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South Africa is sorely lacking in organ donors. This means that doctors have trouble finding suitable donor organs for critically ill patients who would die without a transplant. Sometimes they have to make difficult calls, such as using a blood-incompatible organ to save a patient's life, even if it involves an additional risk.
About a year ago, we made a difficult call: we could save a child's life by doing a liver transplant – but could infect the child with HIV. The donor was the mother of the HIV-positive child and the HIV-negative child. The procedure involved a risk of HIV transmission to the child.
South African law does not prohibit the transplantation of an organ from an HIV-positive live donor to an HIV-negative recipient, provided that a sound informed consent process is in place. But this is not universally accepted as the best clinical practice because of the risk of HIV transmission to the recipient.
The young catcher was on the waiting list of organ donors for 181 days. The average time on the waiting list of our transplant program is 49 days. The mother of the child repeatedly asked if she could give a part of her liver, but we could not take it into account because it was against the policy of our unit at the time. Without a transplant, the child would certainly be dead.
After careful consideration and with the authorization of the Medical Ethics Committee of the University of the Witwatersrand in Johannesburg, we decided to proceed to the transplant. With careful planning, we were able to give the child antiretrovirals in advance, hoping to prevent HIV infection.
The transplant, which took place at the Donald Gordon Medical Center at the University of the Witwatersrand, was a success. The child is in full swing, but for the moment we are not able to determine his HIV status. During the first month after the transplant, we detected anti-HIV antibodies in the child and it seemed that an HIV infection might have occurred. But over time, the antibodies have decreased and are now almost undetectable. We have not been able to determine with certainty whether the child is HIV-positive or not. Even with specialized ultra-sensitive tests, we could not detect any HIV in the blood or cells of the child.
It will probably take some time before you can be sure. However, the child is doing very well on antiretroviral therapy. And we know of cases where HIV has been inadvertently transmitted to people who contract HIV from an organ transplant as well as those who receive an HIV-negative organ.
This operation could change the deal for South Africa. The country has a large pool of HIV-positive people whose virus is inhibited and who have not yet received live liver donations. There is talk of viral suppression when an HIV-positive person takes his antiretroviral drugs as prescribed and his viral load – the amount of virus in his blood – is so low that it is undetectable.
Ethical and legal considerations
The organ transplant poses many ethical and legal problems. In this case, some unique and complex issues have been carefully examined.
We took great care to consult widely before proceeding with the transplant. He met with members of the transplant team, bioethicists, lawyers, experts in HIV medicine and the Wits University Medical Ethics Committee. One of the functions of the committee is to protect patients in the context of medical research and to ensure that physicians practice the procedures for the right reasons.
It was clear that a transplant was in the best interests of the child. The biggest ethical question was whether it was right to deny the mother the opportunity to save her child's life. A fundamental principle of ethics is to treat people fairly. People living with HIV should have the same health care options as everyone else.
In consultation with the Ethics Committee, we agreed that as long as the child's parents understood that he or she was at risk of contracting HIV, it was acceptable to have the transplant.
Then, to ensure that the child's parents were properly informed and in a better position to make a decision, we used an independent donor advocate. The lawyer was not employed by the hospital and their main role was to help parents by ensuring that they understand exactly what the risks were for the mother as a donor. The lawyer also engaged with the transplant team on behalf of the parents, if necessary.
In this case, the parents had committed to continue the operation and had already managed to cope with the risk of HIV transmission to their child. They appreciated that the team was willing to carefully consider this option for them, since there was no alternative and their child was seriously ill. We have asked both parents to consent to the procedure, as they are both responsible for taking care of the child in the future.
Lessons and opportunities
This operation showed that doctors can perform this type of transplant and that the results for the HIV-positive donor and the recipient can be good. This has also created a unique opportunity for Wits scientists to study HIV transmission under highly controlled circumstances.
For now, doctors will not be able to tell parents if their child will be infected with HIV with this type of transplant. Indeed, this is a unique case with many outstanding issues that can be expected to be answered by ongoing research.
In the future, we will continue to ensure that parents are fully aware of the uncertainty surrounding this situation. All future cases will be part of an ongoing research study that will examine in more detail the transmission of HIV in children and the ways in which HIV can be transmitted or not through organ transplantation.
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