HIV-Positive Patients Should Receive Equal Consideration for Organ Transplants, Opinion Piece Says
Because HIV-positive people receiving highly active antiretroviral treatment can "now expect to live substantially longer than before" -- meaning that many are more likely to suffer sooner from end-stage organ failure than HIV-related illnesses -- it is "time for the transplantation community to readdress the safety, efficacy and propriety of transplanting scarce organs in HIV-positive patients who need them," Scott Halpern and Arthur Caplan of the University of Pennsylvania School of Medicine and Peter Ubel of the Veterans Affairs Ann Arbor Healthcare System write in a New England Journal of Medicine "Sounding Board" commentary. The United Network for Organ Sharing states that HIV-positive individuals who are asymptomatic "should not necessarily be excluded from candidacy for organ transplantation." However, only a small number of hospital centers perform transplants on HIV-positive patients, and a 1997 survey of directors of U.S. renal transplant centers found that 88% of respondents said they would not consider approving a transplant for an HIV-positive patient who was "otherwise a good candidate for transplantation." In addition, most insurance companies have "generally refused" to cover such procedures, the authors note. This approach to transplantation in asymptomatic individuals is "not justifiable according to any ethical theory," the authors state, noting that there are two "distinct ethical questions" regarding the efficacy of organ transplantation: "Does transplantation benefit the individual patients?" and "Would it benefit other patients more?" The authors state that transplantation "can certainly help" HIV-positive individuals with end-stage organ failure. With regard to the second question of whether "scarce" organs would be better allocated to people who do not have HIV, the authors say that people do not question whether the elderly should receive certain treatments shown to better benefit younger people. They also note that African Americans and people with hepatitis C and diabetes are offered transplants in most instances, "despite clear evidence that post-transplantation survival is diminished in each of these groups."
Increased Risk to the Patient?
The authors state that efficacy is "not the sole ethical criterion for determining candidacy" for transplantation. Medical factors, such as whether immunosuppressive drugs used to lower the odds of organ rejection may adversely react with antiretroviral drugs or harm an HIV-positive individual's health, must also be taken into account. However, there is no evidence to date that the anti-rejection drugs increase HIV-positive patients' susceptibility to opportunistic infections, and there is some evidence that two of the most common drugs -- cyclosporine and tacrolimus -- may actually improve HIV-positive individuals' health by "inhibiting" the production of interleukin-2-dependent T cell replication, they note. Physicians are also concerned that the transplant surgery itself my accelerate disease progression in HIV-positive individuals, but studies have demonstrated that disease progression is "unaffected" by the surgery, the authors state. HIV transmissibility during surgery must also be taken into consideration, according to the authors.
Some doctors are concerned that they or a member of their team could contract the virus from a patient during the transplant procedure. However, the risk of patient-to-surgeon transmission is "extremely low," the authors state, noting that the risk is lower than that associated with hepatitis C transmission. In addition, they say that some people contend that it is wrong to offer organs to HIV-positive individuals because HIV transmission often occurs through injection drug use and "high-risk" sexual practices. How a patient acquired a disease has "never been a legitimate reason to withhold medical interventions from patients," the authors state, noting that hepatitis B and C, two viruses that can also be transmitted through injection drug use and sexual contact, and alcoholism remain the "most common indications" for liver transplants in the United States. The authors state that they would not advocate transplants for individuals with terminal AIDS. However, HIV-positive individuals who are asymptomatic should not be barred from receiving transplants on the basis of their seropositive status, they conclude (Halpern et al., New England Journal of Medicine, 7/25).