Transplant options for patients with chronic infections are expanding rapidly, a Duke infectious disease transplant specialist says, setting the stage for future policy changes that are likely to add momentum to more efficient use of available organs.
The increasing effectiveness and declining cost of direct acting antiviral medications have accelerated organ transplants involving donors and recipients with Hepatitis C (HCV) and, to a lesser extent, Hepatitis B (HBV) in the United States, says Cameron R. Wolfe, MBBS, MPH. The use of HIV-positive donors has increased at about the same rate as HCV positive donors.
An advocate for increasing the use of infected organs, Wolfe posits that the expansion in the use of available organs is moving too slowly and too unevenly. “There are still many centers who don’t allow these transplants as an option for their patients,” Wolfe says. “With appropriate infectious disease or hepatology expertise, I suggest this option could be offered for everyone to make an informed choice if the essential safeguards are in place."
“Infectious disease doctors want to broaden the discussion of organ availability and use to involve all donors and organ recipients who live with chronic infection,” Wolfe adds. “Transplant options for patients with both HIV and HCV are increasing, especially during the past 12 months as we have learned more.”
Transplants involving HCV-infected organs and recipients are now common in the United States. The incidence of new HBV-positive individuals in the general community is beginning to slowly increase. “We expect there will be a really slow uptick in the number of available HBV-positive organs,” Wolfe says. “We should consider how best to use those.” Like HIV, HBV requires lifetime treatment.
Treatment for patients with HIV and HBV has become easier and less costly, Wolfe says, noting that a single-pill daily therapy has become the standard for most patients with HIV.
Rising Number of Opioid Deaths a Factor
The rising number of deaths related to opioids has emerged as a factor for transplant specialists. “A wider recognition and acceptance of the safety of using infected organs could help maximize the potential gift of organ donation tragically made more common through the ever rising opioid epidemic,” Wolfe says.
Levels of deceased donors remained at about 8,000 for many years, Wolfe says, before rising to more than 10,800 in 2018. Based on the current pace, potential organ donations may exceed 11,000 in 2019.
Enacted in 2013, the HIV Organ Policy Equity (HOPE) act remains the primary regulatory framework guiding the broader use of HIV-infected organs, Wolfe says. The legal and medical arguments restricting the transplantation of HIV-positive organs only into recipients who are also HIV-positive, may likely disappear in the future, Wolfe says, citing a recent South African case in which an HIV-infected mother donated part of her liver to her HIV-negative daughter.
For patients in extremis, he says, the option of accepting an HIV-infected organ means the extension of life. “Let’s expand the ethical horizon to include a hypothetical patient needing a transplant while waiting in the cardiothoracic surgical ICU,” Wolfe says. “If that patient is offered a heart from a 25-year-old HIV-infected donor that’s likely to perform as well as a heart from a non-infected donor, the choice is logical and obvious for that patient."
“In the United States, it cannot happen right now,” he adds. “But the legal and social issues will almost certainly change in the future.”