New rules allow people with HIV to donate to others with disease
New rules for sharing organs among people with HIV could add up to 500 names per year to the national donor list, increasing access to organs for people with and without the virus, according to a transplant surgeon who has advocated for the expanded sharing.
Federal criteria published in November establish the process by which surgeons can for the first time transplant organs from HIV-positive donors to HIV-positive patients. Transplant surgeons estimate they may start doing the transplants as early as spring.
Dr. Dorry Segev, a Johns Hopkins University transplant surgeon who pressed for the change, co-authored an analysis estimating 300 to 500 people per year with HIV may be able to donate viable organs after they die. Giving the newly available organs to people with HIV would free up organs for people without HIV, Segev said.
“If our estimates were correct about the number of HIV-positive donors that were available, this will be the largest increase in deceased-donor organ transplants in the last decade,” Segev said.
An average of 22,256 organs per year were recovered from an average of 8,078 deceased donors from 2005 to 2014, according to United Network for Organ Sharing data. The largest increase was from 2005 to 2006, when 994 organs were given by deceased donors. The number of donors increased by 424 people, an unusually large number compared to other years.
Until recently, transplanting any HIV-positive organs was illegal, though people with HIV could receive uninfected organs. HIV, or human immunodeficiency virus, led to death for most people who contracted it in the 1980s and early 1990s. But new treatments can reduce HIV to extremely low levels in the blood, granting near-normal lifespans to those with the virus.
As they age, their organs — especially livers — often deteriorate more quickly than people without HIV, said Dr. Christopher Hughes, surgical director of liver transplantation at UPMC's Starzl Transplant Institute. Though HIV is not the main cause of liver damage, it often is accompanied by other viruses, such as hepatitis, that can be deadly, Hughes said.
The viruses make it unfairly difficult for HIV-positive patients to qualify on waiting lists for livers from HIV-negative donors, he said. The liver allocation system generally favors the sickest patients, but if they become too sick — often the case with patients who have HIV and hepatitis C — they are excluded, he said.
The new transplant criteria, developed by the National Institutes of Health based on the federal HIV Organ Policy Equity Act of 2013, could help correct the inequity, Hughes said.
“I think it's a milestone, in the sense that an effort is being made to remove the disadvantage that I think HIV patients had under the prior system,” he said.
In San Francisco, the wait for livers and kidneys from deceased donors can be eight to nine years, said Dr. Peter Stock, a professor of surgery at the University of California-San Francisco. Stock predicts the changed rules could reduce the wait to a matter of months for people with HIV.
Prior to the HOPE Act, people living with HIV were forbidden from donating a kidney to a loved one, even though people without the virus were free to donate kidneys.
“They felt that they were a little bit discriminated against,” Stock said.
The act will allow them to donate organs while living, although Stock plans to advise them of the risks.
Criteria from the National Institutes of Health include a long list of requirements for transplant centers planning to start positive-to-positive transplants, and protocols need to be approved by the United Network for Organ Sharing, meaning the transplants cannot begin immediately.
Hughes said he is hopeful the Starzl Institute may start the transplants in six to eight months. About 3 percent of the approximately 150 people on the liver transplant list in the Pittsburgh area are HIV-positive, he said.
The procedure comes with risks, he added. There are several strains of HIV, and surgeons know little about how well recipients' bodies will respond to organs infected with a different strain. Within the strains, some infections may become resistant to some treatments.
“There are questions that will arise through this process,” Hughes said. “And the biggest one is ‘are we going to be giving someone a more difficult-to-control strain of HIV?' ”
Only one study has been completed, in South Africa. Surgeon Elmi Muller transplanted kidneys from 27 HIV-positive to HIV-positive people from 2008 to 2014. The outcomes compared favorably to transplants from HIV-negative to HIV-positive people.
Surgeons said their experiences transplanting livers from donors with hepatitis C to patients with the same virus have been successful, giving them hope for the HIV transplants.
The new transplant criteria require that HIV be controlled in donors and include safeguards for people receiving the organs.
“The goal is to progress thoughtfully, carefully, with the eye toward this becoming the standard of care,” Segev said.
Wes Venteicher is a Trib Total Media staff writer. Reach him at firstname.lastname@example.org or (412) 380-5676.