Moving Past the Gay Blood Donation Ban: A Time for Re-evaluation
While blood utilization rates are difficult to estimate, existing evidence suggests between 41 and 71% of individuals will need blood at some point in their lives. Causes for blood transfusion include acute injury, surgery, chronic liver disease, bleeding disorders (e.g., hemophilia), or anemia. To meet the demand for blood products, Canadian Blood Services (CBS) estimates that nearly 100,000 new donors are required annually. Tasked with managing the supply of blood products, nationally organized blood collection agencies (BCAs), such as CBS and Héma-Québec (HQ), provide chronic and acute blood users with safe and reliable sources for blood transfusion. However, the sustainability of these voluntary, non-remunerated blood donation schemes rely on the civic participation of blood donors. Currently, however, CBS estimates that less than four percent of Canadians participate in blood donation and evidence suggests that donor participation rates are declining in other North American jurisdictions.
Hoping to improve the sustainability of the blood supply, hundreds of studies have been conducted to investigate factors associated with donor participation. In 2013, a literature review and meta-analysis by Bednall and colleagues showed that prosocial motivators are salient antecedents to blood donation. Based on these findings, Bednall et al. noted that public opinion of blood supply services and normative attitudes towards blood donation play an important role in shaping donor rates and preventing blood supply shortages. Given the documented political and civic engagement of blood donors, it is therefore vital that BCAs have concerned themselves with managing public perceptions towards blood donation and blood supply services. This is, of course, in addition to their responsibility to control transfusion transmitted infections (TTIs) and their goal of minimizing potential societal harms resulting from differentiating blood deferral guidelines.
At the intersection of these diverse and sometimes contradictory mandates, men who have sex with men (MSM) are routinely deferred from donating blood due to elevated incidence of HIV in this population. Presenting itself as a significant and increasingly salient public relations concern in which real risks must be balanced against meaningful civic and social values, the MSM deferral policy has been regularly identified as a liability to promoting voluntary blood donation. For example, Haire, Whitford, and Kaldor (2017) report that the existing 12-month deferral for MSM – which is endorsed by several developed countries, including Canada, the United Kingdom, and Australia – poses a challenge to BCAs by hampering civic trust and providing a basis for donor noncompliance to blood safety protocols. Furthermore, these behavior-based deferrals – much like travel- or health-related deferrals (e.g., prescription drug use, low hemoglobin) – are a known long-term deterrent to blood donation. While less than 5% of all deferrals are given to MSM, the perceived discrimination against this vulnerable population is concerning to many, including the BCA’s who are charged with maintaining the safety of the blood supply. As such, CBS has continually sought to align its MSM deferral policy with existing epidemiological evidence and international standards. As a result of these efforts, CBS has twice revised its blood deferral policy for MSM. In 2013, a 5-year time-based deferral was implemented and in 2016, CBS further reduced its deferral to 12-months. Empirical evaluations of these changes show that they have had no impact on HIV rates and advocates suggest that additional reductions in the deferral period are warranted based on the weight of existing evidence. Furthermore, some have suggested that the deferral policy amounts to a 12-month abstinence requirement for MSM, which is unlikely to significantly change donor participation in this group. Thus, MSM are excluded from the benefits of participating in blood donation. Given the notable social capital wielded by MSM as well as their capability in mobilizing potential donors through annual gay pride parades and other LGBT-focused events, the blood deferral guideline represents a significant missed opportunity for promoting civic participation in maintaining Canada’s blood supply.
Rationalizing shorter time-based deferral policies for MSM, the use of antibody testing and nucleic acid amplification testing to screen donated blood samples has greatly reduced the risk for TTIs. While testing alone is not a satisfactory screening mechanism for HIV, when blood products are appropriately screened using these tests, HIV can be identified with nearly 100% sensitivity in as little as 7 to 15 days after an initial infection occurs This suggests that, with regards to HIV, the existing blood deferral policy is 24 to 52 times longer than what is needed to maintain the safety of Canada’s blood supply. Furthermore, it is important to note that behavioural risk among MSM is not uniform. MSM who are in monogamous long-term relationships as well as those who do not engage in anal sex or who use condoms during anal sex are unlikely to acquire HIV. So while MSM in general may be at elevated risk for HIV, donation from some sub-groups of MSM effectively poses no additional risk when compared to the risk from those in the general population. Recognizing this, several countries (Portugal, Spain, and Italy) have transitioned to a behaviour-based deferral which does not specifically target MSM. This highlights the need for more sensitive and specific deferral criteria that go beyond MSM status and explore the risk-factors that actually predict recent, non-detectable infection.
Yet, consensus has not been achieved with regards to optimizing donor eligibility guidelines; nor is there agreement regarding the best screening mechanisms for identifying deferral candidates. Indeed, while the CBS’s 2012 Ipsos Survey indicates that a revised deferral policy is massively popular among MSM and young potential donors (key groups with low donor participation rates), it is unclear how the emergence of alternative risk reduction technologies, such as pathogen reduction/inactivation systems, might change the debate regarding MSM donor eligibility. Additionally, it is unclear whether changing donor deferral guidelines will significantly impact donor behaviour. As such, there is a need for further evaluation of the MSM donor deferral and screening policy – particularly from the perspective of potential donors and blood-users. Such an evaluation would ideally engage multiple stakeholder groups – including MSM, blood product users, prospective donors, and current donors who are routinely screened for deferral.