Four Transplant Recipients Contract H.I.V.

1. Four Transplant Recipients Contract H.I.V. By DENISE GRADY New York Times Published: November 14, 2007 http://www.nytimes.com/2007/11/14/health/healthspecial/14hiv.html?ref=health

2. H.I.V. from a Donor • Four transplant recipients in Chicago have contracted H.I.V. from an organ donor, the first known cases in more than a decade in which the virus was spread by organ transplants. • The organs also gave all four patients hepatitis C, in what health officials said was the first reported instance in which the two viruses were spread simultaneously by a transplant. • Though exceedingly rare, this type of transmission highlights a known weakness in the system for checking organ donors for infection: the most commonly used tests can fail to detect viral diseases if they are performed too early in the course of the infection. Officials say the events in Chicago may lead to widespread changes in testing methods.

3. Most likely kidneys, liver and heart or lungs • Officials would not say what organs were transplanted, but a transplant expert not connected with the case said they were most likely the kidneys, liver and either the heart or lungs. Only four organs, and no other tissue, were taken from the donor. • The University of Chicago said that the operations took place in January, and that the donor was an adult who died in an Illinois hospital “three days after traumatic injury.” Neither the donor’s age nor sex were disclosed. The other hospitals declined to discuss what happened, except to confirm that each had an infected patient. • The situation came to light earlier this month when one of the recipients, who was being evaluated for a retransplant, tested positive for H.I.V. and hepatitis C. At that point, blood preserved from the donor was given a highly sensitive test for viruses, and the infection was found.

4. Was the test too recent? • Initially, the donor had tested negative for H.I.V. and hepatitis C, apparently because the infection was too recent to be detected by commonly used blood tests. Those tests do not find the virus itself, but instead look for the body’s reaction to the infection — the antibodies produced by the immune system. But the body takes time to react, and if the test is done too soon, within 22 days of H.I.V. infection or 82 days for hepatitis C, antibodies may not yet be detectable. • Doctors say that is what probably occurred in Chicago. It has always been known that this kind of transmission was theoretically possible, but it was considered highly unlikely. And indeed, since 1994 nearly 300,000 transplants from cadavers have occurred without any reported cases of H.I.V. transmission.

5. The Naat Test • Another more sensitive type of test can pick up viral infections earlier, but was not used. That test looks for evidence of the virus itself, and can reduce the “window,” the early period in which the test does not work, to 12 days for H.I.V. and 25 days for hepatitis C. • That test, the nucleic acid amplification test, or Naat, is not widely available, and doctors said it was more difficult and time-consuming than other tests — and there is usually no time to spare with transplants because organs deteriorate quickly when the donor dies. • Another concern is that the test is more likely than others to give false-positive results, and lead to the needless destruction of healthy organs, a scarce resource. • Dr. Robert Brown, director of the liver transplant program at NewYork-Presbyterian/Columbia said, “There is always a drive toward better testing, but if it leads to more organ wastage, we’ll probably hurt more people than we help.”

6. Very Simple Economics MB MB' MC' • We don’t use a market for organ donation, so some with MB > MC may not get organs, and others with MB < MC may get them. $ New “Price” with a market MC “Price” with a market • But you still may see increasing costs, if you have to do more tests, and you may throw away useful organs in the event of false positives. O2 O1 # of organs