March 5, 2023

All in Vein? The Ongoing Struggle for MSM Blood Donor Equity

By Ethan Walsh

When I first arrived at Columbia last semester, I observed countless flyers posted around campus and emails in my school inbox encouraging students to participate in an upcoming blood drive. “Make a meaningful statement of support to those battling a tough fight. Donate blood today!”, one read. As a student interested in health and medicine and someone who hopes to help improve these fields however I can, I would have gladly welcomed the opportunity to have a small, but positive, impact on the world by donating my blood. Of course, I knew I could not participate in the drive, merely because I was a sexually active gay man—a member of “men who have sex with men” (MSM), per the formal terminology. At that point, MSM who had had sex in the past three months, as well as anybody who had had sex with any MSM in the past three months, were barred from donating blood to combat possible transmission of the human immunodeficiency virus (HIV). This policy was itself a relaxation of earlier guidelines’ deferral period of twelve months, only ushered in due to a blood shortage in the early stages of the COVID-19 pandemic. With blood crises abounding, rejecting individuals who would otherwise readily donate blood is troublesome.

Months following my personal frustration at being excluded, the United States (US) Food and Drug Administration (FDA) proposed a new system of determining eligibility for blood donation. Rather than blanketly banning MSM, the agency plans to assess individuals “using gender-inclusive, individual risk-based questions.” Though a definite step forward—as was shortening the MSM lifetime ban to twelve months, then to three months—the guidance remains rife with restrictive exceptions. Individuals taking pre-exposure prophylaxis (PrEP) medications to prevent HIV infection will be deferred for three months after their last dose, anybody who has had sex for money or drugs will continue having a lifetime ban, and in order to be eligible “prospective donors [cannot have had] a new sexual partner or more than one sexual partner and had anal sex in the past three months” (my emphasis). The details of the proposed policy thus problematize its supposed inclusivity. While non-monogamous MSM cannot give blood, non-monogamous, non-MSM populations can, provided they have not “had anal sex in the past three months”; research suggests most will not have. Anal sex does indeed carry a higher risk of sexually transmitted infections than other penetrative sex, but it is pertinent to emphasize here that all blood donations are tested for transmissible diseases, including HIV. Moreover, HIV transmission in blood donation is shown to be eclipsed by other viruses, such as hepatitis viruses B and C, West Nile virus, and human T-lymphotropic virus; these in turn are all surpassed by the risk of bacterial infections. Yet, the chance of becoming infected with any of these from donated blood is remarkably low, a testament to modern testing processes.

It must also be noted that HIV infection is in no way exclusive to MSM; though they make up the majority of cases in the US, the same does not hold true globally. Infection in women is most predominant around the world, an immense problem in sub-Saharan Africa (see my synopsis of the impact of imperialism on African healthcare; see also Matt Douglas-Vail’s analysis of neocolonialism’s exacerbation of the HIV/AIDS epidemic in the region). My focus on MSM is because they are the group principally affected by the new FDA guidelines, not to detract from the international victims of the ongoing epidemic. 

Regarding the first of the FDA’s above restrictions, research shows that antiretroviral medications to treat HIV infection can occasionally interfere with HIV testing, resulting in negative results for individuals with early infection: i.e., individuals who should be testing positive. With many shared components between these treatment drugs and PrEP, notably emtricitabine, the concern is that individuals taking PrEP with possible breakthrough infections might donate blood that evades HIV screening capabilities. The likelihood of this happening widespread is quite low, though. Breakthrough infections are rare for individuals taking PrEP and such a scenario would only be possible in the early moments of HIV infection, improbable to overlap with blood donation to a scale justifying this ban. With a substantial rise in MSM taking PrEP, preventing these individuals from donating blood does more harm than good. The task at hand is to improve diagnostic sensitivity, not to passively accept de facto exclusionary policy.

The history of discrimination in blood donation is well-documented and it should continue to be resisted. While it may not be a “right” per se to give blood, it is an essential process for saving lives in the US and worldwide. Stopping willing individuals from participating in this process hurts not only the individuals who need blood—those with blood disorders requiring transfusions, who need convalescent plasma for coronavirus treatment, whose elective surgeries are delayed because of shortages—but also the prospective donors. Preventing MSM from donating blood worsens the stigma against them because of the history of the HIV epidemic. One need only think back to the 2022 mpox outbreak to observe how MSM—though certainly the prevalent population for infection—became the target of blatantly homophobic rhetoric. In working toward more equitable global health outcomes, we need not accept paltry inclusion of marginalized communities as adequate but should demand genuine inclusivity, especially in times of rising anti-LGBTQ+ vitriol and legislation.

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