The future of HIV Organ Policy Equity Act is now: the state of HIV+ to HIV+ kidney transplantation in the United States

Beyond Immunity: Challenges in Kidney Retransplantation Among Persons Living With HIV

INTRODUCTION

While superb outcomes have been observed in the HIV-positive (HIV+) population, graft failure and subsequent need for kidney retransplantation (re-KT) remain a concern. This study aims to investigate the difference in success rates of re-KT allograft survival in the HIV+ versus HIV-negative (HIV-) population in the current era of transplantation (2014-2022).

METHODS

Data was collected from the Organ Procurement and Transplantation Network on all kidney transplant donors and recipients who had their first re-KT between 2014 and 2022. Allograft survival was assessed using Kaplan-Meier analysis with a log-rank test, while risk factors for graft loss were assessed using Cox proportional hazards with statistical significance set to P = 0.05.

RESULTS

HIV+ recipients were significantly more likely to be Black (P < 0.001), have an HLA mismatch >3 (P = 0.018), delayed graft function (P = 0.023), and graft loss from primary nonfunction (P < 0.001). Their HIV- counterparts were more likely to be White (P < 0.001) and Hispanic (<0.001), lose their graft from acute rejection (P = 0.044), and have a living donor (P = 0.001). Being HIV+ was associated with a 1.68-fold increased risk of graft loss, an HLA mismatch >3 held a 1.18-fold increase, experiencing delayed graft function held a 1.89-fold increase, and having diabetes was associated with a 1.16-fold increased risk. Living donor kidneys were associated with a 15.8% decrease in risk for graft failure. Kaplan-Meier curves showed a significantly lower duration of kidney allograft survival in the HIV+ community (P = 0.02).

CONCLUSIONS

Disproportional graft failure and inadequate HLA mismatching persist within the HIV+ Re-KT community. Stronger organ matching and new approaches for desensitizing retransplant candidates are vital.

Racial Disparities in Access to the Kidney Transplant Waitlist Among People with Human Immunodeficiency Virus

The epidemiology of human immunodeficiency virus (HIV) has shifted such that Black individuals disproportionately represent incident HIV diagnoses. While risk of end-stage kidney disease (ESKD) among people with HIV (PWH) has declined with effective antiretroviral therapies, a substantial racial disparity in ESKD burden exists with the greatest prevalence among Black PWH. Disparities in waitlisting for kidney transplantation, the optimal treatment for ESKD, exist for both PWH and Black individuals without HIV, but it is unknown whether these characteristics together exacerbate such disparities. Six hundred two thousand six ESKD patients were identified from the United States Renal Data System (January 1, 2007 to December 31, 2017), and HIV-status was determined through Medicare claims. Cox proportional hazards regression was used to determine waitlisting rates. Multiplicative interaction terms between HIV-status and race were examined. The 6250 PWH were significantly younger, more commonly Black, and less commonly female than those without HIV. HIV-status and race were independently associated with 50% and 12% lower likelihood of waitlisting, respectively [adjusted hazard ratio (aHR): 0.50, 95% confidence interval (CI): 0.36-0.69, p < 0.001; aHR: 0.88, 95% CI: 0.87-0.90, p < 0.001]. There was also a significant interaction present between HIV-status and Black race (aHR: 0.80, 95% CI: 0.66-0.98, p < 0.001) such that, while HIV-status and Black race were independently associated with decreased waitlisting, the interaction of Black race and HIV-status exacerbated those disparities. While limited by lack of HIV-specific data that may impact inferences with respect to race, additional studies are urgently needed to understand the interplay between HIV risk factors, HIV-stigma, and racism, and how intersectionality may exacerbate disparities in transplantation among PWH.

The effect of induction immunosuppression for kidney transplant on the latent HIV reservoir

The HIV latent viral reservoir (LVR) remains a major challenge in the effort to find a cure for HIV. There is interest in lymphocyte-depleting agents, used in solid organ and bone marrow transplantation to reduce the LVR. This study evaluated the LVR and T cell receptor repertoire in HIV-infected kidney transplant recipients using intact proviral DNA assay and T cell receptor sequencing in patients receiving lymphocyte-depleting or lymphocyte-nondepleting immunosuppression induction therapy. CD4+ T cells and intact and defective provirus frequencies decreased following lymphocyte-depleting induction therapy but rebounded to near baseline levels within 1 year after induction. In contrast, these biomarkers were relatively stable over time in the lymphocyte-nondepleting group. The lymphocyte-depleting group had early TCRβ repertoire turnover and newly detected and expanded clones compared with the lymphocyte-nondepleting group. No differences were observed in TCRβ clonality and repertoire richness between groups. These findings suggest that, even with significant decreases in the overall size of the circulating LVR, the reservoir can be reconstituted in a relatively short period of time. These results, while from a relatively unique population, suggest that curative strategies aimed at depleting the HIV LVR will need to achieve specific and durable levels of HIV-infected T cell depletion.

Barriers experienced by organ procurement organizations in implementing the HOPE act and HIV-positive organ donation

In the seven years since the HIV Organ Policy Equity (HOPE) Act made HIV-positive organ donation to HIV-positive recipients legally permissible in the United States, there have been fewer HIV-positive organ donations than expected. Organ procurement organizations (OPOs) play a key role in the transplant system and barriers at OPOs may be partly responsible for the relatively low number of HIV-positive donors. To understand potential OPO barriers, we conducted semi-structured interviews with 20 OPO staff members. Interviews were recorded, transcribed, and analyzed using a conventional content analytic approach with two coders. OPO staff had high levels of knowledge about HOPE. Many had evaluated referrals of HIV-positive donors and approached families for authorization. Barriers to HIV-positive organ recovery identified included obtaining authorization for donation, potentially disclosing HIV status to next-of-kin, and fear of HIV infection among those engaged in organ recovery. Strategies to overcome these barriers include providing continuing education about the specific tasks required to procure organs from HIV-positive donors, implementing targeted interventions to reduce fear of infection, and developing partnerships with HIV advocacy and care organizations. Given the central role OPOs play, HIV-positive donations are unlikely to occur in significant numbers unless these barriers can be overcome.

Long-term Outcomes Following Kidney and Liver Transplant in Recipients With HIV

Importance

Kidney transplant (KT) and liver transplant (LT) in HIV-positive patients have become more widely adopted. Data looking at long-term outcomes of patient and graft survival are lacking.

Objective

To compare the long-term outcomes of KT and LT in HIV-positive recipients with matched HIV-negative recipients.

Design, Setting, and Participants

Retrospective, single-center, cohort, study using data from 2000 to 2019. Patients were observed until death, or graft failure requiring retransplant. All HIV-positive patients who underwent KT and/or LT between 2000 and 2019 were included. Propensity matching was performed to the corresponding HIV-negative cohort, which was obtained from the University of California, San Francisco's transplant recipient registry. The data were analyzed from 2020 to 2021.

Exposures

HIV infection.

Main Outcomes and Measures

Patient and graft survival for KT and patient survival for LT. Incidence of acute rejection and its association with KT graft survival.

Results

For KT, 655 HIV-negative recipients (mean [SD] age, 52.3 [13.6] years; 450 [68.7%] were men) and 119 HIV-positive recipients (mean [SD] age, 51.7 [9.4] years; 86 [72.3%] were men) were included. Patient survival was 79.6% (95% CI, 73.6%-86.1%) and 53.6% (95% CI, 38.9%-74.0%) at 15 years posttransplant, respectively. Graft survival was 57.0% (95% CI, 47.8%-68.0%) and 75.0% (95% CI, 65.3%-86.2%) at 15 years posttransplant, respectively. Diagnosis of HIV was not associated with worse graft survival (hazard ratio, 1.09; 95% CI, 0.61-1.97; P = .77). For LT, 80 HIV-positive recipients (mean [SD] age, 52.6 [8.2] years; 53 [66.3%] were men) and 440 HIV-negative recipients (mean [SD] age, 54.6 [12.8] years; 291 [66.1%] were men) were included. Patient survival was 75.7% (95% CI, 71.8%-79.8%) for HIV-negative LT recipients and 70.0% (95% CI, 60.6%-80.8%) for HIV-positive LT recipients at 15 years posttransplant. Diagnosis of HIV was not a statistically significant predictor of patient survival (hazard ratio, 1.36; 95% CI, 0.83-2.24; P = .22). In KT, HIV-positive patients with at least 1 episode of acute rejection had a graft survival of 52.8% (95% CI, 38.4%-72.5%; P < .001) at 15 years posttransplant, compared with 91.8% in those without AR.

Conclusions and Relevance

In this single-center cohort study, KT and LT in HIV-positive patients had comparable long-term outcomes with those in matched HIV-negative patients. The high incidence of acute rejection was associated with reduced graft survival. The findings support providing transplant to HIV-positive patients, which may be an appropriate use of transplant resources and provides equitable access for HIV-positive patients.

Science Over Stigma: Lessons and Future Direction of HIV-to-HIV Transplantation

PURPOSE OF REVIEW

The HIV Organ Policy Equity (HOPE) Act permits transplantation from donors-with-HIV to recipients-with-HIV (HIV D + /R +). We assess HOPE implementation, summarizing progress and challenges at clinical, legislative, and community levels.

RECENT FINDINGS

As of July 2021, there have been 300 kidney and 87 liver transplants within HOPE research studies in the USA. Early HIV D + /R + kidney transplant outcomes show excellent patient survival (100%) and graft survival (92%). The number of HOPE donors continues to grow annually but remains lower than projections. State-level policy restrictions are identified in 34 states; however, these do not seem to have impacted practice; 16 states have passed new legislation to facilitate HIV D + /R + transplantation. Stigma related to HIV and low donor registration rates pose additional barriers.

SUMMARY

Early outcomes of HOPE Act transplants are encouraging. Progress to reach full implementation and realize the full benefit of this innovation is ongoing.

Potential donor characteristics and decisions made by organ procurement organization staff: Results of a discrete choice experiment

Organ procurement organizations (OPOs) evaluate referrals for deceased organ donation in the United States. Efforts to expand the donor pool, such as the HIV organ policy equity (HOPE) Act that permits transplants from HIV-positive donors to HIV-positive recipients, can only succeed if OPOs pursue referrals. However, relatively little is known about how OPO staff evaluate referrals. To better understand this process, OPO staff completed a discrete choice experiment to quantify the relative importance of seven donor characteristics on the decision to pursue a theoretical donor. Relative importance was defined by Partworth utility using a hierarchical Bayesian conditional logit model. There were 51 respondents from 36 of 58 OPOs in the United States. Of the seven attributes, organ and tissue potential were the most influential, followed by age, type of death, HIV status, donor registration, and Hepatitis C status. To be preferred to an HIV-negative donor, an HIV-positive donor needed to have the potential to donate two additional organs. These data provide insight into the preferences of OPO referral staff and may help explain the lower than expected number of HIV-positive transplants performed since the passage of the HOPE Act.

Estimating the potential pool of uncontrolled DCD donors in the United States

Organs from uncontrolled DCD donors (uDCDs) have expanded donation in Europe since the 1980s, but are seldom used in the United States. Cited barriers include lack of knowledge about the potential donor pool, lack of robust outcomes data, lack of standard donor eligibility criteria and preservation methods, and logistical and ethical challenges. To determine whether it would be appropriate to invest in addressing these barriers and building this practice, we sought to enumerate the potential pool of uDCD donors. Using data from the Nationwide Emergency Department Sample, the largest all-payer emergency department (ED) database, between 2013 and 2016, we identified patients who had refractory cardiac arrest in the ED. We excluded patients with contraindications to both deceased donation (including infection, malignancy, cardiopulmonary disease) and uDCD (including hemorrhage, major polytrauma, burns, and poisoning). We identified 9828 (range: 9454-10 202) potential uDCDs/y; average age was 32 years, and all were free of major comorbidity. Of these, 91.1% had traumatic deaths, with major causes including nonhead blunt injuries (43.2%) and head injuries (40.1%). In the current era, uDCD donors represent a significant potential source of unused organs. Efforts to address barriers to uDCD in the United States should be encouraged.

Donor evaluation in the era of HIV-positive organ transplantation: The importance of the infectious diseases specialist

A 61-year-old female with well-controlled human immunodeficiency virus (HIV) and end-stage renal disease was on the kidney transplant waitlist awaiting an organ offer, including from HIV-positive donors through the HIV Organ Policy Equity (HOPE) Act. We present three different scenarios where HIV-positive donor offers were evaluated for this one recipient, discuss the donor evaluation process, explain where the infectious diseases provider fits in this scheme, and describe the challenges encountered by organ procurement organizations. This is the first case under the HOPE Act at our center where discovery of an HIV-specific issue led to a turndown of an organ offer.

Outcomes of donor-derived superinfection screening in HIV-positive to HIV-positive kidney and liver transplantation: a multicentre, prospective, observational study

BACKGROUND

One of the primary risks of HIV-positive to HIV-positive organ transplantation is loss of virological control because of donor-derived HIV superinfection, which occurs when an HIV-positive individual becomes infected with a new distinct HIV strain. In this study, as part of the larger HIV Organ Policy Equity pilot study, HIV-positive to HIV-positive kidney and liver transplant recipients in the USA were examined for evidence of sustained donor-derived HIV superinfection.

METHODS

In this multicentre, prospective, observational study, HIV-positive to HIV-positive kidney and liver transplant recipients were followed in three hospitals in the USA. Candidates with well controlled HIV infection on ART, no active opportunistic infections, and minimum CD4 T-cell counts (>100 cells per μL for liver and >200 cells per μL for kidney per federal guidelines) were eligible to receive a kidney or liver from deceased HIV-positive donors without active infections or neoplasm. Peripheral blood mononuclear cells were collected from donor-recipient pairs at the time of transplantation, and from recipients at several timepoints up to 3 years after transplantation. Donor samples were assessed for HIV RNA viral load, CD4 cell count, and antiretroviral drug-resistant mutations. Donor and recipient HIV proviral DNA, and viral RNA from the viraemic timepoint were sequenced using a site-directed next-generation sequencing assay for the reverse transcriptase and gp41 genes. Neighbour-joining phylogenetic trees and direct sequence comparison were used to detect the presence of HIV superinfection. This study is registered with ClinicalTrials.gov, NCT02602262.

FINDINGS

14 HIV-positive to HIV-positive kidney and eight liver transplant recipients were followed from March, 2016, to July, 2019. 17 recipients had adequate viral sequences allowing for HIV superinfection assessment. Eight donors were suppressed (viral load <400 copies per mL), and none had multiclass drug-resistant mutations detected. None of the recipients examined had evidence of HIV superinfection. One recipient had a viraemic episode (viral load of 2 080 000 copies per mL) 3 years after transplantation as a result of non-adherence to ART. Only recipient viral sequences were detected during the viraemic episode, suggesting that the donor virus, if present, was not reactivated despite temporary withdrawal of ART.

INTERPRETATION

These findings suggest that loss of HIV suppression due to donor-derived HIV superinfection might not be a significant clinical concern in carefully monitored ART suppressed HIV-positive organ recipients.

FUNDING

US National Institute of Allergy and Infectious Diseases and National Cancer Institute.

Barriers to kidney transplant evaluation in HIV-positive patients with advanced kidney disease: A single-center study

BACKGROUND

HIV-positive kidney transplant (KT) recipients have similar outcomes to HIV-negative recipients. However, HIV-positive patients with advanced kidney disease might face additional barriers to initiating the KT evaluation process. We sought to characterize comorbidities, viral control and management, viral resistance, and KT evaluation appointment rates in a cohort of KT evaluation-eligible HIV-positive patients.

METHODS

We included patients seen between January 1, 2008, and December 31, 2015, at a primary care HIV clinic who met KT evaluation eligibility by an estimated glomerular filtration rate ≤20 mL/min/1.73 meters² or dialysis dependence. The primary outcome was a documented appointment for KT evaluation.

RESULTS

Of 3735 patients evaluated at the HIV primary clinic during the study period, 42 (1.6%) were KT evaluation-eligible patients. The median age was 47 years, 77% were male, and 95%, black. Median CD4 count was 328 cells/mm³ (IQR 175-461). Among the 63% percent with antiretroviral therapy (ART) prescription, 40% had viral loads >200 copies. Among patients with HIV resistance profiles (50%, n = 21), 52% had resistance to at least one class of ART. A majority (60%, n = 25) were scheduled for KT evaluation appointment, but of those, only 8% (n = 2) had evidence of appointments before dialysis dependence. Those without appointments had more schizophrenia (29% vs 4%, P = .02), resistance (78% vs 33%, P = .04), ART prescription (76% vs 48%, P = .04), and more kidney disease of unknown etiology (53% vs 8%, P = .02).

CONCLUSION

Kidney transplant evaluation-eligible HIV-positive patients had a high rate of evaluation appointments, but a low rate of preemptive evaluation appointments. Schizophrenia and viral resistance disproportionally affected patients without evaluation appointments. These data precede the recommendation for universal ART for all HIV+ patients, regardless of CD4 count and viral load, and must be interpreted in the context of this limitation.