Out with the ‘gay blood ban’

So-called “gay blood bans” are controversial internationally but change is on the way. The New Zealand Blood Service has reduced the period people must wait before they donate blood from 12 months to three, following certain behaviours. One of these behaviours is sex between men due to the ongoing HIV epidemic.

The change reflects evidence that a three-month deferral period will not increase risk to blood recipients. It means Aotearoa New Zealand has one of the least restrictive deferral policies in the world, along with Canada and the US.

This is a step in the right direction. It addresses the view of some gay and bisexual men that their ongoing exclusion from blood donation is unjust, unscientific and inconsistent with current HIV prevention approaches. But it still prevents, unnecessarily, many low risk gay and bisexual men and takatāpui (Māori gay and bisexual men) from donating life-saving blood.

Further improvements can be made to the policy by tackling two broad conundrums.

The first is the “social good conundrum”. Society portrays donating blood as a valued civic act imbued with high moral status, and many gay and bisexual men want to donate to help others and perform an important duty of citizenship. However, rejection from blood donation denies them access to these social benefits and can be stigmatising. The policy can fuel inaccurate stereotypes about gay men being reckless, and plays into a wider sense of exclusion from important health and cultural institutions that many gay men already experience.

Although 20 percent of all potential blood donors are deferred for various reasons, gay and bisexual men often feel singled out. These are individuals who are often highly engaged. They want policies that are as fair as possible and view gay blood bans in a context of historic alienation, discrimination and poorer mental health for Rainbow communities.

The second challenge is the “epidemiological conundrum”.

In Aotearoa, HIV transmission is concentrated among gay and bisexual men and takatāpui who, as a group, are approximately 873 times more likely than a heterosexual person to contract HIV. On the other hand, many individual gay men practice safe sex consistently, or are in steady relationships, and their chance of having contracted HIV in the last few days or weeks prior to donating blood is negligible. Low-risk gay and bisexual men and takatāpui could potentially donate blood safely and sooner than after three months.

If we can identify low-risk gay men, we estimate up to 35,000 more people could donate life-saving blood, the policy would be more inclusive and, most importantly, it wouldn’t increase risk to the blood supply.

It might also be asked that, if all donated blood is tested for HIV and other serious infectious diseases, why do we need deferral criteria at all? As Covid-19 has reminded everyone, no test is 100 percent perfect, and there is a small (but not zero) chance of the test not detecting a very recently acquired infection. For HIV, the “window period” (during which a person may test “negative” but be infectious) is five to seven days after infection using state-of-the-art tests. In rare cases it could be weeks. This means a precautionary deferral period for people who have, potentially, been recently exposed to HIV is justifiable, but it also suggests that three months is unnecessarily long for low risk individuals.

Another bugbear is the apparent inconsistency of blood donor criteria with contemporary safe sex guidelines. HIV prevention has undergone nothing short of a revolution in the last five years. Many gay men are using combinations of condoms, regular testing, HIV pre-exposure prophylaxis (PrEP) and HIV antiretroviral treatments to minimise transmission. The outcome has been encouraging so far: in Auckland, diagnoses of locally-acquired recent HIV infection have reduced dramatically among gay and bisexual men since 2016. Successful education campaigns also mean many gay and bisexual men have a relatively sophisticated awareness of HIV transmission science, especially that oral sex carries virtually no risk of HIV.

Consequently, they identify a dissonance between what trusted peer-based HIV prevention organisations are advising and the government’s blood donor policy: Many gay and bisexual men are being safe and responsible, but blood services are marking them as “unsafe”. However, there is fair reason for the dissonance. The safety threshold for blood donation needs to be much higher than for consensual sex. Blood recipients typically need blood urgently, they have little or no choice, and if the transfusion has HIV it will almost certainly result in infection. Blood donor policies are always going to be more precautionary than safe sex advice.

Furthermore, people using PrEP or post-exposure prophylaxis (PEP) to prevent HIV must be deferred for three months since last dose, because those treatments could mask recent infection from being detected. And people living with HIV on treatments with an undetectable viral load are still permanently deferred. This is appropriate since the concept of “undetectable = untransmittable” applies to sexual contact, not blood transfusion.

So, what could future deferral criteria look like? The UK has recently moved towards an individual risk assessment. Potentially, this will mean gay and bisexual men in exclusive long-term partnerships can donate and oral sex is no longer grounds for deferral.

Here in Aotearoa, evidence is lacking to support a more liberal policy but the good news is we are leading a multi-agency study to address this. That study will begin in 2021 to inform the next NZ Blood Service decision. Ultimately, we want to strike a blood donor policy that maintains safety for recipients, maximises the donor pool and promotes inclusion.

Dr Peter Saxton was a member of the Independent Expert Advisory Committee for the 2014 Review of Blood Donor Criteria.