Low perception of sexual behaviours at risk for human immunodeficiency virus infection among blood donors who call the AIDS/STI Help Line in Italy

Abstract

Background

In Italy, the circulation of human immunodeficiency virus (HIV) has expanded to include population groups that do not perceive themselves to be “at risk” of HIV infection and who do not even consider undergoing HIV testing. The aim of this study was to describe the socio-demographic and behavioural characteristics, and perceived risk of HIV infection in a sample of blood donors who reported never having been tested for HIV.

Materials and methods

A questionnaire was administered to a sample of donors who called the Italian National AIDS/STI Help Line and reported never having been tested for HIV.

Results

The study sample consisted of 164 blood donors: 29.3% had given blood in the preceding 2 years. With regards to at-risk behaviours, 39.6% of the donors interviewed were heterosexuals who had sexual contacts with multiple partners, and 5.5% were men who had sex with multiple male partners. Sexual contacts with female sex workers were reported by 11.6% of first-time donors and 25.7% of repeat donors. Of the 164 donors interviewed, 125 (76.2%) said that the main reason that they had never been tested for HIV was that they did not consider themselves at risk. Among these, 56 (44.8%) reported that they would have sexual contacts with a sex worker, 52 (41.6%) reported that they would have sexual contacts with someone having more than one sexual partner, and 36 (28.8%) reported that they would have sexual contacts without using a condom.

Discussion

All the donors interviewed reported that they had never been tested for HIV despite the fact that they had been certainly been tested upon blood donation. These results show that some sexual behaviours may not be perceived as behaviours at risk for acquiring HIV infection. These findings suggest that not all blood donors are knowledgeable about HIV risk behaviours and that an explicit pre-donation questionnaire and effective counselling continue to be important for the selection of candidate donors.

Introduction

In the last decade a small but statistically significant increase in the incidence rate of human immunodeficiency virus (HIV) infection was observed among repeat donors in Europe¹. In the same period, in Italy, the incidence of HIV among repeat blood donors and the prevalence of the same virus among first-time blood donors were about two-fold higher than in the majority of western European countries¹. Although the spread of HIV infection tends to be much lower in blood donors than in the general population^1,2, these data on the incidence and prevalence of HIV infection among blood donors could result from the current HIV epidemic that is showing an increase of people in Italy with a late diagnosis because they are unaware of their at risk behaviour. In fact, in the last decade, the circulation of HIV in Italy has expanded to involve groups of subjects who do not perceive themselves “at risk” and who do not even consider undergoing HIV testing²: a study conducted in Italy showed a progressive increase in the proportion of people who became aware of being HIV positive in an advanced stage of disease³. In 2011, 56.4% of patients with newly diagnosed HIV in Italy were late presenters, i.e. individuals diagnosed with AIDS or with advanced immune-deficiency (CD4 count <350 cell/mm³), and this percentage was 61.1% among those with newly diagnosed HIV acquired through heterosexual contact².

In the light of these considerations, to evaluate donors’ awareness on exposures at risk of HIV infection, we conducted an anonymous cross-sectional telephone survey among blood donors selected from a larger sample of people calling a national help line who reported never having been tested for HIV, with the aim of describing their socio-demographic and behavioural characteristics, their perceived risk of HIV infection, and their reasons for having never been tested for HIV.

Materials and methods

An anonymous cross-sectional telephone survey was conducted among a sample of people who called Italy’s National AIDS and Sexually Transmitted Infections (AIDS/STI) Help Line, based at and coordinated by the Psychosocial and Behavioural Research, Communication, and Education Operative Unit of the Istituto Superiore di Sanità (ISS; Italy’s National Institute of Public Health). The AIDS/STI Help Line provides specific telephone counselling on HIV/AIDS and STI based on scientifically valid, updated and personalised information. The group of subjects to survey was selected using non-probabilistic sampling among persons who called the AIDS/STI Help Line between February 2005 and April 2006. We interviewed 556 participants who reported never having been tested for HIV; of them, 539 (96.9%) accepted to participate in the survey. The characteristics of this sample have already been described by Gallo et al⁴. Out of the 539 people who accepted to participate in the survey, 164 reported having made at least one blood donation in their lifetime and were included in this study. The questionnaire was administered by a trained operator at the end of the telephone counselling session; the operator described the characteristics and the purpose of the study and asked for informed consent to participation, explaining that anonymity would be guaranteed. The questionnaire consisted of 38 questions regarding socio-demographic information, medical history, blood donation history, reasons for never having undergone HIV testing, and information on at-risk sexual behaviour. At-risk sexual behaviour included: heterosexual and/or homosexual sexual contact with multiple partners (more than two partners in the preceding 6 months), sexual contact with a sex worker, and sexual contact with an HIV-positive person. The questions had closed answers and the answers were entered in real time into a database developed specifically for this purpose. The mean duration of the interview was 10 minutes (range, 8–15 minutes). The statistical analysis was performed using IBM SPSS Statistics 20 software.

Results

Of the 164 blood donors who called the AIDS/STI Help Line in the study period and had never been tested for HIV, 129 (78.7%) were first-time blood donors and 35 (21.3%) were repeat blood donors; 29.3% had given blood in the preceding 2 years. The most frequent questions asked regarded modes of HIV transmission, methods for prevention of HIV (61.3%), and information on HIV testing modalities and sites (25.2%).

Table I shows the characteristics of blood donors included in this study. Donors who called the AIDS/STI Help Line were mostly young (18–29 years: 52.4%), male, and all of them were Italian.

Table I.

Socio-demographic characteristics and behaviours of 164 blood donors calling the National AIDS/STIs Help Line, February 2005–April 2006.

	n	%
Repeat donor	35	21.3
First-time donor	129	78.7
Gender
Male	146	89.0
Female	18	11.0
Age (in years)
18–24	35	21.3
25–29	51	31.1
30–34	38	23.2
35–39	19	11.6
40–44	8	4.9
45 and older	13	7.9
Median age (in years) (IQR)	29	(25.25–34)
Marital status
Unmarried	124	75.6
Married/cohabitating	40	24.4
Level of education
Elementary/middle school	28	17.1
High school	95	57.9
University	41	25.0
Employment status
Unemployed	10	6.1
Employed	121	73.8
Student	33	20.1
Nationality
Italian	164	100.0
Non-Italian	0	0.0
Geographical area of origin of the call
Northern Italy	65	39.6
Central Italy	48	29.3
Southern Italy	51	31.1
Median age (in years) at first sexual contact (IQR)	18	(17–20)
Number of lifetime sexual partners
<5	81	50.3
5–20	60	37.3
>20	20	12.4
Missing	3
Previous sexually transmitted infections
Yes	6	3.7
No	158	96.3
Missing	0
Previous pregnancy
Yes	3	18.8
No	13	81.2
Missing	2
Previous hospitalisation
Yes	96	58.5
No	68	41.5

The median age at first sexual intercourse was 18 years. Approximately half of the donors reported having had more than five sexual partners in their lifetime; six donors reported having had at least one sexually transmitted infection. About 60% of the participants engaged in at-risk sexual behaviour (Figure 1). In particular, 39.6% reported having had heterosexual contacts with multiple partners; this behaviour was reported by 44.9% of first-time donors and 28.6% of repeat donors (P >0.05). Sexual contacts with sex workers were reported by 14.7% of donors interviewed: this exposure was reported by 11.6% of first-time donors and 25.7% of repeat donors (P >0.05). Of the participants, nine (5.5%) were men who had sex with multiple male partners; among them, eight were first-time donors (6.2% of first-time donors) and one was a repeat donor (2.9% of repeat donors) (P >0.05).

Figure 1.

At-risk sexual behaviour reported by 164 blood donors calling the National AIDS/STIs Help Line, February 2005–April 2006.

Table II shows risk perception and attitudes towards sexual behaviour at risk for HIV infection: the most frequent reasons the subjects gave for not having been tested for HIV (Table II, question A) were not considering themselves at risk (125/164; 76.2%), and feeling physically well without reason to suspect having acquired HIV infection (80/164; 48.8%).

Table II.

Risk perceptions and attitudes towards sexual behaviour at risk for HIV infection among 164 blood donors calling the National AIDS/STI Help Line, February 2005–April 2006.

	Yes		No
	n	%	n	%
Question A - “Why have you never been tested for HIV?”
“I am not at risk”	125	76.2	39	23.8
“I feel well and have no reason to suspect that I am HIV-positive”	80	48.8	84	51.2
“I was not advised to undergo testing by a physician”	45	27.4	119	72.6
“I do not know where I can get tested”	29	17.7	135	82.3
“I am afraid that my family will find out”	37	22.6	127	77.4
“I do not want to know if I am HIV-positive”	25	15.2	139	84.8
“I am afraid that I will be ‘black-listed”	16	9.8	148	90.2
Only for the 125 donors who answered “I am not at risk” to question A:
Question B - Would you have sexual contacts:
With a sex worker	56	44.8	69	55.2
With a heterosexual partner having multiple partners	52	41.6	73	58.4
With a MSM partner having multiple partners	42	33.6	83	66.4
Without using condom	36	28.8	89	71.2
Question C - Would you have sexual contacts without using condom:
With a sex worker	20	16.0	105	84.0
With a heterosexual partner having multiple partners	17	13.6	108	86.4
With a MSM partner having multiple partners	13	10.4	112	89.6

Of the 125 donors who perceived themselves not to be at risk, 76 (60.8%) reported having engaged in at-risk sexual behaviours. Among these 125 donors, a relevant proportion was prone to engage in sexual risk behaviour (Table II, question B): almost half of them (44.8%) would have sexual contacts with a sex worker, 28.8% would have unprotected sexual contacts, 16.0% would have unprotected sexual contacts with a sex worker and 13.6% with a heterosexual partner having multiple partners.

Analysing the reasons for never having been tested for HIV (Table II, question A) among 99 donors who had engaged in at-risk behaviour, the most frequent answers were: “I am not at risk” (75.8%), and “I feel well and have no reason to suspect that I am HIV-positive” (36.4%).

Discussion

In this study, we investigated risk behaviours and the perception of being at risk of HIV infection in a sample of blood donors selected from a larger sample of persons calling the AIDS/STI Help Line who stated that they had never been tested for HIV.

More than 60% reported having engaged in risky sexual behaviour, such as sexual contacts with multiple partners, sex workers or HIV-positive partners. However, more than three-quarters of them considered that they were not at risk of HIV infection, as shown by their answers to question A on reasons for never having been tested for HIV.

Our study shows that the above mentioned behaviours may not be perceived as being at risk: indeed, a relevant proportion of donors who perceived themselves to be not at risk would have at-risk sexual behaviours. This finding suggests that some donors are not excluded by the pre-donation selection process because the educational material provided may not be fully understandable or the questionnaire may not be sufficiently clear and explicit on questions regarding sexual behaviour at risk^5–7.

These results are consistent with data on epidemiological surveillance of blood donors in Italy showing that about one-third of donors who discover to be HIV-positive at donation are unable to identify the source of their infection; the remaining two-thirds report a sexual exposure at risk in the post-donation questionnaire, although this exposure was not mentioned in the pre-donation interview, highlighting an underestimation of sexual risk behaviour⁸.

The lack of perception of sexual behaviours at risk could lead to an increase in the prevalence and incidence of HIV among blood donors⁹, thus increasing the probability of HIV-positive donors slipping through the filter of donor screening¹⁰.

All the participants reported never having been tested for HIV despite the fact that they certainly had been screened upon blood donation¹¹, suggesting that HIV testing is usually disregarded when performed outside the context of exposure to risk. A study conducted in the USA showed that 10% of blood donors believed that donations were not always tested for HIV^12–14.

It should be stressed that the 164 donors included in this study represent a very small percentage of Italian blood donors (about two million per year)¹⁵, and that they were self-identified as being concerned about HIV risk by calling the AIDS/STI Help Line. Therefore, some limitations should be considered in interpreting the results of this study. First, our results cannot be generalised to the population of donors at large because our population consisted of people who called an AIDS/STI Help Line who had probably been exposed more frequently than the general population to at-risk behaviour⁴. Second, the distribution of repeat and first-time donors in our study did not reflect the distribution of donors in Italy, since more than 80% of those giving blood are repeat donors⁸. Third, the small sample size of participants hampered the analysis of differences between repeat and first-time blood donors. Finally, the attitude of donors in considering blood donation as an opportunity for HIV testing was not explored in the interview.

These findings suggest that although the blood donor population is sensitive and well informed on safeguarding and health promotion, not all blood donors are knowledgeable about risks associated with HIV infection. The current serological screening of blood units identifies the vast majority of HIV infections, but a small residual risk of transfusion-transmitted HIV remains in the case of early stage infection¹⁶.

For these reasons HIV testing should always (also among repeat donors) be preceded by effective HIV/AIDS counselling aimed at clarifying and underscoring all the modalities of sexual transmission, an explicit pre-donation questionnaire, and an in-depth pre-donation interview aimed at investigating risk awareness and improving the selection of donor candidates.