On June 12, 2016, the LGBTQ+ community was targeted by a gunman, leaving 50 people dead and 53 people injured. Doctors treating the injured pleaded for people in the Orlando community to donate blood to save lives, but the US Food and Drug Administration (FDA) prohibited the very people who were targeted in the attack from donating blood.
In the wake of the Orlando LGBTQ+ nightclub attack, there has been renewed attention drawn to the ban on most gay men from donating blood—the group more precisely labeled men who have sex with men (MSM). Beginning in 1983, any man who had sex with another man since 1977 could not donate blood for the rest of his life. This rule was finally amended in 2015 to a year-long ban. That meant that a gay man would be able to donate blood for the first time in over 30 years, but to do so, he had to abstain from sex with another man for at least one year.
Many people have called for the complete removal of the ban, or at least an amendment to target specific risky sexual behaviors rather than a blanket ban on MSM. Indeed, when I first began the study of public health, I declared that my mission was to eliminate what I saw as one of the gravest extant health injustices toward such a specific group of people.
While I thought I was prepared to jump into the debate and end the ban immediately, learning the history of the FDA’s MSM blood donation ban was immensely important in understanding how it will ultimately be undone. Going into my historical study of the MSM ban, I expected to find an overzealous, hastily implemented reaction to a small problem of HIV entering the blood donation system. What I found was a failure to act quickly by the groups responsible for ensuring the safety of the US blood supply.
In And the Band Played On, the late journalist Randy Shilts documents all of the uncertainty around the HIV/AIDS epidemic in the 1980s. While the nation’s response to the overall problem is fascinating, what is particularly relevant to this discussion is the reaction by the blood banks. Despite mounting evidence from the Centers for Disease Control (CDC) of HIV being spread through blood donations, the consortium of blood banks pushed hard against any increased regulation of the blood supply. The blood banks feared a reduction in the nation’s blood supply because in cities like San Francisco, Los Angeles, and New York—cities in which the rates of HIV/AIDS were highest—gay men made up a large portion of the population donating blood. In some locations, they were responsible for up to 10% of blood donations. Ultimately, the decision to do absolutely nothing to protect the blood supply for so long allowed a greater number of HIV infections to be spread through blood transfusions. By allowing the problem to grow, the blood banks contributed to a culture in which the public is in favor of measures like the total lifetime ban of blood donations from any man who has had sexual relations with another man.
Thirty years later, the general public has shifted in their ideas about blood donations for MSM. One explanation is that we as a general public understand HIV better today. Around the time of the ban’s implementation, much of the public believed HIV to be strictly related to homosexuality. Today we understand the transmission of the virus through bodily fluids.
The other major factor in the shift of opinion about the MSM blood donation ban is the greater reliance on blood testing. Every blood donation since 1985 has been tested for HIV. While early tests may have been poorly calibrated, today the false positive rate is just 1 out of 10,000, and the false negative rate is far less frequent than that. In the last 12 years, no more than six people have been infected with HIV through the blood supply, despite there being an average of 13.6 million pints of blood donated each year. That works out to about 1 in every 25 million blood donations leading to a new HIV infection.
The tests are not perfect. There is currently a nine-day window period, a period between infection with HIV and the ability for a test to accurately indicate that the virus is present. This means that if an individual donates blood 5 days after obtaining HIV, it would pass the blood inspection and could potentially infect the recipient of the blood.
This may explain why, when eliminating the total lifetime MSM blood donation ban, the FDA opted for a 1-year deferral. If any man has sexual contact with another man, he cannot donate blood for one year. This certainly is an improvement over the lifetime ban, but it does not take into account a true assessment of risk. For example, a monogamous gay man is lower risk than a heterosexual man who has many unprotected encounters with multiple partners. The one-year deferral continues to discriminate solely based on sexuality. While true that HIV is more prevalent among male members of the LGBT community, much of this stigma is rooted in the early depiction of HIV as a purely gay disease.
Ultimately the MSM ban is largely unnecessary and discriminatory in application. A month-long deferral period for people who had unprotected sex with someone other than a spouse might be more appropriate based on risk assessment. The reluctance to lift the ban completely is likely a function of the negligence the consortium of blood banks exercised in addressing the problem when it was first identified in the early 1980s. Their inaction gave the public the perception that there was a major risk, but testing has largely assuaged those fears. The impact lifting the blood donation would have—which the UCLA Williams Institute indicated would be about half a million additional lives saved per year—is well worth further analysis of how to tailor the ban to reduce the risk and not discriminate against an entire community of people who only wish to assist their friends and neighbors. We cannot rely on past mistakes to justify the continuation of discrimination when testing and risk-appropriate deferrals would offer better protection of our blood supply.