How to Save a Life? Reexamining Organ Transplants and HIV in the United States

Last week, The New York Times reported on the status of organ transplants involving HIV-positive recipients and HIV-positive donors, and the federal health officials and other experts who are agitating for a change to the National Organ Transplant Act. The National Organ Transplant Act (NOTA), a federal law passed in 1988, prohibits transplants using organs from HIV-positive donors. However, as organ transplant technology and health outcomes for people living with HIV/AIDS have improved over the past two decades, the number of HIV-positive people in the United States seeking organ transplants has also increased significantly. In response to these changes, many doctors, patients, and public health policymakers are now pushing for a reevaluation of the parts of NOTA that govern organ transplants involving people who are HIV-positive. 

Allowing organ donation from individuals who are HIV-positive raises numerous ethical, legal, and medical questions. Many questions stem from the issue of whether organs from HIV-positive donors could and should be transplanted only to HIV-positive persons, or to any needy and willing recipients, regardless of HIV status. According to the Times, the first step in answering these questions is to conduct further scientific research to determine the medical viability of transplants utilizing organs from HIV-positive donors. As part of this initial research, the Centers for Disease Control and Prevention (CDC) may release new guidelines to encourage studies on organ transplants between HIV-positive donors and HIV-positive recipients. But, in order for new studies to proceed legally, lawmakers must amend NOTA. To ensure full legal compliance, numerous state laws barring organ donation by individuals who are HIV-positive may also need to be amended.

Performing any organ transplant successfully requires doctors to overcome a series of medical challenges. As a result of continuous improvement in transplant technology, the Times reports that organ transplant recipients who are HIV-positive now have transplant success rates that are comparable to those of the general population. Many doctors and researchers are optimistic about organ transplants involving HIV-positive organ donors, but they are conscious of the fact that these transplants will undoubtedly present new medical obstacles. In transplants involving HIV-positive donors and HIV-positive recipients, doctors must address co-infection (or re-infection), in which the type or virulence of HIV strain varies between donor and recipient, and may negatively impact the recipient's ability to accept an organ or successfully continue an antiretroviral therapy regimen. Doctors and public health policymakers will also have to alter the way in which organs are screened for donation.

Another issue is determining who should be responsible for assessing the risk of receiving an organ from an HIV-positive donor. Medical and public health professionals have worked diligently over the past three decades to develop procedures and enact precautions to prevent HIV infection in healthcare settings. Knowingly transplanting an organ from a HIV-positive donor is counterintuitive to established medical ethics. However, since it is now possible to manage HIV as a chronic illness, and the demand for organs far outpaces the supply, doctors and patients may be willing to weigh the risks between no organ transplant and an organ transplant involving a HIV-positive donor. According to Scott Schoettes, the HIV Project Director of Lambda Legal, "The assessment of the relative risks and benefits of such procedures should be in the hands of medical researchers, public health policymakers and clinicians…Ultimately, the decision as to whether to be the recipient of an HIV-infected organ needs to be in the hands of a well-informed patient -- one who has been counseled by his [or her] doctor as to the relative risks and benefits."

Expanding access to an additional source of organs for transplants could lower the amount of time potential recipients spend on transplant waiting lists. For patients who have lingered on waiting lists and are facing grim odds, having the option to receive an organ from an HIV-positive donor may be a welcome choice. This could make a vital difference for many potential recipients, regardless of their HIV status, but could be especially beneficial to recipients who are HIV-positive. As HIV has evolved into a manageable chronic disease in the United States, the number of HIV-positive individuals in need of organ transplants has also grown. And, though transplant success rates are comparable between HIV-positive and HIV-negative patients, transplanted organs may not function properly for as long a period of time in HIV-positive recipients – a factor that may necessitate multiple transplants over the course of a lifetime. For these patients, having access to a new pool of organs could make the difference between life and death.

Until the results of initial clinical trials on organ transplants involving HIV-positive donors and HIV-positive recipients are known, many scientific and ethical questions regarding the future viability of these transplants will persist. However, if research results are favorable to allowing organ transplants involving HIV-positive donors, doctors and public health policymakers will need to ensure that organs from these individuals are utilized in a manner that is judicious, equitable, and medically sound. Any policy changes that occur in the organ transplant system in the United States must respect the right of potential transplant recipients, regardless of their HIV status, to strive for optimal health outcomes and the highest achievable quality of life.

For more information on organ donation and organ transplants in the United States, please visit the website of the Organ Procurement and Transplantation Network governed by the U.S. Department of Health & Human Services.

Post by Heather J. Heldman, MPH, CHLP Volunteer