Bad blood: gay men and blood donationBMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b779 (Published 27 February 2009) Cite this as: BMJ 2009;338:b779
Most gay men in most Western countries are banned from donating blood for life. The screening test for donors on the website of the National Blood Service for England and North Wales, for example, asks, “Are you a man who has had oral or anal sex with another man (even if you used a condom)?” Answering yes results in an automatic no thank you.1
Men who have ever had sex with men are also excluded from donating blood in most other European countries and in the United States2 and Canada,3 but several developed countries have alternatives to permanent, blanket bans—for example, Spain, Australia, and New Zealand.
Outright bans have become increasingly controversial, and in February the gay rights group Stonewall changed its position after a two year review and called for the UK blood services to apply the same risk assessment to homosexuals as it applies to heterosexuals.4 Last November the Scottish parliament rejected a petition supported by Amnesty International to revise the ban in Scotland.5 6
Blood services introduced policies of “lifetime deferral” in the 1980s, soon after the start of the AIDS pandemic, to try to protect the blood supply from infections that can be transmitted through blood transfusion, such as HIV. Although blood services test donations, screening is fallible. The public expect total safety and after the infection of many haemophiliacs with HIV and hepatitis C through transfusion, blood services are wary of any changes in policy that might increase rates of transmission.
UK health ministers are advised on blood safety by the independent Committee on the Safety of Blood, Tissues, and Organs, whose members include doctors and scientists. The committee’s position is that the service must give the highest priority to ensuring that blood provided to patients who need a transfusion is safe. “Men who have sex with men should be excluded from donating blood to protect the blood supply from transfusion transmissible infections,” it says.7 8 The policy is reviewed regularly, and the next review, scheduled for July 2009, will be informed by research being undertaken by the Health Protection Agency and the blood services.
Prudence or prejudice?
Currently, lifetime deferral applies even if homosexual sex happened only once, decades before, and involved only oral penetration. A promiscuous heterosexual who does not use condoms for anal intercourse is not necessarily excluded, however, and poor communication of the complexity of the situation has led to widespread perception of the ban as homophobic. Campaigns against lifetime deferral have resulted in two UK student unions banning the blood service’s adverts.9 And some US organisations, including a university and student unions, have banned blood collection campaigns in their buildings.10 11
The National Blood Service of England and North Wales says that to allow people in groups that are at high risk of carrying HIV and other blood borne diseases would lead to an unacceptable rise in risk of transmission of these diseases. It says that men who have ever had oral or anal sex with men are disproportionately affected by HIV, accounting for 63% (1897/3024) of diagnoses for infections likely to have been acquired in the UK, citing data for 2006 from the Health Protection Agency.12 13
The UK services screen all donations for antibodies to HIV and hepatitis B and surface antigen for hepatitis B. One of the limitations of testing for antibodies is the long “window” between infection and antibodies being detectable, which can be months for HIV. Tests for HIV RNA or for the p24 antigen have much shorter windows but are not mandated for blood screening in the UK, although countries such as New Zealand and Spain use them. False negative results and accidental release of blood that tests positive can also occur.
The bans in the UK and elsewhere are based on statistical modelling published five years ago that concluded that removing the exclusion might result in a fivefold increase in the risk of HIV infected blood entering the blood supply.14 Changing deferral to one year from the last homosexual contact would increase the risk by 60%, the researchers predicted. The research provides no estimates for the risk associated with a longer finite deferral, and the researchers admit in their paper that they made “many assumptions” in their modelling and “the accuracy of the estimates is therefore uncertain.”
The Terrence Higgins Trust, the UK’s largest HIV and sexual health charity, says that the policy is justifiable and sensible and is “first and foremost a public health issue.” But it says that to lessen accusations of homophobia the National Blood Service should improve the quality of its communication.15
Opponents of the ban argue that the policy is based on outdated research; that safe sex campaigns have increased condom use and awareness of HIV status among individuals; and that advances in testing blood should make it possible to accurately identify infected donations. They also say that gay men live a plurality of sexual lifestyles, including lifelong married monogamy, and that research should investigate risk from donations from low risk gay men. Some argue that the current policy panders to and reinforces stereotypes of gay and bisexual men, with stigmas of disease, promiscuity, and untrustworthiness.
Although its policy excludes most gay and bisexual men, the blood service tries to avoid the charge of homophobia by rationalising that exclusion depends on specific sexual behaviour rather than the sexuality of the potential donor, but its policy acts to exclude all men who have sex with men, whether healthy or not.12 That lesbians may donate, it says, shows that its policy is not grounded in prejudice. The service acknowledges that there are “a range of lifestyles among gay men,” but says that it is “neither feasible, nor appropriate” for its staff to take a detailed sexual history from every donor.
A petition for lifetime deferral to be abolished with 5236 signatories was delivered to the UK prime minister in 2007.16 His response repeated the recommendations of the independent advisory committee and explained that each year out of nearly three million donations collected in the UK and Ireland about 40 test positive for HIV.17 A third to a half of these donations turn out to be from men who are gay.
Another argument for lifelong deferral is to protect the supply from some currently unknown pathogen. The US Blood Safety and Availability Advisory Committee predicts that five years’ deferral would protect its supply against such an entity.18 Although infections that are transmissible through transfusion have a history of dissemination through homosexual sex, blood services cannot know whether a new pathogen might be preferentially transmitted through heterosexual sex.
The National AIDS Trust, which campaigns to change social attitudes towards AIDS, however, is not convinced by the arguments for permanent deferral. It has asked the UK blood services to commission research so that deferral periods are based on accurate and up to date evidence, to ensure the safety of the supply and no unnecessary discrimination. Deborah Jack, the trust’s chief executive, asked why no research had been commissioned on deferral periods longer than one year and commented, “A lifetime ban becomes increasingly indefensible when, for example, there would be next to no one alive with undiagnosed HIV fifteen years after they were infected.”19
Other countries have taken different approaches. In 1999 New Zealand introduced a policy of deferral for 10 years. And in 2007 an expert committee recommended five years’ deferral with clearer definitions of risky sexual behaviour.20 The committee acknowledges, “For gay men more than any other group, it could appear that deferral was on the basis of identity not behaviour.” No RNA positive, antibody negative donations have been detected since nucleic acid testing was introduced in 2000.
Around the world
United Kingdom (www.blood.co.uk)—Lifetime deferral for men who have ever had sex with a man
Spain (http://donarsangre.org)—In the late 1990s Spain moved from excluding homosexual men to excluding people with promiscuous sexual behaviour from donating blood. In Catalonia anyone who has had more than one sexual partner in the past six months is excluded
France (www.dondusang.net)—Although the US ABC Newsletter of September 2006 indicated that the French minister of health had announced that “the blanket prohibition on blood donation by gay men will end soon,” lifetime deferral is still in place
Italy (www.avis.it)—The Italian ban on gay blood donation was repealed in January 2001, but “risky behaviour” is still taken to include all men who have sex with men and lifelong deferral is applied
New Zealand (www.nzblood.co.nz)—Donations are not accepted from men who have had sex with men within the past 10 years. Last year the service’s advisory committee recommended a deferral period of five years with clear definitions of which sexual activities warrant deferral
Australia (www.donateblood.com.au)—One year’s deferral for men who have sex with men plus specific questions about sexual history
United States (www.fda.gov/cber/faq/msmdonor.htm)—Donations banned from all men who have had sex with a man since 1977
Canada (www.bloodservices.ca)—All men who have ever had sex with a man since 1977 are indefinitely deferred
Australia has a one year deferral period, and Spain focuses on promiscuity rather than homosexuality. Blood services in Spain, as in many countries, are decentralised so policies differ from region to region. For example, the Catalonian screening questionnaire asks donors whether they have in the past six months had many partners or slept with someone whom they know has had multiple partners.
Different countries have different epidemiological distributions of HIV and other transmissible diseases. “Each blood service must make decisions as to who can give blood based on the most up to date evidence of disease patterns in their populations; so what is appropriate for one country may not be for another,” says the UK blood service.12
Services around the world often have severe blood shortages. Gay men have traditionally been reliable donors, and tapping into the pool of healthy men who have sex with men should be investigated. Soldan and Sinka estimated a 2% increase in donations if the UK moved to a one year deferral.14
Since lifetime deferral was introduced our understanding of HIV transmission and detection and the sexual behaviour of men who have sex with men have increased considerably. In Tasmania the one year deferral is being challenged in court, and new equality legislation makes a challenge to lifetime deferral likely in the UK.
The primary duty of blood services is to ensure the safety of blood for recipients, but they also have a duty not to discriminate unnecessarily against donors. Any exclusion of a group from participation in normal society must be based on clear and current evidence. Blood services should be proactive in seeking out this evidence. It seems unlikely that lifelong deferral of men who have sex with men is a sustainable policy, but whether a finite period will appease opponents remains to be seen.
Department of Health Advisory Committee on the Safety of Blood, Tissues and Organs (SaBTO)—www.advisorybodies.doh.gov.uk/acsbto
Terrence Higgins Trust—www.tht.org.uk/informationresources/policy/healthpolicy/blooddonations
Cite this as: BMJ 2009;338:b779
Competing interests: None declared.