A scoping review of sociology of voluntary blood donation

BACKGROUND AND OBJECTIVES

Maintaining stable blood supplies presents an increasing challenge for blood collection agencies (BCAs). Novel and multidisciplinary approaches and research have been called for to understand the mechanisms underlying the trends. The current body of sociological research on blood donation is a potentially valuable resource, but it is dispersed over different publications and theoretical frameworks.

MATERIALS AND METHODS

We conducted a scoping review of sociological research on voluntary, non-remunerated blood donation to identify insights and practical applications for researchers and BCAs.

RESULTS

Four organizing themes were identified: donated blood, blood donors, organizations and blood service systems. Key challenges associated with the organization of voluntary blood donation exist at the institutional and systems levels, and they may not be readily resolved by interventions focussed solely on the individual donor level. We identified opportunities for organizations to build trust with donors and the public through communications and working with communities to promote inclusion in blood donation.

CONCLUSION

The results support a multidisciplinary approach and research for BCAs to move forward and find novel ways to ensure safe, resilient blood service systems.

Equity in blood transfusion precision services

BACKGROUND

Blood collection agencies are integrating precision medicine techniques to improve and individualise blood donor and recipient outcomes. These organisations have a role to play in ensuring equitable application of precision medicine technologies for both donors and transfusion recipients. BODY: Precision medicine techniques, including molecular genetic testing and next generation sequencing, have been integrated in transfusion services to improve blood typing and matching with the aim to reduce a variety of known transfusion complications. Internationally, priorities in transfusion research have aimed to optimise services through the use of precision medicine technologies and consider alternative uses of genomic information to personalise transfusion experiences for both recipients and donors. This has included focusing on the use of genomics when matching blood products for transfusion recipients, to personalise a blood donor's donation type or frequency, and longitudinal donor research utilising blood donor biobanks.

CONCLUSION

Equity in precision services and research must be of highest importance for blood collection agencies to maintain public trust, especially when these organisations rely on volunteer donors to provide transfusion services. The investment in implementing equitable precision medicine services, including development of blood donor biobanks, has the potential to optimise and personalise services for both blood donors and transfusion recipients.

The impact of blood donation deferral strategies on the eligibility of men who have sex with men and other sexual risk behavior in Australia

BACKGROUND

In Australia, a man cannot donate blood if he has had sex with another man within the past 3 months. However, this policy has been criticized as being discriminatory as it does not consider lower risk subgroups, and led to calls for modifications to the policy that more accurately distinguish risk among gay, bisexual, and other men who have sex with men (GBM).

STUDY DESIGN AND METHODS

We used data from a nationally representative survey to estimate the proportion of GBM aged 18-74 years old who would be eligible to donate under current criteria and other scenarios.

RESULTS

Among the 5178 survey participants, 155 (3.0%) were classified as GBM based on survey responses, Among the GBM, 40.2% (95% CI 28.0%-53.7%) were eligible to donate based on current criteria, and 21.0% (95% CI 14.5%-29.5%) were ineligible due to the 3 months deferral alone. Eligibility among GBM, all men, and the population increased as criteria were removed. Under the new Australian plasma donation criteria, 73.6% (95% CI 64.4%-81.1%) of GBM, 68.4% (95% CI 65.5%-71.2%) of all men, and 60.8% (95% CI 58.8%-62.8%) of the full population were estimated to be eligible. Only 16.1% (95% CI 8.6%-28.1%) of GBM knew that the male-to-male sex deferral period is 3 months.

DISCUSSION

Changing the deferral criteria and sexual risk evaluation would lead to a higher proportion of GBM being eligible to donate blood. Knowledge of the current GBM deferral period is very low. Improved education about the current criteria and any future changes are required to improve blood donation rates.

Blood, sweat, and fears: Athletes' perceptions of blood donation and engagement in physical activity

BACKGROUND

Athletes are a key group from which likely eligible donors could be sourced. While blood donation has been popularized as detrimental to athletic performance, little is known about how athletes perceive blood donation. The aim of this study was to investigate athletes' perceptions of the impacts of donating blood on their athletic performance and whether these influence their engagement with blood donation.

STUDY DESIGN AND METHODS

A total of 175 athletes (78 donors; 97 non-donors) prescreened as eligible to donate blood in Australia completed an online survey assessing the perceived impact of (i) donating blood on engagement and performance in physical activity (type of impact, direction, and duration) and (ii) engaging in physical activity on blood donation (magnitude of impact and modification of behavior).

RESULTS

We found that 37%-39% of our sample indicated that they had considered the impact of donating blood on their engagement or performance in physical activity, with the impact seen as negative but short term. Fatigue was the most commonly identified impact of donation on performance in physical activity. While the impact of donating did not account for athletes' non-donor status, many donors noted changing their engagement in physical activity pre- and post-donation to allow recovery, and aligning blood donation with their training schedule.

DISCUSSION

Athletes are a key community from which likely eligible donors could be sourced, however a significant proportion of athletes perceive that donating will negatively impact their athletic performance. Strategies to engage athletes with donation should acknowledge and facilitate athletes need to align their training with donating.

The health impacts of blood donation: a systematic review of donor and non-donor perceptions

BACKGROUND

The health and well-being of volunteer donors is of critical concern for blood collection agencies responsible for ensuring a stable supply of blood products. However, lay understandings of the impact of donating blood on health remain poorly understood. As lay perceptions are likely to influence critical decisions about donation, understanding these perceptions is key for informing evidence-based approaches to donor retention and recruitment. As such, we conducted a systematic review of the blood donation literature to identify donors' and non-donors' perceptions of the short and longer-term physiological health effects of whole-blood and/or blood product donation.

MATERIALS AND METHODS

This review was conducted in line with PRISMA guidelines. Studies published from January 1995 to February 2021 were included. Perceptions were defined as both experiences and beliefs. Psychological effects were considered outside the scope of the review.

RESULTS

A total of 247 studies were included. Most studies (89.5%) had donation-related health perceptions as a background rather than a central (10.5%) focus, and they were only assessed in relation to whole blood donation. More results focused on health-related beliefs than experiences (82 vs 18%), specific rather than general beliefs and experiences (80 vs 20%) and more frequently examined negative than positive beliefs and experiences (83 vs 17%). The most commonly studied and reported specific negative beliefs related to increased risk of infectious disease, reduced vitality, vasovagal reactions and low iron. Most studies examining specific negative beliefs were conducted in Asian countries.

DISCUSSION

Findings reinforce that lay perspectives on how donation impacts health are under-researched, and it is difficult to know how important these are in informing critical decisions about donation for donors and non-donors. We suggest that further research with donation-related health beliefs and experiences as the central focus is needed to provide insights to inform communications with donors and the public.

Prevalence of blood donation eligibility in Australia: A population survey

BACKGROUND

Reliable estimates of the population proportion eligible to donate blood are needed by blood collection agencies to model the likely impact of changes in eligibility criteria and inform targeted population-level education, recruitment, and retention strategies. In Australia, the sole estimate was calculated 10+ years ago. With several subsequent changes to the eligibility criteria, an updated estimate is required.

STUDY DESIGN AND METHODS

We conducted a cross-sectional national population survey to estimate eligibility for blood donation. Respondents were aged 18+ and resident in Australia. Results were weighted to obtain a representative sample of the population.

RESULTS

Estimated population prevalence of blood donation eligibility for those aged 18-74 was 57.3% (95% CI 55.3-59.3). The remaining 42.7% (95% CI 40.7-44.7) were either temporarily (25.3%, 95% CI 23.5-27.2) or permanently ineligible (17.4%, 95% CI 16.1-18.9). Of those eligible at the time of the survey, that is, with the UK geographic deferral for variant Creutzfeldt-Jakob disease included, (52.9%, 95% CI 50.8-54.9), 14.2% (95% CI 12.3-16.3) reported donating blood within the previous 2 years. Eligibility was higher among men (62.6%, 95% CI 59.6-65.6) than women (52.8%, 95% CI 50.1-55.6). The most common exclusion factor was iron deficiency/anemia within the last 6 months; 3.8% (95% CI 3.2-4.6) of the sample were ineligible due to this factor alone.

DISCUSSION

We estimate that approximately 10.5 million people (57.3% of 18-74-year-olds) are eligible to donate blood in Australia. Only 14.2% of those eligible at the time of survey reported donating blood within the previous 2 years, indicating a large untapped pool of potentially eligible blood donors.

The knowledge and attitudes of South African-based runners regarding the use of analgesics during training and competition

Background

The use of analgesics is prevalent in runners, with the associated potential for serious harm. However, there is limited information regarding runners' knowledge and attitudes towards the use of analgesics in relation to running.

Objectives

To describe South African-based runners' knowledge and attitudes regarding running-related analgesic use.

Methods

This study has a descriptive, cross-sectional design. South African-based runners, over the age of 18 who ran at least one race in the year preceding the study were included in this study. Participants completed an online questionnaire, including sections on demographic information, training and competition history, pain medication use, and knowledge and attitudes regarding running-related analgesic use.

Results

Data from 332 participants were analysed. Attitudes regarding the use of analgesics in relation to running were generally positive; however, knowledge was poor, with only 20% of participants achieving adequate knowledge scores (75% or above). Very few (n=49; 15%) had both adequate knowledge and positive attitudes, with most respondents (n=188; 58%) having inadequate knowledge and negative attitudes. Negative attitudes towards the use of analgesics were found to increase the odds of running-related analgesic use (OR 2.32; 95% CI:1.31-4.11).

Conclusion

Knowledge regarding running-related use of analgesics was inadequate. Despite a lack of knowledge, attitudes were positive. Participants displayed positive attitudes towards safe practice regarding running-related analgesic use, but these did not translate into good practice. Targeted interventions are required to educate runners and improve their knowledge of all the effects associated with running-related analgesic use.

Understanding Mothers' Experiences of Being Ineligible to Donate Their Milk to a Not-for-Profit Milk Bank

Background: Donor milk banks have strict donor screening criteria to ensure that donor milk is safe for premature or hospitalized babies. Yet little evidence is available to understand how potential donors, who are often breastfeeding their own infants, experience being ineligible ("deferred") to donate their milk to a milk bank. Materials and Methods: Interviews were conducted with 10 mothers who were permanently or temporarily deferred from donating to a large, not-for-profit milk bank in Australia. Interviews focused on becoming a donor and being deferred, meanings of deferral, impact of deferral on feeding own infant, and improving the deferral process. Results: Thematic analysis of interviews identified nine themes: (1) donation as a solution to wasting milk; (2) eligibility questions were acceptable and understandable; (3) more information early on allows self-deferral; (4) deferral is not always clear; (5) deferral is disappointing but does not prevent future donation; (6) deferral did not prevent feeding own infant; (7) early information enables preparation for donation; (8) slow communication disrupts perfect timing to donate; and (9) alternatives to wasting milk. Conclusions: Milk banks have a duty of care to both milk recipients and donors. While mothers who want to donate milk are disappointed by deferrals, clear communication protects their breastfeeding relationships with their own infants. Milk banks can improve their screening processes by providing information up-front and ensuring timely contact with mothers. Mothers can then make informed decisions about donating and not feel as if their milk and resources are "wasted."

Donor and non-donor perspectives on receiving information from routine genomic testing of donor blood

BACKGROUND

Genomic testing is already used by blood collection agencies (BCAs) to identify rare blood types and ensure the best possible matching of blood. With ongoing technological developments, broader applications, such as the identification of genetic markers relevant to blood donor health, will become feasible. However, the perspectives of blood donors (and potential blood donors) on routine genomic testing of donor blood are under-researched.

STUDY DESIGN AND METHODS

Eight online Focus Groups were conducted: four with donors and four with non-donors. Participants were presented with three hypothetical scenarios about the current and possible future applications of genomic testing: Performing rare blood type testing; identifying donors with genetic markers associated with iron metabolism; and identifying donors with genetic markers associated with bowel cancer.

RESULTS

Testing to identify rare blood types was perceived to be an appropriate application for the BCA to undertake, while identifying markers associated with iron metabolism and cancer genetic markers were only partially supported. Participants raised concerns about the boundaries of acceptable testing and the implications of testing for privacy, data security, and health insurance. Perspectives of donors and non-donors on all scenarios were similar.

DISCUSSION

The principles of who benefits from genomic testing and the perceived role of BCAs were key in shaping participants' perspectives. Participants generally agreed that testing should be directly related to blood donation or be of benefit to the recipient or donor. Findings indicate that consent and communication are key to the acceptability of current and expanded genomic testing.

'Stay at home and limit contact': The impact of stay-at-home advice on the behavior of Australian donors aged 70 and over in the first year of the pandemic

BACKGROUND

Early in the COVID-19 pandemic, Australian donors aged 70 and over were advised to temporarily stop donating. The aim of this research was to understand the factors associated with some of these donors continuing to donate despite the advice, and whether adherence to the advice had negative implications for donor retention.

STUDY DESIGN AND METHODS

Survey data from 2078 donors were analyzed to understand the factors associated with donating blood during the first 6 months of the pandemic, and the impact of following stay-at-home advice during the first 6 months of the pandemic on donor return 6-12 months into the pandemic. Panel data were used to gain an overview of donation behavior before, during, and after the initial phase of the pandemic.

RESULTS

Donations by donors aged 70 and over decreased disproportionately to other age groups during the early stages of the pandemic. Sex, total donation count, awareness of stay-at-home advice from the Blood Collection Agency, the mode of receiving stay-at-home advice, donor risk perceptions and attitudes toward stay-at-home advice were associated with donation behavior in the first 6 months of the pandemic. Donors who did not donate in the first 6 months of the pandemic had lower odds of returning 6-12 months into the pandemic.

CONCLUSION

Stay-at-home advice was partially successful in preventing older donors from donating; however, more tailored communication approaches may have prevented more donors from donating. Implementation of stay-at-home advice should be accompanied by strategies to prevent ongoing donor lapse in the medium- to long-term.

"Please help us with important research": A retrospective analysis examining the impact of research invitation and participation on subsequent blood donor behavior

BACKGROUND

As over-communication can negatively impact consumer behavior, it is important to understand the impact of research communication on donors' future donation behavior. The aim of this study was to determine the effect of (i) being invited to participate in research, and (ii) participating in that research, on future donation behavior.

STUDY DESIGN AND METHODS

A retrospective cohort analysis was conducted with 36,418 donors who were invited to participate in one of 17 research projects, and a matched control group of 36,252 non-invited donors. Poisson regression models were used to examine the associations between invitation or participation in the studies and the likelihood of creating an appointment to donate and attending an appointment at 1, 3, and 6 months.

RESULTS

Donors were significantly more likely to create an appointment within 14 days of receiving an invitation compared to controls (RR: 1.91, 95% CI 1.81-2.02), and to return to donate at 1 (RR:1.18, 95% CI 1.13-1.24), 3 (RR:1.10, 95% CI 1.07-1.13) and 6 (RR:1.11, 95% CI 1.09-1.13) months compared to non-invited controls. Donors who participated in the research were more likely to return than control donors at all time points, while donors who were invited but did not participate were also likely to return more at 1 month (RR:1.06, 95% CI 1.00-1.11) and 6 months (RR:1.03, 95% CI 1.00-1.5) than non-invited controls.

DISCUSSION

Our findings suggest that research participation is positively associated with future donor behavior and provides reassurance that contacting donors for research does not negatively impact blood collections.

WHO informal consultation on revision of guidelines on evaluation of similar biotherapeutic products, virtual meeting, 30 June – 2 July 2021

The WHO informal consultation was held to promote the revision of WHO guidelines on evaluation of similar biotherapeutic products (SBPs) adopted by the Expert Committee on Biological Standardization (ECBS) in 2009. It was agreed in the past consultations that the evaluation principles in the guidelines are still valid, but a review was recommended to provide more clarity and case-by-case flexibility. The opportunity was therefore taken to review the experience and identify areas where the current guidance could be more permissive without compromising its basic principles, and where additional explanation could be provided regarding the possibility of reducing the amount of data needed for regulatory approval. The meeting participants applauded the leading role taken by the WHO in providing a much-needed streamlined approach for development and evaluation of SBPs which will provide efficient and cost-effective product development and increase patient access to treatments. It was recognized that the principles as currently described in the draft WHO guidelines are based on sound science and experience gained over the last fifteen years of biosimilar approvals. However, since these guidelines when finalised will constitute the global standard for biosimilar evaluation and assist national regulatory authorities in establishing revised guidance and regulatory practice in this complex area, it was felt that further revision and clarity on certain perspectives in specific areas was necessary to dispel uncertainties arising in the current revised version. This report describes the principles in the draft guidelines, including topics discussed and consensus reached.

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WHO guidelines serve as a basis for the development of national regulatory framework for biosimilars.

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Revision of guidelines is to provide more flexibility and clarification on data required for regulatory approval.

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Revised guidelines would contribute to improving consistency on regulatory decision and patient access to treatments.

It is about who you know (and how you help them): Insights from staff and donors about how to recruit and retain a panel of committed anti-D donors

BACKGROUND AND OBJECTIVES

Maintaining a panel of committed anti-D donors is crucial for the production of anti-D immunoglobulin to prevent haemolytic disease of the foetus and newborn. Given low numbers of donors in the Australian panel, there is a need to better understand motivators and barriers specific to anti-D donors.

MATERIALS AND METHODS

A qualitative approach was used to gather perspectives of staff and current anti-D donors in Australia. Focus groups were held with staff involved with the anti-D programme. An asynchronous online discussion forum and interviews were conducted with donors. All data were coded using deductive and inductive thematic analysis.

RESULTS

Staff stressed the importance of recruiting donors who met their own informal criteria as well as the formal selection criteria in order to maximize the chances of donors committing to making regular plasma donations. In contrast, donors were motivated by having a personal connection to anti-D, the recipient group and being eligible to join the programme. Support from staff and understanding the value of their donations also helped donors overcome concerns about the risks of joining the programme and reduced barriers to remaining in the programme.

CONCLUSION

Anti-D donors in Australia are motivated by multiple factors, including knowing who the recipient is, and dedicated staff are integral to building donors' commitment through education and support. Findings suggest the current approach to recruitment could be broadened to include all donors who meet formal selection criteria, with retention enhanced by reinforcing and rewarding the motives identified by donors for donating.

The vasovagal reaction experience among blood donors: A qualitative study of factors that affect donor return

RATIONALE

Blood collection agencies face ongoing challenges in retaining voluntary donors to meet the demand for blood and blood-related products by healthcare services. A known deterrent to continued blood donation is the experience of a vasovagal reaction (VVR). However, there has been little research into donors' experiences of these reactions and the factors that influence their decision to return, which is essential information to inform strategies to improve donor return.

OBJECTIVE

The aim of this paper was to explore blood donor views and experiences of a VVR, with a particular interest in how the reaction influenced their return behaviour, using the Transactional Model of Stress and Coping.

METHODS

We conducted 34 semi-structured in-depth interviews between February and April 2018 with a sample of Australian donors who had experienced a VVR in the last seven days. Transcripts were analysed using the Framework Method.

RESULTS

The VVR elicited various emotional responses, which appeared to be influenced by social support, being aware of the possibility of experiencing a VVR, or the donation outcome. In turn, the VVR experience affected intentions to return, with those who reported more positive experiences expressing stronger intentions. Further, donors felt more likely to return if they perceived their risk of a recurrent event as low and if they were able to identify appropriate problem and emotion-focused coping strategies.

CONCLUSION

This article provides novel insights into possible ways to encourage blood donor return following a VVR.

Motivators of and barriers to becoming a COVID-19 convalescent plasma donor: A survey study

OBJECTIVES

To determine the motivators and barriers to COVID-19 convalescent plasma donation by those in the United Kingdom who have been diagnosed with or who have had symptoms of SARS-CoV-2 (COVID-19) but who have not donated.

BACKGROUND

Convalescent plasma from people recovered from COVID-19 with sufficient antibody titres is a potential option for the treatment and prevention of COVID-19. However, to date, recruiting and retaining COVID-19 convalescent plasma donors has been challenging. Understanding why those eligible to donate COVID-19 convalescent plasma have not donated is critical to developing recruitment campaigns.

METHODS/MATERIALS

A total of 419 UK residents who indicated that they had been infected with COVID-19 and who lived within 50 km of sites collecting COVID-19 convalescent plasma completed an online survey between 25th June and 5th July 2020. Respondents completed items assessing their awareness of convalescent plasma, motivations and barriers to donation and intention to donate COVID-19 convalescent plasma.

RESULTS

Awareness of COVID-19 convalescent plasma was low. Exploratory factor analysis identified six motivations and seven barriers to donating. A stronger sense of altruism through adversity and moral and civic duty were positively related to intention to donate, whereas generic donation fears was negatively related.

CONCLUSIONS

Once potential donors are aware of convalescent plasma, interventions should focus on the gratitude and reciprocity that those eligible to donate feel, along with a focus on (potentially) helping family and norms of what people ought to do. Fears associated with donation should not be neglected, and strategies that have been successfully used tor recruit whole-blood donors should be adapted and deployed to recruit COVID-19 convalescent plasma donors.

Gone, but haven't forgotten: insights on plasmapheresis donation from lapsed donors

BACKGROUND AND OBJECTIVES

Blood Collection Agencies in several countries have implemented strategies to increase the number of plasmapheresis collections. Despite this, a sizable minority of plasma donors lapse from donation each year, with little research conducted on this topic. An understanding of the plasma donation experience from the perspective of lapsed donors, insights into why they stopped donating and their views on returning to donate may provide opportunities to intervene to increase the retention and reactivation of plasma donors.

MATERIALS AND METHODS

A qualitative approach was used in this study, with 17 lapsed plasma donors (no plasma donation for at least 13 months) interviewed. A purposive recruitment strategy was used to obtain a sample with diversity in gender (47% men), age (M = 36·2 years, SD = 13·6) and donation experience (M = 9·2 years, SD = 9·6). Semi-structured, narrative interviews were conducted, with participants describing their plasma donation careers chronologically from first donation to most recent.

RESULTS

The majority of participants described at least some aspect of the plasma donation procedure as unpleasant. However, adverse experiences were only attributed to lapsing in a minority of cases, with other participants reporting significant life events, perceived ineligibility and concerns about the safety of the procedure as the reason why they lapsed.

CONCLUSION

It is common for lapsed plasma donors to intend to donate again in the future. Recommendations are given for strategies to address barriers to returning, noting the potential role of tailored education and support.

Understanding donation frequency: insights from current plasma donors

BACKGROUND AND OBJECTIVES

Encouraging existing plasma donors to donate more frequently is a key objective for blood donation services committed to expanding yield through voluntary non-remunerated plasmapheresis donation. This requires an understanding of donors' perspectives on their current donation practice and how this relates to their knowledge and beliefs about the need for plasma. To explore this, Australian plasma donors were interviewed about how they arrived at the frequency at which they donate.

MATERIALS AND METHODS

Semi-structured telephone interviews were conducted with 105 Australian plasmapheresis donors.

RESULTS

Key themes identified were as follows: fitting donation into busy lives and how ideas about being an ongoing donor and the institutional context shaped their perspective on frequency; perceptions of the impact of donation on health; and wanting to make a greater contribution.

CONCLUSION

Experienced plasma donors work to maintain a donation practice in the context of busy lives often by adopting a flexible approach to donation frequency. Their knowledge of the contribution their donations make is key to their continued donation, yet most identified constraints to donating more frequently. Health concerns were a particular concern for some, and more research is needed to understand donors' perspectives on the impact of donating on their health.

Why I Can't, Won't or Don't Test for HIV: Insights from Australian Migrants Born in Sub-Saharan Africa, Southeast Asia and Northeast Asia

People born in sub-Saharan Africa and Southeast Asia are overrepresented in HIV notifications in Australia. Just under half of all notifications among people from sub-Saharan Africa and Southeast Asia are diagnosed late. Increased HIV testing among these communities is necessary to ensure early diagnosis, better care and reduce likelihood of HIV onward transmission. Recently, Australia has made new HIV testing methods available: rapid HIV testing and self-testing kits. We conducted 11 focus groups with 77 participants with people from sub-Saharan Africa, Southeast Asia and Northeast Asia in four jurisdictions in Australia. Focus groups discussed barriers to HIV testing and the acceptability of new testing methods. Barriers to HIV testing included: cost and eligibility of health services, low visibility of HIV in Australia, HIV-related stigma, and missed opportunities by general practitioners (GPs) for early diagnosis of HIV and linkage into care. Participants had low levels of knowledge on where to test for HIV and the different methods available. Diverse opportunities for testing were considered important. Interventions to increase HIV testing rates among sub-Saharan African, Southeast Asia and Northeast Asian migrants in Australia need to be multi-strategic and aimed at individual, community and policy levels. New methods of HIV testing, including rapid HIV testing and self-testing, present an opportunity to engage with migrants outside of traditional health care settings.

Achieving a hepatitis C cure: a qualitative exploration of the experiences and meanings of achieving a hepatitis C cure using the direct acting antivirals in Australia

BACKGROUND

Universal access to the hepatitis C direct acting antiviral (DAAs) regimens presents a unique opportunity to eliminate hepatitis C in Australia. Large numbers of Australians have already been cured using these treatments, however, the numbers presenting for treatment have begun to plateau. This study explored how people experienced and understood being cured of hepatitis C, with the aim of informing interventions to increase uptake of DAA treatment among people with hepatitis C.

METHODS

This qualitative study used semi-structured interviews to explore the experiences of people with hepatitis C taking DAAs accessing both hospital and community clinics. Interviews were conducted 12 weeks after treatment completion. Participants were asked to reflect on their experience of living with hepatitis C, their reasons for seeking treatment, and their experience of, DAA treatments. Participants were also asked to reflect on the meaning of being cured, and how they shared this experience with their peers. Interviews were transcribed verbatim and key themes were identified using inductive thematic analysis.

RESULTS

Twenty participants were interviewed. While participants described a range of physical health benefits of achieving a hepatitis C cure it was an improved sense of psychological wellbeing that had the most significant impact on participants' lives. The majority described their relief about no longer living with the burden of an uncertain future due to anxiety about developing liver disease or cancer, as well as fear of infecting others. Participants who had a past history of injecting drug use, described being cured as a way to break the connection with their past. Participants who were current injectors raised concerns about re-infection.

CONCLUSION

Feeling "normal" and not infectious allows people to live with reduced psychological distress, in addition to the physical benefits of no longer being at risk of developing serious liver disease. Future engagement strategies targeting people who are not accessing hepatitis health care need to promote the lived experience of being cured and the substantial psychological, and physical health benefits, offered by achieving a cure. Interventions aimed at people who are currently injecting also need to highlight the availability of re-treatment in conjunction with primary prevention strategies.

Procoagulant Activity of T Lymphoblastoid Cells in Extrinsic and Intrinsic Coagulation Systems

We have measured the procoagulant activity (PCA) of four T lymphoblastoid cell lines (Jurkat, CEM, HSB-2 and Molt 4) as well as normal peripheral blood T lymphocytes, before and after stimulation with phytohaemagglutinin (PHA), using clotting and amidolytic methods.

Of the four cell lines only one, Jurkat, gave enhanced PCA after stimulation with PH A. This activity was shown to be tissue factor-like by its dependence on factor VII in plasma and in an amidolytic assay with purified factors VII and X. Jurkat was also the only one of the four cell lines to secrete interleukin-2. All four cell lines promoted the generation of large amounts of thrombin in platelet-free plasma in glass tubes. This activity was dependent on the presence of plasma factor VIII, and was probably due to phospholipids in the cell membranes. Normal T lymphocytes gave intrinsic PCA in the thrombin generation test which was only 15% of that of the lymphoma cells.

These results show that some T lymphocytes can develop PCA in both intrinsic and extrinsic systems and this should be taken into account in studies of the PCA of mixed leukocyte populations.

HIV Futures 8: Protocol for a Repeated Cross-sectional and Longitudinal Survey of People Living with HIV in Australia

Introduction

More than 27,000 Australians currently live with HIV. Most of these people have access to quality clinical care and antiretroviral treatment (ART) and can expect good general health. However, HIV-related stigma is a problem and many people living with HIV experience poorer than average mental health. Issues of aging are also of increasing concern. This paper describes the methods and sample for the HIV Futures 8 study, a national survey of people living with HIV in Australia that aimed to identify factors that support health and well-being among this population. HIV Futures 8 forms part of a series of cross-sectional surveys (The “HIV Futures” studies) that have been repeated periodically since 1997. In the most recent survey, participants were able to opt into a prospective longitudinal study.

Materials and equipment

HIV Futures 8 was open to people aged over 17 who were living with HIV. Data were collected in 2015/2016 using a self-complete survey that contained approximately 250 items related to physical and mental health, use of ART, HIV exposure and testing, financial security, social connectedness, relationships, life satisfaction, resilience, stigma, use of health and support services, and health literacy. To enable comparison of cross-sectional data over time, questionnaire items were consistent with those used in previous HIV Futures surveys. In HIV Futures 8, participants were invited to volunteer coded information that will allow longitudinal follow-up when participants complete subsequent HIV Futures surveys. The survey was advertised through the networks of HIV organizations, on social media and through HIV clinics and services. HIV Futures 8 was completed by 895 participants. This represents approximately 3.8% of the total number of people living with diagnosed HIV in Australia in 2014.

Expected impact of the study on public health

Findings from HIV Futures 8 will contribute important insights into the complexity of factors that support physical and mental well-being among people living with HIV. The findings will also assist HIV services to align with broader public health goals related to increasing ART use and improving quality of life among people living with HIV.

Cytokine release assays for the prediction of therapeutic mAb safety in first-in man trials--Whole blood cytokine release assays are poorly predictive for TGN1412 cytokine storm

The therapeutic monoclonal antibody (mAb) TGN1412 (anti-CD28 superagonist) caused near-fatal cytokine release syndrome (CRS) in all six volunteers during a phase-I clinical trial. Several cytokine release assays (CRAs) with reported predictivity for TGN1412-induced CRS have since been developed for the preclinical safety testing of new therapeutic mAbs. The whole blood (WB) CRA is the most widely used, but its sensitivity for TGN1412-like cytokine release was recently criticized. In a comparative study, using group size required for 90% power with 5% significance as a measure of sensitivity, we found that WB and 10% (v/v) WB CRAs were the least sensitive for TGN1412 as these required the largest group sizes (n = 52 and 79, respectively). In contrast, the peripheral blood mononuclear cell (PBMC) solid phase (SP) CRA was the most sensitive for TGN1412 as it required the smallest group size (n = 4). Similarly, the PBMC SP CRA was more sensitive than the WB CRA for muromonab-CD3 (anti-CD3) which stimulates TGN1412-like cytokine release (n = 4 and 4519, respectively). Conversely, the WB CRA was far more sensitive than the PBMC SP CRA for alemtuzumab (anti-CD52) which stimulates FcγRI-mediated cytokine release (n = 8 and 180, respectively). Investigation of potential factors contributing to the different sensitivities revealed that removal of red blood cells (RBCs) from WB permitted PBMC-like TGN1412 responses in a SP CRA, which in turn could be inhibited by the addition of the RBC membrane protein glycophorin A (GYPA); this observation likely underlies, at least in part, the poor sensitivity of WB CRA for TGN1412. The use of PBMC SP CRA for the detection of TGN1412-like cytokine release is recommended in conjunction with adequately powered group sizes for dependable preclinical safety testing of new therapeutic mAbs.

Sex, desire and pleasure: considering the experiences of older Australian women

Older age is often associated with asexuality. That is, older individuals are not viewed as desiring of sex, nor as sexually desirable to others. Broader social and cultural norms that downplay women's sexual desire and agency further compound these phenomena. Whether this popular image accurately reflects older women's sexual desires, behaviour and capacity to experience pleasure is unclear. Drawing on semi-structured interviews with 43 partnered Australian women aged 55–81, this article considers women's sexual experiences and desires in older age. The findings of our research confirm that older women's experiences of sex and sexual desire are diverse and fluid. Some of the factors that influenced participants’ sexual behaviour and desire will be considered in this article, as will their understandings of what “counts” as sexual satisfaction and “successful sex”. The factors affecting sexual behaviour and desire also influence the way in which women are able to negotiate sexual interaction with their partners. Participants expressed a need for education and resources in order to gain greater control and to make autonomous choices over their sexual experiences, desire and ability to give and receive pleasure. The implications of these findings for practitioners are also considered.

After TGN1412: recent developments in cytokine release assays

The failure of regulatory science to keep pace with and support the development of new biological medicines was very publically highlighted in March 2006 when the first-in-man Phase I clinical trial of the immunomodulatory CD28-specific monoclonal antibody (mAb) TGN1412 ended in disaster when all six volunteers suffered a life-threatening adverse reaction termed a 'Cytokine Storm'. The poor predictive value of standard pre-clinical safety tests and animal models applied to TGN1412 demonstrated the need for a new generation of immunotoxicity assays and animal models that are both sensitive and predictive of clinical outcome in man. The non-predictive result obtained from pre-clinical safety testing in cynomolgus macaques has now been attributed to a lack of CD28 expression on CD4+ effector memory T-cells that therefore cannot be stimulated by TGN1412. In contrast, high levels of CD28 are expressed on human CD4+ effector memory T-cells, the source of most TGN1412-stimulated pro-inflammatory cytokines. Standard in vitro safety tests with human cells were also non-predictive as they did not replicate in vivo presentation of TGN1412. It was subsequently shown that, if an immobilized therapeutic mAb-based assay or endothelial cell co-culture assay was used to evaluate TGN1412, then these would have predicted a pro-inflammatory response in man. New in vitro assays based on these approaches are now being applied to emerging therapeutics to hopefully prevent a repeat of the TGN1412 incident. It has emerged that the mechanism of pro-inflammatory cytokine release stimulated by TGN1412 is different to that of other therapeutic mAbs, such that standard pro-inflammatory markers such as TNFα and IL-8 are not discriminatory. Rather, IL-2 release and lymphoproliferation are optimal readouts of a TGN1412-like pro-inflammatory response.

A review of the validity and reliability of alcohol retail sales data for monitoring population levels of alcohol consumption: a Scottish perspective

AIMS

To assess the validity and reliability of using alcohol retail sales data to measure and monitor population levels of alcohol consumption.

METHODS

Potential sources of bias that could lead to under- or overestimation of population alcohol consumption based on alcohol retail sales data were identified and, where possible, quantified. This enabled an assessment of the potential impact of each bias on alcohol consumption estimates in Scotland.

RESULTS

Overall, considering all the possible sources of overestimation and underestimation, and taking into account the potential for sampling variability to impact on the results, the range of uncertainty of consumption during 2010 was from an overestimate of 0.3 l to an underestimate of 2.4 l of pure alcohol per adult. This excludes the impacts of alcohol stockpiling and alcohol sold through outlets not included in the sampling frame. On balance, there is therefore far greater scope for alcohol retail sales data to be underestimating per adult alcohol consumption in Scotland than there is for overestimation.

CONCLUSION

Alcohol retail sales data offer a robust source of data for monitoring per adult alcohol consumption in Scotland. Consideration of the sources of bias and a comprehensive understanding of data collection methods are essential for using sales data to monitor trends in alcohol consumption.

Prevention of anastrozole induced bone loss with monthly oral ibandronate: Final 5 year results from the ARIBON trial

Purpose

The ARIBON trial is a double blind, randomised, placebo controlled study designed to evaluate the impact of ibandronate on bone mineral density (BMD) in women taking anastrozole for adjuvant treatment of breast cancer.

Methods

131 postmenopausal women with early breast cancer were recruited to the study. Of these, 13 had osteoporosis, 50 osteopenia and 68 normal BMD. Patients with osteoporosis at baseline were treated with monthly oral ibandronate 150 mg for 5 years; osteopenic patients were randomised to receive either ibandronate or placebo for two years and offered open label ibandronate depending upon the results of their 2-year BMD result.

Results

Of the 20 patients with osteopenia who were randomised to ibandronate and evaluable at the 2 year visit, 17/20 were not offered a bisphosphonate and the improvements in BMD accrued during the first 2 years were lost both at the LS (−3.21%) and TH (−5.0%). Of the 16 patients randomised to placebo 8/16 with high rates of bone loss during years 0–2 received ibandronate over the next 3 years with improvements in BMD of +5.01 and +1.19 at the LS and TH respectively. The 8 patients who were not offered a bisphosphonate experienced relatively little change in BMD throughout the 5 years of the study (LS +0.15%, TH −2.72%). BMD increased steadily in the 9/13 patients initially identified as having osteoporosis (LS +9.65%, TH +2.72%).

Conclusions

Monthly oral ibandronate provides an option to clinicians considering use of a bisphosphonate to prevent bone loss during aromatase inhibitor therapy.

Regulatory requirements for therapeutic proteins: the relationship between the conformation and biological activity of filgrastim

Higher order structure, including conformation, is considered a critical quality parameter of therapeutic proteins, and is mandatory information in development of first use and bio-similar therapeutic protein drugs, the assumption being that the biological activity of a protein is directly dependent on its adoption of a 'correct' conformation. Studies on the relationship between conformation and activity depend on the ability to induce conformational changes in proteins, and conventional approaches such as thermal or chemical denaturation are incompatible with bioactivity measurements. To explore the relationship between bio-activity and conformational studies, we have studied variants of the therapeutic protein filgrastim (rec met huGCSF) which have been mutated by the replacement of helical alanine residues with glycine, to destabilise the conformation of the molecule. In the GCSF A-G mutant series studied, single conformation-destabilising amino-acid substitutions significantly reduced the biological activity. These effects were not, however correlated with changes in secondary structure measurable by far-UV Circular Dichroism (CD) spectroscopy. Only the more extensively mutated double and triple substitutions showed measurable reductions in alpha-helical structure by CD. We conclude that in this system, GCSF does not readily adopt a reduced-activity altered conformational state which can be detected by low resolution techniques such as CD. In contrast, reductions in biological activity do reflect reductions in conformational stability, possibly caused by time-dependent degradation of the protein in the cell-proliferation bioassay. Although not a formal model of biosimilarity, we suggest that our results could inform the regulatory process in determining appropriate experimental approaches to meeting regulatory requirements for higher order structural analysis of therapeutic proteins.

New assisted reproductive technology laws in Victoria: a genuine overhaul or just cut and paste?

A new Assisted Reproductive Treatment Act was passed in Victoria on December 2008 and came into effect on 1 January 2010. The new legislation changed who was eligible for assisted reproductive technology (ART) and the types of services that clinics could provide. This article reports on interviews with service providers in Victoria who experience first hand the impact of legislation on clinical practice and patients, as well as regulators who are able to provide insight into the values underpinning the regulatory framework. The new legislation was viewed by all participants as an improvement on the old Act because of the removal of discriminatory and ambiguous aspects. The authors argue that while some of the details of the legislation have changed, the underlying principles and the framework have not.

Ageing with HIV: health and psychosocial well-being of older gay men

Since the introduction of highly active antiretroviral therapy, people living with HIV/AIDS (PLWHA) are living longer, into older age, and therefore presenting a host of new challenges for health and social service providers. However, not all PLWHA are likely to experience similar transitions into older age. In particular, research has yet to fully investigate the health and psychosocial well-being of older HIV-positive gay men. Drawing from an Australian population-based sample of 693 HIV-positive gay men, the present study assesses the overall health and well-being of this older group compared to their younger counterparts. While older men reported greater comorbidity and were more likely to be living in poverty, other health and well-being indicators suggest this group to be coping comparatively well as they continue to age with HIV. These findings provide new directions for meeting the present and future needs and challenges of older HIV-positive gay men.

Monoclonal antibody TGN1412 trial failure explained by species differences in CD28 expression on CD4+ effector memory T-cells

BACKGROUND AND PURPOSE

In 2006, a life-threatening 'cytokine storm', not predicted by pre-clinical safety testing, rapidly occurred in all six healthy volunteers during the phase I clinical trial of the CD28 superagonist monoclonal antibody (mAb) TGN1412. To date, no unequivocal explanation for the failure of TGN1412 to stimulate profound cytokine release in vitro or in vivo in species used for pre-clinical safety testing has been established. Here, we have identified a species difference almost certainly responsible for this disparate immunopharmacology.

EXPERIMENTAL APPROACH

Polychromatic flow cytometry and intracellular cytokine staining were employed to dissect the in vitro immunopharmacology of TGN1412 and other therapeutic mAbs at the cellular level to identify differences between humans and species used for pre-clinical safety testing.

KEY RESULTS

In vitro IL-2 and IFN-γ release from CD4+ effector memory T-cells were key indicators of a TGN1412-type response. This mechanism of cytokine release differed from that of other therapeutic mAbs, which can cause adverse reactions, because these other mAbs stimulate cytokine release primarily from natural killer cells. In contrast to humans, CD28 is not expressed on the CD4+ effector memory T-cells of all species used for pre-clinical safety testing, so cannot be stimulated by TGN1412.

CONCLUSIONS AND IMPLICATIONS

It is likely that activation of CD4+ effector memory T-cells by TGN1412 was responsible for the cytokine storm. Lack of CD28 expression on the CD4+ effector memory T-cells of species used for pre-clinical safety testing of TGN1412 offers an explanation for the failure to predict a 'cytokine storm' in humans.

Quality considerations for recombinant DNA-derived biological therapeutic products: a control perspective on cytokines

Biological therapeutics, particularly those produced by the biotechnology industry, have been perceived as highly complex, novel and having 'unknown' adverse potential. This has led to the rapid growth of biological regulatory control of such products, with a plethora of regulations (often originally based on classical chemical drugs) in addition to case-by-case treatment by control authorities. There is a need for a relationship between industry and regulators using a scientifically based dialogue in order to establish appropriate scientifically based guidelines. These guidelines need to take into account increasing experience in manufacturing, sophisticated analytical techniques and the clinical use of biotherapeutics. Such dialogue must include a rationale of risk/benefit that is not unique to these products and therefore redresses the concept that complexity equates to potential hazard. Current regulatory issues are focused on the use of scientific experience and understanding to relate regulations produced during the early development of the bioindustry to the present use of these materials in the clinic and the realistic potential for difficulties when compared to chemical drugs. This covers such issues as toxicity, heterogeneity and analysis in relation to quality. When considering the significance of any issue for the regulation of a biological product it must be in relation to the type of product (e.g. homogeneous or heterogeneous) its clinical use (e.g. single or multiple dose form, life-threatening disease or not) and efficacy (e.g. complete cure, palliation or treatment adjunct) as each of these impinges on the scientific appropriateness of any control decision.

Peri-Operative Suppression of Immune-Regulatory Blood Cells Predicts Wound Complications in Breast Cancer Patients

IntroductionWe have previously demonstrated an association between post-operative wound complications and systemic breast cancer recurrence (p<0.0001), Murthy et al (2007) Br J Cancer 97, 1211-7. The aim of this study was to examine the potential role of the immune system in establishing this association, and therefore whether immune factors might be used to predict either wound complications or cancer recurrences.MethodsPatients with primary operable breast cancer were prospectively recruited to the study. Serial blood investigations were performed pre-operatively, peri-operatively and post-operatively. Absolute numbers of various lymphocyte cell populations were measured using multi-colour flow-cytometry including CD45+lymphocytes, CD19+ B lymphocytes, CD3+ T lymphocytes, CD4+ helper T cells, CD8+ cytotoxic T cells and CD56+ NK cells. We also measured the levels of the NK cytotoxicity receptors NKp30 and NKp46 on the NK cell population.ResultsOne hundred and nine patients were recruited to the study and there was a wound complication rate of 13.4%. Absolute numbers of CD3+ T lymphocytes, CD4+ helper T cells, CD8+ cytotoxic T cells and CD56+ NK cells were significantly lower 4 hours post-operatively compared to pre-operative levels (p<0.05), although levels had typically recovered after 24 hours. However, NKp30 expression remained significantly reduced at 24 hours (p<0.05). Mastectomy patients had a significantly greater fall in T lymphocyte numbers than those having breast conserving surgery (p<0.05). Patients who went on to develop wound complications post-operatively had a significantly greater fall in their CD4+ helper T cells at 4 hours post-operatively, than those patients who did not go on to develop wound complications (p<0.05).ConclusionsBreast cancer surgery results in severe disruption to the immune system, with dramatic changes in levels of immune regulatory blood cells populations. Changes are predominantly immuno-suppressive. The greater the immune disruption as a result of surgery, the more likely the patient is to develop a wound complication. We believe that this peri-operative immuno-suppression may also provide a window of opportunity for the successful dissemination of tumour cells post-operatively thereby increasing the risk of future metastases; we are maintaining follow up on this patient cohort in order to test correlations between peri-operative immuno-suppression and systemic recurrences.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4132.

Oral lichen planus: a review

Oral lichen planus (OLP) is a common chronic inflammatory disorder thought to have a low risk of associated malignancy. A genetic predisposition linked to Th1 cytokine polymorphisms may promote the T cell-mediated immunological response to an induced antigenic change that is supposed to lead to OLP lesions. Some putative etiologic factors, mainly amalgam restorations and hepatitis C virus, have been studied in detail. The diagnosis of OLP can be made from the clinical features if they are sufficiently characteristic, but biopsy is recommended to confirm the diagnosis, exclude dysplasia and malignancy and if active treatment is required. The management of OLP is mainly aimed at controlling the symptoms and topical immunomodulators such as powerful corticosteroids and calcineurin inhibitors have been used. However, their long-term effects need to be better explored and understood. Current therapeutic data is probably still insufficient to make detailed recommendations with regard to the specific dosage, formulation, mode of delivery or length of therapy.

Gender differences in patterns of HIV service use in a national sample of HIV-positive Australians

There have been clear gender differences in the experience of living with HIV in Australia since the start of the epidemic. This paper examines the patterns of health service use and experiences at those services over a period of six years. The results reported here are drawn from the HIV Futures surveys, four consecutive national, cross-sectional Australian surveys of the lives of PLWHA. Women were found to use different medical services to men both for non HIV-related and HIV-related treatment, being more likely to use generalist services and hospital-based HIV specialists. Women also reported higher rates of discrimination at health services, however reports of new incidences of discrimination were found to decrease from 2001 onwards. Although women reported higher levels of unwanted disclosure of HIV status than men, particularly by health care workers, new reports of unwanted disclosure decreased between 2003 and 2005. These data indicate that there are long-term gender differences in medical service use by PLWHA in Australia, and that this has been associated with higher rates of discrimination and loss of confidentiality for women. However the decrease in new reports of discrimination over time indicates that improved education of health service providers has been successful.