The safety of the blood supply is achieved through utilization of successive security procedures in donor selection and donation, including the donor health questionnaire (DHQ) and highly sensitive screening tests for known pathogens. The DHQ helps to evaluate behaviors associated with higher risk of transfusion-transmissible infection prior to blood collection in order to decrease the number of donors who might be infected, including those with infections in the window period for detection that might otherwise yield negative results on pathogen screening tests. However, as the public is not fully knowledgeable on HIV transmission, risk behavior, and the window period of detection,1–3 even with the use of nucleic acid amplification testing (NAT), a small residual risk of HIV transmission persists in donations from pre-seroconversion donors due to low-level viremia and deficiencies in detecting viral variants.4–6

Since test seekers come to donate blood with the underlying motivation to be tested for HIV and other bloodborne infections and often have higher rates of these infections,7 these donors represent a risk to the safety of the blood supply. Test-seeking in blood donors has been associated with limited knowledge of the HIV window period, incorrect beliefs about HIV screening tests, or inappropriate perceptions of the acceptability of donating with known risk factors.1,7,8

Brazilian blood donors are screened for disease risk factors using a structured donor health history questionnaire in a face-to-face interview with a blood center staff member. Through this screening questionnaire, donors are asked specific and direct questions regarding lifestyle, health, medical history and travel to assure their own health will not be compromised by a blood donation and that patients will receive safe blood products, as prescribed by the Brazilian Ministry of Health.9 According to the Brazilian guidelines, potential blood donors must be in good general health without evidence of transfusion-transmissible diseases. Local blood centers are allowed to use stricter deferral criteria than those established in the Federal regulation.9

The use of blood centers as testing venues has been observed and investigated in Brazil,7,10,11 but the contribution of healthcare professionals to the phenomenon of test seeking at blood centers is largely unknown. In this study, we sought to evaluate the characteristics of, and frequency with which, donors reported that they came to the blood bank due to a healthcare professional suggestion.

In this study we reported the contribution to test seeking behavior at the blood centers by healthcare professionals, as reported by donors among three different donor groups: deferred donors, accepted donors who tested HIV (+), and accepted donors who tested IDM (−). The HIV (+) and high-risk deferred donors were 10 times more likely to report being referred to the blood centers by a healthcare professional in order to get tested for HIV, hepatitis or for some other reason, compared to the IDM (−) donors.

Referral rates varied across donor groups, blood centers, and type of healthcare professional. Among the HIV (+), the highest frequency of reported professional referral was observed at Hemope-Recife and the lowest at Hemorio-Rio de Janeiro, while among deferred donors, the highest frequency was observed at Hemorio-Rio de Janeiro and the lowest at Fundação Pro-Sangue-São Paulo. Physician referrals were the most reported category by the HIV (+) and deferred donors. The vast majority of the HIV (+) at Fundação Pró-Sangue-São Paulo and two-thirds of deferred donors at Hemominas-Belo Horizonte and at Hemope-Recife reported physician referrals to the blood bank. One-quarter of the HIV (+) and deferred donors reported a general referral from “someone from the health department”. The role of a nurse referral for HIV (+) donors was minimal across the blood centers; however, nearly 20% of deferred donors reported referral by a nurse.

Our results suggest that study participants had experienced some level of health service care and/or might have been aware of their risk. Study participants may have revealed to the healthcare professional some of their HIV risk behaviors and might have learned that they had been at risk for sexually transmitted diseases and for this reason should get tested. In potential corroboration of this hypothesis, we found an association of specific high-risk behavior and acknowledged referral by a healthcare professional, as evidenced by those who reported having sex with a sex worker, having sex with an intravenous drug user (IDU), sex with more than 5 male partners (for males and females), and bisexuality being more likely to report referral by a healthcare professional, which is in line with studies showing that a reported risk behavior is a primary reason for HIV testing in the healthcare setting.12,13

Nevertheless, what triggered the decision to test for HIV at the blood center among our study participants is still unclear. Previous studies have described that some individuals have unsatisfactory perceptions of free public Volunteer Testing Centers (VCT's) sites which include crowded conditions, long wait times for counselors, lengthy counseling sessions, impersonal group counseling, longer wait periods for test results and greater distance to the VCTs from home.14 Dissatisfaction with the VCTs has led some individuals to seek HIV testing at the blood banks in Brazil.10 Fear and stigma have been reported as a barrier to HIV testing.15 Blood donation can minimize these concerns. Test-seeking donors have higher trust in the blood bank for confidentiality, are less likely to know other places to get tested, and are more likely to believe the results of blood bank testing than those of alternative VCT sites16 in Brazil. Contemporary literature shows that HIV test seeking at blood banks is still an important topic.17–20 In a telephone survey among the general population in the US, 33.5% felt that it was acceptable to use the blood center for AIDS testing, while 9.1% believed that it was okay for someone to donate even if they had AIDS risk behaviors.1 Recently, in a MSM blood deferral study in the US, 14% of male blood donors disagreed with the statement that using blood centers as a way to be tested for HIV was a misuse of blood donation.21 Lack of knowledge or information regarding HIV among blood donors has previously been identified as a predictor for test seeking at blood centers.16 Although implemented after these studies were conducted, it is important to note that pooled NAT testing for HIV and HCV was introduced into widespread use at Brazilian blood bank settings in 2013 and now includes HBV.9 However, the NAT is still not available for the general population at the VCT sites.22 The impact of NAT testing availability at blood centers on healthcare referral to testing is unknown at this time, but could be the reason for healthcare professional referral.

This study has limitations. First, our study was focused on donor responses to the ACASI questionnaire performed after donor selection. Concerns can be raised that the study participants might have given what could be considered by some as socially desirable responses by attributing to the healthcare professionals the responsibility of suggesting blood donation as a means to get tested. In this scenario, the sole social gain in giving a desirable response would be to attribute to someone else his/her own test-seeking behavior. This is a plausible possibility, as the HIV (+) participants and those who were deferred for risk behavior had not admitted their test-seeking behavior during the regular donor screening questionnaire. Second, we have not assessed among healthcare professionals whether they disclose referring people to blood center for infectious marker testing. Therefore, we cannot independently verify the responses donors gave.

Third, participation rates varied across the blood centers. This variation might be related to the participants’ feelings after being deferred as blood donors, a potential factor in refraining to participate. For instance, individuals may experience psychological distress22 after deferral as even temporary deferral has a profound negative impact on subsequent donation.22 Moreover, donors may feel rejected and disappointed or possibly annoyed at having their time wasted. In addition, deferred donors are more likely than non-deferred donors to say that donation is difficult and report bad feelings after their experience.22

Our results endorse the measures taken over the past five years by the Brazilian government to promote universal HIV testing. Currently, not only are the VCTs providing free HIV testing, but additionally, more than 515 public outpatient facilities are offering HIV testing at no charge.23 Expanding testing sites and promoting educational campaigns demonstrating the excellence of the VCT's are important strategies to prevent high-risk donors from searching for testing at blood centers. Additional education is needed for donors to advise them that blood centers are not the proper venue to get HIV testing, which may impact test seeking by decreasing this behavior at blood donation sites. Further studies are necessary to assess knowledge, attitude and beliefs among healthcare professionals on the factors that contribute to the safety of transfusion.

Fundação Pró-Sangue/Hemocentro São Paulo (São Paulo): Ester C. Sabino, Cesar de Almeida-Neto, Alfredo Mendrone-Jr., Ligia Capuani, and Nanci Salles.

Hemominas (Belo Horizonte, Minas Gerais): Anna Bárbara de Freitas Carneiro-Proietti, Fernando Augusto Proietti, Claudia Di Lorenzo Oliveira, and Carolina Miranda.

Fundação Hemope (Recife, Pernambuco): Divaldo de Almeida Sampaio, Paula Loureiro, Silvana Ayres Carneiro Leão, and Maria Inês Lopes.

Data warehouse:

University of São Paulo (São Paulo): João Eduardo Ferreira, Márcio Oikawa, and Pedro Losco Takecian.

US investigators:

Blood Systems Research Institute and University of California San Francisco: M.P. Busch, E.L. Murphy, B. Custer, and T.T. Gonçalez.

Coordinating center: Westat, Inc.: J. Schulman, M. King, and K. Kavounis.

National Heart, Lung, and Blood Institute, NIH: S.A. Glynn.

The authors declare no conflicts of interest.