Study offers reassuring findings on HIV-to-HIV transplants
HIV-to-HIV transplantation is on the rise, and there are many donors with good organ quality and an acceptable risk profile in terms of post-transplant ART for prevention of HIV superinfection, according to a recent study.
“There is an ongoing organ shortage in the United States, and end organ disease is common in people with HIV,” William A. Werbel, MD, a fellow at Johns Hopkins Medicine, told Healio.
“With the advent of excellent and safe antivirals, transplantation is a reality for people living with HIV, and the HOPE Act” — which was enacted in 2013, making it legal to transplant HIV-infected organs in the U.S. — “expanded access through utilization of organs from people with positive HIV tests to bridge the organ gap and save lives,” Werbel continued. “That said, the population of organ donors with HIV is not well described, and this is a critical component for counseling patients and providers regarding the safety of the HIV-to-HIV practice.”
According to Werbel, it is difficult to assess donor features and recipient outcomes from public and registry data because they are not able to differentiate between people with HIV and people with false-positive (FP) testing, and transplant providers do not often have access to full donor HIV data at the point of care during the donor selection process.
“It is otherwise important to increase visibility and dialogue that persons with HIV can both receive and donate organs to decrease stigma and misinformation about the practice,” he said.
Werbel and colleagues performed a prospective study of donors with HIV-positive and HIV FP testing within the HOPE in Action studies of HIV transplants between HIV-positive donors and recipients. According to the study, the researchers compared clinical characteristics in HIV-positive donors with those of FP donors and measured CD4+ T cells, HIV viral load (VL), drug resistance mutations, coreceptor tropism, and serum ART detection using mass spectrometry in HIV-positive donors.
Between March 2016 and March 2020, 92 donors 58 whom were HIV-positive and 34 of whom were FP, representing 98.9% of all U.S. HOPE donors during this period donated 131 kidneys and 46 livers.
According to the study, the prevalence of hepatitis B (16% vs. 0%), syphilis (16% vs. 0%) and cytomegalovirus (91% vs. 58%) was higher in HIV-positive compared with FP donors, whereas hepatitis C viremia was similar (2% vs. 6%).
They found that most HIV-positive donors (71%) had a known HIV diagnosis, 90% of whom were prescribed ART and 68% of whom were virally suppressed. Their median CD4 count was 194 cells/uL, and 42% had major HIV drug-resistance mutations, including non-nucleoside reverse transcriptase inhibitors (33%), integrase strand transfer inhibitor (INSTI, 4%), and multiclass (13%).
Werbel said that although HIV-to-HIV transplantation is still permitted only under research protocol in the U.S., it is possible that in the next several years, with full review of this trial’s data, that the federal government could permit such transplants outside of the research setting
“This study confirms that there are many donors with good organ quality and an acceptable risk profile, particularly as it relates to confidence in standard post-transplant ART to prevent HIV superinfection,” Werbel said. “Future directions include understanding the full ‘iceberg’ of potential donors with HIV and impediments to donation as well as building of robust risk models to prospectively identify highest risk donors for resistance or opportunistic infections.”