The issues of organ transplantation for HIV positive patients is talking centre stage in USA with novelist, playwright and AIDS activist Larry Kramer playing a leading role. Kramer who is HIV positive is one of four HIV positive patients currently on the University of Pittsburgh Medical Centre (UPMC) liver transplant waiting list.

Until recently, positive HIV status was considered an absolute contraindication due to shortened life expectancy coupled with the scarcity of donor organs. But as new antiviral drug regimens, specifically triple drug cocktails of protease inhibitors have extended lives, many HIV patients are now surviving long enough to develop liver diseases leading to end stage organ failure. Without transplants, these individuals will die not from AIDS related infections, but from liver cirrhosis. As to the charge that given the chronic shortage of donors, organ should go only people who are otherwise healthy, as they have the best chance for long term survival, John Fung MD, Director of Transplantation surgery at UPMC felt that better allocation of available livers and eliminating those transplant programs that produced sub- optimal results would optimize transplant outcome.

A major concern about transplantation in HIV positive patients is that the transplant immunosuppressive regimen will hasten AIDS progression. According to Fung, the antiviral used today are sufficiently potent to overcome the adverse effects of immunosuppression on HIV activity. In fact, experimental evidence suggests that immunosuooression may actually benefit HIV positive patients. Since T cells responsible for rejection also are factories also are factories for HIV replication, shutting them down with immunosuppression drugs may decrease both viral replication and graft rejection, explained Fung. UPMC has been among the few hospitals willing to transplant persons who are HIV positive. They have provided livers to 8 patients since 1997. Two of these recipients have died, but 6 are alive, including a survivor who has lived more than 3 years post transplant.

To determine the viability of transplantation in HIV positive patients, 10 centres are joining UPMC in an NIH sponsored study at the University of California, San Francisco. The first phase of the study will examine outcome in 75 patients undergoing liver transplantation over 3 years. A parallel study will involve kidney transplant recipients.

In the second phase, the researchers hope to evaluate 300 patients needing liver, kidney, and heart transplantation.