National Landscape of Human Immunodeficiency Virus-Positive Deceased Organ Donors in the United States

Abstract

Background: Organ transplantation from donors with human immunodeficiency virus (HIV) to recipients with HIV (HIV D+/R+) presents risks of donor-derived infections. Understanding clinical, immunologic, and virologic characteristics of HIV-positive donors is critical for safety.

Methods: We performed a prospective study of donors with HIV-positive and HIV false-positive (FP) test results within the HIV Organ Policy Equity (HOPE) Act in Action studies of HIV D+/R+ transplantation (ClinicalTrials.gov NCT02602262, NCT03500315, and NCT03734393). We compared clinical characteristics in HIV-positive versus FP donors. We measured CD4 T cells, HIV viral load (VL), drug resistance mutations (DRMs), coreceptor tropism, and serum antiretroviral therapy (ART) detection, using mass spectrometry in HIV-positive donors.

Results: Between March 2016 and March 2020, 92 donors (58 HIV positive, 34 FP), representing 98.9% of all US HOPE donors during this period, donated 177 organs (131 kidneys and 46 livers). Each year the number of donors increased. The prevalence of hepatitis B (16% vs 0%), syphilis (16% vs 0%), and cytomegalovirus (CMV; 91% vs 58%) was higher in HIV-positive versus FP donors; the prevalences of hepatitis C viremia were similar (2% vs 6%). Most HIV-positive donors (71%) had a known HIV diagnosis, of whom 90% were prescribed ART and 68% had a VL <400 copies/mL. The median CD4 T-cell count (interquartile range) was 194/µL (77-331/µL), and the median CD4 T-cell percentage was 27.0% (16.8%-36.1%). Major HIV DRMs were detected in 42%, including nonnucleoside reverse-transcriptase inhibitors (33%), integrase strand transfer inhibitors (4%), and multiclass (13%). Serum ART was detected in 46% and matched ART by history.

Conclusion: The use of HIV-positive donor organs is increasing. HIV DRMs are common, yet resistance that would compromise integrase strand transfer inhibitor-based regimens is rare, which is reassuring regarding safety.

Keywords: HIV; drug resistance; organ donation; transplant.

Figure 1.

A, Number of HOPE organ donors (both human immunodeficiency virus positive [HIV+] and false-positive [FP]) who donated kidneys and/or livers during the study period, by calendar year. Donations increased significantly in 2018 and continued to increase through March 2020. B, National distribution of HOPE donors during the study period. At least 1 HOPE donation occurred in each of the 11 United Network for Organ Sharing (UNOS) regions. Abbreviation: HOPE, HIV Organ Policy Equity.

Figure 2.

Donor CD4 T-cell percentage versus absolute CD4 T-cell count at donation for 51 human immunodeficiency virus–positive donors with both values available. Solid vertical line corresponds to a CD4 T-cell count of 200/µL; dashed horizontal line, to CD4 T-cell percentage of 14% (ie, AIDS-defining thresholds). Of these 51 donors, 27 (53%) had a donation CD4 T-cell count <200/µL, yet 16 (59%) of these 27 had a preserved CD4 T-cell percentage >14% (upper left quadrant). In contrast, no donors with a CD4 T-cell proportion <14% had a CD4 T-cell count >200/µL (bottom right quadrant).