A leading Canadian transplant organization is calling for greater use of organs from deceased donors considered at increased risk for HIV and hepatitis B and C, including intravenous drug users and homosexual men.
Safe and ethical use of these organs “may lead to an increase in number of transplants in Canada coupled with decreased wait-list times and mortality,” said a report published Wednesday from the Canadian Society of Transplantation and the Canadian National Transplant Research Program.
The new recommendations, which reflect improved testing methods for infectious diseases combined with a more accurate assessment of infection risk, are being lauded by organ-donation advocates. However, HIV/AIDS experts question the continued inclusion of homosexual men in the increased-risk donor category.
Previously, donors, including intravenous drug users, gay men, sex workers and prison inmates, were considered at high risk of infection because of the window period between potential exposure and the time it takes for antibodies to show up on a test, explained Atul Humar, director of the Multi Organ Transplant Program at University Health Network in Toronto, and lead author of the report.
But he noted that nucleic acid testing (NAT) has shrunk the window period to seven days after exposure.
With proper testing, the risk of infection in these donors is “exceedingly low,” he said.
According to the report, the risk of HIV infection in a homosexual donor after blood testing and NAT is 2.4 in 10,000 donors. In an intravenous drug user, the risk is 2.7 per 10,000. The risk of hepatitis C infection is 1.5 per 10,000 in homosexual men, compared with 40.8 in intravenous drug users.
The actual risk may be even smaller, since the mathematical models used in the report assumed the donor engaged in risk behaviour up until the moment of death, Dr. Humar said.
“The old wording of ‘high risk’ [for these donors] is a misnomer as it does not accurately convey the risks,” he said.
He added that donors such as intravenous drug users tend to be younger, “and we’re always faced with a huge shortage of donors.”
Mark Wainberg, director of the McGill University AIDS Centre, applauded the new recommendations. But, he added, “being gay is in and of itself an extremely low risk factor,” he said.
Policies excluding homosexual men from donating blood and organs date from the 1980s, the early days of HIV testing, Dr. Wainberg said. He pointed out that organ donation from live homosexual donors has been permitted for some time. But Canadian Blood Services allows gay men to donate blood only if they have been celibate for five years.
“I think we are diminishing the pool of potential donors of both blood and organs by maintaining a discriminatory policy,” Mr. Wainberg said.
Dr. Humar noted that according to data from the Canadian Standards Association, the risk of infection from homosexual donors is still higher than that in heterosexuals – “two- to four-fold higher,” he said.
Nevertheless, the potential for greater access to donor organs is welcome news for the transplant community, said James Breckenridge, president of the Canadian Transplant Society, a Toronto-based charity.
For patients in urgent need of an organ transplant, the slight chance of HIV or hepatitis infection “is nothing compared to being dead,” he said.
Mr. Breckenridge’s wife, Lisa, spent years on a liver transplant list before falling into a coma in 2009. With hours left to live, she received a damaged liver from a donor who was brain dead. Her recovery from the transplant was slow. Given the choice, Lisa said, she wouldn’t hesitate to accept a healthy organ from a donor considered at increased risk of infection.
The recommendations emphasize the importance of informed consent and provide a sample script for physicians to use with transplant patients. The wording includes: “This donor engaged in behaviours before their death that increase their chances of having an infection. You need to balance the slightly increased risk of accepting this organ with the likely benefits of being transplanted at this time instead of waiting for another organ.”
The report advises physicians to discuss the chances of infection in numerical terms instead of specifying the donor’s risk behaviours. But the reason has nothing to do with the stigma of drug use or homosexuality, Dr. Humar said.
“We try not to disclose too much information because organ donation is supposed to be anonymous,” he said.