Barriers to Organ Transplantation for HIV-Infected Patients Unethical

Research at University of Pennsylvania School of Medicine and Michigan Veterans Affairs Medical Center suggests HIV-positive patients do well after transplantation

(Philadelphia, PA) -- A paper in the July 25th, 2002, issue of the New England Journal of Medicine by researchers at the University of Pennsylvania School of Medicine and the Michigan Veterans Affairs Medical Center argues that there are strong ethical reasons to remove barriers to organ transplantation for HIV-infected patients who need them.

Scott D. Halpern, MSCE, and Arthur L. Caplan, PhD, of the University of Pennsylvania School of Medicine and Peter A. Ubel, MD, of the Veterans Affairs - Ann Arbor Healthcare System, Ann Arbor, MI, found, in a review of the limited available evidence, that HIV-positive patients who had received organ transplants were doing "remarkably well." They argue that this refutes the common notions that transplantation in the setting of HIV is unsafe, and that the HIV virus substantially limits the benefit patients could obtain from organ transplantation.

Halpern, an MD/PhD student in Penn's School of Medicine, a fellowin Epidemiology and Biostatistics and lead author of the paper, says that while there have only been three or four published cases of patients who received organ transplants since the advent of highly active, combination therapy "all of [these patients] have done remarkably well, and their outcomes were unaffected by HIV disease."

"Right now, most transplantation centers are concerned that transplantation might harm HIV patients, and that scarce organs should not be allocated to patients with poor prognoses, so there's a safety concern as well as an efficacy concern," says Halpern. "We believe that the extent of the HIV disease is simply another chronic illness that must be considered in determining candidacy for organ transplantation, and that it is discriminatory to provide organs to patients with diabetes or hepatitis C infection, for example, who are known to have worse outcomes after transplantation, but not to provide organs to HIV positive patients in whom healthcare professionals merely suspect a poorer outcome," he added.

The authors argue that while concerns about transplantation in HIV- positive patients may have been well founded in the past, the ability of new medicines to keep the virus in check has enabled patients
to live comfortably several years after receiving new organs.

The researchers also argue that there is no validity to fears that drugs given to organ transplant recipients to prevent the body's immune system from rejecting the new organ would accelerate the progression of HIV, which also attacks the body's immune system.

"What does happen is that by giving antiretroviral drugs, what you do is decrease the metabolism of the anti-immune drugs, but that can be controlled by adjusting doses of the anti-immune drugs; there are a lot of drugs that [transplant] patients need that affect the dosage of the anti-immune drugs, and anti virals are just another class of drugs that need to be considered and monitored in transplant recipients."

"With this study we spoke with several transplant surgeons across the country who have limited experience with doing this . . . and they corroborated the evidence that's been published with their own clinical impressions, that their patients are doing well," Halpern added.

Halpern says physicians at the Hospital of the University of Pennsylvania provided a liver transplant to a patient with HIV, and that patient continues to do well nearly five years later.

The researchers also make clear that while there is no accepted standard for denying an HIV patient an organ transplant, there is also no written procedure or standard for encouraging organ transplants for HIV patients.

"It's just not common practice," says Halpern. "The governing body of organ donation, the United Network for Organ Sharing, actually says that asymptomatic HIV-positive patients should not, in actuality, be ruled out from receiving an organ, but it doesn't make any positive recommendation that HIV patients should be considered like other patients.

"They simply say it is not an exclusion criterion, and the main reasons that HIV patients continue to be denied organs stem from concerns of transplant physicians, nurses, and also very prominent third party payers who generally have refused to reimburse for transplantation in HIV-positive patients," says Halpern.

The researchers also said that in the few HIV-positive patients who have received organs so far, their organ disease was generally not due to the HIV itself. However, it is also possible that HIV itself could cause liver, kidney, or heart disease requiring transplantation. Almost all transplants in HIV-positive patients to date have involved livers and kidneys.

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