Policies of U.S. heart transplant programs regarding transplantation of human immunodeficiency-positive patients

Abstract

The United Network for Organ Sharing (UNOS) states “HIV positive patients should not necessarily be excluded from candidacy for organ transplantation.” Improved survival of patients with human immunodeficiency virus (HIV) with the advent of highly active anti-retroviral therapy (HAART) has created dilemmas for transplant programs. Some have suggested that the transplant community “remove barriers to transplantation in HIV positive (HIVP) patients for whom it is otherwise indicated.” A further consideration is that HAART may cause cardiomyopathy. Because these patients may need continued HAART, heart transplantation of HIVP patients, in particular, may be associated with higher risk than transplantation of other organs. In view of these issues, 194 heart transplant physicians and surgeons representing all programs registered with UNOS as of July 1, 2002 were surveyed to determine whether they have written policies regarding HIVP candidates and, if so, what their criteria are for assessing the status of these patients. The questions included are listed in Table 1. One hundred two surveys were returned, for a 53% response rate. Of these, 41% (41 of 100) indicated they have a written policy concerning HIVP candidates. Also, 39% (16 of 41) of these policies considered HIVP a contraindication to transplantation. However, despite the absence of a written policy, 95% (56 of 59) of programs indicated they consider HIVP a contraindication to heart transplantation. Only 6 programs indicated they would evaluate patients with HIVP status and make a determination of suitability based on viral load and T cell counts, and 1 of these programs indicated they would only evaluate pediatric candidates. One program indicated that they treated 1 patient transplanted at another institution. With 18 months of follow-up the course was complicated with significant rejection but no opportunistic infections. Another program reported listing 2 HIVP patients. It is apparent from this survey that the majority of programs in the U.S. exclude patients from transplantation due to HIVP status, with only a small fraction of programs willing to evaluate these patients. Also, a significant number of programs do not have a written policy with regard to HIVP patients. Currently, there is only a single experience in the U.S. of an HIVP patient that has undergone heart transplantation, and no published reports. Given this limited information, it is impossible to speculate on the natural history of these patients with heart transplantation and the effects of anti-retroviral therapy in the cardiac transplant patient to allow for reasonable policy and clinical decisionmaking.