If Congress reversed its ban on allowing people with HIV to be
organ donors after their death, roughly 500 HIV-positive patients
with kidney or liver failure each year could get transplants within
months, rather than the years they currently wait on the list, new
Johns Hopkins research suggests.
"If this legal ban were lifted, we could potentially provide organ
transplants to every single HIV-infected transplant candidate on
the waiting list," says Dorry L. Segev, M.D., Ph.D., an associate
professor of surgery at the Johns Hopkins University School of
Medicine and the study's senior author. "Instead of discarding the
otherwise healthy organs of HIV-infected people when they die,
those organs could be available for HIV-positive candidates."
Not only would HIV-positive transplant candidates get organs sooner
if such transplants were legalized, Segev says, but by
transplanting those patients and moving them off the waiting list,
the time to transplant would be shorter for non-HIV-infected
patients.
The ban on organ donation by HIV-positive patients is a relic of
the 1980s, when it was still unclear what caused AIDS, at the time
a devastating new epidemic sweeping the United States. Congress put
the ban into the National Organ Transplant Act of 1984 and it has
never been updated, despite the fact that HIV is no longer an
immediate death sentence but a chronic disease managed with
medication.
The number of HIV-positive patients receiving kidney or liver
transplants — with non-HIV-infected organs — is on the rise as
doctors become more comfortable with the idea, and patients are
having good outcomes, Segev says. In 2009, more than 100
HIV-positive patients got new kidneys and 29 got new livers.
HIV-infected patients may encounter accelerated rates of liver and
kidney disease due in part to the toxic effects of antiretroviral
therapy, the medications that keep HIV at bay.
Segev and his colleagues set out in their study, published early
online in the American
Journal of Transplantation, to estimate the number of people
who die each year in the United States who are good potential organ
donors except for that they are HIV-positive. They culled data from
two main sources — the Nationwide Inpatient Study, which has
information on in-hospital deaths of HIV-infected patients, and the
HIV Research Network, a nationally representative registry of
people with HIV. The team determined that the number of annual
deaths with what are believed to be organs suitable for
transplantation was approximately the same as estimated by each
data source — an average of 534 each year between 2005 and 2008 in
the Nationwide Inpatient Study and an average of 494 each year
between 2000 and 2008 in the HIV Research Network.
While no transplants of HIV-infected organs into HIV-infected
patients have been done in the United States because of the ban,
Segev says doctors in South Africa have started doing this type of
transplant with excellent results.
Segev suggests that, in transitioning to a system where
HIV-infected donor organs can be transplanted into HIV-infected
patients, doctors can call on the lessons and experience of
transplanting hepatitis C patients with organs from people with the
same disease. This practice, which has not always been the
standard, has substantially shortened the waiting list for these
recipients without significantly compromising patient or graft
survival. The decision of whether or not to use these organs is not
a legal one, but one made by the clinician.
Using HIV-infected organs is not without concerns. There are
medical and safety issues that need to be addressed. Doctors need
to make sure that the harvested organs are healthy enough for
transplant and that there is minimal risk of infecting the
recipient with a more aggressive strain of the virus. There is also
a fear that an HIV-infected organ could accidentally be
transplanted into an HIV-negative recipient. Segev says that
hepatitis C-infected organs are clearly marked as such and similar
protocols can be developed with HIV-infected organs.
"The same processes that are in place to protect people from
getting an organ with hepatitis C accidentally could be put in
place for HIV-infected organs," Segev says. "When you consider the
alternative — a high risk of dying on the waiting list — then these
small challenges are overshadowed by the large potential
benefit."
Segev says eliminating the prohibition on HIV-infected organ
donation would have immediate results. At first, he predicts, there
would be more HIV-infected organs than people on the waiting list.
Then, as doctors realized that their HIV-infected patients would no
longer have to wait five-to-seven years for a transplant, Segev
says he thinks more and more HIV-infected patients would sign up
for the shortened list for an HIV-infected organ.
"The whole equation for seeking a transplant for someone with HIV
and kidney or liver failure would change if this source of organs
became available," he says. "We want the decisions taken out of the
hands of Congress and put into the hands of clinicians."
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Thanks to Johns Hopkins Medical Institutions for this article.