Organs From HIV-Positive Donors? Ethicist Weighs In

This transcript has been edited for clarity. 
Hi, I’m Art Caplan. I’m at the Division of Medical Ethics at NYU Grossman School of Medicine in New York City. 
If you’re a faithful listener and viewer of this podcast, you know that there is a huge shortage of organs available to transplant to those in need. The demand for transplantable solid organs, including livers, hearts, kidneys, and lungs, has been exceeding the supply, particularly of cadaver organs. We’re using more and more living donors in the kidney realm, but cadaver organ supply for hearts and livers just hasn’t been keeping up over the years. 
It’s partly due to the fact that there are more people eligible for transplant as transplantation improves, with sicker people, older people, and indeed younger people entering the waiting list, meaning young children. For a variety of reasons, people in the US have not been able to donate organs upon death at a rate that keeps up with this demand. 
What to do? There are a number of ideas out there about how to increase the supply. One that I’ve had the opportunity to discuss with funding groups like the National Institutes of Health (NIH), conducting some research on this topic, is to use organs that have viral infections and give those to people who don’t have those viral infections, but for whom we might be able to manage any trouble. 
In particular, this involves giving organs from people who are known to be HIV positive — that is, there’s a danger they could transmit AIDS — to a recipient, but knowing that the recipient, for a variety of reasons, may not get a heart or a liver and may well die before something appears that doesn’t have this infectious agent, and they’re willing, after a discussion, to say, yes, I would take an organ from an HIV-positive person.
The NIH has done some studies — as I said, I was involved in reviewing those — on tracking giving organs from HIV-positive people to HIV-negative people. There are a couple of things that can be done to minimize the risk — not eliminate it totally, but minimize it. 
You can give the recipient antiretroviral therapy (ART). It’s very successful in keeping viral infections of people who are HIV positive to a minimum. If you take it as prescribed, probably 95% of people maintain almost undetectable levels of HIV virus in their blood, so you know that you will be able to treat any HIV infection that gets transmitted from an HIV-positive donor. That’s an incentive that makes that opportunity appealing to many who fear they’re not going to get an organ at all and may well die unless they take this more risky organ.
There are also treatments, such as preexposure prophylaxis, that involve giving people medicines before they’re exposed to HIV, which are used in high-risk groups now — say, people who engage in dangerous sexual practices or who receive blood frequently through transfusions. Those people can take antiviral medicines before they get infected, and they seem to help the prevention of transmission.
In this HIV idea, you well might be in a situation where you could start medication on the prospective recipient to build up their resistance to HIV, and then once the transplant occurs, give them further medicines in order to make sure that any transmission is tamped down. 
I think this is an ethical approach. It requires a number of steps to make sure that people are getting, if you will, informed consent to this increased risk. You have to tell them what you know about the risk for transmission. You have to tell them what we know about its prevention and treatability. Those are not 100% effective; they’re very good, but not 100%. 
You have to make sure that they understand that they may not be able to have sexual contact or exchange things like toothbrushes with partners who they live with or come in contact with because they may themselves turn out to be HIV positive. That may impact their lifestyle. You’re probably going to want to get a discussion with any romantic partners that they might have so that they’re aware of what exposure might be involved through a successful transplant from an HIV-positive donor. 
It’s also the case that we really don’t know what the long-term risks are. We know that, short term, it looks like these things are both preventable and treatable in terms of HIV transmission and side effects either on the organ that’s transplanted or on other body systems. 
In all honesty, nobody’s been around with 10 years of an HIV-positive heart transplant in order to say whether the drug treatments hold up or whether the HIV in a person who’s undergoing immune suppression is going to have more of a rebound effect than in somebody who’s just getting medicines for HIV exposure. 
You have to be honest and open, and you have to discuss these things. There are many people I know, facing the shortages they do, facing the prospect of death for certain because the supply is just not there and they know they’re at the end of the wait list for a variety of reasons, this is an option that I think ought to be offered. It may not be one that everyone will accept, but it may form a bigger pool of donors that can help more people live. 
I’m Art Caplan at the Division of Medical Ethics at the NYU Grossman School of Medicine. Thank you for watching.