We recently estimated that some 500 to 600 HIV-infected deceased donors could be available each year for solid organ transplantation, and we, along with a number of advocacy groups, have urged the repeal of a congressional ban on transplanting organs from such donors. If nothing else, these efforts are a celebration of the profound advances made in HIV/AIDS: A concept that in 1988 seemed so absurd as to merit a legal ban is now the natural next step in the care of HIV patients with end-stage organ failure.
The concept—transplanting organs from donors with HIV into recipients with HIV—was made illegal in the United States by a 1988 amendment to the National Organ Transplant Act (NOTA) prohibiting the recovery of organs from donors “infected with the etiologic agent for acquired immune deficiency syndrome” (Public Law 100-607). Despite a valiant effort by Illinois in 2004 to allow such transplantation at the state level, federal law has trumped state, and no organs from HIV-infected donors have ever knowingly been transplanted into HIV-infected recipients in the United States.
In 1988, this amendment made sense. With the discovery of AIDS came an intense atmosphere of fear, as little was known about the etiology of this rapidly spreading disease. The same health omnibus bill banning the transplantation of organs that might transmit AIDS also provided funding for AIDS research, directed the Centers for Disease Control and Prevention (CDC) to study the epidemiology of the disease, and began national education efforts on prevention.
However, our understanding of HIV/AIDS and our ability to manage the condition have been profoundly transformed over the past 20 years, representing perhaps one of the most impressive success stories in modern medicine. Once a rapid death sentence, HIV has become, for many patients, a manageable chronic disease.
Experience in South Africa
The development of highly active antiretroviral therapy (HAART) has dramatically improved life expectancy and quality of life in HIV-infected patients. Now that these patients live longer, many with life expectancies mirroring those in the general population, other chronic conditions such as kidney and liver failure have emerged. HIV-associated nephropathy, hepatitis C virus (HCV) coinfection, and HAART toxicity contribute to these conditions, which progress more rapidly in patients infected with HIV.
In a recent national, multicenter, National Institutes of Health (NIH)-funded trial, Peter Stock and colleagues demonstrated that well-selected HIV-infected kidney transplant recipients can have graft and patient survival rates comparable to those in uninfected recipients, despite higher rates of acute rejection. This encouraging experience shows that transplant immunosuppression does not necessarily counteract the ability to suppress HIV with HAART.
Taking the transplantation of HIV-infected patients to the next dimension, Elmi Muller and her team in South Africa have reported results for at least 10 patients transplanted with HIV-infected kidneys. Outcomes, while preliminary, are excellent, with patients remaining virally suppressed with stable graft function up to three years after transplantation.
The Reality of Waiting
With over 90,000 patients awaiting kidneys, wait times can exceed seven years in some geographic areas, and similar shortages exist for livers and other solid organs. In fact, many transplant candidates die before receiving their first organ offer; this risk is higher for HIV-infected patients, given their rapidly progressing diseases.
The direct benefit of providing HIV-infected organs to HIV-infected patients is that these patients would draw from an organ supply that is inappropriate for most of the other 90,000 transplant candidates on the list. Shorter wait times mean lower chances of dying on the list, as well as better patient and graft survival after transplantation. A similar advantage is already available to patients with hepatitis C, who wait on average one year less for a kidney if they choose to consider donors infected with hepatitis C. With HIV patients drawing quickly from a unique organ supply, their uninfected counterparts would also be transplanted faster.
Furthermore, HIV-infected patients are referred and listed for transplantation at much lower rates than uninfected patients, possibly due to the overwhelming waiting list. Providers might be more willing to refer HIV patients for transplantation—and the patients might be more likely to consider transplantation—if they knew this unique option would result in timely, safe transplantation.
And lest we forget, in the setting of health care and budget crises, kidney transplantation—in addition to saving lives—actually saves Medicare money!
The Time Has Come
These four major trends—the increasing prevalence of kidney and liver failure among HIV-infected patients, early demonstrations of transplantation as a viable option for patients with HIV, preliminary data from South Africa detailing the success of HIV-to-HIV kidney transplants, and the ever-growing organ shortage—have motivated the exploration of transplanting HIV-infected organs into HIV-infected recipients.
While the risk of superinfection will need to be better understood, transplanting organs from stable, virally suppressed HIV-infected donors into stable, virally suppressed HIV-infected recipients is likely to be safe based on what is known about disease transmission risk in other settings. And to minimize the risk of inadvertently placing an HIV-infected organ into an uninfected recipient, the transplant community would draw on parallel experiences with hepatitis C, as well as the robust, redundant system for matching donors and recipients that is already in place.
We can discuss the risks and benefits of this concept ad infinitum, but no progress will be made in the United States without a change to NOTA, which will require bipartisan political support. We must remind our elected officials on Capitol Hill that vulnerable patients will benefit from such a change.
Modifying the law will make it possible to carefully study the safety and outcomes of these transplants in the same way that transplantation of HIV-infected recipients with uninfected donor organs has been carefully studied. Continued clinical and comparative-effectiveness research is required in this area, and we must urge the NIH to continue to fund such studies.
Experience from the NIH-funded study of solid organ transplantation in HIV-infected patients has solidified that practice into standard of care, and similar experience will likely do the same for transplantation of organs from HIV-infected donors.