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San Francisco Examiner
Organs offered in HIV cases: UCSF pioneers in
Lisa Krieger, Examiner Medical Writer
August 31, 1997
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 list.

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," Caplan said.

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 one.

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 experimental transplantation."

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 syndrome.

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 prognosis.

"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 transplant.

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 challenge.

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."