Antenatal blood transfusion in South Africa: indications and practice in a high-HIV-prevalence setting.

BACKGROUND: Globally, data on antenatal blood transfusion practices are scarce. We sought to characterize the epidemiology of antenatal transfusion in South Africa. STUDY DESIGN AND METHODS: A cross-sectional study was conducted of women who were transfused during pregnancy (>48 hr before anticipated delivery) at two hospitals in Durban and Soweto in 2014 to 2015. Medical record data on demographics, obstetric history, anemia, HIV status, and indications for blood transfusion were abstracted. RESULTS: The records on a total of 560 transfused pregnant women were evaluated; mean age was 28 years, 98% were of black African ethnicity, and 28% were HIV positive. At time of transfusion, one-half were in the first trimester. Hemorrhage was noted in 76% of women, most of which was associated with abortion (67%) or ectopic pregnancy (27%). Most women were transfused with red blood cells (RBCs; median, 2 units); 14% of women were transfused with plasma and 2% with platelets. Median pre- and posttransfusion hemoglobin levels were 6.9 g/dL and 9.2 g/dL, respectively; the latter differed by hospital (8.7 g/dL vs. 9.5 g/dL; p < 0.01). Hemorrhage was associated with missing HIV status, lower gestational age, and transfusion of 3 or more RBC units (all p < 0.01). In contrast, diagnoses of anemia (Soweto only) were associated with HIV infection, later gestational age, and lower (<3 units) RBC dose (all p < 0.01). CONCLUSION: Abortion and ectopic pregnancy with associated hemorrhage were the leading indications for antenatal transfusion and were concentrated in early gestation. By contrast, anemia was associated with HIV infection and transfusion in the third trimester.

Risk factors for peripartum blood transfusion in South Africa: a case-control study.

BACKGROUND: Obstetric hemorrhage (OH) and access to peripartum blood transfusion remains a global health challenge. The rates of peripartum transfusion in South Africa exceed those in high-income countries despite comparable rates of OH. We sought to evaluate factors associated with peripartum transfusion. STUDY DESIGN AND METHODS: A case-control study was conducted at four large South African hospitals. Transfused peripartum women (cases) and nontransfused controls were stratum matched 1:2 by hospital and delivery date. Data on obstetric, transfusion, and human immunodeficiency virus (HIV) history were abstracted from medical records. Blood was obtained for laboratory evaluation. We calculated unadjusted and adjusted odds ratios (ORs) for transfusion using logistic regression. RESULTS: A total of 1200 transfused cases and 2434 controls were evaluated. Antepartum hemorrhage (OR, 197.95; 95% confidence interval [CI], 104.27-375.78), hemorrhage with vaginal delivery (OR, 136.46; 95% CI, 75.87-245.18), prenatal anemia (OR, 22.76; 95% CI, 12.34-41.93 for prenatal hemoglobin level < 7 g/dL), and failed access to prenatal care (OR, 6.71; 95% CI, 4.32-10.42) were the major risk factors for transfusion. Platelet (PLT) count (ORs, 4.10, 2.66, and 1.77 for ≤50 × 109 , 51 × 109 -100 × 109 , and 101 × 109 -150 × 109 cells/L, respectively), HIV infection (OR, 1.29; 95% CI, 1.02-1.62), and admitting hospital (twofold variation) were also associated with transfusion. Mode of delivery, race, age category, gravidity, parity, gestational age, and birthweight were not independently associated with transfusion. CONCLUSION: Major risk factors of peripartum transfusion in South Africa, namely, prenatal anemia and access to prenatal care, may be amenable to intervention. HIV infection and moderately low PLT count are novel risk factors that merit further investigation.

The impact of human immunodeficiency virus infection on obstetric hemorrhage and blood transfusion in South Africa.

BACKGROUND: Globally, as in South Africa, obstetric hemorrhage (OH) remains a leading cause of maternal mortality and morbidity. Although blood transfusion is critical to OH management, the incidence and predictors of transfusion as well as their relation to human immunodeficiency virus (HIV) infection are poorly described. STUDY DESIGN AND METHODS: A cross-sectional study was conducted of all peripartum patients at four major hospitals in South Africa (April to July 2012). Comprehensive clinical data were collected on patients who sustained OH and/or were transfused. Logistic regression was used to model risk factors for OH and transfusion. RESULTS: A total of 15,725 peripartum women were evaluated, of whom 3969 (25.2%) were HIV positive. Overall, 387 (2.5%) women sustained OH and 438 (2.8%) received transfusions, including 213 (1.4%) women with both OH and transfusion. There was no significant difference in OH incidence between HIV-positive (2.8%) and HIV-negative (2.3%) patients (adjusted odds ratio [OR], 0.95; 95% confidence interval [CI], 0.72-1.25). In contrast, the incidence of blood transfusion was significantly higher in HIV-positive (3.7%) than in HIV-negative (2.4%) patients (adjusted OR, 1.52; 95% CI, 1.14-2.03). Other risk factors for transfusion included OH, low prenatal hemoglobin, the treating hospital, lack of prenatal care, and gestational age of not more than 34 weeks. CONCLUSION: In the South African obstetric setting, the incidence of peripartum blood transfusion is significantly higher than in the United States and other high-income countries while OH incidence is similar. While OH and prenatal anemia are major predictors of transfusion, HIV infection is a common and independent contributing factor.

Human immunodeficiency virus-1 infection correlates strongly with herpes simplex virus-2 (genital herpes) seropositivity in South African and United States blood donations.

BACKGROUND: In South Africa, human immunodeficiency virus-1 (HIV-1) infection correlates with herpes simplex virus-2 (HSV-2; genital herpes) seropositivity in genitourinary disease clinic attendees. HSV-2 infection may be a marker for risk behavior and/or directly facilitate HIV-1 transmission. The rate of HSV-2 infection in HIV-infected South African and US blood donations was assessed, and whether the infections were correlated in donors screened and found negative for high-risk behavior by predonation interview was questioned. STUDY DESIGN AND METHODS: A total of 625 South African and 393 US HIV-1-infected repository samples previously characterized for longstanding or recent HIV-1 infection were tested with two commercially available HSV-2-specific assays. The prevalence of HSV-2 antibodies in South Africa was further assessed in 106 HIV-1-infected and 106 HIV-1-negative donors matched for sex, race, and donation history, as well as 200 random HIV-1-negative donors. RESULTS: A total of 52.2 percent of US and 69.3 percent of South African HIV-1-infected donations were HSV-2-seropositive. Age, race, and sex were independent risk factors for HSV-2 antibody prevalence in HIV-1-infected South African donors, who were more likely to be HSV-2 antibody-reactive than random HIV-1-negative donors (72.6% vs. 8.5%: odds ratio [OR], 28.6; 95% confidence interval [CI], 14.5-55) or matched donors (71.6% vs. 19.6%: OR, 10.3; 95% CI, 5.4-19.8). HIV-1 infection and HSV-2 seropositivity correlated in white and black populations when analyzed by age group. CONCLUSIONS: HIV-1 infection correlates strongly with HSV-2 seropositivity in US and South African blood donors. Our data describe the characteristics of HSV-2 antibody testing as a surrogate marker for HIV-1 infection and support a facilitating role for HSV-2 infection in HIV-1 transmission.

Prevalence of HIV-1 in blood donations following implementation of a structured blood safety policy in South Africa.

CONTEXT: The South African National Blood Service collects more than 700,000 units of blood annually from a population in which 11.4% is infected with human immunodeficiency virus 1 (HIV-1). The prevalence of HIV-1 in blood donations increased to 0.26% (1:385) in 1998, indicating that a significant number of window-period infective units were entering the blood supply (risk 3.4/100,000). OBJECTIVES: To determine whether the implementation of a new donor selection policy and educational program introduced in 1999 was associated with reductions in the incidence and prevalence of HIV-1 in blood donations and the reduced transmission risk. DESIGN: We compared the prevalence of HIV-1 in 880,534 blood donations collected from 1999 through 2000 with the 791,639 blood donations collected from 2001 through 2002. We estimated the incidence of HIV-1 in 93,378 (1999-2000) and 67,231 (2001-2002) first-time donations and the residual risk for all donations in 2001-2002 using the less-sensitive enzyme-linked immunoassay and incidence-window period model. SETTING: All blood donors in the Inland region of the South African National Blood Service were analyzed. INTERVENTION: Donor clinics in high HIV prevalence areas were closed. Programs targeting repeat donors and youth were initiated and HIV risk behavior education programs were developed. Structured donor interviews and an enhanced donor self-exclusion questionnaire were institutionalized. RESULTS: The prevalence of HIV-1 in blood donations declined from 0.17% in 1999-2000 to 0.08% in 2001-2002 after the implementation of the new donor selection and education policy. The number of high-risk donations collected decreased from 2.6% to 1.7% (P<.001), and the likelihood of these donations being infected decreased from 4.8% to 3.25%. The likelihood of first-time donors being recently infected with HIV-1 decreased from 18% to 14% (P = .07) and respective incidence of high-risk donations collected decreased from 2.6% to 1.7%. Donations from the majority black population declined from 6.6% to 4.2% (P<.001). Analysis of HIV-1 incidence in 2001-2002 suggests a residual risk of collecting a window period infectious unit of 2.6/100,000. CONCLUSION: The implementation of enhanced education and selection policies in South Africa was associated with decreased prevalence of HIV-1 in blood donations.