Heart Transplant in HIV+ Man Raises Ethics Issues

A 39-year-old Harvard scientist previously diagnosed with AIDS has survived two years since receiving a heart transplant, according to a report released Wednesday, possibly opening the door for other HIV-infected patients to become candidates for the procedure. Donor hearts are in short supply, and the medical community must decide if HIV-infected patients -- previously considered ineligible due to a poor expected prognosis -- should routinely be placed on transplant waiting lists, said the report in the New England Journal of Medicine.

"This was a benchmark kind of study," said Dr. Gregory Curfman, executive editor of NEJM. The study, along with preliminary results from studies of liver and kidney transplants, "provides hope" that some HIV-infected patients can benefit from a transplant, said an editorial by Drs. Michelle E. Roland and Diane V. Havlir of the AIDS Division of the Positive Health Program at the University of California-San Francisco.

Currently, the National Institutes of Health is conducting a study of 150 kidney transplants and 125 liver transplants in HIV-infected individuals, Roland and Havlir noted. "Originally that study was to include heart transplantations, but its design was revised to focus on those organs for which there is a greater need. It is hoped that funds will become available to add heart transplantation if the preliminary results are positive," wrote Roland and Havlir. To date, the bulk of organ transplants among those with HIV have involved kidney and liver transplants.

Many transplant centers have been reluctant to allocate donor organs to HIV-infected patients, believing that immune system-suppressing drugs -- which must be taken by transplant patients for the duration of their lives -- could further damage an HIV patient's already compromised immune system. But research has suggested that HIV infection does not necessarily affect a patient's response to the new organ. Furthermore, immunosuppressive therapies do not appear to increase an HIV-infected patient's susceptibility to infections.

The heart transplant patient, Dr. Robert Zackin, a researcher at the Harvard School of Public Health, was diagnosed with an AIDS-defining infection in 1992. After receiving chemotherapy for Kaposi's sarcoma, he developed heart failure, possibly as a result of the cancer treatment. He underwent heart transplantation in February 2001. Zackin -- who is also a senior author of the report -- reportedly has not experienced any new or reactivated opportunistic infections, and HIV therapy continues to keep his virus levels low. Although he experienced several episodes of organ rejection, requiring him to receive blood transfusions every two or three weeks, Zackin continues to work full-time and exercise regularly, according to the study.

The full report, "Successful Cardiac Transplantation in HIV-1-Infected Patient with Advanced Disease," was published in the June 5th edition of NEJM (2003;348:2323-2328).

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