alternatives and their implications for individual risk reduction (Carman, Levine interviews; NHF 1982a,b, 1983).

The initial discussions between the NHF leadership and experts from CDC, FDA, and PHS, and industry about the report of three immune-suppressed hemophiliacs resulted in immediate concern and specific recommendations [Medical Bulletin #4 and Chapter Advisory #5, December 1982] from the NHF to the commercial and voluntary blood community (NHF 1982a,b). These recommendations included implementing donor screening and testing measures as well as expediting efforts in viral inactivation methods. Even as early as November 2, 1982, an NHF letter to manufacturers of AHF concentrate urged the exclusion of high-risk donors of plasma (Carman and Aledort, 1982). The timing, range, and advocacy of these recommendations on behalf of instituting these risk-reducing changes in the blood industry is evidence that NHF officials had access to information and did appreciate and take seriously the warnings from the CDC. The MASAC was well aware of the alternative approaches to treatment as early as January 1983 and in some instances made recommendations for their use. On January 14, 1983, MASAC officially recommended a range of clinical options for reducing the risk of HIV exposure for mild or moderate hemophiliacs and previously untreated cases.

As indicated in Appendix C, the communication strategy of the NHF did reveal incremental modification of several recommendations as new information became available (e.g., avoiding sexual contact, considering heat treatment), but provided it relatively late and did not provide physicians with further information on how to switch severe hemophiliac patients to cryoprecipitate.

When plasma fractionators began to withdraw suspected lots of AHF concentrate found to be associated with a donor known to have or suspected of having AIDS (see Chapter 6), physicians had to intensify their efforts to communicate the risks associated with blood and blood products to patients and to notify patients who may have been using, or have in their possession, contaminated lots of AHF concentrate. Dr. Jenne Lusher stated, ''It made it much more apparent to our patients; even if they were not involved in the recall, a particular recall, they would hear all about it. … They all interacted with each other, knew each other. They began to fear that if one of us from the [treatment] center called them, it was because the product was being recalled (Lusher interview). On May 11, 1983, the Hemophilia Newsnotes referred to the recent recall by Baxter [Chapter Advisory #8, May 1983]. In August 1983, the NHF noted two additional recalls of contaminated lots, one by Baxter (Hyland Therapeutics) and one by the American Red Cross. The NHF sent a notification within days of learning of a recall. However, the NHF communications did not always reach the patient, and in some instances the information about the recalled product came from the pharmacy or the physician (Jason interview) and in some cases not at all (Kuhn interview).

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