For 31 years, the United States has banned men who have had sex with other men — even just once, decades ago — from donating blood.
This could finally change tomorrow: the Food and Drug Administration is set to consider replacing the lifetime ban with a one-year deferral period, meaning gay and bi men who haven't been sexually active for 12 months could "give the gift of life."
That's a big step forward, away from a policy that's been derided by everyone from the American Medical Association to the Red Cross. But experts point out that the one-year deferral is still discriminatory and not science-based. It continues to preclude all HIV-negative sexually active men who have sex with men, even those in committed, monogamous relationships, from giving blood.
What's the reasoning behind the ban?
If you ask FDA officials why they've refused the blood of gay and bisexual men for so long, they will tell you that they're just doing their job: minimizing any risk to the blood supply.
Men who have sex with men are more likely than any other group to get HIV, and it's estimated that about 15 percent of the gay and bi population has AIDS.
To prevent the spread of infection, the health regulator has put gay men in the same risk category as intravenous drug-users and sex workers. Any man who has had sex with another man — even once — since 1977 (the year the AIDS epidemic started) can't give blood. (The ban affects trans women who have sex with men, too, because the FDA considers gender one's sex at birth.)
In the early days of HIV, this sweeping approach made some sense: there was no way to screen blood for the test and little was known about the disease.
Of course, science has progressed considerably in the last three decades. We now have nucleic-acid tests that can diagnose an HIV infection within less than two weeks of exposure. And, with very few exceptions, every blood unit received at a bank has to be tested for HIV and a several other pathogens before it can be used.
Other countries like the UK, Australia, Argentina, Hungary, Sweden, and Japan have ditched their lifetime bans on donations from gay men and opted for a one-year deferral policy. Going even further, South Africa has a six-month deferral, while Spain, Italy, Russia, and Poland use behavior-based assessments — and not sexual orientation — to weed out high-risk donors.
The evidence on lifting the lifetime ban
There's good evidence to suggest these less restrictive policies don't put the general population at a higher risk of disease through blood transfusions.
In a seminal study, the Australian Red Cross examined the impact of switching to a one-year deferral policy for men who have sex with men. Comparing five-year periods before and after the policy switch, researchers found no increase in the number of HIV-infected blood units collected, but they did find a 900,000-unit spike in blood donations.
A study on the Italian policy looked at data on the proportion of HIV-positive blood donors before (1999) and after (2009-2010) replacing their ban with an individual risk assessment in 2001. They found the change in donor policy had no impact on the blood supply.
Moving to a one-year deferral would bring the United States more in step with science — but those who study America's blood-donor policy think it doesn't go far enough.
Why experts think a one-year deferral doesn't go far enough
"There are irrational aspects of the policy," said Sean Cahill, director of health policy research at the Fenway Institute.
"If you are a heterosexual man who admits to having unprotected sex with a sex worker or prostitute, you can wait one year and donate blood. But a gay man who has been in a monogamous relationship and who tests negative for HIV still can't."
Glenn Cohen, a Harvard Law professor who wrote about the blood-donor rule in JAMA, sees a 12-month deferral as an interim step, but thinks it's not any more evidence based than the current lifetime ban.
"There's no medical reason to think that a one-year deferral makes a difference as opposed to a month-long deferral when the virus would show up in blood," he explained.
The policy continues to single out men who have sex with other men, too. African Americans, for example, are eight times more likely than white people to have HIV. They aren't prohibited from donating.
Cohen says these long deferrals on gay and bi men are a hangover from the early days of HIV, when the disease was known as GRID, or "gay-related immune deficiency."
But maybe an evidence-based blood policy is too much to ask for when fears about gay men's blood still abound. "It's not just about the safety of the blood supply," Cohen said, "it's about the perceived safety of the blood supply."
There's a better way forward
Fenway's Cahill said that, instead of screening based on sexual orientation, the regulator should ask about individual’s recent high-risk behavior, the way Italy and Spain do.
"I think the most evidence-based policy is one that looks at individual risk behavior and asks questions to screen out the highest risk heterosexual, homosexual and bisexual men and women."
This would make more sense, and it would mean that the FDA wouldn't be asking men who have sex with men to take a vow of celibacy in order to donate.
To learn more, read our explainer on the ban against gay men's blood.