Rethinking the blood donation policies
This commentary is the opinion of the author and does not necessarily reflect that of other authors at Box Turtle Bulletin.
March 8th, 2010
In 1983, the FDA established a policy requiring that blood banks not accept donations from any male who had engaged in sex with any other man at any point since 1977. This was implemented so as to attempt to eliminate blood which was potentially infected with the HIV virus from the pool, and it made sense at that time.
It wasn’t until 1983 that the HIV virus was identified, and a method of testing for the virus wasn’t established for another two years.
In 2006, the AABB, America’s Blood Centers, and American Red Cross jointly asked the FDA to reconsider these rules. They argued that continuing the ban was not justified by scientific advances since the ban was implemented.
AABB, ABC and ARC believe that the current lifetime deferral for men who have had sex with other men is medically and scientifically unwarranted and recommend that deferral criteria be modified and made comparable with criteria for other groups at increased risk for sexual transmission of transfusion-transmitted infections. Presenting blood donors judged to be at risk of exposure via heterosexual routes are deferred for one year while men who have had sex with another man even once since 1977 are permanently deferred.
Current duplicate testing using NAT and serologic methods allow detection of HIV- infected donors between 10 and 21 days after exposure. Beyond this window period, there is no valid scientific reason to differentiate between individuals infected a few months or many years previously. The FDA-sanctioned Uniform Donor History Questionnaire was developed recognizing the importance of stimulating recall of recent events to maximize the identification of donors at risk for incident, that is, recent, infections. From the perspective of eliciting an appropriate risk history for exposure to HIV and other sexually transmitted infections, the critical period is the three weeks immediately preceding donation since false negative NAT and serology reflect these window-period infections, and the length of these window periods provide the scientific basis for the deferral periods imposed for at risk sexual behaviors.
The FDA refused.
They argue that as gay men have a higher concentration of HIV infection than some other demographics, this justifies a blanket ban on all donations by all gay men.
Men who have had sex with men since 1977 have an HIV prevalence (the total number of cases of a disease that are present in a population at a specific point in time) 60 times higher than the general population, 800 times higher than first time blood donors and 8000 times higher than repeat blood donors (American Red Cross). Even taking into account that 75% of HIV infected men who have sex with men already know they are HIV positive and would be unlikely to donate blood, the HIV prevalence in potential donors with history of male sex with males is 200 times higher than first time blood donors and 2000 times higher than repeat blood donors.
This week, Senator John Kerry, along with several other Senators, sent a letter to the FDA requesting that they reconsider their rules.
“Not a single piece of scientific evidence supports the ban,” the Democratic senator said in a statement. “A law that was once considered medically justified is today simply outdated and needs to end, just as last year we ended the travel ban against those with HIV.”
I doubt that this will be effective. If the FDA refuses to listen to those who know the very most about donation, testing, infection, and the blood supply, why would they listen to John Kerry?
But Kerry’s action does allow us as a nation to re-question why the ban is in place. Is it a matter of heath science or a matter of mistrusting (or disliking) gay men?
The FDA argues that any increased risk of tainting the supply is unacceptable. And that allowing gay men to contribute would unquestionably increase that risk.
But is that true? Does the ban effectively increase the safety of our blood supply? Or does it actually do harm?
To answer these questions, I think we need to look closer at the ban and how it functions.
1. The ban is only as effective as it is perceived to be reasonable. Remember, the ban is voluntary; by that, I mean that the only thing which stops donation is a questionnaire and the donor’s decision to answer honestly. If a gay man is determined to donate, he will only be persuaded not to donate if he believes that the criteria of exclusion is based on reason and not on bias.
2. We must assume that only a psychopath would choose to purposefully donate HIV infected blood. And no questionnaire is going to stop a psychopath. Therefore, this purpose of the questions is to eliminate those who are unknowingly infected.
But who donates blood? According to the Red Cross, only 3 out of 100 of Americans donate. And this 3% is not representative of the population as a whole.
Yes, blood donors come from all races, ages, political affiliations, and economic situations. But they have one thing in common, they are motivated by altruism or a belief that it is in the common good that they donate. They donate because it is the “right thing to do”.
And let’s be practical here for a moment. The type of person who donates blood is not generally the type of person who is irresponsible. If you are a ‘give blood’ type of gay man, you are probably also a ‘get tested’ type of gay man.
So the only unaware HIV-positive infected gay men who are likely to be prevented from donating are those who have good reason to believe (falsely) that they are HIV-negative. That’s not a very big demographic.
3. The FDA does not exclude other demographics who are infected at higher rates than the population at large. For example, over half of all new HIV infections detected in 2007 were in African Americans. While many of those infected are also MSM (men who have sex with men, a term used by the infectious disease community), many are heterosexual. Over 60% of women with AIDS are black. (AVERT)
The estimated lifetime risk of becoming infected with HIV is 1 in 16 for black males, and 1 in 30 for black females, a far higher risk than for white males (1 in 104) and white females (1 in 588).
There are many reasons for this (and for godsake let’s allocate more resources to stemming this trend) and I’m not trying to make comparisons or demonize anyone. But it does demonstrate that the FDA’s banning policies seem inconsistent.
The screening does seek to eliminate those women who might have had sex with a MSM or intravenous drug user in the recent past, but it does not issue a blanket ban based on race (nor should it). However, the “ever had sex at any time in your friggin’ life” definition effectively serves as a ban based on orientation.
So while the FDA does not say that the President of the United States is banned from blood donation based on his ethnicity, it does prohibit donation by Rep. Barney Frank.
4. Not all gay men are equally at risk. Homosexual activity does not create HIV. It is a virus, not a consequence of specific sexual acts. Only about 12% of gay men are infected with the HIV virus.
Yet the FDA treats my friends, a couple in their 40’s who met in high school and have been together ever since, the same as it does some gay man who is single and has an active and diverse sex life. Ironically (and amusingly) it considers ex-gays like Alan Chambers to be no less of a risk than the man whose fetish is to be the recipient in unprotected anal sex.
The FDA clumps gay men into a single demographic and assumes that all gay men are at a higher risk than all heterosexuals.
While statistics indicate a rising infection rate among young heterosexual women, their overall rate of HIV infection remains much lower than in men who have sex with other men.
But clumping in this manner is a foolish and rash policy. Contamination is more likely to come from a young single heterosexual woman who relies on the pill than it is from a gay man in a committed relationship who uses condoms regularly.
5. While the ban on gay men donating does not – in my opinion, as discussed in the points above – serve to diminish much risk of contaminating the blood supply with the HIV virus, it is quite effective at something else: labeling all gay people as dirty and diseased.
This universal ban says, in effect, that all gay men are suspect, a cause of concern, human rats carrying contagion. It feeds the myth that gay equals AIDS and lends credence to the anti-gay activists who market in fear and animus.
But is lifting the ban the answer?
I would argue that a full lifting of the ban is not a wise decision. That would increase – at least in some tiny measure – the risk of taint to the blood pool. Rather, I would advise to change the policy in a way that not only increases the blood supply and to reduces stigma but which also could serve an additional medical function.
Obviously the screening questions need to eliminate the risk of undetected recent infections. But such risks should be based on actual behavior based risk, not on stereotyping of communities. This may even serve to reduce the risk of accidental taint from gay men who ignore the current policy as being nothing more than bias.
Science-based periods of either long-term monogamy or sexual abstinence would likely be respected as reasonable and appropriate. Few gay men would argue that every gay man, regardless of sexual history or responsibility, should donate blood.
And revising the rules for donation to match the requests of the Red Cross would certainly be better than the current policy. But I recommend a different approach.
I recommend that all persons who have any risk of HIV transmission – be they gay men, single heterosexuals, or anyone else who could be at risk – be required to take an HIV test as a step in the donation process. Those persons who tested negative and who had no sexual contact for the previous six months (or whatever restrictions are reasonable) could be treated as acceptable donors. The oral swab tests are non-intrusive, give a response in 20 minutes, and are more than 99% accurate.
The current controls over the blood supply do an amazing job at detecting and removing infected blood. But implementing a screening method that is based on measurability rather than voluntary deferral would effectively eliminate unknown carriers, gay or otherwise.
And it would also reach a population of potentially at-risk citizens who might otherwise go undetected.
The single largest contributor to the spread of HIV is unknown infection. Granted, as I discussed above, those gay men who are most likely to donate blood are also among those most likely to be tested regularly. But HIV testing at a blood donation site could provide access and a safe friendly environment for non-gay people who might be a bit intimidated or uncomfortable asking their doctor or going to the testing center in the gay part of town.