Hospitals are increasingly willing to transplant vital and scarce organs into people who have HIV, a once-unthinkable step now made possible with drug regimens that are helping such patients live longer.
Most procedures have involved kidneys and livers, but a small number of centers are transplanting hearts.
The number of centers that reported doing a transplant on an HIV-positive patient rose in 2011 to at least 48 centers out of the 242 that perform transplants, up from 25 centers in 2005, according to the United Network for Organ Sharing, the nonprofit that manages the U.S. transplant system. The number may be higher because not all states permit hospitals to report information regarding HIV status.
At least 198 HIV-positive people received organ transplants in 2011, an increase from at least 58 in 2005.
There has been no formal ban on HIV-positive patients receiving organs, though there is a law against donating organs from HIV-positive people. But only a small number of transplants were done until recent years, largely because of concern that HIV-positive patients wouldn't live long, or that their disease or the drugs they need to take could damage an organ.
Driving the change is the realization that HIV patients are living longer, with antiretroviral drugs that can keep their viral loads at virtually undetectable levels. The Centers for Disease Control and Prevention estimates more than 800,000 people are living with HIV. Since the improved anti-retroviral regimens were adopted in 1996, life expectancy has increased to an estimated 32.1 years after diagnosis.
Older patients face many of the same health problems of the general aging population, including organ failure, and early research suggests transplants haven't resulted in HIV-related health complications.
"There are so many patients who are [HIV-positive] but are in good shape and look better than other patients that we transplant," says Hiroo Takayama, a surgeon at New York-Presbyterian Hospital/Columbia University Medical Center, who has done two heart transplants in HIV-positive patients. "So the question is whether we really should eliminate those patients—should we let them die just because they are HIV-positive?"
New York-Presbyterian Hospital/Columbia University Medical Center is now doing long-term post-transplant follow-up on 11 HIV-positive people who have had heart transplants, something that would have been unheard of five years ago.
Hartford Hospital in Connecticut rewrote its protocols earlier this year to enable the first heart transplant there on an HIV-positive patient. Previously, HIV infection was listed as a bar to a heart transplant along with active substance abuse, severe psychiatric disease and other conditions.
Under the new protocol, someone with HIV must show they have taken their anti-retrovirals for at least a year and have virtually undetectable viral loads. "There is a scarcity of donor hearts, and we want to make sure every patient will survive," says Detlef Wencker, director of heart-failure services and cardiac transplantation. Hartford has done one such heart transplant so far.
Challenges remain. Nir Uriel, a cardiologist and assistant professor of medicine at Columbia University, notes that doctors must coordinate complex drug regimens to prevent negative interactions between drugs that target organ rejection and those that keep HIV in check. Dr. Uriel is an author of a 2009 paper on seven HIV-positive patients with heart transplants.
And some doctors say not enough information is available on outcomes. Heart transplants, in particular, are less common so there is much less data. In the general population, there were an estimated 16,813 kidney transplants done in 2011, according to UNOS, compared with 2,322 heart transplants. Doctors also raise concerns that HIV itself may damage the heart. A study this year by Massachusetts General Hospital researchers found that even patients whose HIV levels were undetectable had inflammation in the aortas comparable to people with known cardiovascular disease. Other studies have found that HIV-infected patients have twice the risk of heart attacks and strokes as non-infected people.
Andrew Smith, medical director for the heart-failure and transplant program at Emory University Hospital in Atlanta, says that since 2007, Emory has transplanted kidneys in 18 HIV-positive patients and livers in three patients, but that someone with HIV can't get a heart transplant under the institution's policy.
"If you have a death, it can impact a center's performance,'' Dr. Smith says. Poor outcomes can create a situation where "potentially patients from Georgia and Atlanta might be forced to go out of state to get transplants," he says.
Scott McCoy, 60 years old, a retired CDC researcher who lives in northern Georgia and is HIV-positive, had a heart attack in 2006 that left him with congestive heart failure. "I literally could not walk across the room without being exhausted,'' he says.
At the time, he says, doctors at Emory told him they didn't know of a center doing heart transplants on HIV-positive patients. So Emory implanted a left ventricular assist device, a mechanical pump.
For a while, it worked. Eight months after the surgery, Mr. McCoy started mountain biking again. But in 2010, he fell and damaged the device. He developed an infection, which doctors could not control, and Emory told him he needed a heart transplant.
By then, Mr. McCoy was able to benefit from wider acceptance of heart transplants for HIV patients. Mr. McCoy was transferred to New York-Presbyterian/Columbia and received a transplant in March 2011.
"The recovery was very difficult,'' says Mr. McCoy. But he is able to work as a part-time white-water rafting instructor, and says, "I have a rich and successful life.''
Despite individual success stories, long-term outcomes on transplants of all organs remain a concern.
Peter Stock, professor of surgery at University of California, San Francisco School of Medicine and a transplant surgeon, says his center first started considering doing kidney and liver transplants in HIV-positive patients once anti-retroviral therapy improved. ``We wanted to move forward but in a way that we would get some answers,'' he said.
Dr. Stock was principal investigator on a National Institutes of Health-sponsored, multi-center trial of kidney and liver transplants in HIV-positive patients. He says the study found that, overall, HIV-positive transplant patients did well, but that they have a two- to three-fold higher incidence of rejection of the kidney.
Rejection episodes can be brought under control by giving additional immunosuppressant drugs, he says, but "each episode takes life out of the kidney.'' This might not show up in the short-term results when compared to the general population, "but we might start to see differences in survival in five or 10 years,'' Dr. Stock says.
Write to Amy Dockser Marcus at firstname.lastname@example.org