A potential new donor pool

Posted on 10 April 2019

In 2017, a mother living with HIV donated a segment of her liver to her critically ill HIV-negative child. The transplant, performed at Mediclinic’s Wits Donald Gordon Medical Centre, is the first of its kind in the world – and opens up new possibilities for organ donation. 

THIS GROUND-BREAKING CASE MAY GRADUALLY ALLOW DOCTORS TO ACCESS A NEW POOL OF LIVING LIVER DONORS IN SOUTH AFRICA.

Although transplanting HIV-positive organs isn’t illegal in South Africa, it’s not considered best practice due to the risk of HIV transmission to the recipient. But when a critically-ill child has been on the donor waiting list for 180 days, when the average is 45 days, and when an HIV positive mother has repeatedly asked for the opportunity to save her child’s life – this procedure becomes reality.

Thanks to a partnership between Mediclinic’s Wits Donald Gordon Medical Centre and the Gauteng Department of Health, the WDGMC transplant programme makes liver transplantation accessible to all children, regardless of whether they are state or private patients.

However, the critical shortage of deceased organ donors – and the dramatic increase in the number of children on the waiting list – now sees South African doctors exploring new alternatives: namely living HIV-positive donors who meet strict medical criteria. Dr Harriet Etheredge, Co-Chair of the Wits Human Research Ethics Committee (Medical) explains the thinking behind the successful 2017 surgery.

▶ WHAT WERE THE ETHICAL DILEMMAS YOU FACED BEFORE DECIDING TO PERFORM THE PROCEDURE?

At the outset, the proposition of transplanting a liver from an HIV-positive living donor to an HIV-negative recipient shocks many people. They say: “How can you risk giving someone HIV?” The answer to this questions is simple – it was our only option to save that child’s life. So, in the case of our living donor liver transplant from an HIV-positive mother to her HIV negative child, this was not the main ethical issue. It was quite clear to us – and to our ethics committee that approved the procedure – that saving the child’s life was the best outcome. The important ethical issue we faced involved the autonomy of the mother – who repeatedly requested to be a donor in spite of her HIV-positive status. We usually wouldn’t consider HIV-positive people as living liver donors, but because we have so few organ donors in South Africa we were not able to find a deceased donor. The other ethical issues we faced was that we couldn’t get consent from the child, because they were too young.

▶ SO THE CHILD’S HIV STATUS IS STILL NOT KNOWN?

In the case of a standard HIV transmission, we would be able to tell whether the child was HIV-positive or not at this stage. But this was no ordinary HIV transmission, and it has opened up many new possibilities which we still need to investigate. This requires some serious scientific gymnastics. We are being very proactive in trying to determine the HIV status of the child, and we are collaborating with the Centre for HIV and STIs and the National Institute for Communicable Diseases to help us do this. Of course there is a chance that the child will be HIV-positive, and for the moment we are keeping the child on antiretroviral drugs until we know more. Until that time, it is very important to stress that just because we don’t know the HIV status of the child, this does not mean that the child is HIV-negative.

▶ WHAT DOES THE SUCCESS OF THIS SURGERY MEAN FOR THE FUTURE OF ORGAN TRANSPLANTS IN AFRICA?

We have to remember this is only one case, and we still have many unanswered questions. We hope this programme may gradually allow us to access a new pool of liver donors in South Africa – namely HIV-positive people with an undetectable viral load, which means they have been taking their antiretroviral medication properly for at least six months – but baby steps are required. We have permission from our ethics committee to perform more HIV-positive to HIVnegative living donor liver transplants, but we also need to be very cautious when looking to the future.

THE MULTIDISCIPLINARY TRANSPLANT TEAM INCLUDED

Professor Jean Botha, Director of Transplantation at Wits Donald Gordon Medical Centre (WDGMC), Dr Francesa Conradie, Clinical Research Specialist, Dr Harriet Etheredge, Co-Chair of the Wits Human Research Ethics Committee (Medical), Dr June Fabian, Director of the Clinical Research Office at WDGMC and Professor Caroline Tiemessen, HIV Research and a multitude of other health professionals from the Transplant Programme at WDGMC.

 

WORDS BIDDI RORKE

PHOTOGRAPH GALLO/GETTY IMAGES