PAPER The transplantation of solid organs from HIV-positive donors to HIV-negative recipients: ethical implications Bram P Wispelwey, 1 Ari Z Zivotofsky, 2 Alan B Jotkowitz 3 1 Ben Gurion University of the Negev—The Medical School for International Health, Beer Sheva, Israel 2 Gonda Brain Science Center, Bar-Ilan University, Ramat Gan, Israel 3 Department of Medicine, Soroka University Medical Center, Ben Gurion University of the Negev—The Medical School for International Health, Beer Sheva, Israel Correspondence to Bram P Wispelwey, Ben Gurion University of the Negev—The Medical School for International Health, POB 653, Beer Sheva 84105, Israel; bwispelw@alumni.princeton. edu Received 14 January 2014 Revised 1 May 2014 Accepted 20 May 2014 To cite: Wispelwey BP, Zivotofsky AZ, Jotkowitz AB. J Med Ethics Published Online First: [ please include Day Month Year] doi:10.1136/medethics- 2014-102027 ABSTRACT HIV-positive individuals have traditionally been barred from donating organs due to transmission concerns, but this barrier may soon be lifted in the USA in limited settings when recipients are also infected with HIV. Recipients of livers and kidneys with well-controlled HIV infection have been shown to have similar outcomes to those without HIV, erasing ethical concerns about poorly chosen beneficiaries of precious organs. But the question of whether HIV-negative patients should be disallowed from receiving an organ from an HIV-positive donor has not been adequately explored. In this essay, we will discuss the background to this scenario and the ethical implications of its adoption from the perspectives of autonomy, beneficence/non-maleficence and justice. INTRODUCTION AND BACKGROUND It is unusual for religious leaders to make progres- sive declarations ahead of legal precedent, clinical practice and professional consensus on controver- sial medical ethics issues. But in May 2013, former Israeli Chief Rabbi Eliyahu Bakshi-Doron (born 1941) ruled that it was consistent with Jewish reli- gious law for HIV-negative individuals to receive HIV-positive organ transplants, even if the evidence indicates that the recipient may contract the disease as a result. 1 As in secular ethics, myriad ethical principles compete in Jewish law, but saving life, even in the short term, is paramount. However, current Israeli law stipulates that HIV-positive indi- viduals cannot donate organs. In the USA, a pro- posed bill allowing people with HIV to donate to others infected with the virus was only just approved by the Senate Health, Education, Labour, and Pensions (HELP) Committee in March 2013 and by the House Energy and Commerce Committee in July 2013. Nevertheless, there has been little discussion in either country of the ethical implications of the next step that Rabbi Bakshi-Doron has boldly authorised: HIV-positive donation to HIV-negative recipients. Recent decades have seen a surge in the success rate of solid organ transplantation such that the primary limitation is donors. Because transplants have been so successful in saving lives, there is a continuous push to open up the donor pool to those who heretofore have been barred from donat- ing. Many organs are rejected because of the com- peting desire to ensure that donated specimens are safe and disease-free, a goal that is achieved by a thorough but still inconsistently applied screening process. The acute need for effective screening has been heightened by modern immunosuppression, the double-edged sword that has made transplant- ation so successful but also puts the recipient at an ever-greater risk of infectious disease infection or reactivation. While screening tests for viruses such as hepatitis B (HBV), hepatitis C (HCV) and HIV have been commonplace for decades in blood banks, they are not yet standardised with respect to solid organs. Thus, in contrast to the mandatory screening of blood for HIV infection by both antibodies and nucleic acid amplification testing (NAT), the screen- ing policies for solid organ transplantation include only HIV antibody testing. A 1992 report 2 stated that although unlikely, transmission of HIV-1 by seronegative organ and tissue donors was a distinct possibility. Consistent with that prediction, a few cases of HIV transmis- sion related to organ donation have been reported. One such case occurred in 2007 3 when HIV was transmitted by renal transplantation after both the patient and her sister-donor were confirmed HIV-negative by antibody testing prior to trans- plantation; a second case from 2009 was reported in New York. 4 Ahn and Cohen 5 described a case in which a liver transplant recipient contracted both HIV and hepatitis C. Although the donor was con- sidered high risk, preoperative testing for both HIV and HCV antibodies were negative and thus it seems that he transmitted the disease while in the window period of both infections. Due to a lack of clarity on the magnitude of risk for donor-derived infections, these tests are not completely standardised. Recently, Kwan et al 6 at the Centers for Disease Control and Prevention (CDC) completed a survey of 18 kidney and liver transplant centres in New York State and found a wide variation in evaluation and screening for HIV risk and infection. All centres screened living donors for serological evidence of HIV infection, but only 44% used HIV NAT to enhance screening efficacy. While such tests are designed to ensure that a non-infected organ is transplanted into a non- infected recipient, there are three possible scenarios in which known infections play a role, each of which gives rise to different ethical questions. First is the situation in which a non-infected donor pro- vides an organ to an HIV-positive recipient. Before the advent of highly active antiretroviral therapy (HAART) in the 1990s, transplantation centres Wispelwey BP, et al. J Med Ethics 2014;0:1–4. doi:10.1136/medethics-2014-102027 1 Clinical ethics JME Online First, published on June 4, 2014 as 10.1136/medethics-2014-102027 Copyright Article author (or their employer) 2014. Produced by BMJ Publishing Group Ltd under licence. group.bmj.com on June 8, 2014 - Published by jme.bmj.com Downloaded from