Should men who have ever had sex with men be allowed to give blood? YesBMJ 2009; 338 doi: http://dx.doi.org/10.1136/bmj.b311 (Published 27 February 2009) Cite this as: BMJ 2009;338:b311
The lifetime ban on blood donation from men who have had sex with men (MSM) has no scientific justification, particularly when other high risk groups are not similarly excluded. Furthermore, the full costs of maintaining the ban often are not taken into account; they need to be tallied in making the risk-benefit decision.
Marc Germain and colleagues at the Hema-Quebec blood service, Montreal, estimate that changing the deferral of MSM to 12 months from when the last sex took place with a new partner would result in the release of only one more unit of HIV positive blood among the 15 million units a year processed in the United States.1
They have continued to refine this model, plugging in the effect of newer, more accurate screening tests and better epidemiological data on the changing face of the epidemic, which reduced the risk even further. Speaking from the audience during a panel discussion at the October annual meeting of the AABB, formerly known as the American Association of Blood Banks, Dr Germain told the international conference, “If we relax the criteria to one year, with the new analysis we estimate there would be one additional case of HIV every 2000 years.”
Eleftherios Vamvakas, head of pathology at Cedars-Sinai Hospital in Los Angeles, told that same audience that the risk from pooled platelets is 20 times greater than the risk of reducing the deferral of MSM to 12 months, even though pooled platelets are only 15% of platelet doses transfused in the US.2
In contrast, a 2007 analysis found a residual risk of transfusion transmitted hepatitis B infections of one in 153 000 units.3
Dr Vamvakas also compared the situation to that of human herpesvirus 8, the infectious agent that has been associated with Kaposi’s sarcoma, where transmission through organ donation but not blood transfusion has been shown,4 5 concluding, “Policy makers in North America appear to have been selectively precautionary in the case of MSM.
“In the absence of evidence of a consistent approach to safety, maintenance of the current MSM deferral cannot be scientifically justified.” Dr Vamvakas called for a consistent policy to tackle every aspect of safety with blood products, tackling the greatest risk first and then going down the scale. “Eventually we get to the risk of MSM, which is very, very small, much smaller than other risks that currently are implicitly or overtly accepted,” he said.
The lifetime ban was put in place in the United States in the mid-1980s, when little was known about HIV: tests for the virus were non-existent or crude; diagnosis was akin to a short term death sentence; and the disease was thought to be concentrated almost exclusively among gay men in the industrialised world.
Discrimination was embedded in the policy from the start. It does not distinguish between sexual acts, how recent or distant the exposure, or whether a man has been in a monogamous relationship, but eternally stigmatises any male same sex contact.
In the US people who fall into other categories of risky behaviour—for example, injecting drug users and female sex workers—are generally allowed to donate blood after a year’s deferral from the last risky activity.
The policy is administered through a screening questionnaire, and this process is flawed because people lie about engaging in activity that is frowned upon by some sections of society.6 This may be particularly true when blood donations are gathered at the workplace, or in religious settings, where there is social pressure to participate.7 The policy provides little protection.
The blood industry understood this; it quickly developed and continues to refine tests that screen the donation for the presence of HIV itself. And it has got very good at it.8
Costs of discrimination
Supporters of the lifetime ban point to the cost of increased risk of transmissions of HIV as the reason to maintain it. The costs of maintaining that policy should also be considered.
Perhaps the greatest cost, and the immediate reason why the question is before the public, is that college students are recognising the policy as unfairly discriminatory and increasingly are refusing to support it. Colleges are a large source of blood donations, but more importantly, they often are where the habit of lifelong donation is established.
Celso Bianco is executive vice president of America’s Blood Centers, the network that collects about half the blood in the US. He told an advisory committee of the Food and Drug Administration in 2006 that many centres are unable to collect blood, particularly in colleges and in other environments “because of a perception that we are being unfair.”
Before the AIDS epidemic, gay men were among the most loyal donors in the San Francisco Bay Area, contributing up to 10% of total donations there, and likely in other large urban areas where the greatest share of blood intense procedures, such as heart and major trauma surgery, are performed.
Change the policy
One group of US residents has a HIV prevalence 17 times that of their comparator: black versus white women. Yet there is no call for a lifetime ban on that demographic group from donating blood. Why? It is because we are more sensitised to racism than to homophobia. This must change.
Australia has had a one year deferral policy for all risk categories since 1992 and a record of one case of probable HIV transmission by transfusion since 1985. AABB has supported harmonisation to a 12 month deferral for all risk categories since 1997, and the American Red Cross adopted that position in 2006.9
FDA workshop on behaviour based donor deferrals in the NAT era. 2006. www.fda.gov/cber/minutes/nat030806t.htm
Is there a right to donate: the ethical issues involving msm deferrals. AABB panel discussion. 2008. www.softconference.com/aabb/acview.asp?SID=112754
UK National Blood Service. Exclusion of men who have sex with men from blood donation. Position statement 10 April 2008. http://guna.org.uk/UserFiles/File/POSITION%20STATEMENT%20-%20EXCLUSION%20OF%20MEN%20WHO%20HAVE%20SEX%20WITH%20MEN%20FROM%20BLOOD%20DONATION.pdf
Roehr B. The gift of life: gay men and US blood donation policy. Understanding existing discrimination and how it might be changed. 2001. www.libertyeducationforum.org/downloads/1h_whtpa_pbl00.pdf
Cite this as: BMJ 2009;338:b311