By way of 1992 policy, men who have had sex with men (MSM) any time since 1977 are ineligible for blood donation. The FDA justifies this difficult decision mainly on grounds that MSM carry a significantly higher burden of HIV infection compared to the general population. Indeed, while gay men (a subset of MSM) comprise some 2% of the population, they comprise 56% of those carrying an HIV diagnosis in the United States (489,121). While public attention has been paid to this hot-button issue in the United States and in other countries, such as this CBS news report, we believe the current policy is possibly justified, but certainly inconsistent with other CDC donation policies, and the the American Medical Association and the American Association of Blood Banks appear to agree. Here we will focus primarily on the latter issue, as it pertains to everyone’s health more so than only the degrading feeling that non-infected gay men likely endure when attempting to give lifesaving resources back to their community.
There are many laudable policies written in the way the FDA regulates blood donation. If I take donated organ parts from an animal, I cannot donate, because not enough is known about possible infectiousness of animal cells. If I shoot a dose of anything into any vein of mine for recreation, I cannot donate. These seem reasonable enough policies. If we can’t ensure safety regarding blood from a tiny subset of the US population (one far smaller than the MSM population) in the animal organ recipients, or another (rather small) population engaging in seriously risky drug use, we’re just practicing good medicine. With 12.6 million units of whole blood donated every year, and roughly 23 million blood components used, it appears we just don’t currently need these small groups’ blood (recall that “whole blood” from donors is separated into plasma, packed red blood cells, and other components, thus the reason that one donation can be used for multiple patients).
Yet there are some 7.1 million men who have sex with men. Now here’s a group that is still fighting for basic rights, and, statistically, also carries a much larger disease burden than their heterosexual counterparts. We do not expect, as activist Dan Savage has written, every blunt tool in the public health tool shed to be able to provide exceptions for the subtleties of each population. However, we do expect for those blunt tools to be used equally to high-risk populations. For example, if a woman were to have sex with a man who has had sex with men, she need only wait one year before donating. Recall that the major reason HIV can spread so quickly in the gay male population is that they serve as both the penetrated and the penetrator. Those that are penetrated are more likely to be inoculated with disease due to microtearing, which would obviously also include women. Thus, we see the obvious odd double standard of saying “you’ve definitely been exposed, but we’ll just wait and then you’re okay to donate!” versus “you might have been exposed or might not have been exposed, but you can never donate.”
Despite the classic gay male stereotype, we believe the majority of MSM are either more like serial monogamists or active practitioners of safe-sex in condom use. In terms of HIV, these are the low-risk majority (82% by 2011 numbers) of a high risk group who are being actively excluded from blood donation because of unfortunate circumstances in a group they share little in common with other than being gay (do you, heterosexual readers, share kinship with other heterosexual readers by nature of liking opposite body parts?).
Don’t we test the blood? Is that good enough?
All donated blood is screened for a number of diseases including HIV 1 and 2, hepatitis C, syphilis among others, and yes, this is likely sufficient to catch virtually all infected blood products. In one way, this supports lifting any ban on MSM donations, or even that of other high risk groups. As stated by the UK-based HIV/AIDS prevention non-profit Avert, “the availability of of nucleic acid tests, which reduces the window period and makes testing much more accurate, helped to support the argument for a change in the ban against MSM donating. These tests have been found to almost eliminate the possibility that HIV infected blood will pass through the testing stage, even in countries with high HIV prevalence.” This is great news, and supports the move to a waiting period with subsequent negative test one year later without making it open season for donations from anyone at all.
How do other countries approach this issue?
While the United States claims there is little to no evidence to change the blood ban, this conclusion is by no means universal. Many Western countries over the last decade have changed their policies on blood donation from the MSM demographic because of the advancements in blood screening. In the United Kingdom, any male who has anal or oral sex with another male must wait one year regardless if a condom was used. This change was initiated in 2011 by the National Blood Service. Among other predominantly English speaking countries, Australia has a similar one-year deferral as the UK, Canada has a five-year deferral, and as of 2014, South Africa no longer has a deferment period. This phenomenon is not just linked to English speakers. There are many countries that have either a one-year deferral, like Japan and Brazil, or no deferral period, like Russia, Portugal and Chile. Most importantly, in those countries that have changed their rules on the blood ban, a 2010 study in the journal Transfusion found no evidence of an increase in transmission of HIV through blood transfusion. With an N value of four million and 4.96 million sample donations in non-deferred and deferred donation groups, we believe this to be very promising results.
How does banning MSM from donating blood affect the blood supply in the United States?
If we’re to stay true to the numbers, with roughly 1.1 million people that are HIV-positive in the United States, and a US population over the age of 18 that is approximately 243 million strong (and those are eligible to donate), there is a 1 in 242 chance that a random person that is HIV-positive will donate their blood. If we exclude MSM, who, recall, make up over half of the HIV diagnoses in this country (489,121), this number drops to a whopping 1 in 242.5, and this is pre-testing of the blood. Clearly, while it’s good to avoid donations from high risk groups, this is not an earth-shattering change. (Note that these numbers are not nearly exact, as not 100% of the approximately 242 million people over 18 are eligible to donate for any other reason, but the point stands: excluding MSM doesn’t cause a massive shift in risk as a blood transfusion recipient. It causes, by this bar-napkin calculation, a 0.0021% reduction.)
So, what next?
Maintaining distance from the political ruckus that follows any large scale public health decision regarding sexuality, we believe that the current FDA denial of blood from all MSM is inconsistent with their current acceptance of blood from other high risk groups including those who have been exposed in the past. Waiting times and changes in pre-donation questionnaires, in particular, seem a reasonable approach, and have been adopted in other countries. Partly to avoid offending the populations they serve, but even more so for public health, the FDA needs to be consistent in the risk stratification they use to guide blood collection. Unfortunately for the United States, despite the changing international landscape on MSM donating blood, the reaffirmation of the current blood ban in 2010 by the CDC and the FDA makes it is hard to believe these changes will happen any time soon. However, given the AMA and other large medical organizations’ support, we remain optimistic that the ban will change. For the time being, we’re not holding our breath.