Stepping Stones or Second Class Donors?: a qualitative analysis of gay, bisexual, and queer men's perspectives on plasma donation policy in Canada

Improving gay, bisexual and transgender inclusion in blood and plasma donation policies and programmes in Canada: A qualitative study

BACKGROUND AND OBJECTIVES

An increasing number of blood operators around the world, including those in Canada, have removed time-based deferral periods for gay, bisexual and other men who have sex with men and replaced them with sexual behaviour-based questions for all donors. While this marks a significant shift in screening approach, what remains unclear is how members of two-spirit, lesbian, gay, bisexual, transgender and queer (2S/LGBTQ+) communities view blood operators' initiatives to be more inclusive. As such, this study was conducted to assess the awareness of donor screening changes and other initiatives among members of 2S/LGBTQ+ communities and to explore their recommendations for blood operators' work with these communities.

MATERIALS AND METHODS

Semi-structured qualitative interviews (n = 15) were conducted with 2S/LGBTQ+ people across Canada. Data were analysed using open inductive coding methods.

RESULTS

Reported here are the key results on recommendations for blood operators. Three themes were identified from the data: (1) the need for increased communications with 2S/LGBTQ+ communities surrounding changes to donor policies and guidelines; (2) the need for trans-inclusive policy and procedures; and (3) the need for culturally responsive and equity-informed staff training at donor centres.

CONCLUSION

Results suggest that blood operators should consider 2S/LGTBQ+ communities when developing blood and plasma donation policies, screening procedures and staff training. Increased consultation with these communities is desired, and further research specific to the experiences of transgender blood donors is needed.

MSM and blood donation: shifting to individualized risk assessment

Deferring donors at higher risk for transfusion transmissible infections is an important part of ensuring blood safety. The deferral for gay, bisexual, and other men who have sex with men (gbMSM) was implemented in the 1980s in many countries, since they were identified as a high-risk group for AIDS/HIV. With the introduction of increasingly sensitive HIV antibody testing, augmented by nucleic acid testing, the window period for HIV infection-when a donor may be infectious but have negative test results-has shrunk dramatically. In Canada, this has led to progressively shorter deferral periods for gbMSM, decreasing from a permanent deferral for sex with another male since 1977 to a 5-year, 12-month, and eventually 3-month deferral period. These time-based deferrals maintained safety; however, they are seen as stigmatizing by many and still result in the deferral of sexually active gbMSM. More recently, several countries have moved to a donor screening approach based on assessing sexual risk behaviors in all donors. This article outlines research supporting changes in policy, current eligibility screening policies in several countries, and preliminary results postimplementation of new eligibility policies in Canada in September 2022.

What influences decisions to donate plasma? A rapid review of the literature

BACKGROUND AND OBJECTIVES

Plasma has become an essential ingredient for various medical treatments. Many blood collection agencies rely on voluntary non-remunerated donation when collecting plasma, but at present many do not collect sufficient plasma to meet domestic demands. This rapid review sought to explore the factors that have been found to influence people's decisions to donate plasma to inform future research.

METHODS

Searches were conducted in PubMed, PsycINFO, Social Sciences Citation Index and CINAHL for peer-reviewed journal articles that discussed plasma donation and the factors associated with donor behaviour. Pertinent information from included articles was extracted and arranged in themes.

RESULTS

In total, 33 articles were included in this review. Three main themes were identified by the authors. The first focused on site-level factors related to blood collection agencies' engagement with plasma donors and their influence on plasma donation experiences. The second theme considered how individual characteristics and experiences influence willingness to donate plasma. The third theme examined social and cultural-level factors, such as how social networks and community shape perceptions and experiences with donation.

CONCLUSION

Our findings suggest that the current understanding of plasma donation is focused mainly on converting whole blood donors and also centres on individual-level factors to donation. Further research must examine what factors attract non-whole blood donors to become plasma donors, focusing on broader social-level influences. This review will inform policies and interventions for blood collection agencies to increase plasma donors.

Evolving the gay, bisexual and other men who have sex with men time-based deferral to sexual risk screening for all donors: The contribution of Canadian research programmes

BACKGROUND AND OBJECTIVES

In Canada, the time deferral for gay, bisexual and other men who have sex with men (gbMSM) to donate blood has gradually decreased. In September 2022, this deferral was replaced with sexual behaviour-based screening for all donors. We investigate how data from targeted research programmes addressed knowledge gaps to support this change.

MATERIALS AND METHODS

We conducted a scoping review describing the Canadian literature available before the research programmes relating to (1) behavioural indicators of HIV risk and (2) attitudes to blood donation among gbMSM, current donors and the general population. We summarize the targeted research programmes, their outputs and impact to date.

RESULTS

For question 1, five projects met inclusion criteria. For question 2, three articles met inclusion criteria. Knowledge gaps identified were insufficient evidence of HIV incidence in gbMSM who met other donor eligibility criteria and scant data on opinions and views of blood donation and screening criteria for sexual risk behaviours. The research programmes funded 19 projects at 11 different research sites involving over 100 individual researchers/collaborators resulting in 19 peer-reviewed publications to date. Leveraging existing gbMSM cohorts yielded relevant HIV incidence data to inform safety modelling studies. Findings indicated that sexual behaviour-based screening was acceptable to gbMSM and donors, and donor discomfort around specific questions could be mitigated with clear explanations.

CONCLUSION

Targeted research programmes filled critical knowledge gaps and informed a change to gender-neutral, sexual behaviour-based screening for all donors. Findings supported successful implementation of these changes with research-informed staff training.

Improved access yet inequitable experience: gay, bisexual and other men who have sex with men's views of more inclusive criteria for source plasma donation

BACKGROUND

Canada has incrementally reduced restrictions to blood and plasma donation that impact men who have sex with men, gay, bisexual, and queer men, and some Two Spirit, transgender and non-binary individuals (MSM/2SGBTQ+). Prior to the launch of a pilot program in 2021 enabling some MSM/2SGBTQ + to donate source plasma, we explored the acceptability of the program among individuals who could become eligible to donate in the program.

METHODS

We invited men identifying as MSM/2SGBTQ + to participate in two consecutive semi-structured interviews to explore their views on blood and plasma donation policy, plasma donation, and the proposed Canadian plasma donation program. Interview transcripts were analyzed thematically and acceptability-related themes were mapped onto the Theoretical Framework of Acceptability.

RESULTS

Twenty-seven men identifying as having sex with men participated in 53 interviews. Eighteen themes were mapped onto the seven construct domains of the Theoretical Framework of Acceptability. Underlying all aspects of acceptability was a tension between four primary values influencing participants' views: altruism, equity, supply sufficiency, and evidence-based policy. The program was viewed as welcome progress on a discriminatory policy, with many excited to participate, yet tension with inequitable aspects of the program undermined support for the program and interest to contribute to it. The high demands of the program are unique for MSM/2SGBTQ + and are only tolerable as part of a program that is an incremental and instrumental step to more equitable donation policies.

CONCLUSION

Findings highlight past experiences of exclusion in Canada as a unique and critical part of the context of the donation experience among MSM/2SGBTQ+. Despite the program's goals of greater inclusivity of MSM/2SGBTQ + individuals, the anticipated experience of the program included continued stigmatization and inequities. Future research should seek to understand the experienced views of MSM/2SGBTQ + donors to ensure that as policies change, policies are implemented equitably.

Alternatives to blood donor deferral of gay, bisexual, and other men who have sex with men: Acceptability of screening the sexual risk behavior of all blood donors

BACKGROUND

Blood operators screen donors to reduce the risk of transfusion-transmitted infections (TTIs). Many are evolving screening procedures from those that defer all who have had a sexual interaction with gay, bisexual, or other men who have sex with men (gbMSM) to an approach that assesses individual donors' recent sexual risk behavior with any partner.

STUDY DESIGN AND METHODS

A representative sample of current blood donors (N = 1194) was recruited online and randomized to complete either the existing (at the time of the study) Canadian Blood Services' donor questionnaire (DQ) that screens out those with recent gbMSM sexual experience, a modified donor questionnaire (MDQ) that assesses individuals' recent sexual behavior with any partner, or an MDQ that assesses individual sexual behavior with any partner and explains why these questions are asked. Respondents were asked for their perceptions concerning difficulty, comfort, and acceptability of these screening questionnaires.

RESULTS

Across experimental conditions, current donors regarded screening questionnaire difficulty to be low; discomfort in responding was minimal; screening questionnaires were perceived to be relatively inoffensive and justified, and very few donors would cease donating if the screening questionnaire they responded to became the one in general use. Some minor sex differences were observed, and in some cases, perceptions of the MDQ with explanation were somewhat more positive than those of the DQ and MDQ without explanation.

DISCUSSION

An individual risk behavior screening approach appears to be acceptable to current blood donors as an alternative to screening out all who have recently engaged in gbMSM sexual interactions.

Inequities in organ and tissue donation and transplantation for sexual orientation and gender identity diverse people: A scoping review

Sexual orientation and gender identity (SOGI) diverse populations experience discrimination in organ and tissue donation and transplantation (OTDT) systems globally. We assembled a multidisciplinary group of clinical experts as well as SOGI-diverse patient and public partners and conducted a scoping review including citations on the experiences of SOGI-diverse persons in OTDT systems globally to identify and explore the inequities that exist with regards to living and deceased OTDT. Using scoping review methods, we conducted a systematic literature search of relevant electronic databases from 1970-2021 including a grey literature search. We identified and screened 2402 references and included 87 unique publications. Two researchers independently coded data in included publications in duplicate. We conducted a best-fit framework synthesis paired with an inductive thematic analysis to identify synthesized benefits, harms, inequities, justification of inequities, recommendations to mitigate inequities, laws and regulations, as well as knowledge and implementation gaps regarding SOGI-diverse identities in OTDT systems. We identified numerous harms and inequities for SOGI-diverse populations in OTDT systems. There were no published benefits of SOGI-diverse identities in OTDT systems. We summarized recommendations for the promotion of equity for SOGI-diverse populations and identified gaps that can serve as targets for action moving forward.

Willingness and eligibility to donate blood under 12-month and 3-month deferral policies among gay, bisexual, and other men who have sex with men in Ontario, Canada

In Canada, gay, bisexual and other men who have sex with men (GBMSM) are a population that are willing to donate blood, if eligible, but have a history of ineligibility and deferrals due to concerns that their blood poses an increased risk of HIV entering the blood supply. Our objective was to examine the proportion of GBMSM who are willing and eligible to donate under the 12-month deferral policy (implemented in 2016) and the 3-month deferral policy (implemented in 2019). Data for this study comes from the #iCruise study, a mixed cohort study designed to examine sexual health outreach experiences through online services and mobile apps among GBMSM in Ontario. A total of 910 participants were recruited between July 2017 and January 2018. Eligibility criteria include identify as male (cisgender or transgender); at least 14 years old; having had sex with a man in the previous year or identifying as sexually/romantically attracted to other men or identifying as gay, bisexual, queer or two-spirit; and living or working in Ontario or having visited Ontario four or more times in the past year. Participants completed a baseline and a follow-up questionnaire. A subset of #iCruise participants (n = 447) further completed this questionnaire. Willingness and eligibility to donate blood were assessed under 12-month and 3-month deferral policies. Of the 447 GBMSM surveyed, 309 (69.1%) reported a general interest in donating blood. 109 (24.4%) GBMSM were willing, 75 (16.7%) were eligible, and 24 (5.4%) were both willing and eligible to donate blood under the 12-month deferral policy. Under the 3-month deferral policy, willingness and eligibility to donate blood increased significantly to 42.3% and 29.3%, respectively. The percent of GBMSM who were both willing and eligible to donate blood also increased significantly to 12.3% under the 3-month deferral policy. The increase in willingness to donate blood varied by age, ethnicity, and geographic residence of participants whereas the increase in eligibility to donate blood varied by education level of participants. Under the 3-month deferral policy, GBMSM who were 50 years or older, identified as bisexual or other, had a lower education level, and who were not 'out' to others were more likely to be eligible to donate. GBMSM who reported a general interest in donating blood were more likely to be willing to donate blood under both deferral policies. The most common reason for not being interested in donating blood was the MSM deferral policy itself; many participants interpreted the policy as discriminatory for 'singling out' GBMSM or self-assed themselves as ineligible. Among study participants, both willingness and eligibility to donate blood was significantly higher under the 3-month deferral policy. The results suggest that a time-based reduction to a 3-month deferral policy is impactful but limited. Future research should measure GBMSM's willingness and eligibility under the individual risk-based assessment (to be implemented in 2022).

'Stay at home and limit contact': The impact of stay-at-home advice on the behavior of Australian donors aged 70 and over in the first year of the pandemic

BACKGROUND

Early in the COVID-19 pandemic, Australian donors aged 70 and over were advised to temporarily stop donating. The aim of this research was to understand the factors associated with some of these donors continuing to donate despite the advice, and whether adherence to the advice had negative implications for donor retention.

STUDY DESIGN AND METHODS

Survey data from 2078 donors were analyzed to understand the factors associated with donating blood during the first 6 months of the pandemic, and the impact of following stay-at-home advice during the first 6 months of the pandemic on donor return 6-12 months into the pandemic. Panel data were used to gain an overview of donation behavior before, during, and after the initial phase of the pandemic.

RESULTS

Donations by donors aged 70 and over decreased disproportionately to other age groups during the early stages of the pandemic. Sex, total donation count, awareness of stay-at-home advice from the Blood Collection Agency, the mode of receiving stay-at-home advice, donor risk perceptions and attitudes toward stay-at-home advice were associated with donation behavior in the first 6 months of the pandemic. Donors who did not donate in the first 6 months of the pandemic had lower odds of returning 6-12 months into the pandemic.

CONCLUSION

Stay-at-home advice was partially successful in preventing older donors from donating; however, more tailored communication approaches may have prevented more donors from donating. Implementation of stay-at-home advice should be accompanied by strategies to prevent ongoing donor lapse in the medium- to long-term.

Staff perspectives on barriers and enablers to implementing alternative source plasma eligibility criteria for gay, bisexual, and other men who have sex with men

BACKGROUND

Canadian Blood Services introduced new eligibility criteria that allows some sexually active gay, bisexual, and other men who have sex with men (gbMSM) to donate source plasma, marking a significant change from time-based deferral criteria. We aimed to identify potential barriers and enablers to implementing the new criteria from the perspective of donor center staff.

STUDY DESIGN AND METHODS

We conducted Theoretical Domains Framework-informed interviews with staff from two source plasma donation centers in Canada.

RESULTS

We completed 28 interviews between June 2020 and April 2021. Three themes representing eight domains captured key tensions. Valuing inclusive eligibility criteria: staff support inclusive criteria; many were concerned the new criteria remained discriminatory. Investing in positive donor experiences: staff wished to foster positive donor experiences; however, they worried gbMSM donors would express anger and disappointment regarding the new criteria, staff would experience unease over using stigmatizing criteria and convey nonverbal cues of discomfort, and recurring plasma donors may behave inappropriately. Supporting education, training, and transparency of eligibility criteria: participants believed providing in-person training (i.e., to explain criteria rationale, address discomfort, practice responding to donor questions) and ensuring donors and the public were well-informed of the upcoming changes would improve implementation.

DISCUSSION

Participant views emphasize the importance of supporting staff through training and transparent communication to optimize the delivery of world-class equitable care for a new cohort of donors who have previously been excluded from plasma donation. Findings inform which staff supports to consider to improve implementation as policies continue to shift internationally.

A mixed methods investigation of the relationship between blood donor policy, interest in donation, and willingness to donate among gay, bisexual, and other men who have sex with men in Ontario, Canada

Background

As of 2019, men who have sex with men (MSM) in Canada are ineligible to donate blood if they have had oral or anal sex with another man in the last 3 months. Deferral policies targeting MSM are largely interpreted as unjust by gay, bisexual, and other men who have sex with men (GBMSM) – shaping their desire to donate blood and engage with blood operators. This mixed methods study explores interest in blood donation among GBMSM as well as willingness (and eligibility) to donate under four different deferral policies.

Methods

We surveyed 447 GBMSM who were recruited from the Ontario-wide #iCruise study. Participants were asked whether they were interested in blood donation and if they were willing to donate under each of our four deferral policies. We also completed interviews with 31 of these GBMSM. Participants were asked to describe their feelings about blood donation, their views on our different deferral policies, the impact of a policy change, as well as other means of redress.

Results

Most participants (69%) indicated that they were interested in donating blood. Despite this, an interpretation of the MSM deferral policy as discriminatory was common among all participants. Our mixed methods findings indicate that, among those who were interested in blood donation, the adoption of one of the alternative policies presented in this study (specifically Policy 2 or Policy 3) would significantly increase the number of participants willing to donate and be viewed as “a step in the right direction.” However, many participants who were not interested in blood donation argued that a gender-neutral deferral policy would need to be implemented for them to donate. Participants recommended that blood operators consider efforts to repair relations with GBMSM beyond policy change, including pop-up clinics in predominantly queer areas and diversity sensitivity training for staff.

Conclusion

We argue that the most impactful policy shift would be the implementation of an individual risk-based deferral policy that is applied to all donors regardless of sexual orientation or gender identity. However, given MSM’s historical exclusion from blood donations, blood operators should pair this policy shift with community relationship-building efforts.