Debate Continues Over Blood Donation From Men Who Have Sex With Men

Laurie Barclay, MD

February 27, 2009

February 27, 2009 — Although some developed countries now accept blood donations from men who have ever had sex with men, most do not. A feature article and 2 other commentaries posted online first February 27 in the British Medical Journal debate the pros and cons of whether men who have sex with men should be allowed to give blood.

"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," writes Richard Hurley, technical editor of the British Medical Journal, London. "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."

Most European countries, the United States, and Canada have a lifetime ban on blood donations from men who have sex with men, whereas Spain, Australia, and New Zealand accept blood from these donors after a specified period has elapsed since the last sexual contact.

UK Policy to Be Reviewed

In the United Kingdom, the independent Committee on the Safety of Blood, Tissues, and Organs advises health ministers on blood safety. Its policy is that the service must give the highest priority to ensuring that blood provided to patients who need a transfusion is safe and that men who have sex with men should be excluded from donating blood to protect the blood supply from transfusion-transmissible infections. The next review of this policy is scheduled for July 2009, after consideration of research by the Health Protection Agency and the blood services.

According to the National Blood Service of England and North Wales, accepting blood donations from people in groups that are at high risk of carrying HIV and other blood-borne diseases would lead to an unacceptable rise in risk for transmission of these diseases. Health Protection Agency data from 2006 indicate that men who have ever had oral or anal sex with men are disproportionately affected by HIV, accounting for 63% of diagnoses for infections likely to have been acquired in the United Kingdom.

Although the UK services screen all donations for antibodies to HIV and hepatitis B virus and surface antigen for hepatitis B, there is a long "window" between infection and antibodies being detectable, which can be months for HIV. Tests for HIV RNA or for the p24 antigen, which are used in New Zealand and Spain, have shorter windows but are not required for blood screening in the United Kingdom. Other problems include false-negative results and the accidental release of blood that tests positive.

Statistical modeling published in 2004 indicates that removing the exclusion might increase the risk of HIV-infected blood entering the blood supply by 5-fold and that changing deferral to 1 year from the last homosexual contact would increase the risk by 60%. However, the accuracy of the estimates is limited by assumptions made in the modeling.

"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," Dr. Hurley writes. "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."

Roehr: Lifetime Ban Has No Scientific Justification

In a commentary opining that the lifetime ban has no scientific justification, Bob Roehr, a biomedical journalist from Washington, DC, notesthat other high-risk groups are not similarly excluded from blood donation. Drug users and female sex workers, for example, are permitted to donate blood after 1 year has elapsed from the last high-risk behavior.

Mr. Roehr cites research in which the investigators estimated that changing the criterion to 12 months from the last male-male sexual contact with a new partner would result in only 1 more unit of HIV-positive blood among the 15 million units a year processed in the United States.

He recommends adoption of Australia's policy, which has had a 1-year deferral for all high-risk categories since 1992, with 1 case documented of probable HIV transmission by transfusion since 1985. The American Association of Blood Banks has supported the 1-year deferral for all high-risk categories since 1997, as has the American Red Cross since 2006.

"Researchers are discovering that blood functionality begins to deteriorate much more rapidly than previously thought, putting a premium on temporal and geographic proximity of the donation," Mr. Roehr writes. "Finally, evidence is growing that indicates that discrimination and stigma have physiological consequences, including impaired immune function. The effect of this on gay men should also be part of the cost benefit analysis in re-evaluating deferral policy."

Brooks: Lifetime Ban Should Be Maintained

Offering the opposing viewpoint is Jay P. Brooks, professor of pathology at the University of Texas Health Science Center in San Antonio. His position is that the lifelong ban on blood donation from men who have had sex with men should be maintained because the risk for transmissible infection is too great.

Dr. Brooks points out that since 1977, prevalence of HIV among men who have had sex with men is 60-fold greater than in the general population, 800-fold greater than in first-time blood donors, and 8000 times greater than in repeat blood donors. He warns against relying on blood screening, even though improved, because of the often large window between infection and detection of antibodies.

He notes that protests and cancellations of blood drives have occurred, purportedly because of the discriminatory rules preventing blood donation from men who have sex with men, and that these have received much media attention but have neither been widespread nor threatened the blood supply. Despite episodic blood shortages, Dr. Brooks doubts that transfusion experts would tap this high-risk donor pool, except for the political pressure encouraging them to do so.

"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," Dr. Brooks concludes. "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."

The 3 commentary authors have disclosed no relevant financial relationships.

BMJ. Published online February 27, 2009.

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