The Association of HIV Criminalization Law and Disparities in Transplant Education among People with HIV

Abstract

While people with HIV (PWH) experience high rates of end-stage kidney disease (ESKD), they were historically denied kidney transplantation and prohibited from organ donation, both elements of treating ESKD. It remains unknown to what extent such HIV criminalization laws correlate with the provision of transplantation education to PWH. We conducted this study to elucidate the relationship between these structural-level policies and individual-level outcomes. State-level HIV criminalization laws were linked with the United States Renal Data System (2017-2020) to examine the association between HIV criminalization laws, HIV-status, and transplant education using logistic regression, and the association between transplant education, mortality, waitlisting, and transplantation using Cox proportional hazards regression. There were 164,223 incident ESKD patients in 2017 (PWH = 2,051). PWH had significantly higher odds of education than people without HIV in states without HIV criminalization laws (OR: 1.78, 95% confidence interval [CI]: 1.48-2.13, p-value < 0.001). Within states with HIV criminalization laws, there was no significant difference in odds of education by HIV-status (OR: 1.22, 95% CI: 0.98-1.53), suggesting that PWH residing in states with HIV criminalization laws were significantly less likely to receive transplant education than PWH residing in states without such laws (interaction OR: 0.76, CI: 0.61-0.96, p < 0.001). While many states have revised or overturned their HIV criminalization laws to permit organ donation from PWH, such laws remain in effect in others and disproportionately limit access to care for PWH. Eliminating laws limiting PWH's ability to participate in organ donation may benefit the health of PWH with ESKD residing in those states.

Keywords: HIV; HIV Criminalization Policy; Healthcare Outcomes; Kidney Disease; Transplant Education.