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recipients, and their caregivers, in a manner that will facilitate negative recipient in a controlled environment when attempts
favourable outcomes. are made to limit transmission. In the absence of definitive data,
it is prudent to assume for ethical purposes that this likelihood
Living human immunodeficiency may be substantial. Extreme care should therefore be taken to
virus-positive donor ascertain that the risk of acquiring HIV is outweighed by the
In addition to standard donor criteria, it is important that risk of continuing to wait for a transplant from an HIV-negative
the HIV-related clinical criteria outlined below (see also donor. We anticipate that further data on HIV’s transmissibility
‘Recommendations’ section) are adhered to, so as to minimise in these scenarios may inform these ethical considerations.
harm to the donor. This may be especially important if
the donor is a close relative or friend of the recipient, where All potential transplant recipients in this situation should be
conflicts of interest may arise. informed fully of the potential that they might acquire HIV
infection, and that the treatment for this will likely require
We advise that an independent donor advocate (IDA) should lifelong ART.
be appointed for all cases involving a living HIV-positive donor.
An IDA is a person with a good understanding of transplants, Considerations for minors
who is fully independent of the donor, the recipient and the Minors who are HIV-negative recipients of organs from
medical team; they need not be a health professional. The role HIV-positive donors require special consideration. This
of an independent advocate is to ensure that the donor’s scenario may be particularly frequent for living-donor liver
interests and rights are upheld at all times, and to ensure that recipients, who are most commonly children because of
the donor has adequate understanding of the consent process, organ size considerations. Given that we recommend that
surgical procedure and follow-up requirements. Independent transplantations involving HIV-positive patients be
donor advocates should be a required signature on the surgical performed under the review of a local research ethics
consent form, affording them veto status for the procedure. committee (see below), the South African National Health Act
Although IDAs are a legal mandate of most living donor requires consent from the minor’s primary caregiver for
transplant programmes in many countries, this is not currently the procedure regardless of the minor’s age. When the
the case in South Africa. However, we regard an IDA as essential minor is capable of understanding the procedure, the
for any programme using increased-risk living donors, minor’s assent should also be sought.
including living HIV-positive donors.
Additional ethical considerations for minors include:
Human immunodeficiency virus-positive • The capacity of the child’s support network to cater for the
recipients additional burden of HIV-related therapies and potential
It is a key principle of medical ethics that equal access to treatment complications: The child will require extensive assistance
should not be denied unreasonably. Where outcomes in HIV- in the post-transplantation period, and this may include
positive recipients of organs have been shown to be similar to ART, additional clinic visits to optimise HIV control and
other patient groups who are offered organ transplantation, as additional admissions in the case of opportunistic
with renal transplants, HIV status alone cannot be used as infections.
grounds for exclusion from transplant programmes. Where • The need for age-appropriate disclosure to the child of their HIV
outcomes for HIV-positive organ recipients are not known, it status should transmission occur: Best practice principles in
should not be assumed that HIV-positive recipients will this regard have been established within the HIV field,
necessarily fare more poorly than other transplantable groups. and include serial disclosures by qualified counsellors in
Rather, well-monitored clinical trials are encouraged to ascertain the presence and with the support of the child’s primary
outcome data. Increasingly, survival data from HIV-positive caregivers (usually the parents), at a complexity level
recipients of solid organs other than kidneys are also proving appropriate for the child’s understanding at that age.
similar to those of HIV-negative controls in many instances, • Donor disclosure: HIV status disclosure facilitates
although often with an increased risk of rejection. 23,25,34 adherence, and adherence in transplant programmes is
essential to promoting good outcomes. It is strongly
As with any disease, medical complications of a condition may encouraged that the primary caregiver of the potential
legitimately disqualify patients from transplantation. In the recipient child (often the mother, who may also be the
case of HIV, these may include active opportunistic infections donor) has disclosed her or his HIV status to her or his
or AIDS-associated malignancies. However, patients with HIV immediate support ‘network’ who will be involved in
should not be disadvantaged solely on the basis of their HIV. caring for the recipient child in future. This network may
be immediate family members, or it may be a family
Human immunodeficiency virus-negative member at a distant location.
recipients of organs from human
immunodeficiency virus-positive donors Research protocols and processes
Currently, it is not definitively known whether, and at what Given the rapidly developing nature of the field, and the
frequency, HIV is transmitted from the donor organ to an HIV- ethical and medical complexities involved, we advise that

http://www.sajhivmed.org.za 63 Open Access