Why the rush to change blood donation deferral policies for men who have sex with men?

Commercial sex workers and men who have sex with men (MSM) in Britain and Scotland are to be allowed to donate blood three months after they last had sex (see also here, here and here).

The rule changes will come into force at blood donation centres in Scotland in November and in England in early 2018.

The Government accepted the recommendations of the advisory committee on the safety of blood, tissues and organs (SaBTO) and are introducing the changes under ‘equalities reforms’.

The rule change will allow more people to donate blood without compromising blood supply safety, experts say.  

Gay rights advocacy groups have praised the move as a triumph for science over prejudice and stigmatisation. Education Secretary Justine Greening (who is herself ‘gay’) has said the changes ‘would build on the progress made in tackling prejudice in the 50 years since the partial decriminalisation of homosexuality’.

All blood that is donated in the UK undergoes a mandatory test for HIV, Hepatitis B and C, and some other viruses.

During the HIV/AIDS epidemic of the 1980s, most of the developed world instituted a permanent ban on blood donations from men who have sex with men (MSM). This is because of the high risk of transmission from sex practices, such as anal intercourse, which are used in high frequency by this group.

People do not easily forget the 'tainted blood scandal', where around 4,670 British haemophiliacs were infected with Hepatitis C - and a further 1,243 co-infected with HIV. More than 2,000 people have died because of their HIV and Hepatitis C infections, while many others are terminally ill.

They were infected through contaminated clotting factor products, which were supplied by the National Health Service in the 1970s and 80s.

International comparisons

In recent years, countries around the world have revised their blood donation policies regarding gay and bisexual men, and other men who have sex with men (MSM).

As of 2015, Austria, Germany and Belgium still had lifetime bans for MSM who wish to donate blood.

The lifetime ban on MSM donating blood was lifted in 2011 in England, Scotland, and Wales, and in 2016 in Northern Ireland and was replaced with a one-year deferral period for sexually active MSM.

The United States lifted the lifetime ban on MSM from donating blood in 2015, replacing it with a one year deferral policy allowing MSM to donate if they abstain from sex for 12 months.

Other countries followed suit, while Italy and Spain have implemented deferral policies based on individual risk assessments regardless of sexual orientation.

Canada reduced its lifetime deferral for MSM to five years in 2013 and to one year in 2016.

Japan, the Netherlands, Australia and New Zealand all have one-year deferrals for MSM blood donation.

In Italy and Spain, donors are screened for high-risk sexual behaviour regardless of the sex of their partners or their sexual orientation. Deferrals are made based on individual risk.

But thus far no one has adopted a three month policy.

The American Red Cross policy is especially sobering:

‘If you ever tested positive for hepatitis B or hepatitis C, at any age, you are not eligible to donate, even if you were never sick or jaundiced from the infection. You should not give blood if you have AIDS or have ever had a positive HIV test, or if you have done something that puts you at risk for becoming infected with HIV. You are at risk for getting infected if you… are a male who has had sexual contact with another male, in the last 12 months’

Scientific basis

Britain’s proposed new policy does have a scientific basis. The nucleic acid test (NAT) used to screen blood can detect HIV in just 9–11 days after infection. New technological advances greatly decrease the risk of HIV-infected blood escaping detection; however, they cannot completely eliminate the risk of HIV in the blood supply. Therefore, NAT technology should be used in conjunction with comprehensive individual risk assessments that can adequately screen potential donors for low- and high-risk sexual behaviours.

It is important to keep this in context. The risk of getting HIV from a blood transfusion is lower than the risk of getting killed by lightning. Only about 1 in 2 million donations might carry HIV and transmit HIV if given to a patient.

The risk of having a donation that carries hepatitis B is about 1 in 205,000. The risk for hepatitis C is 1 in 2 million although if you receive blood during a transfusion that contains hepatitis, you'll likely develop the virus.

But the cost of infection is great and just one infection would be a tragedy.

Are we applying the same risk management principles in all areas of population health or do we make a special case of leniency when it involves the LGBT lobby I wonder? I raised similar questions about the speed at which approval the HIV prevention drug PrEP was railroaded through late last year.

Reason for caution

I argued back in 2011 that allowing sexually active gay men to donate blood was simply not worth the risk and would recommend that readers revisit that article.

Whilst detection technology has moved on one has to question why going down to a three month deferral period after last sexual contact for both men who have sex with men and commercial sex workers is necessary now given that NHS Blood and Transplant have said there is not currently a shortage of blood in the UK.

Also given that MSM make up just a tiny proportion of the UK population and that far fewer of them will abstinent from sex for a three month period, what is the urgency with this measure?

It would seem sensible to err on the side of caution rather than rushing into this especially given that the majority of the international community are being much more cautious.

The push for this seems to be coming much more from gay rights advocacy groups like the National AIDS Trust and Terence Higgins Trust rather than from any pressing need. And it seems that the aim to avoid stigma for gay and bisexual men is the main driver rather than to address any real clinical priority.

People will be reluctant to question the policy in these circumstances for fear of being accused of discrimination but the powerful media support for this relatively insignificant story speaks volumes about just how powerful the gay rights advocacy media machinery is and the level of priority the mainstream media, and especially the BBC, gives to its stories. 

High Court rules in favour of NHS providing 'HIV prevention drug' but big questions remain

The High Court has today ruled that the NHS in England can fund a drug that can reduce the chance of people catching HIV whilst engaging in high-risk sexual activities.

NHS England had previously argued that local councils should provide PrEP ('pre-exposure prophylaxis') as 'health prevention' is their responsibility.

But Mr Justice Green said that NHS England had ‘erred’ and that both it and the local authorities were able to fund the drugs. Summing up, he said:

‘No one doubts that preventative medicine makes powerful sense. But one governmental body says it has no power to provide the service and the local authorities say that they have no money. The clamant [the National Aids Trust] is caught between the two and the potential victims of this disagreement are those who will contract HIV/Aids but who would not were the preventative policy to be fully implemented.’

The ruling has understandably evoked praise from gay rights campaigners and AIDS charities but consternation from NHS England which intends to appeal the decision. They are concerned about the effectiveness of the strategy, the precedent it creates for funding other 'disease prevention' measures and the way resources might be drawn from other health priorities were it to get the go-ahead.

The once a day pill known as PrEP, trade-named Truvada, consists of two antiretroviral medications used for the treatment of HIV/AIDS (tenofovir and emtricitabine or TDF-FTC) and costs £400 a month per person. The total cost to the health service could be in the order of £10-20m.

It is currently used in the US, Canada, Australia and France to help protect the most at-risk gay men.

According to the CDC (Centers for Disease Control) PrEP is for people who do not have HIV but who are at substantial risk of getting it.  It should be used in combination with other 'HIV prevention' methods, such as condoms, but even in these circumstances is not foolproof.

The CDC reports studies have shown PrEP reduces the risk of getting HIV from sex by more than 90% when used consistently. Among people who inject drugs, PrEP reduces the risk of getting HIV by more than 70% when used consistently.

But these figures are what is achievable with good adherence (consistent use), and many of those most at risk are very likely not to adhere with taking the pills regularly.

An authoritative Cochrane review is far less reassuring. Overall, results from four trials (Baeten 2012; Van Damme 2012; Grant 2010; Thigpen 2012) that compared TDF-FTC versus placebo showed a reduction in the risk of acquiring HIV infection by about 51%.

Marked differences between the studies were attributed to differences in levels of adherence.

As one major review has concluded:

‘The efficacy of PrEP is dependent on adherence, and adherence to PrEP medications in efficacy studies has been variable, raising questions about whether persons who are prescribed PrEP in clinical settings will be adherent enough to derive protection.’

Furthermore the drug’s use may in fact lead to a paradoxical increase in other sexually transmitted infections (gonorrhoea, chlamydia etc) by encouraging more high risk behaviour from those who have been lulled into a false sense of security.

This well-known phenomenon whereby applying a prevention measure results in an increase in the very thing it is trying to prevent is known as ‘risk compensation’.

I have previously blogged on the fact, surprising to some, that morning-after pills don’t actually cut teen pregnancy rates and instead increase the incidence of sexually transmitted infections (see also here). 

The term ‘risk compensation’ has also been applied to the fact that the wearing of seatbelts does not decrease the level of some forms of road traffic injuries since drivers, feeling more secure, are thereby encouraged to drive more recklessly.

In the same way making PrEP freely available to already promiscuous homosexuals could well encourage more sexual risk-taking and more sexually transmitted disease as a result. Any effect on decreasing HIV transmission rates is then cancelled out by rising levels of promiscuity.

Many will be shocked at the levels of promiscuity reported in these high-risk groups. In one study in the Cochrane database, during screening, participants reported an average of 12 coital acts per week with an average of 21 sexual partners in the previous 30 days.

It is only when these facts are known that the highly addictive nature of high-risk sexual activity, especially amongst male homosexuals, becomes evident. PrEP is not a prevention strategy at all. It is rather a harm reduction strategy aimed at lessening the damage that people addicted to high-risk sexual behaviours are doing to themselves. More akin to clean needles for drug addicts, filter cigarettes for smokers, protective gloves for compulsive burglars or seatbelts for habitual joy-riders.

As has been recently argued with respect to PrEP for drug addicts, 'PrEP is not ready for our community and our community is not ready for PrEP'. We need instead to address the underlying structural drivers and social context of the HIV epidemic and ask what it is that actually leads people to behave in this way. 

PrEP may reduce the risk of HIV transmission significantly but it does not eradicate it. That is because it is not actually a 'prevention' strategy at all but a 'harm reduction' strategy. And lack of adherence and ‘risk displacement’ simply add to the problem. This means that those who rely on PrEP for protection against HIV are still effectively playing Russian roulette, with the willing assistance and collaboration of health professionals.

NHS England is right to challenge this judgement. We will need much more evidence that PrEP is truly effective in practice before embarking on this strategy, which brings us back to the bottom line in all this: The only way of preventing HIV infections, as opposed to reducing the chance of catching them, is by avoiding the high-risk sexual behaviours that lead to them.