, G. A., et al. (1988) Patterns of blood donations among individuals at risk for AIDS. American Journal of Public Health 78:57~577. Seeff, L. B., Wright, E. C., Zimmerman, H. J., and McCollum, R. W. (1975) VA cooperative study of post-transfusion hepatitis, 1969-1974: Incidence and characteristics of hepatitis and responsible risk factors. American Journal of the Medical Sciences 270:355-362. Shanberge, 3. N. (1987) Reduction of fresh-frozen plasma use through a daily survey and education program. Transfusion 27:226-227. Shilts, R. (1988) And the Band Played On: Politics, People, and the AIDS Epidemic. 2nd ed. New York: Viking Penguin, Inc. Silvergleid, A. J., Leparc, G. F., and Schmidt, P. J. (1989) Impact of explicit questions about high-risk activities on donor attitudes and donor deferral patterns: Results in two community blood centers. Transfusion 29:362-364. Simon, T. L., Hunt, W. C., and Gany, P. J. (1984) Iron supplementation for menstruating female blood donors. Trar~sfusiorl 24:469-472. Simpson, M. B. (1987) Prospective-concurrent audits and medical consultation for platelet transfusions. Transfusion 27: 192-195.

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BLOOD SUPPLY ~ 355 Skettino, S., Sorenson, D., and Perkins, H. A. (1988) A medical history question used to help identify donors in risk groups for AIDS. Transfusion 28(Suppl. 6~:54S(A49). Snyder, A. J., and Vergeront, J. M. (1988) Safeguarding the blood supply by providing opportunities for anonymous HIV testing. New England Journal of Medicine 3 19:37~375. Snyder, A. J., Gottschall, J. L., and Menitove, J. E. (1986) Why is fresh-frozen plasma transfused? Transfusion 26:107-112. Solomon, R. L. (1980) The opponent-process theory of acquired motivation: The costs of pleasure and the benefits of pain. American Psychologist 35:691-712. Solomon, R. R., Clifford, J. S., and Gutman, S. I. (1988) The use of laboratory intervention to stem the flow of fresh frozen plasma. American Journal of Clinical Pathology 89:518-521. Soumerai, S. B. (1988) Factors influencing prescribing. Australian Journal of Hospital Pharmary 18(Suppl.~:9-16. Soumerai, S. B., and Avorn, J. (1984) Efficacy and cost-containment in hospital pharmacotherapy: State of the art and future directions. Milbank Memorial Fund Quarterly 62:447~74. Soumerai, S. B., McLaughlin, T. J., and Avorn, J. (1989) Improving drug prescribing in primary care: A critical analysis of the experimental literature. Milbank Quarterly 67:268-317. Soumerai, S. B., Avorn, J., Gor~naker, S., and Hawley, S. (1987) Effect of govern- ment and commercial warnings on reducing prescription misuse: The case of propoxyphene. American Journal of Public Health 77:1518-1523. Staallekker, L. A., Stammeijer, R. N., and Dudok de Wit, C. (1980) A Dutch blood hank and its donors. Transfusion 20:6~70. Starkey, J. M., MacPherson, J. L., E3olgiano, D. C., Simon, E. R., Zuck, T. F., and Sayers, M. H. (1989) Markers for transfusion-transmitted disease in different groups of blood donors. Journal of the American Medical Association 262:3452-3454. Stehling, L. C., and Esposito, B. (1987) Appropriate intraoperative blood utilization. Transfusion 27:545(AS1521. Strauss, R. G., and Sacher, R. A. (1988) Directed donations for pediatric patients. Transmission Medicine Reviews 2:58~4. Strauss, R. G., Ferguson, K., Black, D., Stone, G., Stehling, L. C., et al. (1988) Surgeon knowledge and attitude of preoperative autologous donation. Presented at the Else Annual Meeting of the American Association of Blood Banks, Kansas City, Mo., October 8-13. StIyker, S. (1980) Symbolic Interactionism: A Social Structural Version. Menlo Park, Calif.: Benjamin/Cummings. Surgenor, D. M. (1987) The patients' blood is the safest blood. New England Journal of Medicine 316:542-544. Surgenor, D. M., and Cerveny, J. F. (1978) A study of the conversion from paid to altruistic blood donors in New Mexico. Transfusion 18:54463. Surgenor, D. M., and Schnitzer, S. S. (1985) The nation's blood resource: A summary report. National Institutes of Health Publication No. 85-2028. Bethesda, Md.: U.S. Department of Health and Human Services.

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