Ban on Gay Men's Blood

[MithLuin]

While hospice decisions can be made by the patient, they are more often made by the family. It's a difficult position to be in, to say, 'no, don't treat my loved one - just let them die.' Obviously, no one words it so harshly, but that is essentially what families are asked to consider.

Ultimately, this is why it's a bad idea to feed sheep brains to cows. It's lousy that that bad decision hurts someone so severely so many years later.

[MithLuin]

Original thread topic

I was curious what the risk of contracting HIV from a blood donation was these days - it's one in two million. As Anthy's story amply demonstrates, if you are that one...it sucks. The main group that is saying they don't want the ban removed without sufficient research is the hemophiliacs association. If you have to have frequent blood units over the course of your life, you certainly want to protect the supply.

My mom almost bled to death when my brother was born; she required 2 units of blood. She remembered one of the last things the doctor said to her before they gave her the transfusion was 'Don't worry, you won't get AIDS.' (She didn't.) This was 1988, so I have wondered since how confident he should have been of that assurance.

The proposal seems to be to limit the lifelong ban to a one year ban. That would make it similar to other high risk factors for contracting HIV, and give people time to figure out if they are infected or not. It seems reasonable to me, but I don't know all the numbers.

[Frelga]

I don't understand the one year deferral part. Do they mean a one year wait after every encounter? That would still rule out most gay men, wouldn't it?

The ban based on high-risk behavior makes much beter sense to me. Someone in a committed relationship, however composed, would be a negligible risk compared to those with multiple partners, wouldn't they?

[nerdanel]

Anecdotally speaking, I have encountered more men in same-sex relationships than any other pairing (i.e., women in same-sex relationships, men and women in opposite-sex relationships) who, despite a primary relationship they view as committed, choose to have sex outside of that relationship, or to bring additional person(s) into that relationship (e.g., threesomes). I say this with some hesitation, because my knowledge is both anecdotal and specific to the San Francisco Bay Area, which may have little predictive value for the rest of the country.

For instance: http://www.nytimes.com/2010/01/29/us/29sfmetro.html - describes what I am talking about. Even though it begins with the story of a lesbian couple and purports to speak about "gay and lesbian" couples, I seriously question whether open relationships are as common within the lesbian world as within the gay male world. The article quote this statistic:

The Gay Couples Study has followed 556 male couples for three years — about 50 percent of those surveyed have sex outside their relationships, with the knowledge and approval of their partners.

(ETA: The Gay Couples Study is affiliated with UCSF, and their home page is here.)

I would still be willing to classify these relationships as "committed", but I would not classify them as low-risk for STDs. Any revised standard for blood donation likely should not include people in non-monogamous MSM relationships (whether it should also exclude people in non-monogamous MSW/WSM relationships, in the interest of fairness and/or safety, is a separate question).

[Inanna]

But how does say, Red Cross, figure that out? So you're gay, committed, but when was the last time you had sex outside your relationship - hmm, No, can't donate.

Doesn't seem realistic to me.

[Frelga]

Well, how does the Red Cross determine who is gay?

And nel, you are right, I should have said exclusive rather than committed. To me, these words are synonymous, but it's a wide world out there.

[nerdanel]

Mahima -- I think it is perfectly realistic. I am not clear on the following statistics, and how they relate to each other: the risk of HIV transmission in unprotected heterosexual sex, unprotected gay male sex, protected heterosexual sex, and protected gay male sex. Knowledge of these statistics is necessary to identify which groups should be screened further.

Assuming for the sake of illustration that it is unprotected sex, whether M/F or M/M, that significantly increases the risk of HIV transmission, then the following questions could be asked of all donors:

Have you had unprotected sex with [another man or a woman (for male donors) / a man (for female donors)] within the last 12 months? (or whatever the risk period is determined to be)

If, on the other hand, it is gay sexual contact, whether protected or unprotected, that significantly increases the risk of HIV transmission, then the following questions could be asked of male donors. (If it is only unprotected gay sexual contact that is of concern, the word "unprotected" could be inserted in the below questions.)

Have you had sex with another man, even once, since 1977? (I believe some variant of this is the current question.)

If yes:

How many [male] sexual partners have you had within the past [relevant period - say, between 1-5 years]?

If the idea is that a gay man must be in a monogamous relationship to be sufficiently low-risk for HIV to donate, then the only acceptable answer to this question would be 1. An answer of two or more would lead to a temporary deferral, until the relevant period is cleared. If the answer is 1, a follow-up question might be merited:

Are you in a strictly monogamous relationship with your partner? OR To your knowledge, how many [male] sexual partners has your partner had within the past [1-5 years]? (This might identify some relationships in which the would-be donor has not had any other sexual partners, but his romantic partner has had other sexual partners of which he is aware.)

Certainly the proposed questions are invasive, but I am not sure they are more so than the questions that are currently asked. To the extent that the NYT is accurately describing a norm in (a subset of) gay culture -- couples who are comfortable with/unashamed of open relationships -- the Red Cross may actually be more likely to receive straightforward/honest answers from gay couples about their secondary couplings than from heterosexual couples, where "extramarital liaisons" are usually not had with the consent of the other partner, and are stigmatized.

[Inanna]

You guys are right - my perspective in this was wrong.

Blood donation is a voluntary activity - so if the Red cross does have a clear set of rules, which would enable people to self-select themselves out (as nerdanel described), no reason why it should not work. It works right now, presumably.

[yovargas]

For instance: http://www.nytimes.com/2010/01/29/us/29sfmetro.html - describes what I am talking about. Even though it begins with the story of a lesbian couple and purports to speak about "gay and lesbian" couples, I seriously question whether open relationships are as common within the lesbian world as within the gay male world. The article quote this statistic:

The Gay Couples Study has followed 556 male couples for three years — about 50 percent of those surveyed have sex outside their relationships, with the knowledge and approval of their partners.

Well. That was depressing as hell.

[Primula Baggins]

If fidelity's fundamental to you, yov, that's the kind of relationship you'll end up in. It just isn't fundamental to a lot people, gay and straight. A way of thinking I completely don't understand, BTW, but no one's asking me to.

[Frelga]

What Prim said. Statistics of this sort are largely irrelevant to the individual.

On topic - it strikes me that the only question that needs to be asked is, "Did you have unprotected intercourse (with a male partner?) either since or less than two weeks before your last negative AIDS test?" Even that is a bit too resrictive as it does not account for monogamous couples who have both checked for AIDS years ago, but better safe than sorry. A side benefit might even be to encourage people to get tested for AIDS.

[nerdanel]

What Prim said. Statistics of this sort are largely irrelevant to the individual.

On topic - it strikes me that the only question that needs to be asked is, "Did you have unprotected intercourse (with a male partner?) either since or less than two weeks before your last negative AIDS test?" Even that is a bit too resrictive as it does not account for monogamous couples who have both checked for AIDS years ago, but better safe than sorry. A side benefit might even be to encourage people to get tested for AIDS.

I think this question would exclude what's likely the lowest risk group of gay men other than the celibate: those who have intercourse with a single, monogamous (romantic) partner. After years together, they would presumably no longer continue to get tested for HIV, and I imagine that they are at least as likely as any other group to want to drop the condoms once in a committed monogamous relationship. Also, the question does not account for the fact that people can be mistaken about "protected" (e.g., condom malfunction or improper usage) -- which is (in my understanding) part of why the current guidelines don't distinguish between protected and unprotected to begin with. Finally, I don't understand the "two week" limitation -- my understanding is that HIV usually is detected within three months after infection, but can take as long as six months. The guidelines I've heard are - if you want to have unprotected sex within a monogamous relationship, get tested, wait six months (while using protection), get tested again, and if it's negative and you are confident that the relationship is truly monogamous, then you can stop using protection. I'm not sure how a two-week period fits into any of that.

yov -- ironically, I have encountered lesbians in SF who bemoan the lack of openness to polyamory. All you need is one person who feels as you do, and if 50 percent are in openly open relationships (again, in SF - where the norms are probably the most permissive in America), then some portion of the remaining 50 percent are in actually monogamous relationships. You'll find one of them.

[Frelga]

Re the two weeks - I was going from memory of the article linked upthread, which stated that HIV virus can be detected 9 days after the infection. Of course the rules need t reflect the best actual science.

Re monogamous couples - yes, I know. However, each person can really only answer for their own fidelity.

And, yes, strike "unprotected."

[Primula Baggins]

There are tests that can detect HIV very soon after infection, but they're extremely expensive compared to routine screenings that can't. From a public health standpoint, it's far better to ask people to go through the routine Nel mentioned.

[yovargas]

The regular HIV test does not detect the virus but the antibodies that the body produces in response to the virus. The test has a certain sensitivity level so the body needs to produce enough of the antibodies before the test can detect them. Many people have a detectable level of antibodies within a month of infection, most by three, and nearly 100% by six.

The test that directly tests for the virus is indeed more difficult and expensive, as well as taking much more time (a few weeks, iirc; antibody tests have been developed that can tell you if you're positive within 30 minutes). It is, to my understanding, usually only used if the first test is positive.

Just bit of information on the subject from memory.

[MithLuin]

Most risk factors (as calculated by groups such as the CDC) aren't as interested in the specifics of your situation, but about whether or not you belong to a high risk group. Meaning, if you know the needle used for your tattoo was sterile and never punctured anyone else...that doesn't mean you get to donate blood before the deferral period has passed. If you lived in the UK but never ate beef, same thing. If you went to a high risk malaria country but never left your air-conditioned hotel room and didn't get any bug bites...tough. Your choices are to a) lie on the questionnaire or b) not donate blood at this time. Just because you know (or strongly suspect) everything is okay doesn't mean they want your blood.

Does this mean they turn away some low-risk donors? YES, all the time. Do the Red Cross questionnaires let through some high-risk donors by forgetting to ask other questions? YES. The system is not perfect, and should be revised as often as flaws are found in it.

But the end goal should be a safe blood supply. If you turn away too many donors, you will have too small of a blood supply, but if you accept people you shouldn't...well, that can spell disaster, too.

So, are men who have had sex with men since 1977 at higher risk for having HIV than the general population? Ummm, yes, definitely. Here's the CDC's statistics:

MSM made up more than two thirds (68%) of all men living with HIV in 2005, even though only about 5% to 7% of men in the United States reported having sex with other men. (link)

Estimates of the proportion of men who engaged in same-sex behavior differed by recall period: past year = 2.6% (95%CI, 2.2-2.9); past five years = 4.0% (2.8-5.3); ever = 7.0% (4.7-9.2). Based upon the five-year recall period, we calculated an HIV diagnosis rate of 692/100,000 and a syphilis rate of 121/100,000 for MSM in 2007. For HIV and syphilis, respectively, the rate was 60 and 61 times the rate for other men and 54 and 93 times greater than the rate for women. (source)

Yes, I understand that if you are monogamous and neither of you are HIV+, then of course your risk is not any different than the rest of the population. Just like if you are a strict vegetarian, your chance of contracting CJD by visiting another country is no higher than someone who stays home. But the Red Cross would rather deal with the group than the individual, so certainly there is going to be a restriction of some sort based on men having sex with men. A one year deferral period would be more reasonable, but dropping it altogether would be irresponsible. After all, people are more likely to remember 'Did you go to England?' than 'Did you get a hamburger there?' - the details are easier to mistake, so simple, direct questions are more useful. In other words, the Red Cross doesn't really care if you think your partner is not cheating on you and/or the condom never broke. They just want to know if you (you being a man) have had sex with other men. They're okay with asking recently rather than ever, but they need an okay from the FDA for that.

Of the estimated 9,209 children under 13 years of age who have been diagnosed with AIDS within the 50 states and the District of Columbia, 8,434 (92%) were probably infected with HIV through mother-to-child transmission. Most others were infected through receipt of blood, blood products or tissue. Avert.org

A small percentage, true, but that's the lives of over 700 kids we're talking about. Yes, we screen the blood. It shouldn't happen....but it still does.

Also, while I'm on the subject of evaluating risk...not all sexual activity is equally likely to infect you with HIV. Yes, you can get AIDS from a single sexual encounter of any kind with an HIV+ individual if bodily fluids are swapped. But that doesn't mean the chances are the same. People are very reluctant to put this in terms of '1 in 1000' style risk factors, because people will be likely to misunderstand and say 'oh, then it won't happen to me; I don't have to worry about that.' But if you hunt around, you can find numbers, and they do vary.

Receptive anal intercourse (i.e. being the “bottom”) carries a higher risk of HIV transmission than receptive vaginal intercourse. The lining of the anus is more delicate than the lining of the vagina, so is more likely to be damaged during sex. Any contact with blood during sex increases the risk of infection. Avert.org

IIRC, women are more likely to get HIV from an infected man than vice versa in vaginal intercourse, but that doesn't mean there aren't cases of men who discovered their HIV+ diagnosis after trying to have a baby with their female partner...and she remained uninfected.

And while I'm not sure the studies that have been done on the topic are altogether reliable, it seems possible that a circumcised male is less likely to contract HIV from an HIV+ female than an uncircumcised male (but that an infected male is more likely to transmit the virus to a female if he is circumcised). Of course, using the same knife to circumcise adult men increases the risk of HIV infection ridiculously.

One reason STDs are considered such a good indicator of risk for AIDS is because you are more likely to transmit most other STIs than HIV. Meaning...the risk of getting HIV is lower than another infection. So...if you've been engaging in behavior that led to acquiring an STI, continuing that behavior puts you at a higher risk of contracting HIV eventually. That, and any kind of sore makes the transmission of HIV more likely, as well as increasing the viral count in secretions.

Most people in the US who are living with HIV/AIDS do not transmit the disease to anyone else. By 'most' I mean 95% (in 2000) - so people are being responsible and getting tested and would know better than to donate blood...for the most part. It's that other 5% the ban is aimed at, as well as all those people who simply don't know yet that they are HIV+. (source)

CDC estimates that one-quarter of HIV-infected people are unaware of their HIV infection and that these persons account for more than half of all new infections. To help ensure that all persons know their HIV serostatus, CDC recommends that everyone in the United States aged 13–64—regardless of perceived risk—get tested for HIV to help stop the spread of this disease. In addition, CDC recommends that sexually active gay and bisexual men be tested for HIV at least once a year. (source)

I don't understand the one year deferral part. Do they mean a one year wait after every encounter? That would still rule out most gay men, wouldn't it?

The ban based on high-risk behavior makes much better sense to me. Someone in a committed relationship, however composed, would be a negligible risk compared to those with multiple partners, wouldn't they?

The high risk behavior in question is men having sex with other men, because such a high percentage of that population (relatively speaking) is infected with HIV. Being in a monogamous relationship with someone only rules out your risks if that person was not infected with HIV before the relationship began. Even leaving aside people who don't know that they are infected, the six month lag time on HIV testing, and the possibility that people would cheat and not inform their partners -- it's going to be considered a risk factor even if you know your blood is safe.

According the article I linked in an earlier post, altering the ban from a lifelong one to a year after the last time a man had sex with a man would allow some people to donate blood who could not before.

A one-year deferral period on blood donations by men who have had sex with another man would yield an estimated 89,000 additional pints annually, according to a study by the Williams Institute at the UCLA School of Law.

[yovargas]

A one-year deferral period on blood donations by men who have had sex with another man would yield an estimated 89,000 additional pints annually, according to a study by the Williams Institute at the UCLA School of Law.

[/quote]

Anyway to know how much that would increase the blood supply, percentage-wise?

[Primula Baggins]

Not much, apparently; the Red Cross collected 15 million donations in 2001, from 8 million donors.

Of course, for those who are told they can't donate because of who they are, this isn't the point.

[yovargas]

I was just wondering if perhaps their logic is something like "this would increase out blood supply 0.4% but increase the risk of an infected blood supply 0.6% so this isn't worth it". Which I get. The galling thing isn't the plain factual observation that gay men are a higher risk factor, it's that they go to such an extreme about it - if a man received oral sex from a man once (a very low risk act) 25 years ago, you are excluded; any woman that man has sex with is excluded too. That seems to go far beyond a rational "gay men are a higher risk factor" - anyone who was infected that long ago would've known way before they showed up at the blood bank - and into actual fear of homosexuals.

[nerdanel]

I think that the extreme nature of the ban (I do agree with your characterization) is probably related to the time in which it was drafted. As far as I know, the language of the FDA policy has not been revised since the mid-1980s. When the ban was put into place, I don't think that the differences between anal and oral sex (and perhaps not the differences between giving and receiving) for purposes of HIV transmission were fully understood. Of course, open homophobia was also more prevalent then, but it's not clear to me that that was the only (or main) factor in play. In fact, when I read "And The Band Played On," I was struck by how long it took to put the ban in place. I came away with the sense that gay men were valued by blood donation organizations as "good citizens" - they donated disproportionately relative to the mainstream - and there actually seemed to be a reluctance to cut off that source of donors until it became indisputable that they were a high-risk group for HIV.

So I find the wording and scope of the original restriction less galling than our slowness to revisit it. This argument is hard to make, because it is often rebuffed by, "Well, it's about the safety of the nation's blood supply, anything else is secondary, and this has nothing to do with, say, the civil rights of gay men." I certainly agree that the foremost concern must be the safety of the nation's blood supply. But a secondary concern is the volume of the blood supply - I can't count how many times I've received "critical shortage" emails from the Red Cross and similar. HIV negative gay men may be able to play a critical role in filling this shortage -- perhaps even are likely to do so, if their pre-HIV-epidemic donations are any indication. And I certainly think that stigmatization and exclusion of gay men - the only sexuality wholly excluded from donating blood if sexually active - is a valid tertiary consideration, particularly if that exclusion is based on an historic, incomplete understanding of what sexual behaviors render men high-risk for HIV.[/list]