Aviva Goldberg and Marie Chantal Fortin describe the benefits of organ donation between HIV-infected persons.
The Johns Hopkins Hospital is set to begin kidney and liver transplants from HIV-infected donors to HIV-infected recipients. This will be a first for the United States. However, similar HIV-infected kidney transplants have already occurred in South Africa and a deceased HIV-infected kidney donor was used in Canada (unpublished report). In addition, it has been reported in Israel that a living donor kidney transplant was performed from an HIV-infected woman to her HIV-infected husband. The ethical justification for this new program appears well founded, and prompts us to reconsider the taboo surrounding HIV and organ transplantation.
It is clear that the organ transplant system needs to have careful methods in place to minimize the risk of virus transmission from donors to non-infected recipients. The ignoble history of HIV transmission through donated blood has cast a long shadow over blood, organ, and tissue donation. This explains the bans on donation from individuals with known infection, and the strict rules governing the allocation of organs from individuals considered to be at increased risk of undetected infection with HIV or other viruses. In rare circumstances where HIV has been transmitted through organ transplants (such as the 2007 Chicago cases and a 2009 case in New York City), we have been reminded of why such levels of caution are warranted.
In the course of ameliorating end-organ disease through transplantation, we should do everything possible to avoid the transmission or development of new diseases. However, the emphasis on avoiding virus transmission comes at a cost. Approximately 500-600 potential organ donors in the United States are rejected each year because of documented or suspected HIV infection. Meanwhile, many people with end-organ disease die each year while waiting for transplants, some of whom are living with HIV. An organ transplant system that errs on the side of caution against virus transmission runs the risk of excessively restricting the organ donor pool thereby increasing the number of wait list deaths. This is especially so when one considers that organ transplants between donors and recipients who both test positive for hepatitis have been performed for many years with relatively good results.
Originally it was thought that the immunosuppression drugs required after organ transplants would be too dangerous for HIV-infected recipients because of their already weakened immune systems. However, recent studies indicate that this concern in overblown- while it is wise to minimize viral load before transplant, HIV-infected recipients have better survival after transplant than if they had remained on dialysis. As well, there likely will be an increasing need for organ transplants within the HIV population, as people with HIV are now living longer and may eventually develop end stage kidney or liver disease due to their HIV or other causes.
Given these reasons in favour of performing organ transplants between donors and recipients who are living with HIV, a continued ban on such transplants would be anachronistic and inconsistent. In response, American health care professionals and public interest groups advocated for change. That change came with the HIV Organ Policy Equity Act (HOPE Act), passed in 2013.
The Act, which repealed the restrictions on using organs from HIV-infected donors, promotes greater access for HIV-infected patients and contributes to reducing existing disparities in access to organ transplantation. For example, HIV-associated kidney disease disproportionately affects African Americans who, as a group, have had historically poor access to transplantation. Further, limitations on donation from groups considered to be at increased risk for having undiagnosed HIV (like men who have sex with men, even if they are monogamous) have been challenged as overly restrictive and discriminatory and accepting organs from HIV-infected donors can help to reduce stigma associated with HIV.
The first pool of HIV-infected organ donors and recipients to be treated at Johns Hopkins will require close surveillance. Although results from the study conducted in South Africa are promising , the patient follow-up was short and we do not yet know the long term outcomes, so recipient informed consent is of paramount importance. Recipients should to be chosen carefully to minimize the risk of exacerbating pre-existing infections. The recipient’s viral load should be minimized prior to transplant to reduce the risk of worsening disease with post-transplant immunosuppression. Patients living with HIV who opt out of participating should keep their place on the regular waiting list- there should be no obligation to accept an organ from someone who is HIV-infected at this time. And, at this relatively early stage, it makes sense to start with deceased donors because organ donation could potentially increase the risk of end stage kidney disease due to HIV in the donor.
With continued surveillance and policy based on the best available evidence, this new program offers hope to people living with HIV and end-organ disease. It also allows people with HIV the opportunity to give the gift of life after they die. It is an ethical step in the right direction.
Aviva Goldberg is a pediatric transplant nephrologist and ethicist in Winnipeg, Manitoba.
Marie Chantal Fortin is a transplant nephrologist and ethicist in Montreal, Quebec.