Consenting to HIV-positive organ donation in the USA: legal and ethical considerations in comparison with a South African context

摘要

Since 2008, 43 HIV positive-to-positive transplants have been performed in Cape Town, South Africa. The ethical decision to utilize HIV-positive donors had been informed by a very unique clinical situation in South Africa. South African transplant recipients are generally young, black patients from low socioeconomic groups where treatment options for their end-stage renal disease are limited. Dialysis is not freely available in the country and strict admission criteria exist to access this treatment option. Because South African patients are competing for scarce resources, with many HIV-positive as well as negative patients unable to access dialysis treatment, a transplant with an HIV-positive organ is an acceptable treatment option to many HIV-positive patients in this country. Furthermore, South African HIV-positive patients are generally young and often have low rates of comorbid disease making them ideal transplant candidates. In the USA, HIV-positive patients are generally older and dialysis is freely available to them. Transplantation with HIV-negative organs as well as dialysis are treatment options available to USA-based HIV-positive patients – an important difference to South African patients. Finally, the HIV-positive deceased donors in South Africa are often young trauma victims where HIV is diagnosed at the time of death and the patient is na?ve to antiretroviral therapy (ART). In general, South Africa has very low ART resistance rates and a fairly uniform subtype C HIV in the country. This means that using a deceased donor who had been exposed to ART before has a different clinical risk than in the USA, where most donors had been treated with ART and seldom are trauma victims. The author debates in this article how this unique scenario makes use of HIV-positive donors in the USA differently in comparison with South Africa.