HIV positive organ donors may help HIV negative patients too

In spite of being one of the most unproductive Congresses on record, it has managed to pass a few bills by acting in a bipartisan manner. One of these is the HOPE (HIV Organ Policy Equity) Act.

The HOPE Act, signed into law by President Obama, enables research on the transplantation of HIV positive donor organs into HIV positive recipients. It will probably lead to transplants between positive donors and positive recipients in the near future.

Before this Act, this research was forbidden under the National Organ Transplant Act written in the 1980s.

 

Researchers may now study transplants of HIV positive organs

Now, researchers can specifically study questions that are related to HIV positive to HIV positive transplants. One of these questions might be the effects of transplanting a liver from a donor with a different strain of HIV to a recipient. This research, and more, needs to be completed before HIV positive-HIV positive transplants can begin.

HIV virus attacking cell. 3D render, via Shutterstock.

HIV virus attacking cell. 3D render, via Shutterstock.

It’s estimated that there are about 110,000 people (adults and children) in the US alone who are waiting for transplants (hearts, livers, kidneys and other vital organs.) Only about 30,000 transplant surgeries are done per year, primarily because of a lack of donors. About 20 people per day die while waiting for an organ transplant. Researchers estimate that if HIV positive to HIV positive donations were allowed, about 500 lives would be saved via transplantation per year, possibly more. Many donors allow for the transplantation of any of their organs after death. So a single donor may be able to save several other people via donations of heart, liver, kidneys, lungs and other organs.

It was a struggle to make HIV positive people eligible to receive organ transplants at all

HIV positive patients can currently go on the transplant lists and receive transplants. And it was a struggle to get them on the list at all. But of course, they are getting HIV negative donor organs. Initially, when looking at transplanting HIV positive patients, several concerns were raised. Some of these were:

If the patient had AIDS, wouldn’t the AIDS kill him rapidly and therefore, he would have no benefit from the transplant? That may have been true when the National Organ Transplant Act was proposed, but now with better drugs and management, that is much less of an issue.

If the patient is immunosuppressed, wouldn’t the added post transplant immunosuppression leave him with a non-functional immune system leading to death? Research has shown that CD4 counts do decrease somewhat after immunotherapy starts post transplant, but the CD4 cell number increases after a few years on the immunosuppressives. Also, there are three different immunosuppressive drugs that can be used post-op. Changing medications may help, as does “fine tuning” the HIV positive patient just before transplant (ensuring good adherence to antiretrovirals that are appropriate for that patient, getting his viral load as low as possible, getting him in the best possible physical shape, making sure that any other diseases are well controlled, etc.)

Wouldn’t an HIV positive patient be more at risk to develop opportunistic infections, Kaposi’s sarcoma and other illnesses post transplant? Again, those may be remote possibilities. But studies on HIV positive patients who have undergone transplant and immunosuppression and ante on antiretrovirals, may show a slight increase in things like Kaposi’s of the skin. But the numbers are very low.

There have been some HIV positive to HIV positive transplants done. South Africa started doing these transplants in 2010. So there is some data available on the success rate of transplants, complications, etc. But so few of these transplants have been done, that the validity of the numbers in the results are limited by the small sample size. In one study on kidney transplant patients, the recipients did well. They maintained their viral loads at less than 50 (both before and after transplant). Their CD4 counts remained about the same over time pre-op and post-op. Their transplanted organs functioned well. They didn’t develop other HIV-related diseases post op on immunosuppressants. But again, not many transplants have been done to get reliable numbers.

Some other countries (Canada, UK) are expressing interest in looking at positive-to-positive transplantation.

There are downsides. It will take a few years to do the needed research to get the information needed to try HIV positive transplantation. Perhaps it will be shown that transplantation between people with different strains of HIV makes the recipient’s HIV more difficult to treat. There is always the possibility that an HIV positive donor organ may get transplanted into an HIV negative recipient (as happened once in Taiwan) in spite of stringent control, testing and labeling. As more data is accumulated, it may be shown that there are other side effects, not yet seen in HIV positive to HIV positive transplants.

HIV positive donors help HIV negative recipients move up the list

One other positive aspect is that non-HIV positive recipients will benefit, as well. As HIV positive donor organs become available for transplant into HIV positive recipients, the waiting list will be shortened for everyone. If 500 HIV positive donors become available per year, those 500 HIV positive recipients will get transplanted and come off the list. This will let the remaining people waiting move up the list and be closer to transplant. So, this could be some very good news for everyone on the transplant list.

Would an HIV negative patient accept an HIV positive organ if it meant saving their life?

I mentioned above the rare possibility of an HIV positive organ being transplanted into an HIV negative recipient. Now, imagine a hypothetical case. You are on a transplant list for a heart transplant and you are HIV negative. Your doctors say that you probably have less than a year to live and your only hope to stay alive is to get a heart transplant. Would you consider accepting a heart from an otherwise healthy, HIV positive compatible donor? Would you opt to wait, hoping to live long enough for a compatible HIV negative heart? What would cause you to make your particular choice?

And, may I suggest that if you aren’t already an organ donor, that you consider it. Before you think, I’m too old. I’m to sick. My religion won’t approve, or something similar, have a look at this site and read the information there. It might surprise you. And, you can begin the registration process there, too.


Mark Thoma, MD, is a physician who did his residency in internal medicine. Mark has a long history of social activism, and was an early technogeek, and science junkie, after evolving through his nerd phase. Favorite quote: “The most exciting phrase to hear in science... is not 'Eureka!' (I found it!) but 'That's funny.'” - Isaac Asimov

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