Quantitative estimate of the risks and benefits of possible alternative blood donor deferral strategies for men who have had sex with men

Changing the deferral for men who have sex with men - an improved model to estimate HIV residual risk

BACKGROUND AND OBJECTIVES

Eight published studies modelled the impact of changing from a lifetime to time-limited deferral for men who have sex with men (MSM); each predicted greater risk impact than has been observed. This study uses these previous efforts to develop an 'optimized' model to inform future changes to MSM deferrals.

MATERIALS AND METHODS

HIV residual risk was calculated using observed HIV incidence/prevalence prior to the change in MSM deferral, then with the additional MSM expected under a 12-month deferral for five compliance scenarios, and finally using data observed after implementation of the deferral. Monte Carlo simulation calculated 95% confidence intervals (CI).

RESULTS

The architecture of reviewed models was sound, and two were selected for combination into the optimized model. HIV risk estimated by this in the UK under MSM lifetime deferral was 0·102 (95% CI: 0·050-0·172) per million. The model predicted from a 27·8% decrease to a 47·6% increase depending upon compliance pre-implementation of the 12-month deferral. A decrease of 0·9% was observed post-implementation. For Canada, HIV risk under a 5-year deferral was 0·050 (95% CI: 0·00003-0·122) per million. Pre-implementation of the 12-month deferral, the model predicted from 30·2% decrease to 10-fold increase. A decrease of 47·0% was observed after implementation.

CONCLUSION

The optimized model predicted HIV risk under 12-month MSM deferral in UK and Canada would remain low, and this was confirmed post-implementation. While the model is adaptable to other deferral scenarios, improved data quality would improve precision, particularly estimates of incidence in individuals likely to donate.

Blood’s ontologies-entangled: Qualitative inquiry into the enactment, representation, and organizational modes of coordination of blood’s multiplicity in a Belgian blood establishment

Since British sociologist Titmuss authoritatively conceived blood donation as an altruistic ‘gift relationship’, blood establishments have adopted blood’s highly symbolic status as a core professional belief. However, important developments since the 1970s have resulted in blood’s bio-objectification, making blood a renewed object of concern. Because different versions of this bio-object are simultaneously present and interfere with one another, we ask how the organization renders this multiplicity workable? Studying how ontological versions are enacted in a specific blood establishment and how the organizational model of a blood establishment functions as a mode of coordination, we develop a praxiographic appreciation of blood in the context of a specific Belgian blood establishment. We show how the organizational mode of coordination allocates versions of blood in specific departments along functional and chronological dimensions. Blood remains the object of a gift relationship but is accompanied by blood’s enactment and representation as the object of suspicion, management, research/biology, and a blood economy. Furthermore, the organizational mode of coordination also allocates personalized and depersonalized enactments according to the level of contact with the donor population. This reflects a third dimension: (de)personalization of blood. Whereas the organizational mode of coordination is successful in rendering blood’s multiplicity workable, at times, it causes suboptimal practices. Moreover, we showed how sometimes a focus on intra-departmental modes of coordination is necessary to understand how blood’s multiplicity complicates the practices of the blood establishment.

What is the evidence for the change in the blood -donation deferral period for high-risk groups and does it go far enough?

In November 2017, the deferral on blood donations from high-risk groups in Great Britain was changed to 3 months from last at-risk sexual contact following recommendations from the Advisory Committee on the Safety of Blood, Tissues and Organs. This represented a reduction from 12 months for men who have sex with men, and from a lifetime ban for sex workers. This is a step forward for equality and for reducing stigma around these groups. However, one argument for deferral is the prevalence of infections, which may not be identified due to the fallibility of current testing approaches. Clearly it is vital that the welfare of blood transfusion recipients is prioritised and they are not exposed to unacceptable risks. However, with the increasingly sophisticated technology used to screen blood, it can be argued that the evidence shows that the reduction in deferral does not go far enough.

Donor deferral policies for men who have sex with men: where are we today?

PURPOSE OF REVIEW

The review summarizes recent publications on the contentious issue of donor deferral criterion for men who have sex with men (MSM).

RECENT FINDINGS

Recent studies from the United States and China demonstrated that MSM is still a frequent risk factor for HIV-positive donors. Noncompliance is an important factor in the overall risk of HIV transmission but does not appear to be affected by the length of the deferral period. A major US study found a 2.6% noncompliance rate with the current indefinite deferral for MSM; similar or lower rates were found in other jurisdictions with shorter deferral periods. Several countries have had a defined deferral period of 1 year or 5 years in place long enough to determine that increases in HIV-positive cases predicted by modeling studies did not actually occur, suggesting that the assumptions made in these models are overly conservative.

SUMMARY

In summary, MSM eligibility policies are slowly changing around the world, with the US FDA now permitting a 1-year deferral. Transparency, involvement of stakeholders, and careful evaluation of risk and societal benefit should be part of future policy discussions on this issue.

Attitudes, perceptions and knowledge among men who have sex with men towards the blood donation deferral policy in Israel

BACKGROUND

Men who have sex with men (MSM) are permanently deferred from donating blood in Israel. Pressure to change this policy exists, despite data showing higher prevalence and incidence of HIV in MSM. A survey was conducted to evaluate current knowledge, attitudes, perceptions and compliance if deferral was changed.

STUDY DESIGN AND METHODS

Anonymous survey was published in a gay-oriented website, collecting demographic information, history of blood donation, attitudes, knowledge and compliance with permanent versus temporary deferral. Responses were analyzed given 1 point for every "yes" response (0-7 points). Student's t-test was applied to compare differences between continuous variables. Correlations were described with the Pearson correlation coefficient.

RESULTS

Responses from 492 MSM were analyzed. Average age was 31±9 years. 76% donated blood at least once, mostly for social solidarity (score of 3.2 on 1-5 scale). Tests seeking or protest scores were 1.7 and 1.6, respectively. 66% were unaware of the higher risk of HIV transmission by MSM, or the potential to infect 3 recipients. Knowledge regarding HIV transmission by blood positively correlated with knowledge regarding other routes of HIV transmission (r = 0.11; p = 0.03), age (r = 0.10; p = 0.04), and higher rate of non-compliance with the current deferral policy (OR = 1.9; p = 0.02). Activism for LGBT rights was associated with lower risk for non-adherence (OR = 0.5; p = 0.03). If temporary deferral is introduced 66% will comply with the new policy, but 23% will continue to donate as long as MSM deferral policy is in place.

CONCLUSION

A high proportion of MSM do not comply with the current lifetime deferral. This may partially change if temporary deferral is introduced.

Righting Anachronistic Exclusions: The Ethics of Blood Donation by MSM

Recently, the FDA announced that it would soon lift the long-standing lifetime ban on blood donation by men who have sex with men (MSM). Re-examining blood donation by MSM, it is clear that there are several ethical goods that must be balanced. Through balancing the primary duty to safety with the imperatives to craft a policy that is formally equal, upholds the public's trust, and is non-discriminatory, an ethical blood donation deferral guideline may be advanced, both for MSM and the population at large.

Should Men who have sex with Men be allowed to donate blood in Israel?

Background

The present permanent deferral policy in Israel for MSM was established in 1977 and was based on the previous (now outdated) USA Food and Drug Administration standards. This study analyses epidemiological data regarding blood donations among MSM, in order to estimate the risk for HIV transfusion transmitted infection (TTI) if the policy is changed to allow at-risk MSM to donate blood.

Methods

An Excel based spreadsheet model integrated demographic, epidemiological data from the HIV National Register, laboratory, blood donation and testing data in order to calculate TTI due to false-negatives in known HIV+ donors, windows period donations, asymptomatic carriers and laboratory misclassification errors. A sensitivity analysis of our estimated TTIs for deferral periods for MSM was performed based on a literature review regarding this overall policy issue worldwide.

Results

MSM in Israel have a considerably higher relative risk (RR) of both prevalence (115) and incidence (143) of being HIV+ than persons without a risk factor. Allowing MSM to donate blood, without any deferral period, will add an additional five HIV TTI cases over the next decade. Imposition of a 1 or 5 years deferral of abstinence will increase the number of HIV TTI cases only by 0.10 and 0.05 cases, respectively.

Conclusion

A 1 year deferral period for blood donations from MSM in Israel is recommended.

[Should we review, on ethical grounds, the conditions of access of men who have sex with men to blood donation?]

In France, men who have sex with men (MSM) were "permanently deferred" of blood donation. This measure reflected the fact that according to scientific research data, MSM have a higher risk to be infected notably by the human immunodeficiency virus. This "permanent postponement" was the subject of much debate as discrimination criterion. Can ethics be the basis for the reexamination of conditions of access of MSM to blood donation? It seems that ethics can and should in fact be reconvened in the reflections. The donor selection criteria should be regularly reviewed in the light of emerging risks. The exclusion must be reexamined, questioned again, remembering the reality and not enclosing blood transfusion in a secure dynamic unsuited to the reality of the risk. Also, it appears capital to keep the debate in mind, far exceeding that of blood donation to involve more that a legitimate search for equality and justice in a society. The debate must take account of these elements of reality, without leave to fascinate at the risk of providing an unadjusted answer to the original problem. Ethics seems to invite us in these discussions as they show the axes of reflection or problematization channels. Far from closing the debate, it opens the latter to new areas and participates in the advance of ideas, thus constituting a main actor.

The risk of allowing blood donation from men having sex with men after a temporary deferral: predictions versus reality

BACKGROUND

In most industrialized countries, men who had sex with men (MSM) are permanently deferred from blood donation. Some countries have adopted a temporary deferral after the MSM behavior, thus avoiding donations made during the window period of human immunodeficiency virus (HIV) infection. However, one concern with this approach is the possible increase in the number of HIV-positive donations obtained from unknowingly infected, abstinent MSM; such donations might inadvertently be made available for transfusion, a risk that was previously estimated through mathematical modeling.

STUDY DESIGN AND METHODS

Model predictions were compared to the actual donor rate of HIV in three countries that went from a permanent to a temporary deferral: Australia, the United Kingdom, and Canada.

RESULTS

Depending on the model, a temporary deferral should have increased the rate of HIV in the male donor pool by 73% to more than 3400%. In reality, the very low baseline rate of HIV before the change in these three countries (22 cases/year) remained unchanged 2 years after the revised policy (16 cases/year).

CONCLUSION

These observations strongly suggest that a temporary deferral for MSM incurs zero risk to recipients, at least in jurisdictions where HIV epidemiology is comparable to that of countries where the change happened.

Sexual risk behaviour and donor deferral in Europe

One of the most controversial policies in blood transfusion worldwide is the permanent deferral from donating blood of men with sexual contacts to other men (MSM). This policy was implemented for safety reasons as sex between men is known to be a high risk factor for acquiring severe infectious diseases transmissible by blood transfusion. Sexual contacts among heterosexual persons may hold similar risks but a clear-cut discrimination between different individual risks is impossible. Nevertheless, the current blood donor deferral periods defined by European Union (EU) legislation depend on a distinction of different grades of risk with respect to sexual behaviour. Under the aegis of the Steering Committee on Blood Transfusion (CD-P-TS) of the Council of Europe (CoE), an international working group evaluated epidemiological and behavioural data, modelling studies on residual risk and spread of infections, and studies on adherence to donor selection criteria. The aim was to distinguish sexual behaviour of different risk categories. It was concluded, that existing data confirm that MSM and commercial sex workers (CSW) are groups at high risk. Any further grading lacks a scientific data base. Modelling studies indicate that adherence to deferral policies is of major relevance suggesting that good donor adherence may outweigh the small negative effects on blood safety postulated for changing from permanent to temporary deferral periods for high risk sexual behaviours. The fact that a considerable percentage of donors are MSM - despite the permanent deferral policy - demonstrates the need to increase donor understanding and adherence.

The rates, perceptions, and willingness of men who have sex with men to donate blood

BACKGROUND

Since 1983 in the United States, any man who has had sex with another man (MSM) at any time since 1977 has been deferred from donating blood for life. Although there has been a push to change the deferral, there is a paucity of information on both the rates of MSM blood donation and the willingness of MSMs to donate if the deferral were changed.

STUDY DESIGN AND METHODS

A 15-question survey was given at two lesbian, gay, bisexual, and transgender festivals in Chicago and New Orleans. Participants were asked about a previous history of blood donation and whether they would be willing to donate were the lifetime deferral changed. Participants were also asked to determine whether it was safe for hypothetical MSMs with varying sexual practices to donate blood and whether they believed that it was safe for them to donate their own blood.

RESULTS

Our study found that 42.0% of all participants had not complied with the deferral policy and have donated blood at least once, with a mean number of donations of 4.84. Additionally, 85.9% of participants would be willing to donate blood if the deferral were changed.

CONCLUSION

Despite the lifetime deferral, many MSMs have previously donated blood, and many more are willing to donate. Given this, along with the safe implementation of temporary deferral policies in other nations, the United States should consider adopting a temporary deferral policy for MSMs.

Infectious disease transmission during organ and tissue transplantation

Transplantation of organs and tissues (bone, tendon, skin, cornea) will always be associated with some risk for transmission of infectious diseases from donor to recipient. Understanding and minimizing this risk is difficult for many reasons: donor screening processes vary, screening for every infectious organism is not possible, and assessment of recipient health after transplantation to determine possibility of disease transmission is often not adequate. In May 2010, the US Food and Drug Administration held a meeting to address these challenges and establish a research agenda for minimizing these transplant transmission risks. Attendees agreed that the focus should be on standardizing donor screening, compiling disease transmissibility data, monitoring of transplant recipients’ health, and assessing effectiveness of measures to minimize disease transmission. Collaboration and sharing of perspectives, experiences, and resources of all stakeholders in the transplantation process (government, private industry, and health care providers) can improve the safety of organ and tissue transplantation.

Infectious disease transmission through organ and tissue transplantation has been associated with severe complications in recipients. Determination of donor-derived infectious risk associated with organ and tissue transplantation is challenging and limited by availability and performance characteristics of current donor epidemiologic screening (e.g., questionnaire) and laboratory testing tools. Common methods and standards for evaluating potential donors of organs and tissues are needed to facilitate effective data collection for assessing the risk for infectious disease transmission. Research programs can use advanced microbiological technologies to define infectious risks posed by pathogens that are known to be transplant transmissible and provide insights into transmission potential of emerging infectious diseases for which transmission characteristics are unknown. Key research needs are explored. Stakeholder collaboration for surveillance and research infrastructure is required to enhance transplant safety.

How should we assess risk behaviour when determining donor deferral? Reflections on the MSM deferral

Concerns are increasingly being raised in a number of countries in relation to the behavioural donor criteria and in particular the on-going permanent exclusion of men who have had sex with other men (MSM). The justification for this is broadly linked to the use of risk models. Generally current exclusion criteria are broadly defined and indirectly it might be argued that this leads to exclusion based on sexual orientation. Available data indicates compliance issues with the exclusion and recent reviews in Europe have recommended that further research in this area is needed before any change in the current permanent exclusion should be made. Lobby groups however promote a more targetted approach to behavioural criteria. Firm data to support this is however currently lacking. There are a number of possible approaches to assessing risk including the period since the activity took place, the number of partners in a given period, the type of sex act or a combination of these factors. Definition of an optimal approach will need to consider both the sensitivity and specificity of the intervention along with an assessment of ease and consistency of application.

Surveillance of transfusion-transmissible infections comparison of systems in five developed countries

Most industrialized countries maintain surveillance programs for monitoring transmissible infection in blood donations, revising approaches to methodology and risk assessment as new threats emerge. A comparison of programs in the United States, Canada, France, the UK, and Australia indicates that they have similar function, although the structure of blood programs vary as does the extent and nature of formal ties with public health. The emergence of HIV in the late 1970s and early 1980s was key in recognizing that surveillance systems specific to blood transfusion were essential. Hence, most industrialized countries monitor transfusion-transmissible infections in donors and evaluate the impact of new testing and of predonation screening strategies. Emerging infections since HIV have had different transmission pathways and challenged blood programs to draw upon resources for a rapid and effective response, with recognition that the original focus on sexual/drug-related risk of HIV and hepatitis was inadequate. The focus of surveillance programs on new and emerging pathogens fulfills a key role in risk assessment and policy formulation. The precise nature of such activities varies by country because of the structure of the blood programs and surveillance systems, the strategic focus of the blood programs, and the epidemiology of disease in each country.

Stored red blood cell viability is maintained after treatment with a second-generation S-303 pathogen inactivation process

BACKGROUND

Transfusion-transmitted infections and immunologic effects of viable residual lymphocytes remain a concern in red blood cell (RBC) transfusion. Pathogen reduction technologies for RBC components are under development to further improve transfusion safety. S-303 is a frangible anchor-linker-effector with labile alkylating activity and a robust pathogen reduction profile. This study characterized the viability of RBCs prepared with a second-generation S-303 process and stored for 35 days.

STUDY DESIGN AND METHODS

This was a two-center, single-blind randomized, controlled, crossover study in 27 healthy subjects. S-303 (test) or control RBCs were prepared in random sequence and stored for 35 days, at which time an aliquot of radiolabeled RBCs was transfused. The 24-hour recovery, RBC life span, and in vitro metabolic and viability variables were analyzed.

RESULTS

The mean 24-hour RBC recovery and hemolysis of test RBCs were similar to control RBCs and were consistent with the Food and Drug Administration (FDA) guidance for RBC viability. The mean differences in life span and median life span (T(50) ) of circulating test RBCs were 13.7 and 6.8 days, while the mean difference in the area under the curve of surviving RBCs was 1.38%, in favor of control RBCs. There were no clinically relevant abnormal laboratory values after the infusion of test RBCs. All crossmatch assays of autologous S-303 RBCs were nonreactive.

CONCLUSIONS

RBCs prepared using the S-303 pathogen inactivation process were physiologically and metabolically suitable for transfusion after 35 days of storage, met the FDA guidance criteria for 24-hour recovery, and did not induce antibody formation.