Can People With HIV Be Organ Donors?

Despite Law Permitting HIV-Positive Transplants, Viability Questioned

Photograph © Xurxo Lobato/Getty Images

On November 12, 2013, President Barack Obama signed into law the HIV Organ Policy Equity Act (the Hope Act) which allows for the donation of HIV-infected organs to either (a) an HIV-positive recipient or (b) an individual participating in clinical research that allows for the use of HIV-infected organs under the regulations and standards of the Hope Act.

The Hope Act amended the Organ Transplant Amendments Act of 1988, which had prevented such donations due to concerns about transmitted drug resistance, organ viability, superinfection, and other issues that could have mitigated the benefits of any such transplant. The new law comes at a time when the need for organ transplants has arguably never been greater, particularly with increased rates of heart, liver, kidney and other diseases affecting the aging HIV population.

The Act also acknowledges the efficacy of combination antiretroviral therapy (ART) in ensuring durable suppression of HIV in both the organ donor and recipient, lessening concerns previously associated with transplantation.

The bill, which was proposed by Senator Barbara Boxer of California, was also seen as a means to relieve the backlog of non-HIV-infected people on organ transplant waiting lists. The measure led to ​an announcement in February 2016 that John Hopkins School of Medicine would be the first institution to begin organ transplants from one HIV-positive person to another.

Why the Hope Act Is Important

Beyond alleviating the waiting list pipeline and addressing the high need for organ donations within the HIV-infected population, the Hope Act is seen by many as the first step in dismantling long-standing medical biases against people living with AIDS. It states quite clearly that, in this age of modern cART, the fear of reinfection simply pales in comparison to the number of death caused by HIV-associated organ failure.

Previous to the Hope Act, it was illegal even to study HIV-infected organ transplant under the aegis of clinical research—a reflection of the bad science and blind fear that crippled many of laws thought to "protect" the general public (including the still-standing and much-criticized gay blood ban in the U.S.)

As with the blood supplies, organ transplants in the U.S. are highly regulated. Current generation, high-sensitivity HIV tests ensure that no HIV-negative person can receive an organ from an HIV-positive person. Currently, all organ and tissue donations are automatically screened for HIV, hepatitis B (HBV) and hepatitis C (HCV) according to the 1994 U.S. Public Health Service (PHS) Guidelines for Preventing Transmission of Human Immunodeficiency Virus through Transplantation.

Viability of the Hope Act Questioned

In September 2014, researchers from University of Pennsylvania conducted the first study into the impact of the Hope Act, assessing the suitability of 578 deceased, HIV-positive patients as potential organ donors.

The study, designed to be representational of the potential organ pool in the Philadelphia area, were comprised of patients with a mean age of 53 years, 68% of whom were male and 73% of whom were African-American.  With a median CD4 count of 319 and undetectable viral loads, the group was considered to be viable donors, with only a few opportunistic infections (4); few documented drug resistant mutations (2); and few, later-stage protease inhibitor drug regimens at the time of death (6).

The study, presented at the 54th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) in Washington, D.C., concluded that the group might have yielded seven kidneys and nine livers from 2009 to 2014, with the majority being excluded under standard organ transplant suitability criteria. These included:

  • 260 excluded for not being in hospital at the time of their death.
  • 87 excluded for not having documented brain death.
  • 75 excluded for having an unknown cause of death.
  • 70 excluded for not being under medical care at the time of their death.
  • 63 excluded for not being on mechanical ventilation.
  • 13 excluded for having diabetes, hypertension, HCV, cirrhosis, or end-stage kidney disease.
  • 3 excluded for having a malignancy.

Moreover, computer modeling determined only a 50% success rate in kidney grafts based on the quality of organs within the proposed donor pool. By contrast, three-year liver graft survival rates were more-or-less in line with that of the general population (71% versus 74%, respectively).

Further research will determine if similar patterns are seen in other HIV populations, wherein access to HIV-positive organs may not necessarily yield a viable number of high-quality donors.

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