University of Zambia Medical Library

Biomedical and Clinical: Blood donation, HIV detection and screening
(Aids in Zambia Bibliography #10-18)

(#10) "HTLV-III infection and AIDS in a Zambian nurse resident in Britain"
Raine, A.E.G., Ilgren, E.B., Kurtz, J.B., Ledingham, J.G.G., Waddell, J.A. (1984) The Lancet ii, p985
Geographical area: Ndola; Key words: Screening, health care workers; Location: UNZA Medical Library

Objective: To identify the link between HTLV-III and AIDS.

Method:
A clinical observation of a Zambian nurse, resident in Britain for over 3 years, who had clinical features of AIDS and died of fulminating cerebral toxoplasmosis. Subsequent serological analysis showed antibodies to HTLV-III.

Results:
A 27-year-old Zambian nurse presented with a 3-month history of fatigue, night sweat and weight loss, having previously been in good health. Her home was Ndola, near the Zambia-Zaire border, and in 1980 she went to Britain for further training. She took drugs and had no recent sexual contact. She had generalised lymphadenopathy, normochromic anaemia, a leucocyte count of 2.8 x 109/l, and an ESR of 106 mm/h. Her cytogalovirus antibody titre was 256, toxoplasma 1gG litre (dye test) 2048 with negative 1gM titre (ELISA). There was a polyclonal rise in immunoglobulins, which persisted throughout her illness ; 1gG 36.3 1gA 6.9, 1gM 5.1g/1. Tests for hepatitis B surface antigen and antinuclear factor were negative. Cervical lymph-node histology was non-specific. Six months later she had headaches, nausea, diarrhoea, weakness in the left arm, a 2 kg weight loss, and more severe lymphadenopathy. She was given a therapeutic trial of pyrimethamine and sulphadimidine for possible toxoplasmosis for 6 weeks, with slow clinical improvement. However, 10 weeks later she had increased headache, diarrhoea, vomiting and left-sided weakness. Leucocyte count was 2.8 x 109/1. CSF was clear; protein 0.5g/1, IgG/alumin ratio 0.76. Toxoplasma IgG titres were 1024 (serum) and 16 (CSF), IgM again being undetectable. A computerised tomographic brain scan revealed a 1 cm mass deep in the right parietal lobe, with surrounding oedema, compression of the right lateral ventricle, and moderate hydrocephalus. A brain biopsy was done and no organisms were seen on microscopy. Some hours later she died. Necropsy confirmed an intense subacute encephalitis with numerous intracerebral toxoplasma cysts. Subsequent serological examination confirmed significant seropositivity for HTLV-III antibodies.

Conclusions:

• This patient had evidence of HTLV-III infection despite no exposure to any homosexual or heterosexual behaviour and any risk behaviour associated to HTLV-III infection in British patients. This implies greater susceptibility to HTLV-III in Africans or perhaps a different mode of transmission.
• If the patient's HTLV-III infection was acquired in Zambia and she stayed in Britain for 3 years before any noticeable symptoms of the infection, then the incubation period for AIDS is prolonged in Africans, as it is in the West.
• This patient had had a full 6-week course of therapy for toxoplasmosis 3 months before she died of overwhelming infection. This emphasises the need when treating suspected cerebral toxoplasmosis in AIDS cases to continue therapy for a long time.

(#11) "Comparison of H9/HTLV-III and ENV-80 ELISAs as screening in Tropical Africa: Prevalence of ANTI-LAV/HTLV-III in some Zambian patients"
Fleming, A.F., Kazi, A.R., Schneider, J., Guillot, F., Mwendapole, R., et al.(1986) AIDS-FORSCHUNG, August 1986, Vol 1, pp 434-439
Geographical Area: Ndola; Keywords: ELISA, screening; Location: UNZA Medical Library

Sera from 155 Zambian patients in Ndola have been studied to compare sensitivity and specificity of two enzyme linked immunosorbant assays (ELISAs), one using H9/HTLV-III lysate and one a bacterially synthesised polypeptide (ENV-80) homologous to a conserved part of viral gp41 membrane polypeptide as antigen. Sera positive on either ELISA were tested further with ENV-80 Western Blot and H9/HTLV-III Radio-Immunoprecipitation (IP). H9/HTLV-III was highly sensitive (100 per cent) but the low specificity (64 per cent) and positive predictive value (37 per cent) make this test unsuitable for screening in tropical Africa. The ENV-80 ELISA was 98-100 per cent specific when applied in both Germany and Zambia, but only 96 per cent sensitive: possibly early seroconversion was not detected in one patient who had antibodies on IP against gp120, but not gp41. LAV/HTLV-III seropositivity was confirmed in 8 out of 10 patients suspected of AIDS, 19 (18 per cent) of 106 successive patients attending the Sexually Transmitted Disease Clinic, only one of whom had on review clinical evidence of immune-depression, and one out of 39 unselected pregnant women. As part of the pandemic of infection by LAV/HTLV-III, transmission in Ndola has reached major public health proportions, and will have devastating social and demographic consequences unless controlled.

(#12) "A Comparison of Six ELISAs in the Detection of Anti-HIV-1 in Zambian Sera"
Mwendapole, R.M., Syabula, C., Schneider, J., Guillot, F., Hunsmann, G., Fleming, A.F. (1988) in Giraldo, G., Beth-Giraldo, E., Clumeck, N., Gharbi, M.R., Kyalwezi, S.K., de The, G. (eds) AIDS and Associated Cancers in Africa, International Symposium, Naples, 1987, Karger, Basel, pp. 283-288.
Geographical area: Ndola; Key words: Screening, ELISA; Location: UNZA Medical Library

The first generation of enzyme-linked immunosorbant assays (ELISAs) for antibodies to the virus employed antigens derived from HIV-1 infected human T lymphoid cells and gave a large number of false positives, especially with African sera, so that expensive and time consuming and expensive confirmatory assays were required. It is a matter of high priority to establish a serodiagnostic test which is specific, sensitive, cheap and technologically undemanding.

Of the three commercially available ELISAs for anti-HIV-1 antibody detection, the Wellcozyme performed best, showing 100 per cent specificity and positive predictive value and 95 per cent sensitivity when applied to Zambian sera, and taking RIP results as the criteria of the true positivity and negativity. Identical results were obtained from the env-80 ELISA. The anti-HIV (EIA) Roche yielded one more false negative result, despite the expectation that it would be more sensitive. This apparent loss of sensitivity in a small series of tests could have been due to loss of activity in the serum following repeated thawing, or may have been the result of the different conditions of the tests, the env-80 ELISA applying microtiter plates and the anti-HIV (EIA) Roche antigen-coated spheres. ELAVIA and Enzygnostic performed much better than the original H9/HTLV-III ELISA, presumably due to the greater purity of the antigens used, but neither test compared favourable with Wellcozyme or the two tests based on bacterially expressed polypeptides. Of commercially available tests, the Wellcozyme is the one we recommend, for use in the serodiagnosis of HIV-1 infections in Africa, as being the least demanding technologically, reasonably sensitive, highly specific and relatively inexpensive.

(#13) "The Use of Neopterin to Screen blood donations in Zambia"
Hosp, M. (1992) On going clinical trial study
Geographical area: National; Keywords: Blood donation, neopterin; Location: UNZA Medical Library

Neopterin is a metabolite that is produced by macrophages when they are stimulated by T-lymphocytes. Levels of neopterin rise rapidly following infection with HIV so that blood donations from patients who have not yet developed antibodies to HIV, but are nonetheless infected and infectious, may already have raised levels of neopterin. A pilot study of samples collected during the initial studies of the impact of HIV on tuberculosis has shown that both HIV and tuberculosis were associated with raised levels but that following anti-tuberculous treatment the levels returned to normal in the HIV negative group but remained elevated in the HIV-positive patients.

(#14) "Risk of occupational exposure to HIV among nurse-midwives and traditional birth attendants."
Kanyama, I., Mmiro, F., Mirembe, F., Kaona, F., Bagenda, D., et al. (1993) Paper presented to the IXth International Conference on AIDS, Berlin, 1993.
Geographical area: NA; Key words: Occupational exposure, health care workers; Location: unknown

Objectives:

• To compare the prevalence of HIV infection among nurse-midwives (NMs), other professional women including hospital nurses (HNs), office workers and teachers (OW/Ts) in the same communities.
• To compare the prevalence of HIV infection among traditional birth attendants (TBAs) and other women (VLs) in the same villages.
• To identify risk behaviours and/or practices that may be associated with HIV infection.

Methods:
A cross sectional study was done in Uganda and Zambia among NMs and HNs, OW/Ts; among TBAs and age-matched Vs. Socio-demographic data, information on sex behaviour, hospital/traditional practices including skin-piercing injuries, was obtained.

Results:
Preliminary results at one centre show an HIV seroprevalence significantly higher among the NWs than the HNs (21 per cent vs 12 per cent, p=0.005) but similar to the OW/Ts (21 per cent vs 18 per cent). HIV seroprevalence among TBAs and VLs were similar (5 per cent vs 8 per cent). Final results and correlation of HIV infection with practices and risk factors will be presented.

(#15) "Constraints in implementing IFRC'RC guidelines on donor counselling in Zambia."
Kongwa, P., Muyinda, G. (1993) Paper presented at the VIIIth International Conference on AIDS in Africa, Marrakech, 1993
Geographical area: Lusaka; Key words: Policy, blood donation, counselling, blood transfusion Location: UNZA Medical Library

Objective:
We analysed current donor counselling at UTH Lusaka and compared it to the IFRC/RC guidelines. We indicate difficulties in the following minimum guidelines. Methods: The current donor counselling procedures at UTH Lusaka developed from the necessity to change donor origin from that of patients' relatives to volunteers with lower HIV frequency. The initial emphasis was on recruiting large numbers of one time donors. Donor motivation, information and counselling is done predominantly in schools and places of work. Post-donation counselling is done at UTH blood bank. There is one donor recruiter and one counsellor. 4000 new donors are recruited annually.

Results:

	Stage	Guidelines	Current Practice
	Stage I	Predonation discussion	Given in talks to groups of up to 150
	Stage II	Predonation counselling	Not possible due to lack of confidentiality
	Stage III	Post Donation counselling	Possible only at blood bank, 5% of donors
	Stage IV	Confidential records	Links of an established NGO not yet made of the HIV-positives
	Stage V	Support of HIV-ve donors	Enrollment as a member of the donor association

Conclusions:
Constraints preventing the implementation of guidelines include:

• Insufficient public awareness
• Lack of appropriate facilities (confidential rooms)
• Inadequate staff number and training
• Time constraints on donors, employers and school authorities
• Cost of travel to sites. 6. Insufficient funding for all blood transfusion activities, particularly for non-laboratory services

(#16) "The effect of blood donor recruitment policies in the provision of safe blood at UTH Lusaka."
Chama, D., Mkoma, J., Mumba, G. (1993) Paper presented at the VIIIth International Conference on AIDS in Africa, Marrakech, 1993
Geographical area: Lusaka; Key words: Blood donation; Location: UNZA Medical Library

Objective:
During the years 1990-1993 UTH Blood Bank used differing policies to recruit blood donors. We have looked at the impact of these different policies in order to plan for the future.

Materials:
Before 1990 the UTH relied upon relatives of patients to give blood. The relatively high HIV rate of these donors and the difficulty of providing blood for emergency need caused a change of policy to try to recruit as many donors as possible. 1990: Appointments were made to bring the blood collection team to schools and places of work. Provision of transport was uncertain and many appointments had to be arranged. 1991: A new vehicle was provided and outside donor sessions increased to four a week. 1992: The full-time donor recruiter visited bleeding sites a few days earlier to give information about the blood bank's needs and the procedures donors would be expected to follow.

Results:
The table below shows the number of blood donations, the proportion from volunteer donors, their average age and the frequency of anti-HIV in donated blood. The HBsAg positive rate was 7 per cent.

Conclusions:

• Increased attention to providing donors with information resulted in reduced HIV rate
• The total number of blood donations did not increase and there was a 20 per cent unmet need
• The cost-saving due to 600 less discarded units is $4,500 and more than the cost of the recruiter and the vehicle
• The lower HIV rate is predominantly due to the lower age group of volunteers who gave blood once only. But this age group is at high risk of acquiring HIV infection. 5. In future, emphasis must be placed on recruiting HIV negative donors to give blood on a regular basis.

Number of voluntary donors, HIV frequency and age at UTH, Lusaka, 1990-1992

	Year	Total Donors	Volunteers	HIV %	Volunteers HIV %	Average Age/Volunteers
	1990	5429	3048	18.1	27.2	26
	1991	4698	3390	11.5	27.0	24
	1992	4885	3652	8.6	34.2	22

(#17) "Quality of blood transfusion laboratory practice in district hospitals in Zambia."
Chipuka, L., Chama, D., Tembo, C. (1993) Paper presented at the VIIIth International Conference on AIDS in Africa, Marrakech, 1993
Geographical area: national; Key words: Blood transfusion, HIV testing, ELISA; Location: UNZA Medical Library

Objective:
To determine the quality of work at the district level one year after training of staff and supply of essential equipment.

Method:
42 hospitals were visited between January and June 1992. 22 had sent one technician for training at a WHO sponsored workshop in Lusaka and the other 20 had been visited by a WHO training team. 19 hospitals had been selected, because of the volume of work, to perform ELISA HIV screening and were equipped with water stills deionisers, 8 channel manual well-washers, strip readers, 37C incubators, refrigerators and micropipettes. Staff at the other hospitals were trained to perform HIV screening by a rapid simple test. It was understood that each had a working centrifuge. Results: In 6 hospitals the trained technician had been posted elsewhere, was on leave or had died, without replacement or training other staff. 8 hospitals had no HIV test kit. Of the 19 selected for the ELISA tests, only 11 had well functioning equipment. In 3 the reader was not reading correctly, 2 could not produce clean water and the other 3 had washer and reader (or distiller) not working. Only 6 hospitals recorded O.D. and cutoff values. No hospital had a temperature monitored refrigerator. 12 did not have a functioning centrifuge. Only 2 had sufficient test tubes for more than one cross-match at a time. Records indicated blood group and the recipient of each numbered blood unit. No hospital had blood for Hepatitis B surface antigen.

Conclusions:
Without frequent monitoring of equipment and distribution of supplies and retaining of staff, peripheral hospitals are unlikely to be able to perform routine blood transfusion laboratory procedures safely.

(#18) "Does RPR testing increase safety of blood transfusion?"
Muyinda, G., Chipuka, L. (1993) Paper presented at the VIIIth International Conference on AIDS in Africa, Marrakech, 1993
Geographical area: Lusaka; Key words: Syphilis, blood transfusion, testing; Location: UNZA Medical Library

Objective:
The use of an RPR test has been suggested to assist in the detection of blood donors who are less selective in their sexual activity, and who are therefore at more risk of HIV infection. We validate this statement by reviewing all the records of all male volunteer blood donors at the UTH for 1990-1993.

Materials and methods:
Blood from all male volunteer donors was tested by an RPR test and by ELISA for anti-HIV. The results were analysed by age group.

Results:
For all ages combined and all years combined if the RPR was positive, 30.5 per cent were also positive for anti-HIV compared with 12.2 per cent of the RPR negative bloods. In the 16-19 year age group those who were RPR positive had 11 times the chance (26.5 per cent compared with 2.4 per cent) of being positive for an anti-HIV.

Conclusions:

• RPR testing DOES identify a population with a higher risk of HIV infection
• Males aged 16 to 19 have the lowest HIV rate (2.6 per cent), but are at high risk of acquiring HIV infection
• It is probable that excluding blood from RPR positive donors will exclude many of those who have recently acquired HIV infection but are anti HIV negative
• The cost of RPR testing (about 20c. a test) could be recovered from savings for not testing RPR positive blood for anti HIV and Hepatitis B antigen
• RPR positive blood should not be used for transfusion even if stored at 4C for 96 hours to destroy Treponema

HIV-positive tests in RPR positive and negative blood
(Male voluntary blood donors UTH, Lusaka Blood Bank)

Age in Years	16-19	20-29	30-39	over 40	Total
RPR Positive and HIV Negative	34/9	215/62	58/23	14/4	321/98
RPR Negative and HIV Positive	2660/62	4101/379	1650/333	624/87	7035/861

Percent RPR Negative and HIV Positive

Age in Years	16-19	20-29	30-39	over 40	Total
% RPR pos/HIV pos	26.5	29	40	28.5	30.5
% RPR neg/HIV pos	2.37	9.2	20	13.9	12.2

Last updated February 4, 1999

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