People with HIV are living longer than ever, thanks to antiviral drugs. While that's great news for those with the virus, it also means that they're starting to face the medical complications that crop up with old age — like organ failure. Researchers have been experimenting with transplants between HIV-positive donors and HIV-positive recipients, and a new study shows that these can be done with increasingly promising results.
Early results led to the US lifting a research ban
When doctors from Groote Schuur Hospital in South Africa first reported on their work transplanting kidneys between HIV-positive patients back in 2010, the results were so positive that it led the United States to lift a research ban on the practice. It's now five years later, and that same hospital is publishing the results of how its original patients are doing in The New England Journal of Medicine. The report includes more than 20 additional patients, after an average of about three years following the transplant.
The hospital found that the survival rate following a transplant between HIV-positive patients is only modestly lower than the survival rates for a transplant in someone who is HIV-negative. For HIV-positive patients, there was an 84 percent survival rate one year after surgery and a 74 percent rate at five years. That's compared to rates of 91 percent and 85 percent for HIV-negative patients in the same hospital unit. Though the trial focused entirely on kidney transplants, the doctors behind it believe that these results show the procedure has potential for broader use.
"Using HIV-positive donors might resolve some of the problems we are experiencing in getting enough donors for our patients with [chronic kidney disease] worldwide," Elmi Muller, the study's lead author, writes in an email to The Verge.
"The question is, 'What is the risk of getting the transplants compared to the risk of not doing the transplant?'"
One early worry was that a more treatment-resistant form of HIV could transfer from a donor to a recipient; fortunately, the doctors saw no sign of increased viral levels after the transplant. That doesn't mean there wasn't some risk to the patients, though. Five patients died within a year after the transplant from various causes, including cancer and heart problems. And transplant rejection was also a problem: of the 24 patients who survived the transplant, five patients had rejections, with eight rejections occurring in total. Prior research has found that organ rejection is more common in HIV-positive recipients — so this may not be a complication specific to receiving an organ from an HIV-positive donor.
Even with the added risk, doctors still see reasons to pursue HIV-positive transplants. "The question is not, 'What is the additional risk of doing the transplant?'" Dorry Segev, a transplant surgeon with Johns Hopkins Medicine who was not involved with the study, tells The Verge. "The question is, 'What is the risk of getting the transplants compared to the risk of not doing the transplant?' And in not doing the transplant, HIV patients have a much higher risk of dying on dialysis. Much higher than their HIV-negative counterparts."
That's particularly pertinent in South Africa, where HIV is more prevalent and more donors are needed. "Because of very high HIV rates in South Africa, more and more HIV-positive, brain-dead donors [are] presented to the Groote Schuur Hospital transplant team," Muller writes. "In South Africa it made sense to try and marry this supply of donors with the group of HIV-positive patients without any treatment options in the country." Only deceased donors were used in Muller's study.
Muller expects to work with other organs in "the next few years."
This is also about more than kidneys. Muller chose to begin with kidney transplants because, she says, kidney problems are "very prevalent in HIV-positive patients," while other issues, like liver and heart failure, occur at rates similar to the general population. But it's likely that the practice will eventually expand to other organs. "Liver transplants are more complicated and logistically more difficult," Muller writes. "But I do think we will expand it over the next few years.
Segev hopes to see transplants between HIV-positive patients start soon in the US. In fact, following the release of Muller's initial study, he worked with Congress to pass the HOPE (HIV Organ Policy Equity) Act in 2013, which could eventually lead to the use of organs from HIV-positive donors. At the time, President Obama expressed support for continued research. "The potential for successful organ transplants between people living with HIV has become more of a possibility," the president said. Segev's research has estimated that thousands of lives could be saved each year by accepting HIV-positive donors.
Though the HOPE Act has been passed, Segev says that the Health Department still needs to create the guidelines under which these trials can be run. He expects to see transplants start in the US in about a year. If it goes well, he says they could be widespread within about three years.
"The outcomes are actually really encouraging."
It's possible that some complications will come up bringing the procedure from South Africa to the United States. Because patients in South Africa may have less access to antiretroviral medication, there's less resistance there and drugs are likely to be more effective. Still, Segev says that medications have come far enough that it shouldn't significantly complicate US transplants. "It's highly unlikely even in the US they will receive an [antiretroviral therapy] resistance that is untreatable," he says.
"The biggest takeaways are that the outcomes are actually really encouraging," Segev says. "...This really is another reminder that we need to move forward in the United States with doing this."