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Infection Pressure in Men Who Have Sex With Men and Their Suitability to Donate Blood


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Background: Deferral of men who have sex with men (MSM) from blood donation is highly debated. To assist in defining MSM donor deferral policies, we investigated their suitability to donate blood. Methods: We compared the antibody prevalence of 10 sexually and transfusion transmissible infections (TTI) among 583 MSM from the Amsterdam Cohort Studies and 583 age-matched repeat male blood donors. MSM were classified as low-risk (lr) or medium-to-high-risk (hr) based on self-reported sexual behavior and as qualified or unqualified using Dutch donor deferral criteria other than male-to-male sex. Infection pressure (IP) was defined as the number of antibody-reactive infections, with class A infections (HIV-1/2, HBV, HCV, HTLV-1/2, syphilis) given double weight as compared to class B infections (CMV, HSV-1/2, HHV-8, HEV, Parvovirus B19). Results: Donors had a lower median IP than qualified lr-MSM and qualified hr-MSM (2[IQR-1-2]) versus 3[IQR 2-4), p<0.001). A low IP was found in 76% of donors, 39% of qualified lr-MSM, and 27% of qualified hr-MSM. The prevalence of class A infections did not differ between donors and qualified lr-MSM but was significantly higher in qualified hr-MSM and unqualified MSM. Recently acquired class A infections were detected in hr-MSM only. Compared to blood donors, human herpesviruses were more prevalent in all MSM groups (p<0.001), and prevalence increased with self-reported risk behavior. Conclusion: IP correlates with self-reported risk behavior among MSM. Although lr-MSM might form a low threat for blood safety with regards to class A infections, the high seroprevalence of human herpesviruses in lr-MSM warrants further investigation.
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Clinical Infectious Diseases
CID 2018:XX (XX XXXX) • 1
Blood Donation byMSM
Infection Pressure in Men Who Have Sex With Men and
eir Suitability to DonateBlood
Ward P.H.van Bilsen,1,a Hans L.Zaaijer,2,3,a AmyMatser,1 Katjavan den Hurk,4 EdSlot,2 Maarten F.Schim van der Loeff,1,3 MariaPrins,1,3,b and
Thijs J.W.van de Laar2,b
1Department of Infectious Diseases, Research and Prevention, Public Health Service of Amsterdam, 2Department of Blood-borne Infections, Sanquin Research, 3Department of Internal Medicine,
Amsterdam Infection and Immunity Institute, Academic Medical Center, and 4Department of Donor Studies, Sanquin Research, Amsterdam, The Netherlands
Background. Deferral of men who have sex with men (MSM) from blood donation is highly debated. We therefore investigated
their suitability to donate blood.
Methods. We compared the antibody prevalence of 10 sexually and transfusion-transmissible infections (TTIs) among 583
MSM and 583 age-matched repeat male blood donors. MSM were classied as low risk (lr) or medium-to-high risk (hr) based on
self-reported sexual behavior and as qualied or unqualied using Dutch donor deferral criteria. Infection pressure (IP) was dened
as the number of antibody-reactive infections, with class Ainfections (human immunodeciency virus-1/2, hepatitis B virus, hep-
atitis C virus, human T-cell lymphotropic virus-1/2, syphilis) given double weight compared to class B infections (cytomegalovirus,
herpes simplex virus-1/2, human herpesvirus 8, hepatitis E virus, parvovirus B19).
Results. Donors had a lower median IP than qualied lr-MSM and qualied hr-MSM (2 [interquartile range {IQR}, 1–2] vs 3
[IQR, 2–4]; P<.001). Low IP was found in 76% of donors, 39% of qualied lr-MSM, and 27% of qualied hr-MSM. e prevalence of
class Ainfections did not dier between donors and qualied lr-MSM but was signicantly higher in qualied hr-MSM and unqual-
ied MSM. Recently acquired class Ainfections were detected in hr-MSM only. Compared to blood donors, human herpesviruses
were more prevalent in all MSM groups (P<.001).
Conclusions. IP correlates with self-reported risk behavior among MSM. Although lr-MSM might form a low threat for blood
safety with regard to class Ainfections, the high seroprevalence of human herpesviruses in lr-MSM warrants further investigation.
Keywords. blood donation; men who have sex with men; deferral policy; infection pressure.
In response to the AIDS epidemic, lifetime donor deferral of
men who have sex with men (MSM) was introduced to increase
blood safety in the 1980s [1, 2]. The scientific rationale for
MSM donor deferral has weakened over time, as nucleic acid
amplification testing (NAAT) for human immunodeficiency
virus (HIV) has substantially decreased the window period,
during which HIV cannot yet be detected but may be transmit-
ted via transfusion [3, 4]. As a result, public and political pres-
sure to liberalize deferral policies has caused many high-income
countries to change from permanent to temporary MSM donor
deferral [1, 2, 5].
Currently, in Europe, donor deferral of MSM varies from
gender neutral” policies that are based on sexual practices
without considering the gender of the sex partner (Spain, Italy,
and Portugal), to temporary deferral of 3–12months aer last
male-to-male sex contact (eg, United Kingdom, Germany,
France, and the Netherlands), to permanent deferral (Denmark,
Austria, and Croatia) [6]. In the Netherlands, MSM deferral is
continued for sexually active MSM, dened as having male-to-
male sexual contact in the past year. Despite a leveling o of the
HIV incidence among Dutch MSM in recent years, MSM remain
the major risk group for HIV infection in the Netherlands [7].
In 2016, 67% of the 816 new HIV diagnoses were in MSM who
comprise an estimated 3% of the adult male population [7]. In
addition, a recent phylogenetic study suggested that 24 of 32
(75%) Dutch and Flemish male donors diagnosed with HIV in
the period 2005–2014 acquired their HIV infection through
male-to-male sex [8].
To achieve a harmonized European approach on MSM donor
deferral, the Council of Europe has requested epidemiological
and behavioral data to support an evidence-based recommen-
dation to both protect the blood supply and avoid stigmatiz-
ing population groups who are deferred unreasonably [9, 10].
High-quality studies investigating the risk of transfusion-trans-
missible infections (TTIs) in MSM who donate blood are scarce
[11, 12]. In this study we investigated the suitability of MSM to
donate blood by comparing the antibody reactivity to 10 sexu-
ally transmitted and/or blood-borne infections between MSM
© The Author(s) 2018. Published by Oxford University Press for the Infectious Diseases Society
of America. All rights reserved. For permissions, e-mail:
DOI: 10.1093/cid/ciy596
Received 10 February 2018; editorial decision 12 May 2018; accepted 24 July 2018; published
online July 25, 2018.
aW. P.H. B.and H.L. Z.contributed equally to this work.
bM. P.and T.J. W.L.contributed equally to thiswork.
Correspondence: W. P. H. van Bilsen, Public Health Service of Amsterdam, Department
of Infectious Diseases, Nieuwe Achtergracht 100, 1018 WT Amsterdam, The Netherlands
Clinical Infectious Diseases® 2018;XX(XX):1–8
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2 • CID 2018:XX (XX XXXX) van Bilsen etal
and the general male donor population. We hypothesized that
MSM with self-reported low-risk behavior pose a low threat to
blood safety if their infection pressure (IP) is comparable to that
of male donors.
Study Population
The Amsterdam Cohort Studies (ACS) among MSM is an open
prospective cohort study initiated in 1984 to investigate the
prevalence, incidence, and risk factors of HIV and other blood-
borne and sexually transmitted infections [13]. Participants
biannually visit the Public Health Service of Amsterdam, where
they give blood for testing and storage and complete a stan-
dardized questionnaire about sexual behavior in the preceding
6 months. We selected all HIV-negative MSM with an ACS
visit between January and August 2016. The ACS questionnaire
was extended with donor eligibility questions from the Dutch
Donor Health Questionnaire (DHQ) and questions regarding
the willingness to donateblood.
For a primary comparison group, we randomly selected
age-matched repeat male blood donors from blood collection
sites in Amsterdam between January and August 2016. Because
repeat donors went through several selection and testing cycles,
a second comparison group included all men who registered as
a (potential) new blood donors at a collection site in Amsterdam
in that period.
Routine Donor Screening
Upon registration as blood donor and at every donation visit,
donors complete a standardized DHQ, and their blood is
screened for TTIs if no risk factors for donation are reported.
New and repeat donors are routinely tested for antibodies
to HIV types 1 and 2 (HIV-1/2), hepatitis B surface antigen
(HBsAg), antibodies to hepatitis B core antigen (anti-HBc),
antibodies to hepatitis C virus (HCV), and antibodies to human
T-cell lymphotropic virus types 1 and 2 (HTLV-1/2; new
donors only) using chemiluminescent immunoassays (PRISM,
Abbott Laboratories), and for syphilis antibodies using par-
ticle agglutination test (TPHA PK 2000, Trinity Biotech). In
addition, donors are tested for HIV-1/2 RNA, hepatitis B virus
(HBV) DNA, and HCV RNA in pools of 6 donations (COBAS
6800 MPX assay, Roche Diagnostics). Confirmation testing
includes alternative NAT for HIV-1/2, HBV, and HCV (Cobas
AmpliPrep/Cobas TaqMan version 2.0, Roche Diagnostics);
HBsAg neutralization (Architect HBsAg confirmatory test,
Abbott); immunoblots for HIV-1/2, HCV, HTLV-1/2, and
syphilis (INNO LIA Score, Fujirebio); and Venereal Disease
Research Laboratory testing. Anti-HBc–reactive donors are
tested for anti-HBs (Architect Anti-HBs, Abbott) and require
an antibodies to hepatitis B surface antigen (anti-HBs) titer of
200 IU/mL for eligibility [14, 15].
Laboratory Methods
MSM and repeat donors were screened for antibodies against
10 sexually transmitted and/or blood-borne infections, cate-
gorized in classes Aand B.Class Aincluded the 5 infections
that are part of routine donor screening (ie, HIV, HBV, HCV,
HTLV, and syphilis). Class B infections included cytomegalo-
virus (CMV), herpes simplex virus 1 and 2 (HSV-1/2), human
herpesvirus 8 (HHV-8), hepatitis E virus (HEV), and parvovi-
rus B19. Class B infections were included as they are potential
markers for (sexual) risk behavior for which the estimated
prevalence in the general Dutch population varies from very
low (HHV-8) to very high (parvovirus B19). Serological assays
included Murex HIV antigen/antibody, CMV immunoglobulin
G2, and HSV-1/2 immunoglobulin G (IgG) (Liaison, Diasorin);
anti-HCV, anti-HBc II, HTLV-1/2, and Syphilis TP (Architect,
Abbott Laboratories); Kaposi sarcoma–associated herpes-
virus/HHV-8 IgG enzyme-linked immunosorbent assay kit
(Advanced Biotechnologies); HEV IgG (Wantai Pharmacology
Pharmacy Enterprise); and parvovirus B19 IgG (Biotrin). MSM
found to be anti-HBc reactive were subsequently tested for
HBsAg and anti-HBs (Architect, Abbott Laboratories).
Study Variables
Infection Pressure
The IP for each participant was defined as the number of anti-
body-reactive infections, with antibody-reactive class Ainfec-
tions arbitrarily given double weight. The cutoff to distinguish
between low and high IP was set at the median IP determined in
repeat male donors. If antibodies against any class Ainfection
were detected, the IP was defined as high.
Recent Class AInfections
Recent class Ainfections were defined as antibody seroconver-
sion within the preceding year. Antibody seroconversion was
determined using previous test results and testing stored serum
samples. This 1-year period was set because the current eligibil-
ity criteria for blood donation require 1year without male-to-
male sexual contact.
Sexual Risk Behavior
MSM were categorized as low risk (lr-MSM) or medium-
to-high risk (hr-MSM) based on self-reported sexual beha-
vior during the preceding year. Low-risk sexual behavior was
defined as either (i) no anal intercourse, (ii) a monogamous
relationship with a steady male partner (including condomless
sex with that partner), or (iii) consistent condom use during
anal intercourse with casual partner(s). All other MSM were
categorized as hr-MSM. HIV preexposure prophylaxis was not
included in MSM risk classification.
Qualication of MSM as Potential BloodDonors
All blood donors fulfilled the Dutch eligibility criteria for dona-
tion, as assessed in the DHQ. Currently, in the Netherlands,
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CID 2018:XX (XX XXXX) • 3
Blood Donation byMSM
MSM face a temporary deferral of 12 months after the last
male-to-male sexual contact. In this study, MSM were qualified
as potential blood donors if they did not report any of the fol-
lowing Dutch permanent deferral criteria: a history of inject-
ing drug use or commercial sex work, blood transfusion, or
transplantation after 1980; a UK visit >6months between 1980
and 1996; a family history of Creutzfeldt-Jakob disease; a pre-
vious diagnosis with HIV, HCV, HTLV, or syphilis; or an active
HBV infection. Note that permanent deferral criteria in the
Netherlands might differ from those used in other countries.
Willingness toDonate
For MSM, intention to donate was measured on a 7-point Likert
scale (ranging from completely disagree to completely agree)
using the following statement: “If Iwould be allowed to donate
blood, Iwould apply as a blood donor in the future.” We distin-
guished moderate to high intention (score 4–7) from no to low
intention (score 1–3).
Statistical Analysis
Age, IP, seroprevalence per infection, and number of recent class
Ainfections of qualified lr-MSM, qualified hr-MSM, unquali-
fied lr-MSM, and unqualified hr-MSM were compared to those
of repeat donors using the unpaired t test (normal distributed
numerical data), the Mann-Whitney U test (nonnormal distrib-
uted numerical data), or the χ2 test/Fisher exact test (categorical
data). MSM with missing data on risk behavior and/or eligibility
were excluded from the main analysis. Additional analyses were
performed to determine differences in the main outcomes within
the group of qualified lr-MSM. AP value≤.05 was considered
significant. Analysis was performed using Stata Intercooled ver-
sion 13.1 software (StataCorp, College Station, Texas).
Sensitivity Analyses
Sensitivity analyses were performed to assess the impact of
missing data. In addition, we repeated our analyses on IP using 2
alternative methods to calculate IP. First, class Ainfections were
weighted 4 times more than class B infections. Second, IP was
defined as the individual predictive probability of class Ainfec-
tions given all individual class B infections (Supplementary
Data 2).
Study Population
During the study period, 583 of 604 (97%) MSM agreed to par-
ticipate in our study. They were age-matched to 583 repeat male
blood donors. We then excluded MSM with missing data on
sexual risk behavior and/or eligibility, leaving 520 MSM for the
main analysis (Figure1). The median age of MSM and repeat
donors was 42years (interquartile range [IQR, 35–48years for
MSM and 34–48years for donors). New donors had a median
age of 28years (IQR, 24–34).
Based on our sexual risk criteria, 245 of 520 (47%) were
lr-MSM, and 275 of 520 (53%) were hr-MSM. Among lr-MSM,
52 of 245 (21%) reported no anal intercourse in the preceding
year, 60 of 245 (24%) had a monogamous relationship, and 133
of 245 (54%) consistently used condoms during anal sex with
casual partners. Based on our qualication criteria for blood
donation, 380 of 520 (73%) MSM qualied as potential donors,
and 140 of 520 (27%) MSM did not qualify. Of those unqualied,
92 reported a history of syphilis, 20 reported commercial sex
work, 22 lived in the United Kingdom between 1980 and 1992, 9
had a history of transplantation, 7 received a blood product aer
1980, 4 had ever injected drugs, 2 reported a family history of
Creutzfeldt-Jakob disease, and 1 had a previous HCV diagnosis.
e majority of MSM had a moderate-to-high intention to
donate (380/520 [73%]; median score, 5 [IQR, 4–6]). Intention
did not dier among qualied lr-MSM, qualied hr-MSM,
unqualied lr-MSM, and unqualied hr-MSM (P=.223).
Infection Pressure
The median IP among repeat donors (2 [IQR, 1–2]) was sig-
nificantly lower than among qualified lr-MSM (3 [IQR, 2–4]),
qualified hr-MSM (3 [IQR, 2–4]), unqualified lr-MSM (4 [IQR,
3–5]), and unqualified hr-MSM (4 [IQR, 4–6]) (P<.001 for all;
Figure2; Supplementary 1). The proportion of participants with
a low IP (≤2) was 76% (443/583) in repeat donors, 39% (76/197)
in qualified lr-MSM, 27% (50/183) in qualified hr-MSM, 13%
(6/48) in unqualified lr-MSM, and 4% (4/92) in unqualified
hr-MSM (P<.001 forall).
Class AInfections
None of the donors or MSM had HIV-1/2 antibodies. Anti-
HCV was detected in 1 of 48 (2%) unqualified lr-MSM, 2 of 92
(2%) unqualified hr-MSM, and 1 of 361 (1%) new donors. Anti-
HTLV-1/2 was detected in 1 of 92 (1%) unqualified hr-MSM. None
of the repeat donors or qualified lr-MSM had antibodies against
syphilis, while 2 of 361 (1%) new donors, 5 of 183 (3%) qualified
hr-MSM, 23 of 48 (48%) unqualified lr-MSM, and 51 of 92 (55%)
unqualified hr-MSM tested positive for syphilis. Anti-HBc reactiv-
ity was lowest in repeat donors (6/583 [1%]) and new donors (8/361
[2%]). It was significantly higher among MSM (P<.001), increas-
ing from qualified lr-MSM (15/197 [8%]), qualified hr-MSM
(17/183 [9%]), to unqualified lr-MSM (6/48 [13%]), to unqualified
hr-MSM (26/92 [26%]). An anti-HBs titer <200IU/L was found
in 0 of 583 repeat donors, 4 of 361 (1%) new donors, 5 of 197 (3%)
qualified lr-MSM, 8 of 183 (4%) qualified hr-MSM, 4 of 48 (8%)
unqualified lr-MSM, and 9 of 92 (10%) unqualified hr-MSM. One
qualified lr-MSM and 1 qualified hr-MSM had a chronic HBV
infection (HBsAg-positive). We found no recent class Ainfections
in repeat donors and (un)qualified lr-MSM. In qualified hr-MSM
we found 2 recent syphilis infections and 2 recent anti-HBc sero-
conversions. In unqualified hr-MSM we found 6 recent syphilis
infections and 1 recent anti-HBc seroconversion.
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4 • CID 2018:XX (XX XXXX) van Bilsen etal
Class B Infections
Prevalence of antibody to HEV (anti-HEV) and to parvovirus
B19 (anti–parvovirus B19) was similar among repeat donors
and MSM, regardless of MSM group. It varied from 13% to
23% for anti-HEV and from 74% to 90% for anti–parvovirus
B19. The seroprevalence of human herpesviruses (HHVs) was
significantly higher among MSM compared to repeat donors
(P < .001 for all). CMV antibody reactivity varied from 68%
in qualified lr-MSM to 92% in unqualified hr-MSM, compared
to 38% in repeat donors. HSV-1/2 antibody reactivity varied
from 81% in qualified lr-MSM to 90% in unqualified hr-MSM,
compared to 46% in repeat donors. HHV-8 antibody reactiv-
ity varied from 39% in qualified lr-MSM to 65% in unqualified
lr-MSM, compared to 5% in repeat donors.
MSM With Low Sexual Risk Behavior
Additional analyses revealed no significant difference in
seroprevalence of class Ainfections, HEV, or parvovirus B19
between 3 groups of qualified lr-MSM (Table 1). MSM who
reported consistent condom use with casual partners had
a higher prevalence of CMV, HSV, and HHV-8 (P < .001,
P=.004, and P=.049, respectively), compared with MSM who
reported no anal intercourse or a monogamous relationship in
the precedingyear.
Sensitivity Analysis
Results did not change when all 35 MSM with missing risk
behavior data were classified as lr-MSM or hr-MSM. Likewise,
results did not change when all 38 MSM with missing qualifica-
tion data were classified as qualified or unqualified. Finally, our
results remained similar if using 2 alternative approaches for IP
calculation (Supplementary Data 2).
To our knowledge, this is the first study focusing on suitabil-
ity of MSM to donate blood, taking into account self-reported
sexual risk behavior linked to the seroprevalence of multiple
sexually transmitted and TTIs. None of the qualified lr-MSM
had acquired HIV, HBV, HCV, HTLV, or syphilis within the
Figure1. Flowchart of the study population of men who have sex with men (MSM), repeat male donors, and potential new male donors. We distinguished MSM with
low- and medium-to-high-risk sexual behavior from MSM who were qualified and unqualified to donate blood using Dutch donor deferral criteria other than male-to-male
sex. Abbreviations: ACS, Amsterdam Cohort Studies; DHQ, Donor Health Questionnaire; MSM, men who have sex with men.
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CID 2018:XX (XX XXXX) • 5
Blood Donation byMSM
Percentage, 95%-CI
repeat new qualified qualified unqualified unqualified
donors donors lr-MSM hr-MSM lr-MSM hr-MSM
Percentage, 95%-CI
repeat new qualified qualified unqualified unqualified
donors donors lr-MSM hr-MSM lr-MSM hr-MSM
Percentage, 95%-CI
repeat new qualified qualified unqualified unqualified
donors donors lr-MSM hr-MSM lr-MSM hr-MSM
Percentage, 95%-CI
repeat new qualified qualified unqualified unqualified
donors donors lr-MSM hr-MSM lr-MSM hr-MSM
Percentage, 95%-CI
repeat new qualified qualified unqualified unqua lified
donors donors lr-MSM hr-MSM lr-MSM hr-MSM
Percentage, 95%-CI
repeat qualified qualified unqualified unqualified
donors lr-MSM hr-MSM lr-MSM hr-MSM
Percentage, 95%-CI
repeat qualified qualified unqualified unqualified
donors lr-MSM hr-MSM lr-MSM hr-MSM
Percentage, 95%-CI
repeat qualified qualified unqualified unqualified
donors lr-MSM hr-MSM lr-MSM hr-MSM
Percentage, 95%-CI
Parvo B19
repeat qualified qualified unqualified unqualified
donors lr-MSM hr-MSM lr-MSM hr-MSM
Percentage, 95%-CI
repeat qualified qualified unqualified unqualified
donors lr-MSM hr-MSM lr-MSM hr-MSM
Median, IQR
Infecon pressure
repeat qualified qualified unqualified unqualified
donors lr-MSM hr-MSM lr-MSM hr-MSM
Percentage, 95%-CI
Low infecon pressure
repeat qualified qualified unqualified unqualified
donors lr-MSM hr-MSM lr-MSM hr-MSM
Figure2. Infection pressure, proportion with low infection pressure, and antibody prevalence in repeated donors, new donors (class Aonly), qualified low-risk (lr) men who
have sex with men (MSM), qualified high-risk (hr) MSM, unqualified lr-MSM, and unqualified hr-MSM. Abbreviations: CI, confidence interval; CMV, cytomegalovirus; HBV,
hepatitis B virus; HCV, hepatitis C virus; HEV, hepatitis E virus; HHV-8, human herpesvirus type 8; HIV, human immunodeficiency virus; hr-MSM, MSM with medium-to-high
sexual risk behavior; HSV, herpes simplex virus; HTLV, human T-cell lymphotropic virus; IQR, interquartile range; lr-MSM, MSM with low sexual risk behavior; MSM, men
who have sex with men; Parvo B19, parvovirus B19.
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6 • CID 2018:XX (XX XXXX) van Bilsen etal
previous year and, except for HBV, the antibody prevalence of
these 5 infections were comparable to prevalence in new and
repeat male donors.
e anti-HBc prevalence among qualied lr-MSM was
higher than in donors, but two-thirds of these MSM had anti-
HBs titers >200 IU/L, making them eligible donors according
to the current donor guidelines on HBV in the Netherlands
[15]. One qualied lr-MSM who reported no male-to-male
sex within the preceding year had a preexisting chronic HBV
infection. is MSM complied with current donor eligibility
criteria in the Netherlands, and his HBV infection would have
been detected with routine donor screening. Qualied hr-MSM
had an increased seroprevalence of both HBV and syphilis com-
pared to donors and, importantly, 4 of 23 (17%) had acquired
these infections within the last year. As recent infections may
slip through routine donor screening as infectious “win-
dow-phase donations,” deferral of hr-MSM seems legitimate.
In the Netherlands, universal vaccination of newborns without
catch-up of adolescents was introduced in 2011 [16]. HBV vac-
cination is free of charge for MSM since 2002, and actively stim-
ulated using a targeted vaccination program [17]. Over time,
these preventive measures will result in a further decrease of
HBV transmission among all citizens [17–19].
e median IP in qualied lr-MSM and hr-MSM was sig-
nicantly higher than in repeat donors. For qualied lr-MSM,
this was due to an increased seroprevalence of HHVs (ie, CMV,
HSV, and HHV-8). ose who reported consistent condom
use with casual partners had a signicantly higher prevalence
of HHVs than MSM in a monogamous relationship and MSM
who had no anal intercourse in the preceding year. HHVs are
easily transmitted by close contact, and could be a marker
for increased sexual activity. Because CMV, HSV-1/2, and
HHV-8 are cell associated, universal leukodepletion consider-
ably reduces their risk of transmission via red blood cells and
platelets. eir infectious burden in plasma for transfusion or
fractionation is reduced using a combination of pathogen-inac-
tivating and virus-reducing procedures. Although donors in the
Netherlands are not screened for HHVs, it cannot be excluded
that the increased seroprevalence of CMV, HSV-1/2, and
HHV-8 observed in lr-MSM represents increased sexual risk
taking that might compromise blood safety. Further research is
needed on whether these and other potential laboratory mark-
ers are indeed relevant to maintaining blood safety.
The major strength of this study is that MSM were classified
based on detailed information on sexual risk behavior collected
in a prospective longitudinal cohort study. We used predefined
Table1. Age, Antibody Reactivity, and Infection Pressure of 583 Repeat Male Blood Donors and 197 Qualified Men Who Have Sex With Men With
Self-reported Low Sexual Risk Behavior
Repeat Male Blood
MSM With Low Sexual Risk Behavior
No Anal
Condom Use
(n=583) (n=42) (n=48) (n=107)
Age, y, median (IQR) 42 (34–48) 44 (39–48) 39 (30–44) 42 (36–48) .014
Class Ainfections
HIV 0 (0) 0 (0) 0 (0) 0 (0)
HBV (anti-HBc) 6 (1) 3 (7) 1 (2) 11 (10) .204
HBsAg 0 (0) 1 (1) 0 (0) 0 (0) .157
Anti-HBs >200 IU/L 6 (1) 2 (5) 1 (2) 7 (7) .502
HCV 0 (0) 0 (0) 0 (0) 0 (0)
HT LV 0 (0) 0 (0) 0 (0) 0 (0)
Syphilis 0 (0) 0 (0) 0 (0) 0 (0)
Class B infections
HEV 116 (20) 5 (12) 11 (23) 13 (12) .183
Parvovirus B19 432 (74) 33 (79) 38 (79) 74 (69) .303
CMV 220 (38) 21 (50) 27 (56) 86 (80) <.001
HSV 267 (46) 30 (71) 34 (71) 96 (90) .004
HHV-8 30 (5) 16 (38) 12 (25) 49 (46) .049
Infection pressure
Median IP (IQR) 2 (1–2) 3 (2–3) 3 (2–3) 3 (2–4) .004
Low IP 443 (76) 19 (45) 47 (50) 33 (31) .047
Data are presented as No. (%) unless otherwise indicated.
Abbreviations: anti-HBc, antibodies to hepatitis B core antigen; anti-HBs, antibodies to hepatitis B surface antigen; CMV, cytomegalovirus; HBsAg, hepatitis B surface antigen; HBV, hepatitis
B virus; HCV, hepatitis C virus; HEV, hepatitis E virus; HHV-8, human herpesvirus 8; HIV, human immunodeficiency virus; HSV, herpes simplex virus; HTLV, human T-cell lymphotropic virus;
IP, infection pressure; IQR, interquartile range; MSM, men who have sex with men.
aP value for comparing 3 groups of qualified MSM with low sexual risk behavior.
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CID 2018:XX (XX XXXX) • 7
Blood Donation byMSM
criteria to distinguish between lr-MSM and hr-MSM, based on
sexual behavior associated with acquiring HIV infection [20–22].
The criteria could easily be incorporated in the DHQ and are
generally accepted and even suggested by MSM [23].
Our study has the following limitations. First, the study size
might have resulted in a low power for accurate estimates and
comparisons, in particular for low prevalent class Ainfections.
Second, the infection pressure calculation is arbitrary. Class
Ainfections were weighted double, because of their higher rel-
evance to blood safety. However, alternative approaches to cal-
culate IP did not substantially change our results. ird, ACS
participants might not represent the larger MSM population
living in the Netherlands. Due to its objectives and inclusion
criteria, ACS enrolls sexually active MSM and might underrep-
resent MSM with very low sexual risk behavior. is selection
bias might have led us to overestimate the IP among MSM. On
the other hand, all MSM from the ACS were oered HBV vac-
cination. is might not be representative for the larger MSM
population, leading to an underestimation of the IP. Fourth,
antibody reactivity was used as a marker for lifetime sexual
behavior and does not solely represent sexual behavior within
the previous year. As sexual behavior uctuates over life [24],
the antibody reactivity in lr-MSM could result from beha-
vior that has been discontinued. To partially correct for this,
we distinguished between past and recent class Ainfections.
Fih, repeat donors do not represent the general population, as
they are selected based on their low risk of TTIs. Dutch donors
have a 6- to 60-fold lower TTI prevalence and incidence com-
pared to the general population [14]. Moreover, repeat donors
had been screened for HIV, HBV, HCV, and syphilis at every
donation visit. If found positive, they would have been perma-
nently deferred. Hence, by denition, class Ainfections among
repeat donors would be recent infections among a selected
group without a history of class Ainfections. New donors were
included as a second comparison group. ey have not previ-
ously been tested for class Ainfections and therefore are less
likely to be subject to selection bias. Indeed the seroprevalence
of HBV, HCV, and syphilis in new donors is higher than in
repeat donors and closer to that of qualied lr-MSM.
Our study shows that MSM with low sexual risk behavior who
did not report any of the criteria for permanent donor deferral in
the Netherlands had no recent HIV, HBV, HCV, HTLV, or syph-
ilis infections. Their seroprevalence of these infections was sim-
ilar to new and repeat donors. Antibody prevalence to HHVs in
lr-MSM was significantly higher than in repeat donors, but the
epidemiological significance of this finding to recipient safety
is unclear. Our results suggest that hr-MSM pose an increased
threat to blood safety, as recently acquired HBV and syphilis
infections were found in this group. Our results justify further
study of the suitability of lr-MSM to donate blood, with addi-
tional focus on MSM compliance with guidelines and self-with-
drawal, especially considering the high proportion of MSM
with a moderate-to-high intention to donate.
Supplementary materials are available at Clinical Infectious Diseases online.
Consisting of data provided by the authors to benet the reader, the posted
materials are not copyedited and are the sole responsibility of the authors,
so questions or comments should be addressed to the corresponding author.
Author contributions. T.J. W.L., K.H., H.L. Z., and M.P.are respon-
sible for the study design. M.F. S.L.and M.P.supervised data collection
for MSM, and E.S.and T.J. W.L.supervised data collection for donors. T.J.
W.L.was responsible for laboratory testing. W.P. H.B.performed the statis-
tical analysis under supervision of A.M.and M.P.. All authors contributed
to the interpretation of the results, writing of the manuscript, and providing
intellectual feedback. All authors have seen and approved the nal submit-
ted version of the manuscript.
Acknowledgments. e authors gratefully acknowledge the
Amsterdam Cohort Studies (ACS) on HIV Infection and AIDS, a collab-
oration between the Public Health Service of Amsterdam, the Academic
Medical Center of the University of Amsterdam, the Sanquin Blood
Supply Foundation, Medical Center Jan van Goyen, and the HIV Focus
Center of the DC-Clinics. It is part of the Netherlands HIV Monitoring
Foundation and nancially supported by the Center for Infectious Disease
Control of the Netherlands National Institute for Public Health and the
Environment. e authors thank all ACS participants and blood donors
for their contribution. On behalf of the authors, we also thank Alexandra
Kovaleva and the research nurses of ACS for their contributions to data
collection, Udi Davidovich for his valuable input on study design and
interpretation of results, and Anders Boyd for his statistical advice and
Financial support. is study was nanced by the Research and
Development Foundation of the Public Health Service of Amsterdam and a
Product and Process Development Cellular Products grant (PPOC 15-04)
of Sanquin.
Potential conicts of interest. All authors: No reported conicts of
interest. All authors have submitted the ICMJE Form for Disclosure of
Potential Conicts of Interest. Conicts that the editors consider relevant to
the content of the manuscript have been disclosed.
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... were collected under permanent [20,21] or 1-year [19,22] male blood donors reporting sex with another man (MSM) deferral. Statistically significant results are shown in bold font ( p < 0.05). ...
... [8][9][10][11][12][13][14][15][16][17][18][19][20]. Separate data for first-time and repeat donors are provided in [20]; the prevalence of recent infections (0%-1%) is provided in [22]. ...
... 42) [18]. [19,20], HIV [21], HBV (based on HBV core antibody, but not on HBV surface antigen) [21,22] and syphilis [22]. An increased risk of HCV could not be demonstrated, and the relative risk for HTLV-I/II was not estimable due to zero observed cases during the study period [22]. ...
Background and objectives: This systematic review update summarizes evidence concerning transfusion-transmissible infections (TTIs) in male blood donors reporting sex with another man (MSM) or after easing the MSM deferral period. Materials and methods: We searched five databases, including studies comparing MSM versus non-MSM donors (Type I), MSM deferral periods (Type II) or infected versus non-infected donors (Type III) in Western countries, and used GRADE to determine evidence certainty. Results: Twenty-five observational studies were included. Four Type I studies suggest that there may be an increased risk for overall TTIs, human immunodeficiency virus (HIV), hepatitis B virus (HBV) and syphilis in MSM donors, but the evidence is very uncertain. There was insufficient evidence of MSM with low-risk sexual behaviour. A Type II study indicates that easing the MSM deferral period to 1 year may have little to no effect on TTI risk. TTI prevalence in blood donors under 5-year, 1-year, 3-month or risk-based deferral in eight other Type II studies was too low to provide clear conclusions on the effect of easing the deferral. Three Type III studies reported that MSM may be a risk factor for HIV. Increased risk of HBV, hepatitis C virus and HTLV-I/II could not be shown. The evidence from Type III studies is very uncertain. Conclusion: There may be an increased risk of HIV in MSM blood donors. Shortening the deferral from permanent to 1 year may have little to no effect on TTI risk. However, there is limited, unclear evidence from observational studies concerning the impact of introducing 3-month or risk-based deferrals.
... Baseline characteristics of the 40 people with HIV, 40 COBRA HIV-negative individuals and 35 blood donors have been described previously (16,17) and are summarized in Table 1. Briefly, people with HIV and COBRA HIV-negative individuals had a median (IQR) age of 59 (54-64) years, blood donors had a median (IQR) age of 59 (52)(53)(54)(55)(56)(57)(58)(59)(60)(61)(62)(63)(64)(65) years. People with HIV had been diagnosed with HIV for a median (IQR) of 13.9 (9.1-18.6) ...
... We observed that increased PD1 expression, a marker of T cell exhaustion and activation (61) in the CD4 + T cell population was associated with age advancement. This may be indicative of a higher lifetime infection burden and antigen exposure in COBRA participants both with and without HIV as compared to blood donors (62). Similarly, this may also explain the association between age advancement and the increased proportion of CD4 + naïve T cells expressing the IL-7 receptor, which is indicative of homeostatic proliferation to maintain the CD4 + T cell pool especially during HIV infection (63). ...
... Both the monocyte and the T cell profile related to age advancement was able to separate blood donors from COBRA participants which is in line with the generally negative age advancement observed for this group, as opposed to the generally positive age advancement seen in both COBRA participants with and without HIV. By virtue of the study's design (30), COBRA HIV-positive and HIV-negative participants were comparable with regard to many lifestyle-related factors, and thereby generally at higher risk for blood borne infections than blood donors (62). Indeed, blood donors in the Netherlands are specifically selected for their low risk of blood borne infections regarding their general and sexual health based on medication use, sexual risk behavior, and global travel. ...
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Motivation: People with HIV on successful antiretroviral therapy show signs of premature aging and are reported to have higher rates of age-associated comorbidities. HIV-associated immune dysfunction and inflammation have been suggested to contribute to this age advancement and increased risk of comorbidities. Method: Partial least squares regression (PLSR) was used to explore associations between biological age advancement and immunological changes in the T cell and monocyte compartment in people with HIV (n=40), comparable HIV-negative individuals (n=40) participating in the Comorbidity in Relation to AIDS (COBRA) cohort, and blood donors (n=35). Results: We observed that age advancement in all three groups combined was associated with a monocyte immune phenotypic profile related to inflammation and a T cell immune phenotypic associated with immune senescence and chronic antigen exposure. Interestingly, a unique monocyte and T cell immune phenotypic profile predictive for age advancement was found within each group. An inflammatory monocyte immune phenotypic profile associated with age advancement in HIV-negative individuals, while the monocyte profile in blood donors and people with HIV was more reflective of loss of function. The T cell immune phenotypic profile in blood donors was related to loss of T cell function, whereas the same set of markers were related to chronic antigen stimulation and immune senescence in HIV-negative individuals. In people with HIV, age advancement was related to changes in the CD4+ T cell compartment and more reflective of immune recovery after cART treatment. Impact: The identified monocyte and T cell immune phenotypic profiles that were associated with age advancement, were strongly related to inflammation, chronic antigen exposure and immune senescence. While the monocyte and T cell immune phenotypic profile within the HIV-negative individuals reflected those observed in the combined three groups, a distinct profile related to immune dysfunction, was observed within blood donors and people with HIV. These data suggest that varying exposures to lifestyle and infection-related factors may be associated with specific changes in the innate and adaptive immune system, that all contribute to age advancement.
... Recently, we reported that the levels of activation, exhaustion and terminal differentiation within the T cell population were increased in HIV-negative men who have sex with men (MSM) from the COBRA A c c e p t e d M a n u s c r i p t 5 study as compared to blood bank donors (BBD), which could at least in part be attributed to the high prevalence of CMV infection in this population [11][12][13][14][15]. Moreover, MSM with high risk behavior show an increased prevalence of blood born and sexually transmitted infection (STI) [16], which are likely to contribute to the observed immunological changes. In the current study, we evaluated whether changes in immunological markers of T cell activation, exhaustion, and (terminal) differentiation and the bioenergy metabolism profile of PBMC are associated with CMV infection and risk behavior in MSM. ...
... Previous studies have shown that CMV infection is associated with increased expansion of terminally differentiated and senescent T cells [11][12][13][14][15]. Indeed, we observed higher frequencies of CMV infection in both lr-MSM (77.3%) and hr-MSM (91.4%) compared to BBD (29.0%) as determined by the presence of CMV specific IgG in plasma. Moreover, risk behavior in MSM has been associated with an increased prevalence of blood born infections and STIs [16]. We analyzed whether CMV infection and risk behavior were associated with changes in the T cell compartment and the bioenergy metabolism. ...
... The increased CD8 + T cell activation, terminal differentiation of T cells and proportion of CD4 + effector T cells were associated with high-risk behavior in the MSM. The CMV prevalence in HIV-1 seronegative MSM was significantly higher as compared to BBD, confirming previous observations [11,16]. Moreover, we observed that the frequency of CMV infection in hr-MSM was higher as compared to lr-MSM. ...
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Background Recently, we reported that the levels of activation, exhaustion and terminal differentiation within the peripheral T cell compartment were increased in men who have sex with men (MSM) as compared to blood bank donors. During activation and differentiation, T cells undergo metabolic changes to maintain their energy demand. Methods The effect of CMV infection and risk behavior on the immune phenotype of peripheral T cells and the immune bioenergy metabolism profile in HIV-negative MSM (with high or low sexual risk behavior) and blood bank donors was evaluated. Results MSM exhibited increased levels of T cell activation and terminal differentiation, and an impairment of the bioenergy metabolism (mitochondrial respiration and glycolysis) compared to blood bank donors. CMV infection was associated with increased terminal differentiation of CD4+ (B=3.41 (95%CI 1.98-4.85) p<0.0001) and CD8+ T cells (CD57+: B=1.21 (95%CI 0.41-2.02) p=0.004, CD27-CD28-: B=2.20 (95%CI 1.21-3.18) p<0.0001 and CD57+ of CD28-: B=1.02 (95%CI 0.38-1.66); p=0.002) and increased glycolysis (B=0.97 (95%CI 0.27-1.67) p=0.007). Risk behavior was associated with increase activation of CD4+ T cells (B=0.22 (95%CI 0.07-0.37) p=0.005), increased terminal differentiation of CD4+ (B=0.82 (95%CI 0.44-1.20) p<0.0001) and CD8+ T cells (B=1.55 (95%CI 0.58-2.51); p=0.002), and decreased glycolysis (Glycolysis: B=-0.40 (95%CI -0.68--0.12) p=0.006) and glycolytic capacity: B=-0.54 (95%CI -0.91--0.16); p=0.005). Conclusions MSM show an increased prevalence of blood born and sexual transmitted infection, indicating that immunological changes in the T cell population and the bioenergy metabolism observed in MSM can most likely be attributed to chronic antigen exposure.
... The study reported by van Bilsen et al in this issue of Clinical Infectious Diseases presents a new approach, based on the joint analysis of data on behavior and infectious diseases. The study provides support for the potential suitability of some MSM to donate blood without deferrals based on last sex, but it also raises further questions [9]. ...
... While anti-HBc was more common in the qualified low-risk MSM than in matched repeat donors, two-thirds had anti-HBs titers at levels that made them acceptable blood donors according to current Dutch guidelines. Similarly, age-matched male repeat blood donors did not acquire any TTIs [9]. ...
... This conclusion must be drawn cautiously because the authors noted that the sample size was insufficient for accurate comparisons between groups regarding low-prevalence class A infections. Of note, new male blood donors had a higher prevalence of TTIs than both agematched repeat male donors and qualified low-risk MSM, with high-risk and/ or unqualified MSM having higher prevalence [9]. ...
... 9 Of all whole blood donation attempts made in 2019 at Sanquin, 0.15% were deferred for this reason, 10 despite a previous study conducted in the Netherlands suggests that the prevalence of TTIs among MSM donors who either refrain from anal intercourse, maintain a monogamous relationship with a steady male partner (including condomless sex with that partner), or consistently use condoms during anal intercourse with casual partners did not exceed that of donors not engaged in MSM. 11 As of September 2021, Sanquin no longer defers sexually-active MSM from making whole blood donations, as long as they do report being in a monogamous and long-term relationship (more than 1 year). To better balance the safety of the blood supply with donor inclusiveness, however, further advancements to the deferral policy are needed. ...
... Self-reported sexual behaviors were classified as high-risk for TTIs based on previously described infection pressure correlates among MSM. 11 Sexual behaviors were classified as high-risk with the same criteria for both male and female donors. A high-risk sexual behavior pattern was defined as having had multiple sexual partners and having engaged in anal sex, without consistent condom use for at least one of the two. ...
Background: To better balance the safety of the blood supply and the inclusion of men who have sex with men (MSM), further improvements are needed to the risk management strategy employed in the Netherlands to reduce transfusion-transmissible infections (TTIs). A gender-neutral individual risk assessment could provide a solution by determining donor eligibility based on sexual behaviors known to increase the risk of TTIs. Our objective is to estimate the proportion of blood donors that would be deferred by such an assessment, as well as their discomfort answering such questions. Study design and methods: Two surveys were distributed in May 2020 to assess sexual behavior in blood donors in the last 4, 6, and 12 months, as well as their discomfort reporting such information. A combination of both surveys measured the extent to which discomfort was associated with reporting sexual behavior. A high-risk sexual behavior pattern was defined as having had multiple sexual partners and having engaged in anal sex, without consistent condom use. Results: Of all 2177 participating whole blood donors, 0.8% report engaging in high-risk sexual behaviors over the last 4 months and would therefore be ineligible to donate. When accounting for the additional proportion of donors that reported such questions would stop them from donating, 2.0% and 3.2% of female and male donors, respectively, would be lost. Discussion: Gender-neutral eligibility criteria based on high-risk sexual behaviors may reduce the overall number of eligible donors in the Netherlands, but could make blood donation more accessible to a broader group of donors.
... 18 Given the increasing number of GBM taking PrEP in Australia, it is likely that many men believe that they pose little to no risk of HIV transmission, regardless of their sexual behaviour (although these men may be at increased risk of other sexually/transfusion transmissible infections). 25 Many may also apply this belief to blood donation. For many GBM, the distinction between what they believe to be 'safe' and 'risky' sex is likely to be important for their own decisions about blood donation and is therefore key to informing policy about the appropriateness of blood donation. ...
... A study from the Netherlands showed that 'low risk' men who have sex with men (those who reported either no anal intercourse, sex including condomless anal intercourse within a monogamous relationship, or consistent condom use with casual partners) showed no higher risk of transfusion transmissible infections than matched heterosexual male donors. 25 In the era of changing perceptions of HIV transmission risk (PrEP, treatment as prevention, undetectable=untransmittable) it is important to note these are based on lowered sexual transmission risk, and does not apply to the risk of transmission to recipients of their blood. 26,27 In a recent commentary, Australian authors highlight that because of the proportionally larger inoculum and parenteral administration route, a much lower viral load than the 200 copies/mL threshold used for sexual transmission is potentially infectious in the context of a transfusion. ...
BACKGROUND Men who have sex with men in Australia are currently ineligible to donate blood (are “deferred”) for 12 months since last oral or anal sexual contact with another man. In Australia and overseas, there has been limited research on attitudes and perceptions related to blood donation in this population. STUDY DESIGN AND METHODS Questions on blood donation histories and attitudes toward the deferral policy were included in the questionnaire of an online prospective cohort of gay and bisexual men (GBM) living in Australia. RESULTS In 2018, 1595 GBM responded to the survey. In this sample, 28.7% reported previously donating blood. Among the remaining men who had never donated blood, 64.5% expressed an interest in doing so. Nearly all men indicated they were not willing to abstain from sex with another man for 12 months in order to donate, and the vast majority believed the rule was unfair, too strict, and homophobic. Three‐quarters (77.7%) said that if the policy changed, they would likely donate blood. Age and openness about oneʼs sexuality were independently associated with oneʼs willingness to donate blood in the absence of the deferral. CONCLUSION There was a high level of willingness and desire to donate blood among GBM. However, rather than abstaining from sex in order to donate, many men comply with the deferral policy and do not donate. A less conservative deferral policy may increase donations from GBM.
... Men who have sex with men are not only at increased risk of acquiring HIV but also of acquiring a wide range of other sexually transmitted infections (STIs). These not only include treatable bacterial STIs such as syphilis, gonorrhea, and chlamydia but also chronic viral infections such as viral hepatitis and herpesvirus infections, including CMV [22]. Cytomegalovirus seropositivity in particular [23], but also transient bacterial STIs [24,25], have each been associated with a decreased CD4/CD8 ratio and an increased CD8 count. ...
... Likewise, in animal models, CMV superinfection was demonstrated and was related to CD8 T-cell expansion [30,31]. Other viruses, such as herpes simplex virus 1/2, Epstein-Barr virus, and human herpesvirus 8, are also more prevalent among MSM and could contribute to differences in immunological phenotypes [22,32,33]. Finally, Noguera-Julian et al [34] showed MSM to have a different gut microbiome compared with MSW irrespective of their HIV status. ...
Full-text available
Background: We reported T-cell senescence to be similar in people living with HIV (PWH) with suppressed viremia (predominantly men who have sex with men (MSM)) and HIV-negative otherwise comparable controls, but greater than in healthy blood donors. This lead us to compare CD4+ and CD8+ T-cell counts and CD4+/CD8+ ratios between HIV-negative MSM and men who only have sex with women (MSW), and relate observed differences to behavioral factors and infectious exposures, including cytomegalovirus (CMV) infection. Methods: In 368 HIV-negative MSM and 72 HIV-negative MSW T-lymphocyte phenotyping was performed 3 times biennially. Baseline CMV serology, and STI-incidence/-seroprevalence, sexual and substance-use behavior data were collected during study visits. Results: MSM, compared to MSW, had higher CD8+ counts (551 vs. 437 cells/mm3, P<.001), similar CD4+ counts (864 vs. 880 cells/mm3, P=.5) and lower CD4+/CD8+ ratios (1.84 vs. 2.47, P<.001). Differences were most pronounced for MSM with >10 recent sex partners, and partly explained by higher CMV seroprevalence in MSM. Discussion: These findings suggest that factors other than HIV may, both in PWH and certain HIV-negative MSM, contribute to a low CD4+/CD8+ ratio. Whether this, like in PWH, contributes to comorbidity risk in HIV-negative MSM requires further study.
... Note that some papers are included in multiple categories. Charted data pertaining to these sub-categories are included in Additional le 2. Table 3, Additional le 2 summarizes the data charted in studies (16)(17)(18)(19) that included both gbMSM and non-gbMSM in the study population. ...
Full-text available
Background: Globally, the updating of donor policies in relation to gay, bisexual and other men who have sex with men (gbMSM), transgender, and gender diverse populations remains an important public health issue. The purpose of this scoping review was to determine how Canada and other OECD countries are addressing this issue in relation to plasma and whole blood donation policies. Methods: The scoping review included English-language peer-reviewed empirical studies from OECD countries from 1997 to 2020 to better understand the shifts in donor policies over this time period. Initial search criteria resulted in 3,974 abstracts and titles. Researchers reviewed abstracts according to eligibility criteria which yielded a total of 51 published studies for full review. Data charting was based on Arksey and O’Malley’s framework for scoping reviews. Results: Key considerations included the reliance on mathematical modeling and behavioural risk surveillance data as a means of continuing with the status quo in informing donor policies which continue to ban sexually active gbMSM from donating. In addition, there is a lack of focus on the unique concerns facing transgender, gender diverse, and racially diverse populations who may wish to donate whole blood or plasma. Conclusions: There is a growing international policy shift in reducing the lifetime donor ban and/or removing the ban for gbMSM to donate blood. More needs to be done to both clarify the rationale for such policies in the face of current scientific evidence and testing and to ensure inclusion of transgender, gender diverse, and racially diverse populations in the formation of policies and information about both whole blood and plasma donations. Finally, blood operators need to work more closely with diverse donor communities to ensure the approach taken is in keeping with the needs of gbMSM, transgender, and gender diverse populations.
... Our analysis demonstrates that many GBM are highly aware and reflexive of their sexual risk levels and thus capable of self-reporting for the purposes of donation. This trend is supported by quantitative literature that has demonstrated an association between self-reporting risk behaviours with actual risk to the blood supply [38]. ...
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Background Researchers and activists have long called for changes to blood donation policies to end what is frequently framed as unjustified bans or deferral periods for men who have sex with men (MSM). Since 2016, in Canada, a man had to be abstinent from all sexual contact (anal or oral sex) with other men for at least 12 months in order to be an eligible blood donor. As of June 3, 2019, this deferral period was reduced to 3 months. Methods To better understand the acceptance of existing deferral policies and possible future policy, we conducted 47 in-depth interviews with a demographically diverse sample of gay, bisexual, queer, and other men who have sex with men (GBM) in Canada’s three largest cities: Vancouver, (n = 17), Toronto (n = 15), and Montreal (n = 15). Interviews were coded in NVivo 11 following an inductive thematic analysis. We focus on men’s preferred policy directions and their opinions about a policy change proposed by Canada’s blood operators: a 3-month deferral for all sexual activity between men. We interviewed GBM approximately one-year before this new deferral policy was approved by Health Canada. Results Most participants were opposed to any deferral period in relation to MSM-specific sexual activity. A fair and safe policy was one that was the “same for everyone” and included screening for several risk factors during the blood donation process with no categorical exclusion of all sexually active MSM. Participants believed that multiple “gender blind” and HIV testing-related strategies could be integrated into the blood donation process. These preferences for a move away from MSM-specific exclusions aligned with their opinions concerning the possible change to a 3-month MSM deferral, for which participants shared three overarching perspectives: (1) step in the right direction; (2) ambivalence and uncertainty; and (3) not an improvement. Conclusion A predominant assertion was that a change from a 12-month to a 3-month deferral period would not resolve the fundamental issues of fairness and equity affecting blood screening practices for GBM in Canada. Many participants believed that blood donation policy should be based on more up-to-date scientific evidence concerning risk factor assessment and HIV testing.
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Background WHO has set targets for hepatitis C virus (HCV) elimination by 2030. We did a global systematic review of HCV prevalence and incidence in men who have sex with men (MSM) to provide updated estimates that can guide community education and public health policy. Methods We did a systematic review and meta-analysis of studies published and listed on MEDLINE or Embase between Jan 1, 2000, and Oct 31, 2019, including conference proceedings. Studies were eligible if they reported measures of HCV prevalence or HCV incidence (or both) among MSM. Studies that relied on participants' self-reported HCV status with no laboratory confirmation were excluded. Pooled HCV estimates in MSM were stratified by HIV status and by injecting drug use, then by WHO region and by income level. Random-effects meta-analysis was done to account for between-study heterogeneity and examined using the I² statistic. Pooled HCV prevalence was also compared with HCV estimates in the general population and presented as prevalence ratios (PRs). In HIV-negative MSM, incidence estimates were stratified by use of HIV pre-exposure prophylaxis (PrEP). The systematic review was registered with PROSPERO, number CRD42020156262. Findings Of 1221 publications identified, 194 were deemed to be eligible and included in the systematic review and meta-analysis. Overall, the pooled HCV prevalence in MSM was 3·4% (95% CI 2·8–4·0; I²=98·0%) and was highest in Africa (5·8%, 2·5–10·4) and South-East Asia (5·0%, 0·0–16·6). Globally, HCV prevalence was 1·5% (1·0–2·1) in HIV-negative MSM and 6·3% (5·3–7·5) in HIV-positive MSM. Compared with the general population, HCV prevalence was slightly higher in HIV-negative MSM (PR 1·58, 95% CI 1·14–2·01) and markedly higher (6·22, 5·14–7·29) in HIV-positive MSM. Pooled HCV prevalence was substantially higher in MSM who had ever injected drugs (30·2%, 22·0–39·0) or currently injected drugs (45·6%, 21·6–70·7) than in those who never injected drugs (2·7%, 2·0–3·6). In HIV-negative MSM, the pooled HCV incidence was 0·12 per 1000 person-years (95% CI 0·00–0·72) in individuals not on PrEP and 14·80 per 1000 person-years (9·65–20·95) in individuals on PrEP. HCV incidence in HIV-positive MSM was 8·46 per 1000 person-years (6·78–10·32). Interpretation HIV-positive MSM are at substantially increased risk of HCV. Overall, HIV-negative MSM had a slightly higher prevalence of HCV than the general population but had a lower prevalence than HIV-positive MSM. High HCV incidence in more recent PrEP studies suggests that as PrEP use increases, greater HCV transmission might occur. HCV burden in MSM varies considerably by region, which is likely to be associated with variation in the prevalence of injecting drug use and HIV. Funding World Health Organization.
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Background: Like a number of other countries, Australia mandates that a man who has had sex with men is deferred from donation until 12 months has elapsed since the sexual activity. This review examined whether this deferral period is justified by current evidence. Study design and methods: Databases (Medline, EMBASE, Scopus) were searched using terms "blood donation" and "gay" or "MSM" and "HIV risk" from the mid-1980s to the present to investigate the history of donor deferral policy and its rationale in Australia. Results: Gay and bisexual men in Australia face a higher risk of human immunodeficiency virus and other blood-borne viruses (BBVs) than other populations. All blood donations, however, are tested for BBVs, and with current testing technologies the window period during which infection may be present but not detected is now less than 1 week. While there is a moral imperative to maintain blood safety, there is also a moral imperative to ensure that differential treatment of population groups with regard to donation eligibility is scientifically justified. Potential social harms that may flow from a dissonance between deferral policy and its evidence base include loss of trust and increased nonadherence to policy. Conclusions: A 12-month deferral for gay and bisexual men exceeds what is required to maintain blood safety. This disparity potentially causes social harm without any additional benefit to public health. Reducing the deferral period to 3 months will not increase health risk to recipients and may have the social benefit of increasing inclusiveness.
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We review the history and evolution of blood donor criteria for men who have sex with men (MSM). Deferral policies in many jurisdictions, including Australia, New Zealand, Canada, the United States, Brazil and many western European countries are based on a period of abstinence from MSM, often of 12 months duration. Several countries (Italy, Spain and Portugal) defer donors based on sexual behaviours considered to be at high risk, regardless of whether the partner is same sex or opposite sex. Compliance is a key determinant in the efficacy of any deferral policy. We summarize research themes and strategies discussed at a January 2017 meeting held in Toronto, Canada, to provide an evidence basis for future policy changes.
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Background: The predominant mode of transmission of human immunodeficiency virus (HIV) in Europe is male-to-male transmission. Men who have sex with men (MSM) are deferred from donating blood in many countries, but nevertheless do donate blood. Based on data from 34 countries, we estimated the proportion of MSM screened for HIV in the context of a blood donation and identified individual factors associated with this HIV screening in order to propose possible public health interventions. Materials and methods: In 2010, the first European MSM Internet Survey (EMIS) collected self-reported data on HIV testing from >180,000 MSM in 38 European countries. Using logistic regression, demographic and behavioural factors associated with screening for HIV in blood establishments were identified. Stratified by European sub-region, we analysed the proportion of MSM screening in blood establishments by time elapsed since last negative HIV test. Results: Donor eligibility criteria for MSM vary across Europe with most countries using permanent deferral. The Western region had the lowest (2%) proportion of MSM screened in blood establishments and the Northeastern region had the highest (14%). Being <25 years old, not disclosing sexual attraction to men, never having had anal intercourse with a man, having a female partner, living in a rural area, and certain European sub-regions or countries of residence increased the likelihood of being screened in blood establishments. Discussion: In spite of deferral policies, MSM are screened for HIV in the context of blood donations. Gay-friendly testing services are rare in rural areas, and young men might be reluctant to disclose their sexual orientation. Recent developments, such as home sampling, might offer new testing possibilities for those not reached by established services yet wishing to know their HIV status. Donor selection procedures should be improved. Both interventions might help to further reduce the risk of transfusion-transmitted infections.
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Background: Separate transmission networks for human immunodeficiency virus (HIV) coexist. Molecular typing of viral genomes can provide insight in HIV transmission routes in donors for whom risk behavior-based donor selection failed. Study design and methods: This study includes all HIV-infected Dutch and Flemish donors in the period 2005 to 2014 (n?=?55). Part of the HIV polymerase (pol) gene was amplified, sequenced, and compared with more than 10,000 HIV strains obtained from HIV-infected Dutch and Flemish patients. The most likely transmission route was determined based on HIV phylogeny and the donor's self-reported risk behavior during the exit interview. Results: HIV-infected donors were predominantly male (69%), were repeat donors (73%), were born in the Netherlands or Belgium (95%), and harbored HIV Subtype B (68%). Seventy-five percent of HIV-infected male donors were part of robust phylogenetic clusters linked to male-to-male sex, while only 24% of HIV-infected male donors reported male-to-male sex during posttest counseling. Sex between men and women accounted for 13% of HIV infections in male donors and 93% of HIV infections in female donors based on phylogenetic analysis. Only 40% of HIV-infected female donors had HIV Subtype B; 65% of female donors reported a foreign partner and indeed HIV sequences interspersed with sequences from HIV-endemic areas abroad, in particular sub-Saharan Africa. Conclusion: HIV typing helps to understand HIV transmission routes in donor populations. We found substantial underreporting of male-to-male sex among HIV-infected male donors. Donor education on HIV risk factors and the danger of window-period donations and a donor environment that encourages frank disclosure of sexual behavior will contribute to a decrease of HIV-infected donors.
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Background: Risk behavior-based donor selection procedures are widely used to mitigate the risk of transfusion-transmissible infections (TTIs), but their effectiveness is disputed in countries with low residual risks of TTIs. Study design and methods: In 1995 to 2014, Dutch blood donors infected with hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), human T-lymphotropic virus (HTLV), or syphilis were interviewed by trained medical counselors to identify risk factors associated with TTIs. Trends in the prevalence and incidence of TTIs were analyzed using binomial regression models. Results: A total of 972 new donors and 381 repeat donors had TTIs. New donors had higher rates of TTIs compared to repeat donors. Although the HBV and HCV prevalence gradually decreased over time, the incidence of all five TTIs remained stable during the past two decades. In new donors the TTIs had the following risk profiles: "blood-blood contact" for HCV, "unprotected sex" for HIV and syphilis, and "country of birth" for HBV and HTLV. In infected repeat donors, sexual risk factors predominated for all TTIs. At posttest counseling, 28% of infected repeat donors admitted to risk factors leading to permanent donor exclusion if revealed during the donor selection procedure (predominantly male-to-male sex and recent diagnosis of syphilis). Conclusion: The prevalence and incidence of TTIs among Dutch blood donors are six- to 60-fold lower than in the general Dutch population, illustrating the effectiveness of donor selection procedures. However, at least a quarter of infected donors appeared noncompliant to the donor health questionnaire (DHQ), suggesting that DHQs, or the way donor questioning is implemented, can be improved.
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Background: Although increased prevalence of transfusion transmissible infections (TTI) among "men who have sex with men" (MSM) has been well documented, the exclusion of MSM as blood donors is contested. The aim of this systematic review is to find studies that describe the risk of TTI in MSM blood donors. Methods: We searched MEDLINE, Embase, The Cochrane Central Register of Controlled Trials, Cinahl, and Web of Science, and used GRADE for determining evidence quality. We included studies comparing MSM and non-MSM blood donors (or people eligible to give blood), living in areas most relevant for our Blood Service. Results: Out of 18 987 articles, 14 observational studies were included. Two studies directly compared MSM with non-MSM donors showing that MSM donors have a statistically significant higher risk of HIV-1 infections. In one of these studies it was shown that this was related to recent (< 12 months) MSM contact. In two additional studies no evidence was shown in favour of a certain deferral period for MSM. Ten studies, applying permanent deferral for MSM, compared infected versus non-infected donors. One study found that MSM is a statistically significant risk factor for HIV-1 infection in blood donors. For other TTI such as HBV or HCV, an increased risk of infection could not be demonstrated, because the precision of the results was affected by the low numbers of donors with MSM as risk factor, or because of risk of bias in the included studies. All studies included low level evidence, because of risk of bias and imprecision of the results. Conclusions: High-quality studies investigating the risk of TTI in MSM who donate blood are scarce. The available evidence suggests a link between MSM blood donors and HIV-1 infection, but is too limited to be able to unambiguously/clearly recommend a certain deferral policy.
Objective: Sexual risk behaviour changes during a person's life course. Insights in sexual risk behaviour trajectories of MSM may provide starting points for the timing of HIV prevention methods. We aimed to study longitudinal trajectories of sexual risk behaviour predictive of HIV acquisition from sexual debut onwards. Design: A longitudinal study among 815 HIV-negative participants of the Amsterdam Cohort Studies (ACS) who completed extensive questionnaires about their sexual behaviour every 6 months between 2007 and 2017. Methods: A comprehensive behavioural risk score predictive of HIV seroconversion was developed. On the basis of this risk score, linear trajectories of sexual risk behaviour and MSM group membership were estimated using latent class growth mixture modelling. Associations between longitudinal trajectories and demographic and psychosocial factors were examined. Results: Three trajectories of sexual risk behaviour were identified, which were labelled Low risk (90.3% of the sample), Falling high risk (6.5%) and Rising high risk (3.3%). MSM following the Falling high risk (20.5%) and Rising high risk (25.0%) trajectories were more likely to acquire HIV during follow-up. The Falling high risk trajectory was associated with younger age at sexual debut, fewer steady partnerships and high percentages of substance use. The Rising high-risk trajectory was associated with increasing percentages of substance use over time. Conclusion: MSM follow different trajectories of changing sexual risk behaviour over time. Early identification of MSM following a trajectory of falling or rising high-risk behaviour and adequate timing of individual-based preventive interventions may reduce HIV transmission.
The U.S. ban on blood donations from men who have sex with men was instituted at a time of great uncertainty, but advances in testing and in understanding of disease transmission offer better ways than a sweeping ban to minimize the risk of transfusion-related HIV.
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.