Researchers at Johns Hopkins are arguing for the reversal of the ban on transplanting HIV-infected organs and making them available to HIV-positive patients.
The new Hopkins research suggests that if Congress lifts its ban on allowing people with HIV to be organ donors after their deaths, roughly 500 HIV patients with kidney or liver failure every year could get a transplant within months rather than the years they currently have to wait.
“If this legal ban were lifted, we could potentially provide organ transplants to every single HIV-infected transplant candidate on the waiting list,“ said Dorry L. Segev, an associate professor of surgery at the Hopkins School of Medicine and the senior author of the study. According to Segev, the otherwise healthy organs of HIV-infected people, which are discarded after they die, could instead be available for HIV-positive candidates.
The ban on organ donation by HIV-positive patients was enacted in the ‘80s when the deadly AIDs epidemic was newly sweeping the United States. Congress put the ban into the National Organ Transplant Act of 1984. Though in most cases HIV is not an immediate death sentence but rather a chronic infection that can be managed with medication, the Act has never been updated.
According to Segev, not only would HIV-positive transplant candidates get organs, but transplanting those patients and moving them off the waiting list would also lessen the time non-HIV-infected patients have to wait for transplants.
The number of HIV-positive patients receiving kidney or liver transplants with non-HIV-infected organs is rising. In 2009, more than 100 HIV-positive patients received new kidneys and 29 received new livers. Accelerated rates of liver and kidney disease in HIV-infected patients may be due in part to the toxic effects of antiretroviral drugs, the medications that keep HIV in check.
Segev and colleagues set out in their study, published online on March 28 in the American Journal of Transplantation, to estimate the number of people who die each year who would make good organ donors except for the fact that they are HIV positive.
They collected 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.
Both data sources gave similar information: 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.
Because of the ban on organ donation by HIV-positive patients, no transplants of HIV-infected organs into HIV-infected patients have been done in the United States. However, Segev says doctors in South Africa have started doing this type of transplant with very good results.
In transitioning to a system where organs from HIV-infected donors can be transplanted into HIV-infected patients, doctors can call on the lessons and experiences of transplanting hepatitis C patients with organs from people with the same disease, Segev
suggests. This practice, which has not always been the standard, has considerably shortened the waiting list for 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.
Segev acknowledges, however, that using HIV-infected organs is not without concerns. Several medical and safety issues 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 HIV. There is also the fear that an HIV-infected organ could accidentally be transplanted into an HIV-negative recipient, but hepatitis C-infected organs are clearly marked as such and similar protocols can be applied to 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 ban on HIV-infected organ donation would have immediate results. He predicts that initially 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 between five and seven years for a transplant, Segev thinks more and more HIV-infected patients would sign up for the shorter 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.”
If Congress were indeed to reverse this ban, and if the benefits of this practice outweighed the potential medical risks involved, then transplanting organs from HIV-positive donors into HIV-positive patients would go a long way towards shortening the ever-growing waiting lists for organ donation.
