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HIV-positive individuals as both potential organ donors and long-term follow-up results in 2015. 17,18 Among 27 patients,
organ recipients and are intended for use by healthcare survival at 1, 3 and 5 years was 84%, 84% and 74%,
practitioners in the transplantation field in Southern Africa in respectively, and graft survival was 93%, 84% and 84%,
both the state and private sectors. Considerations for HIV- respectively. Recipient inclusion criteria included a CD4
+
negative recipients of organs from HIV-positive donors are count ≥ 200 cells/µL, a suppressed VL and ART duration > 3
also discussed. months prior to transplantation. Patients with acquired
immune deficiency syndrome (AIDS)-defining opportunistic
Guideline development process infections and malignancies were excluded. The VL remained
suppressed in all patients during the study period.
An expert panel was constituted, consisting of HIV experts from
the Southern African HIV Clinicians Society, representatives
from the South African Transplant Society, the National Institute Following these data, an advocacy campaign in the USA led
for Communicable Diseases, transplant surgeons from the to the passage of the HIV Organ Policy Equity (HOPE) Act in
University of Cape Town and Wits Donald Gordon Medical 2013, which allowed for research into transplanting organs
19
Centre, a medical ethics specialist and a transplant infectious from HIV-positive donors into HIV-positive recipients.
diseases specialist. Both adult and paediatric domains were When this became federal policy in 2015, several US
represented. The scope and outline of the guidelines were transplant centres began embarking on such efforts. To date,
discussed at a meeting in November 2018. A PubMed literature these have included deceased donor HIV-positive-to-HIV-
search was conducted on all publications relating to the positive kidney and liver transplantations, and living donor
keywords ‘HIV’, ‘transplantation’ and ‘transplant’ up to January HIV-positive-to-HIV-positive kidney transplantations. 20,21,22
2020. Owing to a paucity of published data, all types of articles Successful outcomes in heart, pancreas and lung transplants
were reviewed, including case series and case reports. Draft have also been reported in HIV-positive patients, despite
guidelines were compiled and circulated for comment and using organs from HIV-negative donors. 23,24,25,26
amendments to the entire committee prior to publication, and
decisions were made by consensus. The guidelines will be Human immunodeficiency virus-negative
reviewed as needed in the light of new evidence. recipients of solid organs from human
immunodeficiency virus-positive donors
Evidence to date Prior to 2017, HIV-positive-to-HIV-negative transplantations

Human immunodeficiency virus-positive both internationally and locally had been inadvertent (because
of diagnosis of the donor’s HIV status subsequent to
recipients of solid organ transplants transplantation). In 2017, Botha et al. performed the first
Patients with HIV have received organ transplants since the intentional liver transplantation from a living HIV-positive
27
1980s, although, owing to inconsistent testing at the time, donor to an HIV-negative recipient. The recipient was a
many of these patients were only diagnosed with HIV 7-month-old child with biliary atresia and end-stage liver disease
months to years subsequently. 13,14,15 In the pre-ART era, who was placed on the waiting list for a liver transplant from an
patient survival was frequently poor. HIV-negative donor. After a prolonged period on the waiting
list, the child’s HIV-positive mother requested to be considered
In 2010, Stock et al. reported the outcomes of 150 prospectively as a donor because she was otherwise a suitable candidate and
enrolled, HIV-positive recipients of a renal transplant from furthermore fulfilled donor criteria outlined in the HOPE Act.
HIV-negative donors. Recipient inclusion criteria included She was on stable ART, had a CD4 count > 200 cells/µL and was
16
+
+
a cluster of differentiation 4 T-cell (CD4 ) count ≥ 200 cells/ virally suppressed with no evidence of any opportunistic
µL and a suppressed viral load (VL) on a stable ART regimen infections or AIDS-associated malignancies. Following extensive
prior to transplantation. Kidneys from both living and multidisciplinary meetings and counselling, permission for the
deceased donors were used. Patient survival rates at 1 and procedure was obtained from the local institutional review
3 years were approximately 95% and 88%, respectively, and board as part of a research trial, and both of the child’s parents
graft survival was 90% and 74%, respectively. These consented to the procedure. The recipient received triple ART
percentages were lower than the national US average at the before the transplantation to minimise the risk of HIV
time, although they were comparable with results for other transmission, and this was continued after transplantation. To
high-risk renal transplantation groups. Importantly, no date, the recipient remains well, with normal-for-age growth
evidence was seen of any immunosuppression-precipitated and excellent graft function. HIV antibodies were detected at
HIV viraemia, nor of any HIV-related opportunistic day 43 post-transplantation, although this response gradually
infections. Two patients developed limited cutaneous attenuated with time. No plasma or cell-associated HIV-1 DNA
Kaposi’s sarcoma that was successfully treated, but no other or RNA was detected at any stage in the recipient, although early
sign of increased malignancies was observed in comparison post-transplantation samples were not available for testing.
with HIV-negative kidney transplant recipients.
Transmission risks
Muller et al. then demonstrated the feasibility of renal
transplantation from deceased HIV-positive donors to HIV- Blood from donor organs are routinely flushed out prior to
positive recipients. Initial results were reported in 2010, and insertion in the recipient. However, these organs may still

http://www.sajhivmed.org.za 59 Open Access