Safer Blood in 14 African Countries: What PEPFAR Built, and the Gaps Left

Women with pregnancy complications, people with traumatic injuries and children with severe anemia from malaria all depend on blood transfusions. In 14 sub-Saharan African countries with high HIV prevalence, the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) spent about $468 million from 2004 to 2016 helping national blood transfusion services collect more blood and make it safer. A CDC review of 2014–2016 data shows real gains, and gaps that will matter as the countries' own health ministries take over.

Deferred donors, donors deferred as high risk, HIV-positive donors, and HIV-positive donors told their status, nine PEPFAR-supported countries, 2014–2016. Credit: CDC, Morbidity and Mortality Weekly Report.

The 14 countries: Côte d'Ivoire, Ethiopia, Ghana, Kenya, Lesotho, Mozambique, Nigeria, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia and Zimbabwe.

The background

Safe blood depends on voluntary, unpaid donors and on screening for transfusion-transmissible infections: HIV, hepatitis B, hepatitis C and syphilis. In 2016, the World Health Organization reported that Africa collected 5.6 million units of blood, 4 percent of the world's supply, and that 38 African countries collected fewer than 10 whole-blood donations per 1,000 people, WHO's target. To make up the shortfall, countries often rely on family or replacement donors giving for a relative or friend — donations that carry a higher risk of infection. PEPFAR helped the 14 countries set national blood policies, screen donors, recruit voluntary donors, and strengthen laboratories, accreditation, information systems and quality improvement.

More blood

Total yearly collections rose 60 percent, from 1,469,561 units in 2004 to 2,352,905 in 2016. Still, only South Africa and Swaziland reached WHO's recommended collection rate.

Most donors were men (65 percent in 2014, 86 percent in 2016). Even so, female donors aged 20 to 24 rose from 4,424 in 2014 to 146,571 in 2016, and male donors aged 30 to 34 — the largest increase among men, 201 percent — from 45,725 to 137,596.

Safer blood, but not safe enough

• HIV. Between 2014 and 2016 the share of donated units screening positive for HIV fell in many of the countries but rose in Nigeria, Rwanda and Swaziland. Seven countries remained above WHO's target of under 1 percent — and all were far above the 0.003 percent reported by high-income countries.
• Other infections. Hepatitis B, hepatitis C and syphilis fell in six countries, by 0.1 percentage points (Tanzania) to 1.3 points (Mozambique), but rose in several others. In 2016, the share of units positive for any of the four infections ranged from 0.7 percent in South Africa to 14.6 percent in Nigeria.

Handing over

By 2016, the health ministries of Ethiopia, Swaziland and Tanzania paid the full cost of collecting and testing blood, and 9 of the 12 countries with data reported their ministry providing at least half of the national blood service's support; two reported falling ministry funding.

The gaps

• Linking donors to care. No system linked people turned away as donors because of high-risk behavior to HIV testing and prevention. HIV-positive donors were not reliably told their status or linked to confirmatory testing and treatment — a growing concern as countries aim for the UN's 95-95-95 targets for HIV.
• Information systems. Half the PEPFAR-supported countries still had no computerized system for tracking donors and infection tests; three had installed one since 2016, and two more were planned by 2019.
• Accreditation. Only four national blood services in sub-Saharan Africa — Namibia (accredited in 2012), South Africa, Rwanda and Tanzania — had external accreditation, and seven countries were working toward it through the African Society for Blood Transfusion. CDC's goal was for half of national blood service sites to reach at least the first of its three steps within two to three years.

The authors call for sustained investment by health ministries in quality improvement, accreditation, more sensitive testing, information systems, and linking donors to testing and treatment.

Limits

The figures cover only national blood services, not private or other collectors; testing capacity varied, and most services could not confirm hepatitis B or C results; without information systems, the number of donors notified may be inaccurate; and the data were self-reported.

Sources

Based on "Trends and Gaps in National Blood Transfusion Services — 14 Sub-Saharan African Countries, 2014–2016," by Udhayashankar Kanagasabai and colleagues, Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention; a work of the United States government in the public domain.