Head To Head

Should men who have ever had sex with men be allowed to give blood? No

BMJ 2009; 338 doi: http://dx.doi.org/10.1136/bmj.b318 (Published 27 February 2009) Cite this as: BMJ 2009;338:b318
  1. Jay P Brooks, professor of pathology
  1. 1University of Texas Health Science Center, San Antonio, Texas, USA
  1. brooksj{at}uthscsa.edu

    Bob Roehr (doi:10.1136/bmj.b311) says that the current ban on blood donations from gay men is not supported by evidence, but Jay P Brooks says that the risk of transmission of infection is too great

    New HIV infections in the US among men who have had sex with men (MSM) declined in the 1980s and 1990s but increased by 11% from 2001 to 2005, and MSM still account for most new HIV infections.1 Men who have had sex with men since 1977 have an HIV prevalence 60 times higher than the general population, 800 times higher than first time blood donors, and 8000 times higher than repeat blood donors.2

    The approach to minimising infections in the US all-volunteer blood supply is two pronged—the donor questionnaire and laboratory testing. Testing for HIV includes antibody testing as well as molecular methods (nucleic acid amplification testing).

    Window period

    Some people have asserted that laboratory testing is so good that there should be no deferral period for MSM.3 Although testing is better than it has ever been, infections can be transmitted during the window period—the period between infection and detectability by laboratory testing. Additionally, laboratory screening, like most human endeavours, is fallible.

    Few blood banking experts favour dropping the ban entirely, but some sections of the US blood banking community have proposed instead a one year period, which they view as more congruent with other deferrals based on behaviour,4 such as the one year deferral of men who have had sex with a prostitute. Longer deferrals such as five years have been suggested. A study commissioned for the Canadian Blood Services by the McLaughlin Centre found no clear evidence that changing the deferral to five years would result in an increase in HIV risk for blood recipients. It did conclude, though, that a change to a one year deferral would increase the risk of HIV for blood recipients.5

    Given the extraordinary lengths to which blood services go to improve and add expensive tests, which make transfusion minimally safer, those who propose a change to policy should meet a burden of proof that they cannot: evidence that there would be no extra risk to transfusion recipients whatsoever.

    In fact, studies to elucidate the risk of changing to a shorter deferral period have failed to find scientific evidence to support such a change.6 7 8 One study in the United Kingdom estimated that the increased risk of HIV in the blood supply by substituting a one year deferral would be 60%, and no deferral period would result in a 500% rise.6 The same study indicated that the rise in non-infected donations would be relatively small, and another concluded that the rise would be negligible.9

    In the 1980s the blood establishment was criticised for being dilatory in banning donations from gay men to decrease the incidence of post-transfusion AIDS, and many have charged that donor centres were too deferential to their gay donors.10 It is ironic that the blood establishment now stands accused of being slow to return MSM to the donor pool.

    A right to donate?

    Some deferred donors and their advocates have asserted a right to donate, alleged unfair discrimination, and have labelled the MSM deferral stigmatising.11 12 It is not clear that changing the deferral period to one year would be viewed as less stigmatising or more acceptable to deferred donors than the current permanent deferral because many activists advocate dropping the ban entirely.

    The right of recipients to receive safe blood should trump the asserted rights of donors to give blood. The primary if not exclusive responsibility of blood collection centres and transfusion services is to provide adequate amounts of safe blood to recipients. An all-volunteer blood supply remains the single most significant advance in blood safety, and is the envy of developing countries throughout the world. In his book The Gift Relationship, Richard Titmuss portrays blood donation as an altruistic gift.13 But no fundamental right exists to make this donation and there is no requirement that a gift be accepted, whether that gift is an engagement ring or a unit of blood. If recipients were required to accept what was offered, even if well intentioned, it is not a gift.

    Protests and cancellations of blood drives have occurred. In the US, one university president halted a blood drive citing the MSM ban as a violation of the university’s non-discrimination policy.14 Although such actions have received much media attention, they have neither been widespread nor threatened the blood supply. In fact, a subsequent blood drive at the same university was merely relocated off campus property with no ill effect.15 Some deferred donors have elected to take positive steps: at the University of California in Berkeley, deferred students recruited eligible donors to give blood in their place.16

    Although episodic blood shortages occur,17 18 it seems unlikely that transfusion experts would tap the high risk donor pool of MSM were it not for the political pressure that has been exerted. No serious consideration has been given to re-entering other deferred groups such as former intravenous drug users or female sex workers who have refrained from high risk behaviours for an extended time, who could invoke similar arguments.

    Notes

    Cite this as: BMJ 2009;338:b318

    Footnotes

    • Competing interests: None declared.

    • Provenance and peer review: Commissioned; externally peer reviewed.

    • See Bob Roehr’s argument for, doi:10.1136/bmj.b311, and more about the situation in the UK and elsewhere, doi:10.1136/bmj.b779.

    References