Child saved in HIV+ trans­plant

Wits Univer­sity doc­tors trans­planted the liver from a mother liv­ing with HIV to her crit­i­cally ill HIV neg­a­tive child

Inner City Gazette - - Front Page - By Staff Re­porter news@in­ner-city-gazette.co.za

In­ner-City based Wits Univer­sity doc­tors trans­planted the liver from a mother liv­ing with HIV to her crit­i­cally ill HIV neg­a­tive child, who had end-stage liver dis­ease.

In South Africa, a coun­try with the largest anti-retro­vi­ral ther­apy (ART) pro­gramme in the world, peo­ple with HIV live long and healthy lives.

The suc­cess of this world-first oper­a­tion thus presents a po­ten­tial new pool of liv­ing donors that could save ad­di­tional lives.

Lever­ag­ing “liv­ing pos­i­tive” to save more lives

In a pa­per pub­lished in pres­ti­gious, peer-re­viewed jour­nal AIDS on Oc­to­ber 4, 2018, sci­en­tists in surgery, ethics, and HIV from the Univer­sity of Wit­wa­ter­srand, Jo­han­nes­burg (Wits) ex­plain how a chronic shortage of or­gans com­pro­mise their ef­forts to save lives, and how the de­ci­sion they made to per­form a world-first oper­a­tion could ad­vance trans­plan­ta­tion.

Jean Botha, prin­ci­pal in­ves­ti­ga­tor and trans­plant sur­geon is Pro­fes­sor of Surgery in the Depart­ment of Surgery in the School of Clin­i­cal Medicine, Fac­ulty of Health Sci­ences at Wits Univer­sity.

“Two as­pects of this case are unique. Firstly, it in­volved in­ten­tional do­na­tion of an or­gan from a liv­ing HIV pos­i­tive in­di­vid­ual. Se­condly, pre-ex­po­sure pro­phy­laxis [med­i­ca­tion to pro­tect atrisk in­di­vid­u­als from con­tract­ing the HI virus] in the child who re­ceived the or­gan may have pre­vented the trans­mis­sion of HIV. How­ever, we will only know this con­clu­sively over time,” says Botha, who is also Direc­tor of Trans­plan­ta­tion at the Trans­plant Unit at the Wits Don­ald Gor­don Med­i­cal Cen­tre.

Cur­rently, the Wits Don­ald Gor­don Med­i­cal Cen­tre is the only Trans­plant Pro­gramme do­ing liv­ing donor liver trans­plan­ta­tion in south­ern Africa. It is also the first pri­vately ad­min­is­tered teach­ing hospi­tal in Jo­han­nes­burg and, as a Wits hospi­tal, ad­vances spe­cial­ist train­ing and re­search.

In this case of trans­plant­ing a liver from an HIV pos­i­tive donor to a non-in­fected re­cip­i­ent, the trans­plant team had to un­pack the po­ten­tial risks and ben­e­fits to both. The Hu­man Re­search Ethics Com­mit­tee (Med­i­cal) at Wits Univer­sity approved the liver trans­plan­ta­tion from the mother liv­ing with HIV to her HIV neg­a­tive child. Their per­sonal de­tails re­main con­fi­den­tial.

The child – on the wait­ing list for a de­ceased donor for 180 days (the av­er­age is 45 days) – was fre­quently ad­mit­ted for life-threat­en­ing com­pli­ca­tions of end­stage liver dis­ease. With­out trans­plant, the child would cer­tainly have died. How­ever, sav­ing the child’s life needed to be bal­anced against harm to the donor and the risk of al­most cer­tainly trans­mit­ting HIV if the mother was the donor.

Dr Har­riet Etheredge is a med­i­cal bioethi­cist who holds an honorary po­si­tion in the Depart­ment of In­ter­nal Medicine, School of Clin­i­cal Medicine at Wits, and over­sees Ethics and Reg­u­la­tory Is­sues at the Wits Don­ald Gor­don Med­i­cal Cen­tre.

“Ex­ten­sive ef­forts were made to iden­tify ei­ther a de­ceased liver donor or an HIV neg­a­tive liv­ing donor for the child be­fore con­sid­er­ing an HIV pos­i­tive par­ent donor. Trans­plant­ing HIV pos­i­tive or­gans is not il­le­gal in South Africa; how­ever, it is not con­sid­ered best practice in­ter­na­tion­ally be­cause of the risk of HIV trans­mis­sion to the re­cip­i­ent. To min­imise risk to donors and re­cip­i­ents, this oper­a­tion is of­fered only un­der ex­cep­tional cir­cum­stances. Full con­sent is re­quired from the par­ents who must be able to care for a child in­fected with HIV,” says Etheredge, whose PhD is in the field of med­i­cal ethics and or­gan trans­plan­ta­tion.

In this trans­plan­ta­tion case, the mother asked a num­ber of times for the op­por­tu­nity to save her child’s life by do­nat­ing a seg­ment of her liver. For this mother, quan­ti­fy­ing the risk was sim­pler for the trans­plant team. Dr Francesca Con­radie, HIV clin­i­cian, notes, “When con­sid­er­ing an HIV pos­i­tive par­ent, it is im­por­tant that they have an un­de­tectable vi­ral load. This means that they know they are HIV pos­i­tive and that they have been tak­ing their an­tiretro­vi­ral med­i­ca­tion prop­erly for at least six months”.

This made the risk of do­na­tion equiv­a­lent to that of an HIV neg­a­tive liv­ing donor. How­ever, liv­ing liver do­na­tion is never a risk-free pro­ce­dure, and the team took care to en­sure that the mother un­der­stood the full am­bit of the risk she was un­der­tak­ing.

“Our In­de­pen­dent Donor Ad­vo­cate helps the par­ents un­der­stand the risks, makes rep­re­sen­ta­tions to the trans­plant team on be­half of the donor if nec­es­sary, and pro­vides emo­tional sup­port through­out the process,” says Etheredge.

In­ten­tional trans­mis­sion of HIV to save a life

The trans­plant team faced the dilemma of sav­ing the child’s life whilst at the same time know­ing that the child might end up HIV pos­i­tive be­cause of this de­ci­sion. How­ever, be­cause this in­ten­tional HIV pos­i­tive liv­ing donor liver trans­plant is likely a world first, the ac­tual chance of trans­mit­ting HIV was un­known.

The team de­cided to work on the ba­sis that the child would con­tract HIV, and pro­vide man­age­ment ac­cord­ingly. But in the time since the trans­plant, there have been some sur­prises when it comes to the child’s HIV sta­tus.

“In the weeks af­ter the trans­plant, we thought that the child was HIV pos­i­tive, be­cause we de­tected HIV an­ti­bod­ies,” says Botha.

The trans­plant team then ac­cessed spe­cialised test­ing by HIV ex­perts at the Na­tional In­sti­tute of Com­mu­ni­ca­ble Dis­eases (NICD) who sub­se­quently could not find any ac­tive HIV in­fec­tion in the blood stream of the child, mean­ing there is a chance that the child is HIV neg­a­tive. Caro­line Tiemessen is Re­search Pro­fes­sor in the School of Pathol­ogy at Wits and head of Cell Bi­ol­ogy within the Cen­tre for HIV and STIs.

“At the mo­ment, we are de­vel­op­ing new meth­ods for test­ing the child, and we hope to be able to have a de­fin­i­tive answer to the ques­tion of se­ro­con­ver­sion in fu­ture.”

Wits Trans­plant Team FROM LEFT TO RIGHT: Dr June Fabian, Dr Har­riet Etheredge, Prof. Jean Botha, Prof. Caro­line Tiemessen Dr Francesca Con­radie

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