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With the prevalence of end-stage kidney and liver disease on the rise in people living with HIV (PLWH), complex challenges require comprehensive medical care and innovative solutions. Transplant ID providers and general ID/HIV providers play an essential role in not only evaluating and referring transplant candidates and donors, but also providing proper post-transplant and post-donation care, as discussed in the “A Second Chance: Donation and Transplantation in People with HIV” session presented at the 2023 IDWeek conference.

Here's a quick recap of the key points from that session.

Survival Rates and Transplantation

The survival rates for PLWH requiring dialysis vary depending on factors, such as race and comorbidities. A study, titled “Survival in HIV-Positive Transplant Recipients Compared with Transplant Candidates and with HIV-Negative Controls,” suggests that kidney transplantation should be considered the standard of care for well-managed HIV-positive patients. Liver transplantation can also be a viable option in selected candidates. And the study indicated that while there may be a modestly increased risk of mortality compared to HIV-negative recipients, transplantation can offer a survival benefit.

However, non-White patients with HIV mono-infection on dialysis were at a 44 percent higher risk of death, while there was no increased risk of death among White patients. Additionally, White patients with HIV/HCV co-infection who were on dialysis were at a 48 percent higher risk of death, and patients of other races were at a 71 percent higher risk of death.

Challenges and HOPE in Action

Along with the above disparities, many other challenges for PLWH still exist, such as having access to care. In fact, these patients are less likely to be referred for a kidney transplant within one year and are less likely to be waitlisted within one year of evaluation. There are also concerns about the safety of kidney donation for PLWH since HIV is associated with kidney disease.

But some progress has been made. For instance, the National Institute of Health HIV transplant recipient study has established kidney and liver transplantation as standard of care for PLWH. And the HIV Organ Policy Equity Act (HOPE Act) was implemented in 2015, which allowed the transplantation from donors with HIV to recipients with HIV (HIV D+/R+) under research protocols. However, there are some potential risks from donor to recipient to consider, such as HIV superinfection, HIV-associated organ disease in allograft, a possible increase in infections, and an increase in rejections.

HOPE in Action has 35 transplant centers across the U.S. From March 2016 to March 2020, there were a total of 92 donors, 58 of whom were HIV-positive. A total of 177 organs were donated, 131 of those being kidneys and 46 livers, with 29 percent discovered HIV and 71 percent known HIV. Moreover, 42 percent of donors had drug resistance primarily with the treatments M184V, K103N, and V179D.

And in a recent study that was summarized in an article, titled “A prospective multicenter pilot study of HIV-positive deceased donor to HIV-positive recipient kidney transplantation: HOPE in action,” 36 percent of patients had an episode of serious rejection, and five cases of graft failure from T cell mediated rejection occurred out of seven instances.

Overall, from March 2016 to March 2023, there have been a total of 225 donors and 382 transplants of kidneys, livers, and the heart. The HOPE Act safeguards and uses criteria for living donors with HIV eligibility that include:

• Documented HIV using an FDA-licensed, approved, or cleared test device
• The ability to predict and prescribe safe, tolerable, and effective regimens
• Identification of the donor’s history of ART regimens and ART resistance
• Proof of no invasive opportunistic complications of HIV infection
• Proof of no increased risk of progressing to end-stage organ failure after donation by way of liver or kidney biopsy

Though there are still challenges with PLWH and transplantation, the HOPE Act and other research has made it possible for HIV-positive patients to have transplants by safeguarding donors and recipients to reduce rejection and infection.