Australia: it’s a land where the government encouraged child abduction for a century, and only just got around to apologising for it. It’s a land where three separate marriage equality bills have been rejected by parliament in the past three years. It’s a land where asylum seekers are left to die in the ocean because Kevin Rudd prefers his coffee and his country white. Yet, despite all this state-sanctioned discrimination, it’s still got better blood donation equality rules than we do. Here in the land of the long white cloud and the big gay rainbow, we still think it’s okay that gay men can’t give blood.
Before we go any further, let’s address the lisping elephant in the fabulously decorated room. As a gay guy with veins so large a blind drunk could still get blood out of them, it frustrates the hell out of me that I can’t give blood. I’m more than happy to admit I’m biased in this regard; it makes my blood boil when I’m told I can’t support such a worthwhile cause by donating, which might actually be a good thing if you tend to take metaphors literally.
Thanks to the health sci first year grade-booster that is BSNS104, I’m well aware that equality (how similar things are) and equity (how fair things are) are not the same thing. I can handle different rules for different groups, provided you can prove that the inequalities are equitable. Looking through the deferral criteria, however, I just don’t see any fairness in the system, and it really Grindrs my gears that the New Zealand Blood Service (NZBS) does.
The Deferral Criteria:
The deferral criteria consists of a list of things that prevent you from being able to give blood. They either prevent you donating for a specified amount of time (as in the case of man-love moments) or else prevent you from donating indefinitely (as in the case of snorting coke or shooting up heroin).The deferral criteria constitute one of many layers of safety checks and protocols the NZBS uses to protect blood recipients. As blood transfusion is reserved for seriously crook people, it’s no surprise that maintaining the safety of blood is the cornerstone principle of the service. One of the biggest safety concerns when talking about blood is HIV, so it’s also not surprising that many deferral criteria, including the criterion regarding gay sex, centre around this risk.
The deferral criteria for homosexual relationships reads as follows: “You must not give blood for FIVE YEARS following oral or anal sex with or without a condom with another man (if you are male).” The CAPITAL LETTER EMPHASIS on the deferral period comes directly from the NZBS, but also serves nicely to emphasise the incredulous tone in which you should read it. Apparently two HIV negative men in a long-term, monogamous relationship sucking each other’s condom-clad cocks to completion pose enough of a risk that they would have to stop for FIVE YEARS before they’re considered “safe.”
To put that in perspective, here’s a list of things that you’re allowed to do in the bedroom that will only prevent you from donating for ONE YEAR: have sex with somebody known to carry Hepatitis, have sex with a prostitute, have sex as a prostitute (in New Zealand), have sex with somebody who has injected themselves with drugs, or have sex with somebody who comes from a country with high levels of HIV (including sub-Saharan Africa, which accounts for 69 per cent of people living with HIV worldwide). In theory, you could be paid to have sex with a hepatitis-riddled druggie from sub-Saharan Africa and still donate four years earlier than our two hypothetical homos.
Swiss Cheese, D&D and HIV
As mentioned earlier, the deferral criteria are not the only safety checks in place to protect our blood pool. There are a number of safety steps involved, and the first occurs well before you come through the donation centre’s door; it happens when you cum in your partner.$100,000 of student loans and six years of medical school has taught me that in order to get HIV, you’ve got to come into contact with somebody who has it. It also taught me that gay guys are proportionally more likely to have HIV than heterosexuals, so – assuming that gay men are a homogenous group who don’t have different demographic, behavioural and risk profiles – your odds of bumping into somebody with it are higher if you’re gay. What medical school doesn’t do such a great job of teaching, though, is how relatively non-infective HIV actually is.
Let’s assume you’re HIV negative and your partner is HIV positive and isn’t receiving any form of adequate treatment. Receptive anal sex (taking it in the bum) is the riskiest thing you could do without bringing needles or childbirth into the mix. There’s a whole bunch of appetite-losing reasons for this involving anal accomodation, lubrication and mucosal microtears, but the CliffNotes version is that bumming is about as bad, transmission-wise, as you can get in the bedroom. Of course, not all gay men have anal sex, and not all people who have anal sex are gay, but let’s not go crazy and start bringing individuals’ behaviour into policies based on individuals’ behaviour.
There are three 2012 documents that quite thoroughly look at the risk of HIV transmission behind closed doors: “An overview of the relative risks of different sexual behaviours on HIV transmission,” “Antibiotic Essentials 2012 (11th edition)” and “HIV Transmission Risk: A Summary of the Evidence.” These three publications report very similar results, and essentially show that anal sex is more risky than vaginal sex which is more risky than oral sex.
As anal and oral sex are the two specifically mentioned by the blood service, it is worth looking at the cold hard figures involved. Blatantly disregarding the “if you don’t got a rubber there’ll be no hubba hubba” campaign, we’re also going to look at the numbers for unprotected sex.
Having an HIV+ guy do you in the bum gives you approximately a 0.05 to 3 per cent chance of catching the virus. Doing an HIV+ person in the bum gives you roughly a 0.07 per cent chance each time, which is roughly on par with vaginal sex. Sucking off an HIV+ hooded warrior gives you around a 0 to 0.04 per cent chance of catching the virus, and being sucked off by somebody who is HIV+ gives you a whoppingly low 0 to 0.005 per cent chance. To put these numbers in perspective, you’re more likely to get pregnant within a year of a successful vasectomy (a 0.15 per cent chance) than you are to get HIV by performing most of these acts of unprotected sex.
Sure, those numbers do start climbing if you’ve got another infection, like ulcerating syphillis, or if you’re into particularly aggressive sex. On the flip side, simply using a condom causes the numbers to shrink faster than a post-climactic penis. To quote the Centre for Disease Control and Prevention, “the body of research on the effectiveness of latex condoms in preventing sexual transmission of HIV is both comprehensive and conclusive. The ability of latex condoms to prevent transmission of HIV has been scientifically established in ‘real-life’ studies of sexually active couples as well as in laboratory studies … latex condoms provide an essentially impermeable barrier to particles the size of HIV.”
So before you even get to the blood donation questionaire, you’ve already been through a series of Dungeons and Dragons-esque pass/fail checks. First off, you’re either aware or unaware of your own HIV status; then you’re either aware or unaware of your partner’s status; and then you’re either practicing safe or unsafe sex (condom use, type of sex and adequate treatment when appropriate). Before you arrive at reception, you make one final check in deciding whether or not you even want to present to the blood service. This “self-deferral” check is based on your own individual behaviours and self-assessed risk of HIV, and relates to the fact that you are not allowed to donate blood if you feel you need an HIV or Hepatitis test.
Only if you “fail” all of these checks can you reach the pre-donation questionaire without some idea of your potential HIV status. This required alignment of safety check failures is known in public health as “the Swiss cheese model.” The delicious metaphor is designed to capture the fact that all the holes in a random stack of swiss cheese slices have to fortuitously line up before something can slip through. The homosexual contact deferral criterion is meant to be another slice of cheese in the stack, but isn’t so much swiss cheese as it is a bigoted piece of brie.
Blood Testing
Even if you believe the deferral questionaire cheese slice is holier than the hypothetical offspring of the Pope and Jesus, we still haven’t touched the final, least hole-riddled check: blood testing. Irrespective of the boxes you tick on your deferral criteria questionaire form, and regardless of how often you donate blood or how celibate you are, your donated blood will always be tested for HIV. Simply put, ticking “No” isn’t enough of an assurance that you haven’t been shooting up with used needles while listening to Mötley Crüe.According to the 2008 Transfusion Medicine handbook and the 2008 Behavioural Donor Deferral Criteria Review, blood in New Zealand is screened by looking directly for HIV (HIV RNA testing) and by looking for the body’s reaction to it (testing for Anti-HIV1 and Anti-HIV2 antibodies).
The point of having multiple tests is to increase sensitivity (i.e. to make it very unlikely that a disease will be missed if it is present) and specificity (i.e. to make it very unlikely that a disease could be falsely reported if it is not present). Based on the sensitivity and specificity of these tests, the review paper models the risk as only 1 in 1,000,000 that they will fail to identify an established infection. To put a smaller, more concrete number on that, between the year 2000 and the review paper, 12 HIV+ donors were identified and their donations destroyed. No HIV-infected blood products have ever been known to reach clinical use in New Zealand. Notably, only three of those 12 identified cases were men who had had sex with men.
One final concern with testing is “the window period,” or the length of time between when you get infected and when you start testing positive for the infection. This is a very real concern, because a matter of timing can turn the blood testing phase from a rigorous safety check to a pointless exercise. Indeed, any time a regular donor is flagged as being HIV+, there is a significant and costly “look-back” process for all donated products and recipients to ensure that the donor hadn’t donated during their window period.
In the 2008 review paper, the estimated average window period for HIV testing was 11 days. This suggests that in the first 11 days after you get infected, you’re more likely to test negative than you will positive, which is obviously a large concern. For that reason, some form of behaviour- and time-based deferral is warranted when HIV is not unreasonably unlikely.
So what’s the moral of the story?
If you have your own bias in the form of a homophobic elephant in the machismo-oozing room, feel free to stop reading here and go away content that your world view hasn’t been challenged by a gay guy with a chip on his shoulder. Behaviour-based inequality does make sense because the safety of blood products in New Zealand is tantamount.The question, however, is whether this inequality can rationally justify a ubiquitous, five-year ban after any homosexual contact, particularly in light of the much lesser deferral periods for other high-risk sexual behaviours. The New Zealand Blood Service says it can; I say it can’t.
Certainly the NZBS has to take a harsher line than me – they have a direct duty to ensure that absolutely nothing can go wrong, whereas I’m just a guy who doesn’t have HIV but does have a lot of blood to give. That being said, it is still hard to see how the NZBS can justify taking a stance as rigid as the one they do currently.
For starters, they base much of their argument on the now five-year-old review. In the current era of medical advances, five years is a lifetime. The review desperately needs updating in light of newer evidence around HIV epidemiology, treatment outcomes and testing methods. It also explicitly states that there needed to be a followup review by now, particularly given that more extensive evidence from the Australian one-year deferral policy is now available. Additionally, some of the evidence in that review is poorly acquired: the 2006 study on sexual behaviours recruited 18 per cent of its participants from a sex-on-site venue, which is practically the definition of a sampling bias (provided you’ve got a really strange dictionary).
Additionally, the “one size fits all” rule poses a direct challenge – the NZBS struggles enough to get enough donations without arbitrarily excluding healthy gay men. If you look at their marketing programmes you’ll see that they focus on the need for more blood. They ram the “42,000 people a year need blood yet only four per cent of eligible people donate” message so aggressively down your throat that it would certainly increase the risk of HIV transmission if it were an infected knob. Their ad campaigns are littered with adorable cancer-riddled children pleading for you to give blood, or reminders of the three lives you could save by donating.
I promise you, NZBS, that I would churn out blood for you every three months if I didn’t have to stop having sex for five years to do so. And you know what? I’d be willing to jump through a few more hoops than my straight counterparts as well.
There’s one safety check we didn’t mention in our swiss cheese discussion: the mandatory one-on-one nurse interview. After you’ve ticked your boxes, you’re taken into a room to further discuss your answers with a nurse. Couldn’t the nurses have an extra sheet from which they ask a few more questions about individuals’ condom use, HIV testing, number of partners and types of sex? If you’re really worried, why not reduce the deferral period for people who can show nurses independent evidence of negative HIV status? Sure, some people wouldn’t want to go through that, but some people would given the value of the cause. There are a range of solutions that, whilst still inequal, would be a hell of a lot more equitable than a five-year blanket ban. If those filthy xenophobic Aussies can do it, we can too.
Editor's Note:
Since the time of writing, the New Zealand Blood Service has confirmed they are in the process of establishing a review group for the donor deferral criteria. They hope to begin this review by the end of 2013.