As this note has been triggered by British current events, I thought that it might be interesting to translate it in English in order that my fellow friends from across the Channel could take part in the debate.

« Dr Borée » – general practitioner, France

 

La rédaction de ce billet a été provoquée par l’actualité britannique. Il m’a donc semblé intéressant de le publier également en anglais afin de participer au même débat que mes amis d’Outre-manche.

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My father has always been a blood donor.

As a kid, I was very proud of that.

Not only that but he used to bring home some of the food goodies offered after donation. It was a kind of celebration party.

I always told myself that, when I was an adult, I, like my Dad, would be a blood donor too. It was obvious.

When I found myself in my first year of medical school, there were these posters I read one day: « Faculty of Medicine – Blood Donation next Wednesday ». So I went along with two girlfriends. No questions asked; it was obvious.

On arrival, we were handed a form to read and complete, before an interview with the doctor in charge.

When it was my turn, I handed her the completed form and she asked me with a grinning face:

– So, no problems I presume?

– Well… hum… yes, I guess. I’m gay. Can’t I be a donor?

– No, I’m sorry……….

– But, I’ve always been careful……….

– It doesn’t matter. That’s the way it is. We can’t afford to take any risks.

And so I left, passing in between the tables of people who had just seen me arrive. Angry, and above all, humiliated.

That was in 1992.

Today, in 2011, despite heated controversies, the French law has not changed yet.

Men who have sex with men are still banned from donating blood, even their bone marrow. For their organs however, in case of death, no problem. I would even go as far as to conclude, if I was of wicked temperament, that an acceptable “homo” is a dead “homo”…

France is not an isolated case.

Most developed countries have the same rules. Some have opted for more subtle limitations. Only some regions of Spain and the very macho Italy (surprisingly), have abandoned any restrictions based on sexual orientation.

The British also practice the same exclusion. But their government is to lift this ban. Bitter consolation. In the future, gay men will be allowed to donate blood … on the condition of not having had sex for at least 10 years prior to the donation.

Between this condition and our state I must admit that I prefer the logic of no choice at all. I feel that this British pseudo-progress is totally surrealist and humiliating and, more seriously, I am not aware of any scientific data upon which would support this decision.

The few studies that have addressed the issue, used and quoted by the politicians, are already dated and questionable in an area that is experiencing constant technological updates. (1) (2)

At this point, it may be worthwhile to recall that blood samples are routinely tested, among other things, for HIV. And if the usual screening tests can take up to six weeks to become positive, the blood services are now using a diagnostic technique (NAT), which turns positive from the twelfth day (and never beyond 3 weeks) following a possible contamination. There is practically no more room for doubt.

I don’t mind that we practise a comfortable safety margin, to be sure not to miss the zero-point-something percent of tests falsely reassuring in the usual time, but I’d still like to know from where the “powers that be” conjured up the ten year rule!!

Yes, HIV is still present.

And yes, in proportion, gay men are more frequently affected. Worse still, among the different ways of contamination, it is the only group for which the number of new cases keeps increasing.

It is useless to try to deny it.

Not only is it useless but it is wrong. Refusing the obvious, in the name of « all equal, all the same » is to condemn us to keeping in place wide scale prevention, which is, largely ineffective. Prevention propaganda is far more efficient when targeted.

Recognizing that there is still, thirty years after the beginning of the epidemic, a specificity of the impact of HIV among homosexuals, is to enable the development of an appropriate strategy.

But let’s get back to blood donation.

It is perhaps worth recalling that the transmission of HIV by transfusion has been a tragedy but that this problem is now clearly under control. The residual risk is currently estimated at about 1 theoretical risk over 3 millions transfusions. That’s not anything. But, in 2008, the CDC deplored the first U.S. case of transfusion-transmitted HIV infection reported since 2002, even though  the U.S. practice approximately 14 million transfusions per year.

In contrast to this, life-threatening transfusion accidents occur about once per 100 000 transfusions and the risk of death directly resulting from a transfusion is about 1 per 300 000 (figures for France and USA) .

I would like to stress I do approve being careful regarding the HIV risk and I can understand politicians getting their knickers in a twist since the French HIV infected blood related scandal.

But still…

The French Blood Agency, (Etablissement Français du Sang), to justify the exclusion of gay men, invokes an absolutely startling figure of a 17.7% prevalence (the proportion of infected people) of HIV among « gay men ». End of story, without any qualification or clarification. (3)

These figures are based on the Prevagay survey.

This survey was conducted “within the population of men having sex with men frequenting the gay Parisian ‘Hot Spots’ (bars, saunas, and backrooms). »

Hum… hello People!!!!

Can anyone explain to our public health professionals that for starters Paris is not France and that the Marais area, in particular, is not representative of all the « gay men”.

Researching this community, with it’s specificities (12% of surveyed men had at least unprotected anal intercourse once in the year with a casual partner, 18% had at least one STI in the year), in order to enable us to know it better and to be able to develop specific prevention, is OK by me, good idea. But, generalising the research to all French gay men using figures collected in Parisian backrooms, is unfortunately incredible. (4)

What constitutes the risk? Love preferences or sexual practices?

I have lived for over ten years in a stable and faithful relationship; just like thousands of others. And just like those thousands of others, I don’t think I’m more of a « high risk person », than, say, my brother, or my neighbour living heterosexually.

Perhaps I should point out at this point, that there is no test to “detect homosexuality? » Therefore, the answers to any questions are based on the good faith of he who answers.

When the French Blood Agency asks, « Have you ever had sex with another man? Yes / No », they have to trust people’s answers. They have no other choice.

They also ask donors if they have changed partners over the past four months. Surprisingly, this question is only directed at heterosexual donors. Are they to be trusted more than homosexuals? Do we imagine that homosexuals may be more susceptible to lie? If a homosexual lied in the previous question, what’s to stop him lying again?

Ultimately, it’s still the question of a possible recent change of partner which is important if we want to limit the risks of transfusion, isn’t it? FDA itself recognizes that the rare potentially residual risks of HIV transfusion-transmission are almost exclusively linked to the short window period (about twelve days) after a possible contamination.

The only important questions would therefore be the ones to exclude those donors who might be in this situation, possibly including a reasonable safety margin, such as: « Have you had a new partner in the last month? »

Donating blood is free; those who participate act generously. How can we imagine that they would offer to give blood, knowing they had recent risky behaviour? Especially if the risk is well defined, precise and above all well founded.

Studies are based on an estimation of the theoretical risk, as if the potential donors were to give blood at random, regardless of their sexual activity days and weeks before. The logic of giving blood is itself based on trust and the sense of responsibility of the donors. How can we not believe in those who choose to give, or not, depending on their recent intimate activity? As long as the established rules are logical, understandable and non-discriminatory, there should be no desire to break them.

Unless………. political pressure is applied to make us forget former scandals and in designating a scapegoat group, they try to give to the public the illusion that all necessary measures for their protection are being taken.

No, really, I cannot find one solid scientific or logical reason to all this. (5)

Blood and marrow donations save lives. It is a gesture of great generosity, a selfless gift, and, without a valid reason, it is wrong to stigmatize certain potential donors. When will all this silly, once scientific and harmful discrimination end?

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(1) This policy seems to rely primarily on two studies. Both built entirely on statistical calculations and probability.

A Quebec study has considered the possibility for MSM (« Men who have sex with other men » which is the accepted definition today) to become eligible to donate blood if they recently (12 months) abstained from male-to-male sex.

Such relaxing would bring in about 3,000 additional donations each year in Quebec, which would be an increase of 1.3%.

On the other hand, the study concludes with an increased risk of HIV transmission of 8%. WHAO!!  Well, 8% of almost nothing, it is not much. This possible increase in risk would mean one additional contamination in Quebec every… 69 years. For the whole United States, this would extrapolate to an additional theoretical 1 unit escaping detection every 1.1 years.

Two significant weaknesses in this study:

– It “already” dates from 2003. To determine the « window period » (which is THE big problem that largely determines the overall reasoning), it is based on a study itself of 1997, which took into account the seroconversions. However, it is stated that “In addition, the mean window period for HIV in blood donors is reduced even further by the recent implementation of minipool NAT. Therefore we assigned an even lower probability in the model. » but without explaining the details of the calculation and setting a probability of 1 / 2000 which might seem surprising.

– “For parameters that were more difficult to estimate, in particular, those related to potential system failures, we usually assumed a worst-case scenario. (…) If we exclude these parameters from the model, the estimated risk is reduced by a factor of 5, although it is still not zero.” Well, no risk will ever be zero, even considering an “honest family father”. Considering such a modest increase, if we have to divide it by 5 on top of that…..

 

(2) Then there is an English study which is THE main study justifying the exclusion of MSM from blood donation. The study that even allows LGBT or AIDS fighting associations to share this line of thought states that allowing 12 months abstinent MSM would increase the risk by 60% and the abandonment of this discrimination would increase the risk by almost 600%. In the light of these results, I’m also against it!

But this study is also very questionable…

– It is a mathematical model based on the « old » method of serodiagnosis. The accuracy is lower and the window period is significantly longer: usually 22 days, but sometimes more. Taking into account the first seven days “incubation” period, during which the person contaminated does not himself contaminate others, we obtain a risk window of 15 days against 5 with current techniques. A fundamental element of the equation must therefore be divided by three.

– The prevalence of HIV among MSM was estimated based on data from a population attending a GUM (unlinked anonymous testing of Genitourinary Medicine clinic) in London. The authors themselves admit: « We assumed that GUM attenders are representative of ‘active-MSM’. It seems probable that GUM attenders would be of higher risk than not-attenders and the prevalence in active-MSM may therefore have been overestimated. » One can suppose, indeed … and this too changes a little the calculation.

– Moreover, the calculated figures, which seem to me credible, estimate that allowing all MSM to give would lead to the identification of approximately 170 undiagnosed HIV cases formerly ignored amongst the 30 000 new donors and, subsequently, every year, 29 new seroconversions per year (note that London MSM donors would represent only 17% of new donors accepted but 86% of these new seroconversions).

In the current situation, the study estimates the risk at 0.45 infectious donations per year for the whole of England and Wales.

If donation was allowed to all MSM (active and passive), during the first year, there would be about 200 (170 +29) potentially contaminated donations.

Thus the study estimates that this would cause the issue of two additional infectious donations over the year for all of England and Wales: 2.5 instead of 0.45, the highlighted 558% increase.

This would mean in total, 2 per 200 infectious donations that « fall through the cracks » of the security network: a failure rate of the system of 1% which is huge.

Even though the bulk of the 200 infectious donations corresponding to the discovery of undiagnosed HIV, the question of « silent window » does not arise then.

This 558% increase in risk is, in my opinion, highly questionable and should be reconsidered. It is unbelievable that LGBT associations have not yet raised this issue.

 

(3) Apart from this particular case, which is frankly scandalous because of the huge « recruitment bias » of the survey, we can also find a relatively impressive incidence – the number of new cases each year – of 1% of HIV infection among MSM, in the French Bulletin Epidémiologique Hebdomadaire (p. 474). This figure is based on the number of 330 000 MSM throughout France, in other words a proportion of 1.6% MSM amongst the sexually active male population. Am I the only one laughing or what??

In fact, there are no consensual studies on the proportion of gay men in the French or, more globally, western population. Many studies rather suggest a proportion of gay men (which is a more restrictive notion than « MSM ») about 4 to 5% of the male population.

It is also noticeable that the proportion of men reporting themselves as gay seems more important among younger generations. It must certainly be seen as the consequence of better acceptance and the fact that a significant proportion of men of former generations denied or repressed their homo or bisexuality.

It is anything but trivial to remark this, because, as the number of new infections is fixed and known, it would mean that « incidence » can vary in proportions of 1 to 4 at least.

 

(4) It is particularly noteworthy that the authors of the already quoted English study took care during the bulk of their analysis, to make a distinction between London and the rest of the country … before then combining their results.

The estimated prevalence of HIV among MSM is between 6 and 10 times higher in London than elsewhere.

 

(5) In a time where the watchwords are “Safety and Precaution” and we are in search of the mythical « zero risk », this problem could simply be approached from a risk management perspective.

The Quebec study, like the English one, deals with the problem in a fairly mathematical way, which when translated gives this roughly; « Well, if we allow the MSM abstainers to be donators, it would increase the risk by 8% and the number of donations by 1.3%. As there is no absolute need to gain those 1.3% and that there could be other ways to achieve this (ad campaigns, etc …), we can conclude that risks would outweigh the benefits. So why take the risk? »

It would be a typically public health method of analysis, rational and therefore legitimate (subject to the validity of figures used in these studies that I quoted above).

It might be noted that this reasoning does not seem to apply to the military transfusion centres for which the risk is nevertheless 35 times higher than the general population!

The real question, actually, is not the one that puts in the balance the potential increased risk (which has become virtually nothing with current technology but will indeed never be zero), with the Public Health benefit (Do we really need those extra few percent of donations?), but what are the social and civilization benefits to be drawn, (What is the non-discrimination of a certain category citizens worth, based on their sexual orientation?).

And here we are no longer talking about public health but about philosophy and politics.

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Many thanks to Mark for correcting. He is a friend of mine, one of those potential male liars, who is heterosexual but British (Edith Cresson notwithstanding). He came to France 22 years ago and continued to give blood here just as he did in the U.K.

Then one day the EFS (French donor board), asked THE question, « Have you visited the U.K. in the past x months? or indeed lived there in the past x years? »

He replied « Yes », of course, and was, after several years of loyal French bleeding (not only by the government), directed to the door. « Vache Folle »!!!

Do the British import French, Spanish or Italian blood? Because apparently THEY can’t give blood. Unless the rest of Europe just simply thinks that it’s O.K. because « after all they’re only infecting themselves!!!!! »

This also could be scientifically questioned. But that’s a clearly French issue.