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antibody responses may be attenuated because of anti- The patient must also demonstrate virological control of
rejection immunosuppression. Possible explanations for the their HIV, as evidenced by a suppressed plasma VL within
HIV antibody pattern observed include the recipients’ the 3 months prior to transplantation. Achieving this
systemic infection with HIV, confinement of the HIV infection demonstrates that the patient is able to tolerate and adhere
within the maternally derived donor liver, a purely serological to their ART regimen and provides sufficient time to
response generated by the donor liver, and a recipient unmask any immune reconstitution inflammatory
serological response generated to HIV antigens in the absence syndrome (IRIS) reactions. In the setting of acute organ
of replication-competent virus. 27,34,40 failure, however, patients may not yet have had sufficient
time to obtain a suppressed VL, which may take 3 or more
We recommend that all available donor HIV treatment months. Patients on ART for shorter than this time period
history and resistance test information should be may still be considered for transplantation provided that
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reviewed prior to transplantation, as for HIV-positive their CD4 count exceeds the thresholds above, but
recipients. Any anticipated inability of the recipient to consultation with an infectious diseases specialist is
control the donor’s HIV strain should similarly be a advised. Such patients would be regarded as being at
contraindication to transplant, regardless of the higher risk post-transplantation than patients
precautions put in place to limit the acquisition of HIV demonstrating stable VL suppression.
(see ‘Recommendations’ section).
Information about the donor’s ART history may not be
Recommendations for donor and available in certain time-sensitive transplantation scenarios,
recipient eligibility such as with deceased donors. Although every effort should
be undertaken to obtain such information, transplantation
Recipient eligibility should not be delayed unduly in its absence.
Human immunodeficiency virus-positive recipient Human immunodeficiency virus-negative recipient
Eligibility criteria for HIV-positive transplant recipients:
• The benefit of accepting an organ from an HIV-positive
• CD4 count ≥ 200 cells/µL (≥ 100 cells/µL can be donor must outweigh the potential risks thereof and the
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considered for liver transplant recipients provided there risks of remaining on the transplant list while awaiting an
is no history of opportunistic infections or malignancies). organ from an HIV-negative donor.
For children aged < 5 years, a CD4 % threshold of 15% • The recipient (and/or caregiver in the case of a minor)
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should be used. must receive appropriate counselling about the potential
• Chronic patients: plasma VL < 50 copies/µL (most recent additional risks of the procedure given the donor’s
test performed within 3 months prior to transplantation). HIV-positive status.
• For organs from HIV-positive donors: the recipient must • The recipient must be able to tolerate an ART regimen
be able to tolerate an ART regimen effective against the effective against the donor’s HIV strain and must agree to
donor’s HIV strain. take lifelong ART.

• Transplantation should be undertaken as part of a human
Rationale: Patients are required to have a CD4 count
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≥ 200 cells/µL (for patients aged < 5 years, a CD4 % threshold research ethics committee (HREC)-approved research
of 15% should be used). Although any cut-off is somewhat protocol.
arbitrary, we endorse a CD4 threshold of 200 cells/µL for
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two reasons: (1) it is a threshold which provides Suggested antiretroviral therapy: The following ART is
suggested for HIV-negative recipients of organs from
protection against many opportunistic infections, some of HIV-positive donors:
which may be difficult to diagnose and may cause significant
post-transplantation morbidity and mortality; and (2) with • The regimen chosen will vary according to the donor’s
the exception of liver transplants, the safety of organ ART history and the recipient’s comorbidities. For most
transplantation below this recipient CD4 level has not been recipients weighing > 20 kg, we suggest using a
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established, as trials have generally excluded patients with dolutegravir (DTG)-based regimen where possible.
CD4 counts below this level. In the case of HIV-positive Dolutegravir has a very high barrier to resistance, is only
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recipients of liver transplants, there is evidence that using a rarely hepatotoxic and has no significant drug–drug
CD4 threshold ≥ 100 cells/µL is safe provided there is no interactions with commonly used immunosuppressant
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history of any opportunistic infection or malignancy drugs. Dolutegravir is now freely available in both the
(in which case a CD4 threshold of 200 cells/µL is public and private sectors. Regimens for paediatric
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recommended). Another exception to the rule would be patients weighing < 20 kg should be discussed with a
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immune non-responders, who fail to reconstitute an adequate paediatric HIV expert.
CD4 count despite prolonged viral suppression, but this • We suggest starting ART prior to transplantation, so as
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requires consultation with an infectious diseases specialist on to achieve therapeutic drug levels at the time of surgery.
a case-by-case basis. The exact time period required is not currently well

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