In a move that other medical centers challenge on medical and
moral grounds, UC-San Francisco Medical Center is offering
organ transplants to people whose infection with the AIDS virus
is under control but who are dying from other disease.
Every other transplant center in the nation, with the exception
of the University of Pittsburgh Medical Center, has a policy
against offering the $200,000 procedure to HIV patients. They
say that America's critical shortage of donated organs demands
a very high standard.
But in San Francisco, "we had to do what was right...and look
at the new long-term prognosis of people with HIV in the same
way as we look at people (seeking transplants) with any other
disease, whether cancer or heart disease," says Dr. John Lake,
medical director of UCSF's transplant program who, after
consulting with university-based AIDS doctors, worked to change
the transplant policy two months ago.
"They fit the criteria," he said.
UCSF liver transplant surgeon Dr. Nancy L. Ascher said HIV
patients will get organs that otherwise would have been thrown
away. Thus others will not be deprived of a transplant.
HIV patients would receive organs from donors who are
HIV-negative but considered "high risk" for infection - people
who are gay, have multiple sex partners, a history of
intravenous drug use, or are in jail.
Ascher said it is a sensible compromise to an ethical problem
not explored by any other medical center.
A Southern California man, rejected for a transplant at two
other California medical centers, was the first to be accepted
at UCSF Medical Center, but he died last weekend while awaiting
a donor organ.
Two other HIV patients, one from San Francisco and the other
from the Lake Tahoe area, are being evaluated for the waiting
Their cases are unusual but no longer unique. Hepatitis, a
viral disease transmitted through the same routes as the AIDS
virus, is the major cause of liver failure in HIV patients. HIV
patients also sometimes suffer from cardiomyopathy, a failure
of the heart muscle.
Improvements in HIV therapy are extending lives in ways once
unimaginable. Transplant technology also has improved, offering
five-year survival rates of 70 percent, up from a one-year
survival rate of only 30 percent a decade ago.
Medically, "there has been a push to broaden the transplant
criteria, as transplants move from an experimental to proven
(procedure) and as the indication for taking people with
"borderline' cases expands," said Dr. Arthur Caplan, director
of the Center for Bioethics at the University of Pennsylvania.
Legally, since passage of the federal Americans with
Disabilities Act, "there is pressure to be more inclusive,"
Because there aren't enough healthy livers to go around - and
because they haven't sought out "high-risk" donors - medical
centers have resisted expanding the criteria for transplant to
HIV patients. They refuse HIV patients, saying that the
institutions' responsibility is to those who have the best
chance for a long and productive life.
Healthy livers are in such short supply that hundreds of people
die each year awaiting a transplant, experts note. Last year,
about 7,280 people awaited an organ, but only 3,922 received
About 520 people died waiting - the rest wait.
"I'm not quite sure it is the best use of a precious organ,"
said Dr. Steven Rudich, a transplant surgeon at UC-Davis
Medical Center. "It is still out of the mainstream of
transplantation. It is considered to be an extremely
The state's other transplant centers at California Pacific
Medical Center, Stanford University Medical Center, UC-Los
Angeles Medical Center and UC-San Diego consider it a highly
questionable policy with no guarantee of success.
AIDS activist Jeff Getty of Oakland, recipient of a landmark
baboon bone marrow transplant last year, said that denial of
transplants to HIV patients reflects "outright discrimination
and exclusion. . . . Everyone points to everyone else (to
blame). It is a circle of death."
Transplant experts deny that a "sin test" is used to decide who
gets scarce organs. They point to former alcoholics who
received new livers - including baseball Hall of Famer Mickey
Mantle and actor Larry Hagman. Former heroin addicts are
offered kidneys. People over the age of 70, once considered too
old for transplants, are now eligible. So are people with some
forms of mental illness or mild mental impairment, such as Down
But many experts worry that publicity about HIV transplants
might discourage donations from people - whether "high risk" or
"low risk" - who still see the disease as a death sentence or
who believe that HIV patients are morally undeserving.
"I think it would have a severely negative impact on organ
donation," Rudich predicted. "We need to be concerned with the
public perception of things."
A survey by the International Hepatitis Foundation in New
Jersey found that organ donors have two requests: that their
organs go to someone who will adhere to proper post-transplant
regimens and that the recipient has a favorable long-term
"Donors need to know that good decisions are being made," said
foundation President Thelma King Thiel.
Caplan, the bio-ethicist, said: "You have to proceed with
caution. . . . Organ donation is a very fragile thing, based on
pure altruism at a difficult time."
The procedure also carries potential risk to doctors.
"Surgeons don't discriminate based on (HIV) status. But there
is always this subconscious concern," said Dr. John Fung of the
University of Pittsburgh, who has transplanted organs to many
HIV patients. "Liver transplants are very bloody, with a lot of
needles flying around. It is not uncommon to stick yourself."
But the biggest issue, experts say, is whether HIV patients
will be helped - or hurt - by transplants. There are other
instances where potential recipients are turned down due to
systemic illnesses, like scleroderma, a disease of the
connective tissue that can compromise the success of a
There is concern that the medicines that transplant patients
must take for the rest of their lives will aggravate HIV. Some
doctors also predict deadly interactions between the medicines
needed to treat both conditions, HIV and the transplant.
The first study of liver transplants in HIV patients, conducted
in 1980 by Pittsburgh transplant pioneer Dr. Thomas E. Starzl,
concluded that carefully selected HIV patients do almost as
well as transplant patients without the virus. But all the
patients later succumbed to HIV.
Since then, there have been great advances against HIV. In some
cases, death and disease are delayed, perhaps for a lifetime.
Dozens of HIV patients have received transplants at Pittsburgh,
the world's leader in liver transplants. One patient has lived
more than a decade with both HIV and a new liver.
"New medicines have changed the landscape of HIV disease," said
Dr. John Roberts, a liver transplant surgeon at UCSF. "It is
now looking like these people with HIV and no complications of
the virus may have normal life expectancies.
"In many respects, they are like anyone else," said Roberts.
But not enough time has elapsed to know if success against HIV
will last a lifetime - or merely years, even months. New data
suggest that keeping HIV at bay, even with the most potent
three-drug cocktails now available, remains a daunting
If successful, the UCSF and Pittsburgh experiments will be
copied by other medical centers, transplant doctors say. The
experiment is being closely watched by the Mayo Clinic in
Rochester, Minn., the University of Pennsylvania in
Philadelphia, and the University of Michigan in Ann Arbor, all
of which are re-evaluating their anti-HIV policies.
"It is a tricky business," Caplan said.
"Does it buy a good quality of life for a significant period of
time? If so, then it is a good return on your money."