One in four of us will need a blood transfusion at some point in our lives. Donations are used for an expansive range of patients, including those undergoing chemotherapy treatment and surgeries, or victims of serious traffic accidents. 1,000 transfusions are carried out in Ireland each week on average. This requires weekly donations from 3,000 members of the public each week to meet this vital demand, but only 3% of the population that is eligible to donate blood actually do.
Blood donation is entirely voluntary and participants must meet an extensive list of criteria in order to be allowed to donate, to prevent infection from being passed from donors to vulnerable recipients. One of the eligibility criteria currently in place is a controversial 12 month waiting period to give blood for men who have sex with men (MSM). The Irish Blood Transfusion Service (IBTS) states that it cannot accept blood donation from men who, in the past twelve months, have had oral or anal sex with another man. This includes safe sex using precautions such as condoms or pre-exposure prophylaxis (PrEP).
Regulations such as these were introduced during the onset of the AIDS epidemic in the early 1980s. In a landscape of panic and fear, lifetime bans were placed on men who have sex with men donating blood, in the hopes of preventing transmission via transfusions. In Ireland, this ban stayed in place for almost 40 years, despite huge developments in relation to the illness in this time period. In the early decades, contracting HIV/AIDS meant a life-altering and fatal diagnosis. Now, HIV/AIDS can be carefully and safely managed by modern healthcare.
Additionally, HIV screening is much more widespread and available. In 2018 it was estimated that 90% of people living with HIV in Ireland have received a diagnosis. Medicines such as pre and post-exposure prophylaxis prevent transmission, and those who are diagnosed and received treatment reach undetectable levels of the condition. The condition becomes untransmittable to their sexual partners. In essence, there has been a seismic shift in what HIV-related health in Ireland looks like since the early 80s, but for some, there is a lingering fear about the virus.
So what is the process blood goes through to get to be used for transfusions? Firstly, donors have to answer a series of questions prior to giving a donation. These include questions to ensure giving blood will not impact their own health, for example, whether you are within a certain age and weight bracket. Other questions try to establish whether the donation will be safe for the recipient, asking whether the donor is on medications that could cause issues, whether they have had cancer or any allergies, all with the aim of establishing their health profile. There are also several questions about the donor’s sexual health. They cannot give blood if they have ever had certain STIs, of which HIV is one. But further to this, men who have had sex with any men in the past 12 months (even if this is just one partner if they have had safe sex, and if both have tested clear of STIs) cannot donate. This is a criterion that has caused considerable confusion and anger, as some argue that it is based on homophobic and outdated fears and that other countries approach of a case by case evaluation of sexual health is just as effective in protecting the blood supply.
The Irish Blood Transfusion Service cites a “window period” where infections are not detected as the crux of this ban. This is a time at the early stages of an infection where it may not show up on screening tests. The donor may be oblivious to their infection and not be showing any symptoms, and if the infection also failed to register during screening, it could be passed on to a vulnerable transfusion recipient. This is the logic used by the IBTS and some other transfusion services across the world.
The disease markers which the IBTS tests for include HIV 1 and 2, Hepatitis C, Hepatitis B, Hepatitis E, Syphilis and Human T-Lymphotropic virus types I and II. Other tests are carried out on specific donor samples if they are at higher risk of certain diseases eg, cytomegalovirus. No samples are batch tested; each donor’s blood is tested individually and if any of these disease markers register, the donation is destroyed and does not enter the blood supply. Testing is fully automated, to remove any element of human error.
The window period arises because some testing relies on antibodies being detected. This can not occur until the body has produced sufficient antibodies which can take weeks or longer. So this is the dangerous time, where the infection is in fact present but in terms of antibodies, the person looks completely healthy. Other tests can help with this test for material from the virus itself, which will be in the body from the very beginning of the infection and does not involve the same window period. Nucleic Acid Amplification testing (NAT) looks for DNA or RNA belonging to viruses in the blood and can show an infection before antibodies are made. For HIV, NAT tests can look for RNA belonging to the HIV.
The IBTS has been screening for HIV-1 using antibody-based testing since 1985, and the equivalent for HIV-2 since 1990. But since 2004 NAT testing has been used which detects HIV-1 RNA much sooner than the antibody window period. The IBTS says “NAT closes the window period between infection and detection of an antibody for those infected with HIV by about two weeks for donations tested individually, significantly reducing the risk of HIV transmission by transfusion.” This leads to a period of only 5-7 days where a new HIV infection may not show up in a donor sample. Currently, the chance of a transfusion recipient gaining an HIV-1 infection through blood transfusion has been calculated by the IBTS at about 1 in 15 million donations transfused. The detection of HIV-2 gained by transfusion has no reported cases in the IBTS to date.
These statistics seem to back up the calls by many to remove the MSM 12 month ban, or to reduce it. In fact, many countries around the globe have done this and had success. In the UK, the waiting period for men to donate blood since they last had sex with a man was changed to three months in 2017, and they did not report any increase in cases of transfusion-related transmission. As of June of this year, the UK has changed the regulation to allow men who have had only had sex with the same male partner for at least three months to give blood without any wait time. This will open up a much larger pool of donors that previously would have been unable to contribute to the country’s blood supply.
This criterion makes giving blood fairer, grounded in more modern science, and more concerned with individualised risk rather than stereotypes and historical experiences. In the UK, all donors are asked the same questions about their sexual health, sexual partners, and sexual activities regardless of their gender or sexual orientation. This moves the focus to the person themselves as an individual rather than group all MSM as having the same lifestyle and from the archaic idea that the choices of MSM are inherently promiscuous or dangerous.
Ireland is far behind in the global movement for more equal blood donation, a movement backed thoroughly by science. As a country, we are becoming more aware and more proactive about our sexual health, preventative measures are changing the landscape of HIV, and we desperately need to increase our donor pool in this country. It is not just time for equality in our healthcare, it is greatly overdue.