New York Times

November 13, 2007

Four Transplant Recipients Contract H.I.V.

By DENISE GRADY



Four transplant recipients in Chicago have contracted H.I.V. from an organ donor, the first known cases in more than a decade of the virus
being spread by organ transplants.



The organs also gave all four patients hepatitis C, in what health officials said was the first reported instance of the two viruses being
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.



"There are important policy implications," said Dr. Matthew Kuehnert, director of the Office of Blood, Organ and Other Tissue Safety at the
federal Centers for Disease Control and Prevention, which is investigating the incident. "Clearly, the organ transplant community is
going to think about the issues raised by this, and we look forward to being involved in those discussions."



The cases were first reported today by The Chicago Tribune. Two patients were infected at the University of Chicago Medical Center, and one each
at Rush University Medical Center and Northwestern Memorial Hospital. The transplants were coordinated by an organization called the Gift of
Hope, in Elmhurst, Ill. 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 Centers for Disease Control and Prevention is investigating the case.



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. The remaining three patients were also tested, and found to be infected.



Dr. J. Michael Millis, the chief of transplantation at the University of Chicago, Millis said the patients were devastated, and the doctors
heartbroken. But he said the viral diseases were treatable, even in transplant recipients.



Initially, the donor had tested negative for both 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 - 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 have occurred without any reported cases of H.I.V. transmission.



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, called the nucleic acid amplification test is not widely available, and doctors said that it was more difficult and
time-consuming than other tests and that 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 a false positive result and lead to healthy organs, a scarce resource,
mistakenly being thrown away.



"It still remains that the biggest risk for patients on the transplant list is being on the list and not receiving an organ," said Dr. Robert
Brown, director of the liver transplant program at New York-Presbyterian/Columbia. "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."



He added: "What I tell my patients is, the likelihood of being infected with HIV or hepatitis in that small window of time is incredibly small,
and the risk of dying on the waiting list is not incredibly small."



According to the University of Chicago, the organ donor in Illinois, an adult, was known to be "high risk," based on a risk factor revealed by a
close friend who provided "a health and social history." The exact nature of the risk was not disclosed. Federal guidelines recommend
against transplanting organs from high-risk people unless the recipients are so likely to die for want of a transplant that H.I.V. seems a lesser
threat.



Dr. Millis said that he did not know whether the patients there had been informed of the donor's status.



About 9 percent of organ donors qualify as high risk based on behaviors like prostitution or drug use with needle-sharing. Transplant experts
say the percentage would probably be higher if they had full information on all donors.



Dr. Brown said calls about high-risk donors came every week at Columbia.



"People drink and take drugs and get into car accidents," he said. "Think about it. We've put in I don't know how many of those organs in
the last 10 years at Columbia, and we've yet to have a problem. The number of lives we've saved outweighs the risk."



He also said patients (or family members) at Columbia were informed if a donor was high risk, and were required to sign a special consent form
acknowledging it.



Dr. Millis said that although the organ supply was generally safe, he hoped it could be made safer, probably by developing regional centers
around the country to perform nucleic acid amplification testing reliably and quickly enough to meet transplant needs.



Although it is rare, organ transplants have spread other diseases in the past, including rabies, West Nile fever and a rodent virus called LCMV.
In all those cases, patients died.



There is a shortage of organs for transplant, and many patients die waiting. Currently in the United States, 98,000 people are on the
transplant list, but only about 19,000 transplants have been done this year. Last year, 7,200 died waiting.