379

1992 1993

Figure: IPTH(:t.-84) (A) and haemoglobin (0) )

A 62-year-old man with IgA nephropathy, on dialysis sinceApril, 1977, was transferred to our unit in August, 1991. Hereceived epoetin subcutaneously (1250 IU thrice weekly). InJune, 1992, serum iPTH was 1812 pg/mL and intravenousalfacalcidol was started at 6 Ilg per week. Haemoglobinincreased from 9-6 to 13-3 g/dL after 9 months (figure, lower),and serum epoetin went from 12 to 98 IU/L. Epoetin waswithdrawn in February, 1993 (haemoglobin 14 g/dL).The improvement in haemoglobin concentrations associated

with alfacalcidol allowed the withdrawal of epoetin. Hyper-parathyroidism is a resistance factor in epoetin treatment.2 Ourdata suggest a direct effect of vitamin D3 derivatives onhaematopoiesis. The benefits of oral alfacalcidol in myelo-dysplastic syndromes without renal failure have been re-

ported.3 The rationale was based on the data showing thatvitamin D3 derivatives may induce cell differentiation and/orcell division. Similar effects have been reported for otherlipophilic vitamin derivatives, such as retinoids.4

Àngel ArgilésSchool of Medicine, University Montpellier I-UP 9008 CNRS, 34033 Montpellier,France

Ronan Lorho

AIDER, Montpellier

Georges Mourad, Charles M MionDepartment of Nephrology, University Hospital "Lapeyronie", Montpellier

1 Argilés A, Kerr PG, Canaud B, Flavier JL, Mion C. Hemodialysis andhemodiafiltration Ca kinetics, and long-term effects of loweringdialysate calcium concentration. Kidney Int 1993; 43: 630-40.

2 Rao DS, Shih MS, Mohini R. Effect of serum parathyroid hormoneand bone marrow fibrosis on the response to erythropoietin in uraemia.N Engl J Med 1993; 328: 171-75.

3 Kelsey SM, Newland AC, Cunningham J, Makin HLJ, Coldwell RD,Mills MJ, Grant IR. Sustained haematological response to high-dosealfacalcidol in patients with myelodyspLastic syndromes. Lancet 1992;340: 316-17.

4 Argiles A, Kraft N, Hutchinson P, Senes-Ferrari S, Atkins RC.Retinoic acid affects the cell cycle and protein metabolism in epithelialkidney cells. Kidney Int 1989; 36: 654-59.

HIV-positive blood donors: can India afford toInform?

SiR-Proponents, such as your June 12 Round-the-Worldcorrespondent (p 1527), who wish to inform blood donors inIndia of their HIV status assume that this information would

help positive donors to take precautions not to infect others.However, the group that is in greater need of testing is pregnantwomen. HIV prevalence in pregnant women is almost twicethat in blood donors (per 1000)1:

Moreover, the benefits of informing donors are uncertainbecause their behavioural pattern is unknown, whereas thespouse and unborn child and possibly others might gain fromthe pregnant woman’s knowledge of her HIV status.With respect to blood donors, there is a latency period

between the acquisition of the virus and the appearance ofantibody to HIV.2 Thus, a negative HIV status communicatedto the donor may give them a false sense of security. Thepsychological effect on those who are misclassified as HIVpositive should not be ignored. The average false-positive rateis 13%, as shown by confirmatory tests done in twenty-eightnational reference laboratories.3

In India, the annual blood requirement is 4 million units, butonly half this amount is collected (1 95 million units in 1989).Of these units, 0 76 million are obtained by private andcommercial blood banks.’ The government of India envisagesthat HIV testing will eventually be done by these blood banksat their own cost. In a market economy, if the private bloodbanks choose to screen 0-76 million units of blood (at a roughcost of US$1-5 million), and subsequently destroy HIV-positive blood (purchased at a cost), it would be a bigachievement. Furthermore, to expect them to do confirmatorytests, without any tangible profit to the blood bank, is wishfulthinking. In this respect, it is noteworthy that, according to theDrug Controllers’ Office, 57% of government-managed bloodbanks are unlicensed. 4

We support the view that the objective of blood banks is toprovide safe blood, and current testing policy of not informingthe donors about their HIV status is realistic.

Shashi Kant, L R MurmuDepartments of Community Medicine and Surgery, All India Institute of MedicalSciences, New Delhi 110 029, India

1 Ministry of Health & Family Welfare. National AIDS controlprogramme India-country scenario: an update. New Delhi:Government of India, 1993: 13.

2 Gellert G, Moore DF, Greenwood R, et al. More on office-basedtesting for HIV. N Engl J Med 1993; 328: 1717-18.

3 Snell JJ, Supran EM, Esparza J, Tamishiro H. World HealthOrganization quality assessment programme on HIV testing. AIDS1990; 4: 803-06.

4 Ministry of Health & Family Welfare. National AIDS controlprogamme India-country scenario: an update. New Delhi:Government of India, 1993: 61-65.

HIV testing: reduce costs by all means, butnot at all costs

SIR—As stated by Tamashiro et al (July 10, p 87), anti-HIVantibody screening costs can be reduced by alternative

strategies based on one or several tests. The classical strategyinvolves a screening test which, if positive, is followed by aconfirmatory western blot (WB) on a new sample. WHO haspublished guidelines on the interpretation of WB and on