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Surgical policy. Congress is advancing legislation that would make organs from HIV-positive donors available to surgeons.
2013-07-19 12:00
A U.S. House of Representatives committee this week unanimously approved a bill approving transplants using organs taken from people infected with HIV. The HIV Organ Policy Equity Act would lift a nearly 3-decade-old federal ban on such transplants and allow expanded research into the outcomes of transplant patients. Similar legislation has already passed the Senate, and the bill's advocates say that the policy shift could save hundreds of lives each year if it ultimately makes it into law.
"The shortage of organ donations in our country is a critical matter," said Representative Lois Capps (D-CA), who introduced the bill, in a statement. "We need to begin to research the feasibility and safety of these transplants in hopes that more people can receive transplants, and more lives can be saved."
Congress banned transplant of HIV-infected organs in 1988, when AIDS was rapidly spreading and little was known about how to prevent and treat it. A concerted effort to lift the ban began about 2 years ago, after a 2011 study published in the American Journal of Transplantation (AJT) concluded that the ban was outdated and that these organs could help fill a gap between supply and demand.
Today, there are more than 118,000 people in the United States on the waiting list of the Organ Transplant and Procurement Network, a nonprofit established to coordinate the transplant system. Perhaps 1000 people on the list are HIV-positive, researchers estimate. Antiretroviral drugs can extend the lives of these patients, physicians say, but many are vulnerable to kidney failure, and adding more HIV-positive organ donors to the pool would give them a better chance of survival.
"We should really offer them transplants as a cure for kidney failure," says Mohamed Atta, an associate professor of medicine at Johns Hopkins University in Baltimore, Maryland. In the past, he says such "positive-to-positive" transplants were "not even an option for those patients and that was discrimination."
The pool of potential HIV-positive organ donors is about 500 per year, according to the 2011 study by researchers at Johns Hopkins that was published in AJT. These donors could provide an additional 1000 organs, says transplant surgeon Dorry Segev of Johns Hopkins, who worked on the study. "If we were able to successfully use all those organs, we would at least be able to transplant everybody with HIV that is currently on the waiting list," says Segev, who has urged Congress to fix what he calls "a mistake in the law."
Segev and his allies have found supporters in Congress. A Senate bill lifting the transplant ban (S.330), sponsored by Senator Barbara Boxer (D-CA), won unanimous approval in June. Now, the House bill (H.R. 698) has passed its first major hurdle, winning unanimous approval from the Energy and Commerce Committee on 17 July.
"Our current organ transplant polices are outdated and do not reflect the most current research and clinical outcomes," said Representative Michael Burgess (R-TX), a co-sponsor, in a statement. Initially, Burgess said that he was "concerned" about the idea of lifting the ban, "but it does seem to be sound, science-based policy." He noted that surgeons are already able to do positive-to-positive transplants with donors and recipients infected with the hepatitis C virus, which is spread by means similar to those of HIV.
Lifting the HIV transplant ban would also be "good fiscal policy" because it could reduce treatment costs, Burgess said. For patients with HIV and kidney failure who get government-subsidized dialysis, for instance, a successful kidney transplant could save the government $500,000 per patient, says Kim Miller, policy officer for the HIV Medicine Association in Arlington, Virginia, one group backing the bill.
Several studies have suggested that positive-to-positive transplants work. A team of doctors in South Africa transplanted HIV-positive kidneys into four HIV-positive recipients in 2010; a year later the patients were still doing well. Another 2010 study published in The New England Journal of Medicine followed 150 HIV-positive kidney transplant recipients for 3 years, finding that most were successful. One big challenge, the study found, was determining how to balance antiretroviral drugs that the patients took to combat HIV with the immunosuppressive drugs meant to thwart organ rejection.
To address such problems, both the House and Senate bills would task the organ network with monitoring research on positive-to-positive transplants. The U.S. Department of Health and Human Services, which oversees the network, would use the findings to develop new healthcare standards for the transplants 2 years after the bill became law. Researchers say that lifting the ban could also ease studies that could help improve pre- and post-transplant treatments, donor selection criteria, and preventing HIV-infected organs from being transplanted into patients without the disease.
One difference between the House and Senate bills is that the Senate version makes it clear that surgeons who transplant HIV-infected organs would not be subject to criminal charges, as they are under the current law, if research shows that the transplants pose no health risks. That and other differences between the bills could be cleared up if the full House passes its version, allowing the two bodies to negotiate a final bill. The legislation's backers are optimistic that it will win final approval in the House later this year. The Obama administration has yet to take a formal position on the proposal.
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