“In the late 1990s, we started to see a very large number of patients referred for liver and kidney transplants,” said Peter Stock, a Professor of Surgery at UCSF who researches solid organ transplantation in people with HIV. But the transplant physicians knew they had their work cut out for them. “People in transplant didn’t know much about HIV, because we’d always been prohibited from transplanting into people with HIV.”
They didn’t just stand by. By 2000, Stock and colleagues performed nine transplants for people with HIV and their work kicked off a series that was joined by investigators in Pittsburgh, Miami, Germany, France, and the UK. A few years later, Stock and a University of Pittsburgh-led research team reported on their multicenter study of liver transplants. What they found turned the conventional thinking on its head. Not only did patients with HIV have similar survival rates within a year, but they also had similar survival rates at two and three years. “These findings suggest that survival of HIV-positive liver transplant recipients does not differ from that of HIV-negative liver transplant recipients,” the authors wrote, “and they suggest that HIV infection should no longer be a contraindication.”
Even with these excellent outcomes, lung transplants posed a trickier problem. After all, the lungs are exposed to the environment, and they are easily bombarded with bacteria, germs, and pollutants. Until the 1990s, lung transplants were rare and survival rates continue to be dismal compared with other transplants.
So when, in 2006, a patient with HIV and cystic fibrosis walked into Alessandro Bertani’s offices in need of a lung transplant, his team’s knee-jerk reaction was to reject him. But then they took a closer look. “We were thinking to decline this patient, until we came to the point that all his numbers, all his exams, medical tests, everything was exactly matching the numbers, medical tests, of non-HIV positive patients,” Bertani explained.
“This guy was perfectly stable and we had a lot of discussion at that point about whether we should think about trying to innovate and push,” said Bertani. They did. In their corner, they had the backing of the director general of the hospital and the Italian National Center for Transplantation. In 2007, Bertani and colleagues reported that the lung transplant was a success. And the patient continues to do well to this day.
Four years later, there was another successful report. This time, the patient was a 65 year old man with pulmonary fibrosis (a scarring and thickening of the lungs that makes it difficult to breathe). He needed a double lung transplant. Like Bertani’s patient, he had an undetectable level of HIV in his blood. And like Bertani’s patient, he made a complete recovery.
If we know lung transplantation has been successful in patients with HIV, then why do some centers still consider the disease an absolute contraindication? One reason is that the guidelines have not been updated since 2006–before these cases were reported.