HIV Patients Getting More Transplants
By DENISE LAVOIE, Associated Press Writer, Thursday August 2 8:51 PM ET
BOSTON (AP) - When Belynda Dunn's HMO rejected her request for a liver transplant because of her HIV infection, she felt like she had been slapped across the face.
''I think it just goes along with the idea that if you have HIV, you've got the black plague,'' said Dunn, a 49-year-old AIDS activist who's worked to stop the spread of the disease for the past decade.
Five years ago, doctors and insurers routinely rejected AIDS patients for transplants because of their lower life expectancies and the unproven benefits of surgery in such patients. Since transplant patients must take drugs to suppress the body's attempts to reject new organs, doctors assumed the medication would exacerbate problems in HIV patients, who have weaker immune systems.
But in the last few years, as new drugs have significantly increased the life expectancies of HIV patients, doctors are beginning to perform more transplants.
In 1999, five transplants were reported to the United Network for Organ Sharing. In 2000, there were 11.
However, many doctors still don't support transplants for HIV patients; only 37 transplants have been done on HIV patients in the last 12 years, according to the organ network. The numbers do not reflect all transplants because some states have laws against disclosure of information on people with HIV. In Dunn's case, Neighborhood Health Plan Inc. rejected her transplant as experimental. Chief executive James Hooley said there isn't enough evidence to tell whether the procedures are safe or can prolong the lives of HIV patients. Dunn also has hepatitis, a dangerous liver disease.
The University of California San Francisco Medical Center is organizing a clinical trial in as many as 15 U.S. hospitals - the largest of its kind for HIV transplant patients, said Dr. Peter Stock, a transplant surgeon involved in the study.
Once the clinical trial is completed, he said, insurance companies may be less likely to consider the procedure experimental. ''In order to get insurance companies to pay, you have to show that it's safe and effective,'' he said.
Empire Blue Cross and Blue Shield changed its policy earlier this year to allow people with HIV to be considered for transplants.
''The previous policy basically said that HIV was too significant a risk factor for consideration of transplants,'' said Dr. Alan Sokolow, Empire's chief medical officer. ''Now that we know more about how HIV and transplants interact, it's possible to consider certain situations of HIV infection to be acceptable conditions for transplant.''
The main reason for the change is the improved prognosis for people with HIV since the widespread use, beginning in 1996, of highly active antiretroviral drugs, known as HAART regimens.
''That has allowed people to live with their HIV infections much longer and with better control of the underlying diseases,'' Sokolow said. HIV is not the only medical condition for which transplants are routinely denied. Patients over 65 are often turned down for heart transplants, no matter how healthy they are otherwise.
But Larry Kramer, a New York writer who has helped focus attention on the AIDS pandemic for two decades, said a growing number of HIV-infected patients need transplants because they're also infected with hepatitis.
''This is a major problem facing this country and this world because there are going to be so many co-infected people,'' said Kramer, who is on the waiting list at the University of Pittsburgh Medical Center for a liver transplant because he has hepatitis.
The center has performed seven liver transplants on HIV patients since 1998. Their survival rates have been comparable to those of transplant patients without HIV, said Dr. Andrew Bonham, a liver transplant surgeon there. One patient died within the first two weeks from surgical complications, while another patient died 18 months later from chronic rejection of the organ. The other five are still alive.
Doctors have given Dunn only a few months to live without a liver transplant. It's not HIV that is killing her. It's hepatitis, which she has had for 30 years since receiving a blood transfusion during the birth of her son. After Dunn's case began receiving widespread publicity two weeks ago, her HMO agreed to donate $100,000 for the operation. and the remaining $150,000 she needed was raised through private funds. Doctors hope to soon transplant a lobe from her younger brother's liver.
''I have a future again,'' Dunn said. ''I just feel like I can see tomorrow.'' Commentary:
Of course the best approach is prevention. Get tested for HCV. If HCV+, see a good doctor for an evaluation and begin strategizing about potential treatment options. Stay on top of your situation. Because trying to get a transplant should be your last desperate move. Demand for livers is increasing and liver availability for transplant is not increasing, so demand for livers is increasingly competitive. HIV-infected patients generally receive less priority for transplant and the issue of reimbursement is a bigger obstacle for coinfected than in HCV.
Transplantation in HIV-positive Patients?
Latest update from University of Pittsburgh from John Fung, MD, PhD, 06/28/01 <A HREF="http://www.natap.org/2001/jul/transplantation070901.htm"> http://www.natap.org/2001/jul/transplantation070901.htm</A>
At the 2001 Feb HIV Retrovirus Conference, there were two posters reporting discotraging experience with liver transplants in HCV/HIV coinfected. But the University of Pittsburgh experience has been good so far. I have heard anecdotal reports from France that several HCV/HIV coinfected patients who received liver transplants were doing well over the short-term. The University of Miami has performed several hepatitis/HIV liver transplants but I think it has mostly been in patients with HBV and HIV.
Our experience with liver transplants in coinfected is limited in number and the length of the follow-up. But I think the preliminary results are encouraging. So far, for some reason the results at the University of Pittsburgh appear to be the best and this site appears to be the most willing to undertake transplants in coinfected patients. Reimbursement by insurance is an issue but the Pittsburgh group has a specialist devoted to trying to secure coverage and she can be very helpful. As referred to above, the UCSF research group headed by Michelle Roland, MD, hopes to launch this study of transplants for coinfected patients soon. If successful, hopefully the data from this study will help establish this procedure as not experimental and will help convince insurers to cover for the expenses.