Solid Organ Transplantation (SOT)

General features

HIV infection is not a contraindication for transplantation consideration
Experts in HIV medicine should preferably be members of the multidisciplinary team, responsible for the pre-transplant evaluation, and take primary responsibility for the management of the HIV infection and the prevention and treatment of OIs

Organ criteria for SOT

Persons with HIV should be considered for organ transplantation using the same indications as used in HIV-negative persons. Persons with HIV with HCC can be evaluated for liver transplantation if they fulfill the Milan criteria⁽ⁱ⁾

Organ donation

Persons with HIV can receive organs from living (renal) and deceased (all types of SOT) HIV-negative donors
In some European countries the use of organs from HIV-positive donors is allowed but the efficacy and safety of this approach is currently being evaluated in the context of research studies

HIV-infection criteria for SOT

According to most international guidelines, persons with HIV should fulfill the following criteria to be considered for SOT

Clinical criteria. No active OIs or HIV-related cancers. Individuals with PML, chronic crypto/microsporidiosis, multi-drug resistant fungal or mycobacterial infections, NHL and visceral KS to be excluded. For non-HIV-related cancers same criteria apply as in the general HIV-negative population
Immunological criteria. CD4 > 200 cells/μL for all SOT except for liver transplantation where CD4 > 100 cells/μL. Persons with previous opportunistic infections should have a CD4 > 200 cells/μL
Virological criteria. Full control of HIV replication prior to and after transplantation should be confirmed/predicted in all cases
Drug abuse. Abstinence period: alcohol = 6 months; heroin/cocaine = 2 years. People who previously injected drugs can be in a methadone maintenance programme

Preparing for transplantation

Antiretroviral therapy

Choice of ART components should avoid drugs known to cause organ dysfunction or drugs with a high potential for drug-drug interactions if at all possible, see Drug-drug Interactions between Immunosuppressants (for SOT) and ARVs
Using a pharmacological booster (RTV or COBI) and some of the NNRTIs are best avoided, see Drug-drug Interactions between Immunosuppressants (for SOT) and ARVs
For individuals nearing indication for transplantation, ART should be modified to ensure this if at all possible
Unboosted INSTIs plus 2 NRTIs are the preferred regimens
If the individual has not yet started ART and transplantation is considered, ART should be commenced as soon as possible and preferably before the transplantation is started

Viral hepatitis co-infection

In liver transplant candidates, every effort should be made to treat the underlying viral hepatitis independently of MELD score, see Treatment of HBV/HIV Co-infection and Treatment of HCV/HIV Co-infection. Use of DAAs in persons with HCV co-infection may improve their liver function, and possibly lead to them being removed from the transplant waiting list

Prevention of infections

While screening and treatment for latent TB is recommended in all persons with HIV, see Diagnosis and Treatment of TB in Persons with HIV, it is particularly important in persons pre-and post-transplantation due to the additional use of immunosuppressants. Immunisation regimens and pre-transplant diagnostic protocols are the same as in HIV-negative SOT recipients

Follow-up after transplantation

Antiretroviral therapy

Same recommendations in individuals under preparation for transplantation
Additionally, ARVs may exacerbate immunosuppressive agents’ adverse drug effects (kidney impairment, bone marrow suppression, drug-induced liver injury, etc.). Therefore, careful consideration of which drugs to use is essential, see Adverse Effects of ARVs & Drug Classes
TAF is preferred to TDF, when available, to reduce additive nephrotoxicity to immunosuppressant agents
There is no experience with LEN, FTR, ibalizumab and long-acting CAB and RPV in people with HIV with SOT, see Drug-drug Interactions between Immunosuppressants (for SOT) and ARVs

Primary and secondary disease-specific prevention

Transplant recipients living with HIV should receive the same surveillance, immunisation prophylaxis and pre-emptive regimens as HIV-negative SOT recipients
Screening and treatment for latent TB is a priority, see Diagnosis and Treatment of TB in Persons with HIV

Viral hepatitis co-infection

The efficacy and safety of DAAs in liver transplant recipients living with HIV with HCV recurrence is the same as in HIV-negative recipients
Anti HBV treatment should follow the same schedules as people who are HIV-negative

Screening for co-morbidities and frailty

Persons with HIV undergoing SOT have higher risk for some comorbidities including CVD, DM, bone disease (osteoporosis and aseptic necrosis of the femur) and frailty, see Prevention of Cardiovascular Disease (CVD), Type 2 Diabetes Mellitus, Bone Disease: Screening and Diagnosis and Managing Frailty in Older People Living with HIV

Immunosuppressive regimens

Same as in transplant recipients who are HIV-negative. The risk of acute rejection is however double of that of SOT recipients who are HIV-negative and, therefore, requires close monitoring. Recipients with a pre-transplant CD4/CD8 ratio ≥0.5 have the highest risk of acute rejection*
Special attention to interaction with ART, see Drug-drug Interactions between Immunosuppressants (for SOT) and ARVs
Using a pharmacological booster (RTV or COBI) and some of the NNRTIs should be used with caution and require close monitoring of immunosuppressive drugs, see Drug-drug Interactions between Immunosuppressants (for SOT) and ARVs

i Milan criteria: solitary tumor smaller than 5 cm or 2 - 3 tumors of < 3 cm in the absence of macrovascular tumor invasion and extrahepatic metastases

* Arrieta SS, Serrano L, Rafecas A et al. CD4/CD8 Ratio ≥0.5 is a risk factor of acute rejection in HIV infected LT recipients. Poster presented at: 29th Conference on Retroviruses and Opportunistic Infections (CROI); February 12-16, 2022; Virtual meeting. Poster number 00551. www.croiconference.org/wp-content/uploads/ sites/2/resources/2022/croi2022-abstract-ebook.pdf