'One step closer': Acceptability of a programme of plasma donation for fractionation from men who have sex with men.

BACKGROUND AND OBJECTIVES: In Canada, Héma-Québec is considering the possibility of allowing men who have sex with men (MSM) to donate plasma for fractionation combined with a mandatory quarantine period. This study aims to assess the acceptability and operational feasibility of the programme in the targeted population.
MATERIALS AND METHODS: Seven focus groups with MSM (N = 47) were conducted in Montréal, regarding their beliefs underlying attitudes, subjective norms and perceived behavioural control relating to intention to participate in a programme of plasma donation for fractionation. A theoretical thematic content analysis was realized.
RESULTS: Participants brought up benefits of the programme. Some are altruistic (help others, save lives, contribute as citizens), while others are linked to what it could bring to their community (progress, opportunity to include MSM in blood donation programmes, acknowledgement of MSM's contributions to the well-being of others). However, even if the programme is in accordance with their altruistic values, it clashes with their values of equality and social justice. Many disadvantages were raised (discrimination and stigmatization of MSM, the fact that their blood is presented as being not as good as the blood of others). Facilitating factors and barriers to participation were put forward in terms of programme characteristics and sites where donations would be made.
CONCLUSION: The findings suggest some interest in the programme of plasma donation for fractionation, but this is significantly tempered by the fact that differential treatment for MSM would continue and that their demands regarding access to whole blood donation are still unmet.

Introduction

In 1986, a lifetime ban on blood donations from men who had had sex with men even once since 1977 was instituted in Canada. In 2013, the ban was reduced to 5 years since last sexual contact. In the light of data concerning transfusion safety, the exclusion period was reduced to 12 months in 2016, then to 3 months in 2019. Although more inclusive than in the past, the policy remains restrictive. Many groups are urging evaluation of individual risk rather than categorization of men who have sex with men (MSM) as a risk group. The main difficulty in considering a more permissive policy is the lack of evidence‐based data on risks of infection among sexually active MSM, especially those who wish to donate blood. Since the emergence of HIV, research involving MSM has focused more on recruitment of men who take sexual risks, creating a systematic selection bias that influences results in terms of what those risks actually represent.

Recently in Canada, there has been a political will to generate evidence‐based data supporting policy changes regarding MSM while ensuring the safety of recipients. One option to consider is donation of plasma for fractionation: the fractionation process eliminates or greatly reduces the risk of contamination by HIV and other viruses. In itself, the inherent pathogen reduction that happens with plasma fractionation could justify the eligibility of MSM for this type of donation. Quarantining these donations and retesting the donors at a later time would provide another layer of safety. A similar approach was recently implemented in France, where MSM are allowed to donate plasma intended for transfusion, which is put under quarantine until donors return for testing 1. More specifically, the sexual contacts criteria applied to MSM to assess their eligibility is also applied to heterosexual donors, who are ineligible if they have had more than one sex partner in the past 4 months.

Based on the French model, Héma‐Québec (the agency providing blood products in the province of Québec) is exploring the possibility of implementing a programme of plasma donation for fractionation from HIV‐negative MSM who have never had hepatitis B or C. Other eligibility criteria would apply. The programme could look as follows: (i) eligible MSM donate plasma by apheresis in a dedicated plasma donation site; (ii) each donation is quarantined for a minimum period of time (e.g. 2–4 months), after which the donor returns to the dedicated site to get tested and make another donation, if he wishes; (iii) once the donor tests negative for blood‐borne infections, the quarantined donation is sent for fractionation. A programme of blood plasma donation for fractionation combined with a mandatory quarantine period would guarantee the safety of products derived from this plasma and eliminate the risk of including a donation made during the silent period of sexually transmitted and blood‐borne infections (STBBI).

Few studies have analysed factors characterizing the acceptability of plasmapheresis donation according to donors. Plasma donors' motivations vary: desire to help others 2, 3 and save lives 4; show solidarity 4; it's the right thing to do 5, 6; increased self‐esteem and personal gratification 2, 3, 5, 7; opportunity to meet other donors and add to weekly activities 7; perception there is demand for the product 3; and for the good of society 3. Motivations can be altruistic, but also of a more personal nature. Prior to their first donation, people who had become plasma donors had a higher intention to donate blood in the next two years 8. Facilitating conditions mentioned by plasmapheresis donors include having more frequent opportunities to develop relationships with collection staff and other donors, being able to donate more often, and establishing regular donation schedules and routines 5. Conversely, the main barriers to plasma donation are time required to make a donation 5, 9, being too busy and having trouble booking an appointment 9, and experiencing discomfort in the arm 5. From an organizational perspective, barriers include multiple demands (e.g. questionnaires) and high expectations of the organization regarding number and frequency of donations (e.g. feeling pressure to donate more often) 5, 9. However, those findings are not from studies of MSM.

As for feasibility of implementing a plasma donation programme, it seems easier to recruit plasmapheresis donors among regular whole blood donors 10. Moreover, since the apheresis process is less convenient for donors, due to time required and higher risk of adverse reactions, it is preferable for a donor to develop a whole blood donation habit before undergoing apheresis. This approach optimizes the probability the person will return after the initial plasma donation. At Héma‐Québec, the percentage of individuals returning for plasma donation among donors with no history of giving blood is 71% at 12‐month follow‐up, compared with 85% among donors with prior histories of blood donation [internal data]. Recruitment of new plasma donors in the LGBTQ+ (lesbian, gay, bisexual, transsexual, queer and others) communities must consider the fact that most MSM will not have experienced blood donation.

A study in Israel 11 has examined MSM's perceptions regarding a programme that would allow men to donate plasma, which would be frozen, quarantined and released for transfusion if a future donation at least 4 months later is negative for STBBIs. Among respondents, 64·5% would consider participating in this programme. Being younger and reporting lower income were associated with a higher willingness to donate.

Since the 1980s, exclusion of MSM from blood donation has been denounced by gay men, who were frequent blood donors prior to the ban 12 and are still interested in donating blood 13, 14, 15. At a time when gay men still faced extensive prejudice, establishing a link between being gay and spreading HIV and thus being excluded as a group from a valued social practice was seen as discriminatory. In addition to redefining gay men's blood as a deadly hazard rather than a welcomed gift, such exclusion undermined this population's sense of belonging and citizenship 12. Although recipient safety will always take precedence over donor rights 16, blood donation is a powerful expression of social solidarity; exclusion of an entire population from donation can give rise to feelings of discrimination, social marginalization and stigmatization 17. Those feelings add to the many stigmatizing experiences linked to being gay, also referred to as ‘minority stress’. Perceived or experienced discrimination creates a hostile and stressful social environment that can affect health behaviours and psychological functioning, causing physical and mental health problems 18, 19, 20. Despite scientific advances that have resulted in lifting the lifetime ban and shortening the exclusion period, this population appears to continue to face discrimination and to fight for a donor selection process based on risk behaviours rather than on belonging to a defined risk group 21, 22, 23, 24.

Although the proposed plasma donation process is more inclusive than that for blood donation, it is also more invasive and challenging. To highlight its benefits and constraints, and its consequences for MSM and organizations, this study aims to assess the acceptability and operational feasibility of the programme in the targeted population. To this end, focus groups with MSM were used to understand the beliefs underlying the attitudes, subjective norms and perceived behavioural control relating to intention to participate in a programme of plasma donation for fractionation.

Theoretical model

Intention was explored using a model integrating Ajzen's theory of planned behaviour 25, to which were added various theoretical concepts 26 tested in studies on health behaviours, including intention to donate blood 27. Various factors grouped into three categories were used to define intention. First, behavioural beliefs (attitudes) constitute variables that refer to an individual's perception of the consequences of adopting a behaviour (e.g. perceived benefits, inconveniences and consequences). Next, normative beliefs (subjective norms) correspond to constructs about what people in the individual's social environment do and would think about the behaviour (e.g. perceived approval or disapproval of people important to the individual, personal standards regarding adoption of the behaviour). Lastly, control beliefs (perceived behavioural control) refer to variables related to a person's ability to adopt a behaviour (e.g. facilitating or limiting factors, perceived ability to adopt a behaviour despite the barriers).

Materials and methods

To reach the study objective, focus groups were conducted with men who identify as MSM in Montréal, Canada. Participants presented the following characteristics: identified as men (cisgender or transgender); had sexual relations with men; were 18 or over; reported HIV‐negative or unknown status; and spoke French or English. Participants were recruited through ads in local LGBTQ+ print and social media until data saturation was reached. Participants were given $50 as compensation for attending focus groups.

Focus groups lasted about 120 min. First, a descriptive sheet to characterize the sample was completed; this included participants' sociodemographic information (e.g. age, place of birth, ethnocultural group, sexual orientation) and past blood donation experiences. In order to document the overrepresentation of men highly involved in their community and activists on issues of blood donation among MSM (biases in recruitment), participants' sense of belonging to LGBTQ+ communities was measured using 4 statements (e.g. consider to be a part of, participate in its activities) on a scale of 1 (weak sense of belonging) to 5 (strong sense of belonging), adapted from Frost and Meyer's community connectedness scale 28. They were asked, both before and after the meeting, about intention to donate whole blood without regard to current qualification criteria, then after the meeting about intention to donate plasma as part of Héma‐Québec's programme. In each case, intention was measured on a scale of 1 (low intention) to 5 (high intention). Participants then took turns introducing themselves and talking about their blood donation experiences. The current blood donation policy was explained to them. Then, the process and conditions of the programme of plasma donation for fractionation were presented, along with videos produced by Héma‐Québec on plasmapheresis, plasma donation use and the fractionation process. A series of open questions (see Appendix 1) provided insight into participants' beliefs concerning their participation in the plasma donation programme. More general questions were asked about what this experience would mean for them and their community, and about their intention to participate in the programme. Lastly, characteristics of possible locations for the programme were discussed.

The discussions were recorded, transcribed and entered in NVivo. The text was first divided into the three types of beliefs proposed in the theoretical model (behavioural, normative, control). It was then analysed using theoretical thematic content analysis, which involves systematically coding relevant data and grouping codes into themes 29 (Tables 2, 3 and 4). Since part of the focus groups were conducted in French, some quotes presented in the results section have been translated by the authors. Data from the descriptive sheets were entered in SPSS and descriptive analyses were conducted (proportions, average standard deviations) to describe the sample. Bivariate analyses (Chi‐square and independent sample t‐test) were performed to identify characteristics associated with intention to donate plasma as part of Héma‐Québec's programme. Paired t‐test was performed to compare intention of giving blood or plasma before and after the meeting.

Table 2

Behavioural beliefs

Themes and codes	Number of citations	Number of focus groups
A programme that discriminates MSM	67	7
MSM are still excluded, ghettoized, treated differently from others	30	6
Labels, discriminates and stigmatizes MSM	13	5
Implies that MSM's blood is less pure, not as good as others'	12	5
Reinforces prejudices that MSM take more risks and spread more STBBI than others	7	3
Based on fear, conservative	2	2
Implies that MSM are less truthful and reliable than other donors	2	2
Does more harm than good	1	1
An onerous programme that does not meet MSM's needs	66	7
Relegates MSM to an onerous, restrictive and complicated programme	20	7
Leaves MSM feeling used, offended and frustrated	19	7
Meets Héma‐Québec's needs rather than those of the LGBTQ+ communities	8	4
Less glorious than transfusion	5	3
Bittersweet	5	2
Could be used to silence critics and end discussions with the communities	4	3
Sidesteps MSM's demands regarding whole blood donation	3	3
Too little, too late	2	2
A positive change for MSM	55	7
A step forward, in the right direction	20	7
Represents an inclusion of MSM in blood donations programmes	12	5
A sign of social progress, of openness towards MSM	11	4
Enhances social recognition of MSM's contribution to other people's well‐being	7	5
A way to renew discussions about MSM's access to whole blood donation	3	3
Reduces prejudices and stigmatization towards MSM	2	2
An opportunity to do some good	41	7
Allows MSM to help people in need and save lives	16	5
Allows MSM to do their duty as citizens, be useful to others	10	5
Allows MSM to contribute to blood banks	7	4
Increases plasma reserves and medication production	6	3
Reduces costs for society	2	2

Table 3

Normative beliefs

Themes and codes	Number of citations	Number of focus groups
Most people would be in favour	21	6
All or most people they know would be in favour	21	6
Some people would be against because of discrimination or fear	10	6
Members and activists of the LGBTQ+ communities might be against or boycott the programme	5	4
Family members would disapprove because of fear of receiving MSM's blood	3	2
Family members would disapprove because of the discrimination they face	2	1
In line with their altruistic values	15	6
In line with their values of altruism and contribution	15	6
In dissonance with their values of equality	13	5
Divided between doing some good and wanting complete inclusion of MSM	8	5
Clashes with their values of equality and social justice	5	4

Table 4

Control beliefs

Themes and codes	Number of citations	Number of focus groups
Barriers	47	7
Being judged, treated differently or outed	34	7
Having to go to a site reserved for MSM that would forcibly reveal their sexual orientation	16	7
Feeling judged, rejected or treated differently by staff	8	4
Fear of breaches of confidentiality regarding personal information	6	3
Having to go through a different process than other donors	3	2
Being used to gather statistics about MSM	1	1
Having to go through a process that is lengthy and restrictive	13	6
Having to return to get tested before their donation is released from quarantine	8	4
Having to book an appointment beforehand	3	2
Being refused once on site due to other admissibility criteria	2	2
Facilitating factors	120	7
A site where they can receive other medical services	39	7
Receiving a complete STBBI screening	16	7
Being able to donate plasma when they go for their regular medical check‐ups	14	5
Linking their medical data to their Héma‐Québec file, so they wouldn't have to go back to the donation site	6	3
A site that is part of a global service offer	3	2
Being treated with respect and discretion on site	30	7
Being greeted on site by MSM or trained staff sensitive to the realities of LGBTQ+ communities	20	6
Not having to declare your sexual orientation to staff members	10	4
Being treated equally as other donors	18	6
A site for everyone	10	5
Being treated equally as others	4	2
Going to the donation site of their choice	2	2
Imposing quarantine for everyone on site	2	2
A site that is accessible and flexible	17	6
A site that is open evenings and weekends	7	6
A site that is near a metro station or have a free parking lot	5	3
Being able to book an appointment	3	3
Having slots for appointments and for walk‐ins	2	1
Having more transparency and commitment from Héma‐Québec	14	5
Having a large‐scale promotion of plasma donation	6	3
Héma‐Québec apologizing for the years of oppression	3	2
Héma‐Québec displaying their pride in the programme through an awareness campaign	3	2
Héma‐Québec committing to offer more than the programme that is proposed	2	1
A site for MSM only that would provide	2	2
A site for MSM only that would provide an open space where they wouldn't be judged	1	1
A site that is openly gay‐friendly	1	1

Results

Sample description

Focus groups were held in May and June 2018: 6 groups were conducted in French and 1 in English, for a total of 47 participants (Table 1). Average age of participants was 33 years and ranged from 21 to 54. Most were Francophones (87%), and 70% were born in Canada. Two thirds (66%) had university degrees. Most (98%) self‐defined as men and 89% as homosexual. Over half of participants (60%) were single and 40% in couples. The average overall score for feeling of belonging to the LGBTQ+ communities was 3·9 (on a scale of 1–5; standard deviation = 0·9). As for blood donation experiences, 61% reported never having donated blood.

Table 1

Sample description (N = 47)

Variables	Number (n)	Proportion (%)
Number of participants
French‐language focus groups (#1, 2, 3, 4, 5 and 7)	41	87·2%
English‐language focus group (#6)	6	12·8%
Age of participants (m ± SD) Varies from 21 to 54	32·8 ± 8·8
Mother tongue
French	35	74·5%
English	5	10·6%
Spanish	5	10·6%
Portuguese	1	2·1%
Arabic	1	2·1%
Place of birth
Canada	33	70·2%
France	7	14·9%
Colombia	2	4·3%
Mexico	2	4·3%
United States	1	2·1%
Brazil	1	2·1%
Peru	1	2·1%
Ethnocultural group
White, Caucasian	36	76·6%
Hispanic, Latino	6	12·8%
Middle Eastern, Maghrebi, Arab	2	4·3%
South Asian	1	2·1%
Black	1	2·1%
Other (mixed)	1	2·1%
Education
None, High school diploma or Vocational diploma	4	8·5%
College or Technical	12	25·5%
University	31	66·0%
Approximate total annual income, before taxes
No income	2	4·3%
Under $30 000	23	48·9%
$30 000 or more	21	44·7%
Rather not answer	1	2·1%
Main occupation(s) (Not mutually exclusive)
Full‐time job	28	59·6%
Part‐time job	10	21·3%
Full‐time student	10	21·3%
Part‐time student	4	8·5%
Other (unemployed, self‐employed)	5	10·6%
Gender identity
Man	46	97·9%
Queer, genderfluid, non‐binary	2	4·3%
Trans man	1	2·1%
Sexual orientation (Not mutually exclusive)
Homosexual or gay	42	89·4%
Queer, pansexual, fluctuating	5	10·6%
Bisexual	3	6·4%
Rather not answer	1	2·1%
Marital status
Single	28	59·6%
Dating/in a relationship	19	40·4%
Proportion of friends who are gay, bisexual or queer
Half or less	28	59·6%
More than half	19	40·4%
Feeling of belonging to the LGBTQ+ communities Average overall score (m ± SD) On a scale of 1–5	3·9 ± 0·9
Blood donation, lifetime
No	28	60·9%
Yes	15	32·6%
Not sure	3	6·5%
Intention to donate blood before the meeting (m ± SD) On a scale of 1–5	4·5 ± 1·0
Intention to donate blood after the meeting (m ± SD) On a scale of 1–5	4·4 ± 1·1
Intention to donate plasma after the meeting (m ± SD) On a scale of 1–5	3·9 ± 1·2

Intention to donate whole blood and plasma

Average intention of donating whole blood without regard to current qualification criteria was 4·5 (standard deviation = 1·0) at the beginning of the discussion, on a scale of 1–5. After the discussion, average intention of giving whole blood was similar at 4·4 (standard deviation = 1·1; non‐significant difference P = 0·17). However, after the discussion, the average intention to donate plasma as part of the programme was 3·9 (standard deviation = 1·2), a score significantly lower than the post‐discussion intention of giving whole blood (P = 0·003). When comparing participants regarding their intention to donate plasma, analyses identified statistically significant associations with marital status: 72% of individuals with a high intention to donate plasma (score of 4 or 5 on the intention scale) were single, compared with 33% of those with a low intention (P = 0·012).

Behavioural beliefs

Participants' attitudes towards Héma‐Québec's proposed plasma donation programme were mixed, as shown in Table 2. All groups perceived the programme as a vehicle for discrimination and stigmatization against MSM (7 groups, 67 citations), who are still ghettoized and treated differently from others. Participants said the programme made them feel excluded, isolated, rejected, labelled or discriminated against. Some said they were afraid – of being treated differently, of having to ‘come out’ every time they donated, of experiencing discrimination. All groups questioned the type of donation chosen for the programme: plasma for fractionation. Some participants had the impression that MSM's blood is not as good, or less pure, than others'. In some groups, participants questioned the idea of a quarantine period applicable only to MSM, which reinforces prejudices that MSM take more risks and spread more STBBI and implies that they are less truthful and reliable than other donors, who are shown more trust. Few participants stated that the programme was conservative, based on fear and, in the end, will do more harm than good.

At Héma‐Québec, [the programme will create] a separation, like “Don’t worry, he’s not here to give blood. He’s just gonna donate plasma. He’s impure, but we’ll filter it.” – Group #1

Participants in all groups considered that this onerous programme does not meet MSM's needs (7 groups, 66 citations). They stated they were being relegated to a burdensome, complicated programme that still excludes them from donating whole blood. They felt frustrated and offended that so many safety measures were imposed. Participants decried that this programme only meets Hema‐Québec's needs, and makes them feel used and like they have been downgraded to a second‐rate type of donation (because products are not directly destined to be transfused). Participants were left bitter and afraid that the programme will be used to sidestep MSM's demands regarding whole blood donation, and to end discussions with LGBTQ+ communities. For some participants, Héma‐Québec is doing too little, too late.

I don’t wanna be punished for being gay. If someone who isn’t gay can go on their lunch hour and I have to devote an entire day, not only that day but [again] 6 weeks later, that feels like a punishment. […] This feels like donating in the closet. – Group #6

Despite these inconveniences, the programme was also deemed in all focus groups to be a positive change for MSM (7 groups, 55 citations). Participants perceived the programme as a step forward in the right direction and an opportunity to finally include MSM in blood donation programmes. In most groups, participants acknowledged Héma‐Québec's will to change things and deemed the programme socially progressive, taking it as a sign of openness towards them. Participants stated that the programme could enhance social recognition of MSM's contribution to other people's well‐being, and reduce prejudices and stigmatization against MSM. The idea was also raised that if such a programme was implemented, it would bolster discussions about MSM's access to whole blood donation.

It’s the advantage of being recognized as donors, that we’re not just carriers of HIV. – Group #2

All groups also mentioned that this programme represents an opportunity to do some good (7 groups, 41 citations). It would be an occasion for MSM to help people in need and save lives. Most groups expressed feeling proud, gratified, or useful when presented with the idea of doing their duty as citizens and contributing to blood banks. Some groups talked about benefits of increasing plasma reserves and reducing costs for society.

[I’d feel] proud to say “I contributed, I did something, and I don’t just take advantage of society. I can give too.” – Group #1

Normative beliefs

As shown in Table 3, when asked about the perception people in their circle would have about their participating in the programme, most participants said all or most people they know would be in favour (6 groups, 21 citations). Participants could identify some people that might be against because of discrimination or fear (6 groups, 10 citations). More precisely, some stated that members and activists of LGBTQ+ communities might be against it, and even boycott the programme. A few indicated that family members would disapprove of their participation, either because of the discrimination they face, or fear of receiving an MSM's blood.

I think it might not be well received in the MSM community, because if there’s political mobilization, saying ‘No, that’s not what we asked for, we’re not gonna give you what you want from us,’ […] there could be a boycott. […] And a boycott moves fast. The communities aren’t that big, social movements are quick, and with social media, it’s really fast. – Group #1

When they compare the plasma donation programme to their personal values and principles, many participants mentioned that the donation itself is in line with their values of altruism, and contribution to society and other people (6 groups, 15 citations). However, for some participants, the way the programme is constructed conflicts with their values of equality and social justice (5 groups, 13 citations). Some participants mentioned being torn between these two points of view, and the weight given to each varied from person to person.

For me, [the program] is strongly ambiguous, because it is strongly on stigmatization, etcetera, so against my values. On the other hand, I have always had values of altruism and helping others, and I think it’s a way to help. And it is very ambivalent because yes, I would be able to help, but at the same time if I agree to help, that is to say that I accept to be labelled and ghettoized, which on the other side, I do not accept at all. I think that the negative side would win – Group #3

Control beliefs

Participants were asked about perceived barriers and facilitating factors to their taking part in the programme (Table 4).

Barriers

Regarding factors that would act as a barrier to their participation, the fear of being judged, treated differently or outed was mentioned in all groups (7 groups, 34 citations). If they were limited to a site reserved for MSM, it would forcibly reveal their sexual orientation to staff members or people they could cross on their way there. Feeling judged, being treated differently (e.g. staff wearing gloves with MSM donors only), or having to physically go through a different process than others (e.g. another door or waiting line) would create a major barrier. A few participants listed fear of breaches of confidentiality regarding personal information, and the fact that their participation could be used to gather data regarding MSM without their knowledge.

The problem is having to go to Héma‐Québec, in a straight and super conservative society, and having to wait in a different line than everyone else and saying “I'm gay, I'm here to give plasma.” – Group #3

Another major barrier mentioned by most groups is the process itself (6 groups, 13 citations) – the fact that they have to book an appointment beforehand that the procedure is lengthy and that they have to return to get screened before their donation is released from quarantine. A few participants mentioned that being refused once on site due to other admissibility criteria could impede their participation in the programme.

It’s not like they’re going to spend time in your university or workplace or near you, and then "I want to donate". It's no, no, no, take your appointment, then do all the steps, then if you don’t go to your follow‐up appointment, we do not take you. – Group #1

Facilitating factors

In all focus groups, having access to additional services available on site was perceived as a factor facilitating participation (7 groups, 39 citations), like receiving a complete STBBI screening or being able to donate plasma when they go for their regular medical check‐ups. Some participants suggested that it would be easier if their medical data were linked to their Héma‐Québec file, so they would not have to go back to the donation site. Another facilitating factor discussed in every group is the importance of being treated with respect and discretion on site (7 groups, 30 citations). Participants stated wanting to be greeted by MSM or trained staff sensitive to the realities of LGBTQ+. Not having to verbally declare your sexual orientation to staff members by only doing so in the eligibility questionnaire was also considered facilitating. Participants mentioned wanting to be treated as equal to other donors (6 groups, 18 citations), meaning they could go to a donation site of their choosing, one that is opened to everyone, and have to go through the same steps as others – whether that implies quarantine or not.

[Having] qualified staff. That’s mostly it. Meaning qualified volunteers, that there are no signs of hostility, homophobia, or things like that. In fact, that the staff inside is qualified and tolerant, open to receiving anyone. – Group #5

Ideally, the site would need to be accessible and flexible (6 groups, 17 citations), that is, to be open evenings and weekends, and be near a metro station or have a free parking lot. The idea of making an appointment was perceived by some as a facilitator, with a few participants suggesting there be slots for appointments and for walk‐ins. Some participants listed elements that Héma‐Québec could put in place that would facilitate the implementation of the programme (5 groups, 14 citations), such as a large‐scale promotion of plasma donation, a formal apology for the years of oppression, an awareness campaign to display pride in the programme, or a firm commitment to offer more than the programme. Only a few participants reported preferring a site for MSM only or a gay‐friendly site (2 groups, 2 citations), since this would provide a safe space where they know they wouldn't be judged for their sexual practices.

The historical oppression […] deserve an apology, which I would be happy to ask for, but I don’t know what it should look like. Acknowledging it isn’t enough. 'We’re working to do more, this is what we can do now, please work with us so that we can do better.' Something like that. – Group #6

Discussion

Concerning behavioural beliefs, focus group participants for Héma‐Québec's proposed programme of plasma donation for fractionation brought up many benefits of the programme. As noted in several studies 2, 3, 4, some benefits are altruistic: help others, save lives, contribute as citizens and reduce societal costs. Participants named other benefits not reported in the literature, since these were mostly linked to what the programme could bring to their community: progress, opportunity to include MSM in blood donation programmes, acknowledgement of MSM's contributions to the well‐being of others, reduced biases towards this population, opportunity to renew discussions on access to whole blood donation for MSM, etc. However, many disadvantages of the programme were raised and, being specific to MSM's situation, had not been included in the literature: discrimination and stigmatization of MSM, the fact that the programme circumvents their community's demands regarding whole blood donation, that they are treated differently from the rest of the population and a perception that their blood is presented as being not as good as the blood of others, etc. Participants said they felt excluded, discriminated against, frustrated and offended to see that this programme does not meet their demands and that more safety measures were imposed on them than on other donors. Concerning normative beliefs, most participants said that plasma donation is in accordance with their altruistic values, but for some, the programme clashes with their values of equality and social justice. Compared to other aspects of the theoretical model, normative beliefs seemed to be of less importance to participants, as illustrated by the fewer citations. Concerning control beliefs, several factors that could influence participation in the programme were put forward in terms of programme characteristics and sites where donations would be made. Barriers to participation included being judged, treated differently or outed, and having to go through a process that is lengthy and restrictive. Facilitating factors included an accessible site where they can receive other medical services and be treated with respect and as equals to other donors. Factors discussed in the literature focused mostly on characteristics of the experience that participants could not name, since most had never donated before.

During focus groups, it was observed that positive elements of the programme were rationally identified; participants were aware of these and listed them rapidly, but rarely passionately. However, when negative elements were discussed, the emotional weight of their experiences and what the ban on blood donation means to them and their community was palpable; these elements were debated passionately and brought to light on every possible occasion.

Consistent with the willingness to donate reported by the Israeli study 11, our findings suggest some interest in the programme of plasma donation for fractionation, but this interest is tempered by the social context of the programme rather than by barriers pertaining to the programme itself. Participants' views indicate a keen perception of injustice and discrimination directed towards themselves. Even though explanations justifying the ban were presented, a majority of participants thought it was unacceptable to be categorized as a risk group without regard for their individual behaviours. The programme would permit them to donate, but at what price? In their eyes, they continue to be treated differently from others: relegated to a separate programme, excluded from blood donation practices highly valued by society. Although there are many criteria that can disqualify blood donations from groups considered at risk, for MSM, the roots of exclusion run deep, are linked to identity and are inflexible. When taking into account the minority stress that MSM experience daily 18, it is clear that the feeling of exclusion, reported since the bans' beginning 12, 17, 21, 22, is intolerable. Every step taken regarding qualification policies has been too small, and none seem to shake that feeling. There seems to be a consistent opinion that incremental changes in policy short of equal treatment of people of all sexual orientations are mere stopping points 23, 24. MSM will express their dissatisfaction and fight until they have access to what they have been demanding: not being excluded from the process simply based on their sexual orientation.

As Mauss 30 states, donation is voluntary and provides prestige and honour to the donor, but it is neither free nor purely altruistic. It is also a way of obtaining a reciprocal exchange, creating an obligation to return a donation. As a community, gay and bisexual men and other MSM would take advantage of this programme and donate plasma, since it is a good thing to do. But in return, they expect to be acknowledged and listened to, and that efforts be made to consider their demands. The programme might be perceived to be acceptable if, and only if, these conditions are put in place.

Study limits and impacts of the findings

To our knowledge, this is the first study on the acceptability of a programme of plasma donation for fractionation from MSM; the Israeli study 11 examined a programme of plasma donation that is used for transfusion, and all other prior studies identified involved active donors who, by this very fact, are not MSM. However, our study has limitations. Participants were recruited through channels linked to LGBTQ+ communities; the sample may be biased because of their greater sense of belonging to their community and higher rate of activism. In focus groups, the influence of participants adamantly opposed to the programme may have had an impact on the ease with which positive elements could be brought up, even though facilitators made efforts to encourage this. Although recruitment continued until data saturation was reached, the low number of participants creates limitations in generalizing the results.

Based on elements discussed in the focus groups, a questionnaire has been developed to measure MSM's intentions on a broader scale. Promotion efforts are in place to reach MSM with various profiles, including those less involved in LGBTQ+ communities. Recommendations regarding the acceptability and feasibility of such a programme for MSM will be drawn up using the results of these two components of the study.

PART 1 ‐ Reactions to the current policy and the presented program

What are your thoughts on the current policy regarding blood donation for MSM? What are your thoughts on the plasma donation programme for fractionation for MSM?

PART 2 ‐ Behavioral beliefs and attitudes towards their participation in the plasma donation program

Within the programme framework, what benefits do you see to give plasma? Within the programme framework, what disadvantages do you see to give plasma? Now, I would like you to think about the idea of donating plasma. What feelings or emotions does it awaken in you? If you would not be able to give plasma, how would you feel? Why?

PART 3 ‐ Normative beliefs regarding their participation in the plasma donation programme

Within your close circle of friends and family, which people or groups of people that are important to you would approve your decision to donate plasma? Why? Within your close circle of friends and family, which people or groups of people that are important to you would disapprove your decision to donate plasma? Why? ○ What impact would this have on whether or not you would donate plasma? Is a plasma donation in agreement or disagreement with your personal values and principles? Why?

PART 4 ‐ Intent and meaning that the experience would have for them

If such a plasma fractionation programme existed, would you intend to participate? Why? ○ How often would you intend to donate plasma? Why? What would it mean for you to be able to donate plasma? Why?

PART 5 ‐ Intent and meaning that the experience would have for the community

In the following questions, we will refer to "the community" as a whole that includes all the communities of men who have sex with men. "The community" includes LGBT+ groups based on common interests, common characteristics or hobbies (i.e., leather community, bear community or gay sports groups), gay living environments (i.e., the Village, mobile apps), or more simply your circle of gay or bisexual friends. If a programme such as the plasma fractionation programme existed, how do you think that the community would welcome it? Why? What would it represent for the community to be able to give plasma? Why? In your opinion, what proportion of eligible people in the community would participate? Why? What would facilitate the implementation of the programme in the community? ○ How should the programme be promoted?

PART 6 ‐ Control belief towards their participation in the plasma donation program

What would make it possible, or even easier, for you to donate plasma in the context of a plasma fractionation program? What would make it difficult for you to participate in this programme (in terms of personal resources and external resources)? ○ Which of these conditions would completely prevent you from participating?

PART 7 ‐ Characteristics as to the possible location for the programme

Now, I would like you to think of a plasma donation programme that is ideal for you. Describe this site. How would you learn about it? Where is the blood collection site located? ○ What would you think if the blood collection site was in a donation center managed by Héma‐Québec (such as Globule and Plasmavie centers)? ▪ Should this site be specific to MSM or should it be a center for the general population? ▪ Should this site be located in the Village or in a neutral location? ○ What would you think if the blood collection site was in an existing place that you are familiar with? ▪ Should it be in a community setting or a medical clinic? What days and operating hours would you like? What would make you feel well? What kind of people should be present (reception, eligibility evaluation, connection to the apheresis device)? What services should be offered at this site? What would you like to have at your disposal during plasma collection, which takes 45 min? ○ If it were possible to offer you an intervention during your donation, would you be interested? ▪ If so, what would you like to talk about? Under this program, donors must return 2–4 months after their donation to conduct tests allowing us to release the donation. How would you like to be contacted to return to the center for a blood test and, ideally, a new plasma donation?