Month: August 2021

The blood supply in the US is critically low. Donations dropped off so dramatically during the COVID-19 pandemic that the American Red Cross has declared a national blood crisis. And since donated red blood cells only last about six weeks, supplies cannot be stockpiled in advance. A severe shortage could require difficult decisions about who should or shouldn’t receive a transfusion — decisions with life-or-death consequences.

So it makes sense to eliminate unnecessary restrictions on who can donate blood, right? And yet, one group of potential blood donors — men who have sex with men (MSM) — is not eligible to donate blood if they’ve been sexually active in the last three months, according to FDA guidelines.

Why single out men who have sex with men?

Such restrictions were first applied in the 1980s. HIV, the virus that causes AIDS, had not yet been discovered, but it had become clear that men who had sex with men were at particularly high risk for AIDS. Additionally, researchers learned that HIV could be transmitted through blood, including blood transfusions. The lifetime restriction on blood donations made by gay and bisexual men that quickly became policy was intended to help stop the spread of AIDS.

What’s the justification now?

More than 40 years later, the viral cause of AIDS is well established and detection tools have advanced.

• Highly accurate blood tests can detect HIV.
• Potential blood donors are asked about risk factors for HIV and other infections that can spread through a blood donation.
• Donated blood is routinely tested so that tainted blood is not transfused.

Yet not until 2015 was the lifetime ban on blood donation revised by the FDA to allow donation by MSM who reported being abstinent for a full year. When blood donations plummeted during the pandemic, restrictions were revised again. Currently, men who have sex with men can choose to donate blood as long as they attest to not having had sex with men for three months.

Why three months? The concern is that even with highly accurate testing, a recently acquired infection could be missed.

Vital steps to keep the blood supply safe

Of course it’s vitally important to keep the blood supply safe. No system is perfect, but the safety track record of transfused blood in the US is remarkably good: transfusion-related infections such as HIV and hepatitis are exceedingly rare. For HIV, the estimated risk of infection by transfusion is well under one in a million in this country.

Blood banks achieve this high safety standard through

• Questionnaires that seek to disqualify people whose donation could cause illness in the recipient. For example, potential blood donors are asked detailed questions about risk factors for infection and medicines they take. Of course, this relies on accurate and honest self-reporting.
• Testing donated blood: Regardless of answers to the screening questions, all donated blood is routinely tested for a number of transmissible infections, including
  • hepatitis B and C
  • HIV
  • syphilis
  • West Nile virus.

Not surprisingly, blood testing is much more reliable than self-reporting. The spectacularly accurate testing available now is far more effective than an honor system that asks potential donors about risk factors for having an infectious disease.

That’s one big reason behind increasing calls for changes in the blood donation policies that apply to MSM. Research underway now may help with policy decisions. The ADVANCE study (Assessing Donor Variability And New Concepts in Eligibility) is examining the impact of changing the screening questionnaire to ask gay and bisexual men about specific behaviors that raise infection risk, rather than requiring sexual abstinence for the previous three months. For example, having unprotected sex with multiple partners or being paid for sex are high-risk activities, regardless of one’s sex or sexual orientation.

The bottom line: Who can safely donate blood?

Currently, no compelling evidence shows that blood donation by men who have sex with men compromises the safety of our blood supply. Policies that require a period of abstinence for MSM may exclude many people at low risk for having an infection spread through blood, while allowing others at higher risk to donate.

Many countries focus on individual risk factors for infections that can be transmitted through a blood transfusion, not a person’s sex or sexual orientation. Britain, France, Israel, and other countries use such policies to keep their blood supplies safe. The American Medical Association, American Red Cross, and several US senators support similar policies for the US — an approach also backed by many experts in the field.

In my view, a change in blood donation policy is long overdue: all donor eligibility should be based on medically justified risk factors, and all potential donors should be screened the same way. And the sooner these restrictions are lifted, the better. A just, equitable, and medically sound blood donation policy is not only the right choice — it could allow donation of blood that saves your life.

Dr. Freeman: “Mr. Vargas, great news on the biopsy results: all negative. It means the workup we have done, including imaging, blood work, and endoscopies, is all normal. You’re all set.”

Mr. Vargas: “How can that be? I feel miserable!”

What are disorders of gut-brain interaction?

The clinical scenario above (names altered for privacy) is surprisingly common for gastroenterologists. These doctors of the esophagus, stomach, small intestines, colon, pancreas, and liver are well trained to identify and treat conditions of the gastrointestinal (GI) tract that occur from diseases caused by inflammation, infection, or cancer.

While some of these conditions can be devastating, they are usually easy to diagnose on standard testing. But there are other illnesses that can impact the GI tract that do not have a clear laboratory test or finding on endoscopy to identify them. One such class of these is called disorders of gut-brain interaction, or DGBIs. Some people (including doctors) may be familiar with the older term used to describe these conditions — functional GI diseases — but it is no longer used.

DGBIs can include irritable bowel syndrome, reflux hypersensitivity, or functional dyspepsia. They are called disorders of gut-brain interaction because it is believed the most critical abnormality is impaired communication between the gut and the brain via the nervous system in both directions (from gut to brain and brain to gut).

What can cause a DGBI?

Some things are associated with the development of DGBIs, including having suffered from prior infections, particularly those that have symptoms like nausea or diarrhea. DGBIs are more prevalent in certain populations, including women. Depression and anxiety are independent illnesses that can be associated with DGBIs as well. Unfortunately, the mechanisms of why DGBIs happen are still not well defined, which can be frustrating for patients and their providers.

From the perspective of specialists like me, DGBI management is not given a lot of attention in clinical training. This can lead to unnecessary testing that has risks, including perforation from endoscopy or radiation from imaging. Even more confusing is that DGBIs can overlap with other GI diseases. As an example, functional dyspepsia (a type of chronic indigestion) can overlap with gastroparesis (slow stomach emptying). Irritable bowel syndrome can overlap with inflammatory bowel diseases (like ulcerative colitis and Crohn’s disease).

What are the treatments for DGBIs?

DGBIs can be treated with multiple primary approaches, and these can also be combined: lifestyle, including dietary approaches; medications; complementary/alternative medicine approaches; and behavioral therapy. Lifestyle and complementary and alternative medicine approaches can be attractive options for some patients.

While eliminating very fatty and processed foods may improve GI symptoms when you have a DGBI, it is hard to sustain such severe changes in diet to control symptoms, and when done too strictly can lead to other conditions, such as feeding difficulties from avoidant restrictive food intake disorder.

Some people might try a low-FODMAP diet (this should be avoided if you’ve had an eating disorder). You can try to avoid FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols)-containing foods for one month (ideally guided by a doctor and/or a dietitian), and completely return to a normal diet if there is no improvement. If there is improvement, then add back foods systematically to make sure your diet is varied and provides all necessary nutrients.

Sometimes people consider acupuncture, ginger, turmeric, or herbal supplements, which you should always discuss with your doctor to prevent side effects or serious health issues, including liver problems.

Medication-based approaches typically use medications that have been used to treat conditions like depression, neuropathy, and fibromyalgia. Sometimes doctors do not clearly explain the rationale for using such medications; however, they are meant to improve the gut-brain interaction by improving pain sensation pathways in the brain, and perhaps even stimulating improved nerve function.

Finally, GI-directed behavioral therapies use cognitive behavioral approaches to improve GI symptom-specific anxiety with the help of a psychologist or therapist.

How can I talk about managing a DGBI with my doctor?

If your doctor has identified that you have a DGBI, make sure to emphasize how much it is negatively impacting your quality of life. For a condition like irritable bowel syndrome, the change in bowel movements and the associated pain can really cause daily distress. Many DGBIs can affect your ability to do certain types of work that may not allow you easy access to a bathroom. DGBIs also affect sexual health.

Make sure your provider understands that managing your DGBI is important, and you want to work together to find the right treatment approaches (or a combination of approaches), as discussed above.

Beyond this, it is important to recognize that DGBIs are established diagnoses, and are just as valid as any other gastrointestinal disease. When you have symptoms of a DGBI, it is not because of an issue of willpower or weakness, or ” just in your head.” These are disorders for which good treatments exist, and they can improve your symptoms and quality of life.