HIV positive mother is living donor to negative child: HIV is considered an acceptable outcome of liver transplant
Simon Collins, HIV i-Base
In a first from South Africa, researchers from University of the Witwatersrand, Johannesburg, report results from a successful liver transplant from an HIV positive mother to her HIV negative baby. Although there is evidence that the child has become HIV positive, this was an acceptable and better outcome to not having the transplant.
The results are detailed in an open-access fast-track article in the journal AIDS. After more than a year of follow-up, both the donor and recipient are healthy, without complications. 
The case involved a 13-month old baby with end stage liver disease due to progressive obliterative cholangiopathy (biliary atresia). The child had been added to the waiting list for a deceased liver transplant when a 7-month infant. Although the mother wanted to be considered for a living donor, this was initially declined (due to international transplant guidelines).
Both parents are HIV positive and the mother had been diagnosed before pregnancy, with a CD4 count of 169 cells/mm3. The mother used ART before, throughout, and after pregnancy (efavirenz, lamivudine, tenofovir-DF). The baby received standard prophylaxis for 6 weeks and was exclusively formula fed – and was confirmed HIV negative.
Although the expected waiting list time was about seven weeks, the child was still waiting almost six months, before being urgently admitted to intensive care with life-threatening complications. The mother repeated her request to be a donor and this was urgently considered and approved by the institutional review board. Factors affecting the decision were the mother having an undetectable viral load for >6 months, a CD4 count >200 cells/mm3 and no active co-infections or complications. Both parents consented to the transplant operation.
The transplant was reported as standard, although post-operative recovery for the child was complicated by pneumonia and an epigastric collection requiring surgical drainage. Oral corticosteroids and tacrolimus were continued in the child for six months afterwards when corticosteroids were weaned. The child remains on oral tacrolimus only, dose-adjusted with therapeutic drug monitoring and has since been well with normal catch-up growth.
HIV prophylaxis for the child with integrase-inhibitor-based ART (raltegravir, lamivudine, abacavir) was started before the transplant, throughout recovery and has been continued since. However, although HIV viral load testing remained negative, indeterminate antibody results at day 225 using western blot showed antibodies only to Gag and Pol (but not Env) indicating potential HIV seroconversion in the child. The positive antibodies might also be linked to the donor organ however.
Ultrasensitive viral load (PCR) tests have been negative, with no proviral HIV DNA in plasma PBMCs or CD4 cells.
No complications have been reported for the mother.
So far these short-term results are extremely promising in terms of the transplant but disappointing that the baby may have become HIV positive. Future management includes continuing HIV treatment for the child.
This is the first report of an HIV positive living donor to an HIV negative recipient.
Although the transplant was a success and it has been a life-saving operation, the child is likely to now be HIV positive.
Part of the risk evaluation for the transplant included the recognition that with optimal HIV treatment, the benefits to the child, even with a possibility of HIV infection, outweighed the risks.
The management of the child by continuing on ART is clearly essential. The potential for latently infected cells in the donor organ to remain active for many years, perhaps decades, will make lifelong ART in the baby the most likely management plan for many years.
Early and continuous use of ART throughout might have the potential to eradicate HIV at some point in the future. However, this is likely to still require many years of viral suppression on ART and the only way to test for this possibility would be to stop HIV treatment as part of a very carefully controlled protocol. There should be no urgency to try this.
Unfortunately, HIV viral rebound has nearly always been reported even when ART prophylaxis is started in very early infection. This will complicate the timing of any future decision to stop ART.
South Africa has allowed HIV positive donors to recipients who are also HIV positive since 2008. 
The US only allowed HIV positive people to receive organ transplants from HIV positive donors in 2016, but only in cases where the donor had died. 
HIV negative recipients of organs from an HIV positive deceased donor have been reported in a case where initial HIV screening was missed. 
- Botha J et al. Living donor liver transplant from an HIV-positivemother to her HIV-negative child: opening up newtherapeutic options. AIDS 2018, 32(16):F13–F19. doi: 10.1097/QAD.0000000000002000. Open access article. (23 October 2018).
- Muler E et al. Renal transplantation between HIV-positive donors and recipients. N Engl J Med. 2010 Jun 17; 362(24): 2336–2337. doi: 10.1056/NEJMc0900837.
- Collins S. HIV positive transplant donors approved in the US. HTB March 2016.
- Lin SN et al. Outcomes of solid organ transplantation from an HIV positive donor to negative recipients. 2016 American Transplant Congress; 2016. Abstract C292.