Spain Nears Legal Shift on HIV-Positive Donors

Historically, the presence of HIV infection in a patient with end-stage organ failure has been considered an absolute contraindication for organ transplantation. However, advances in antiretroviral therapy have significantly improved life expectancy for people living with HIV to the extent that the condition is now generally managed as a chronic disease. At the same time, a growing number of these individuals are experiencing or dying from end-stage organ failure, prompting renewed debate about this long-standing contraindication.

In addition, many national transplant policies require that organs from HIV-positive donors be discarded due to safety concerns. Even if the intended recipient is also HIV-positive, there is a risk of superinfection — acquiring a different strain of HIV from the donor, which may be resistant to certain antiretrovirals. There is also the potential for transmission of common coinfections.

These issues were addressed during a roundtable session at the 28th Congress of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), held in Málaga, Spain, from May 22-25. The session, titled Advances in Solid Organ Transplantation in People Living With HIV: Use of HIV-Positive Donors, was moderated by Federico García, PhD, president of SEIMC, and Beatriz Domínguez, MD, PhD, managing director of Spain’s National Transplant Organization.

Expert speakers included Josep Maria Miró Meda, MD, PhD, Infectious Diseases Service, Hospital Clinic of Barcelona, Barcelona, Spain; Christine Durand, MD, Johns Hopkins School of Medicine, Baltimore; and Paolo Grossi, MD, PhD, University of Insubria and ASST-Sette Laghi, Varese, Italy.

The objectives of the session were to:

1. Present clinical criteria and prognostic outcomes for solid organ transplantation in patients with HIV.
2. Explore the perspectives of Spanish transplant experts on the use of HIV-positive donor organs for HIV-positive recipients — a practice that has been prohibited by Spanish law since 1987.
3. Review the current regulatory landscape across the European Union regarding this practice.

According to Domínguez, while Spain is widely recognized as a global leader in organ donation and transplantation, the country has fallen behind in its approach to transplant access for people living with HIV.

International examples presented during the session, particularly from South Africa and the United States (under the HIV Organ Policy Equity Act), demonstrate that kidney and liver transplants from HIV-positive donors to HIV-positive recipients can have favorable short- and medium-term outcomes. These data, presented by Durand, support the reconsideration of long-standing transplant restrictions.

Miró Meda presented long-term outcomes from the Hospital Clinic of Barcelona, where, between 2003 and 2024, 81 patients living with HIV received organ transplants from HIV-negative donors. Of these, 85% survived at least 10 years posttransplant.

These findings support a growing consensus that it is time to reconsider policies restricting the use of organs from HIV-positive donors and to recognize individuals living with HIV as eligible both to receive and donate organs. In late 2024, Spain began the legal process to repeal its longstanding ban on such transplants — a change expected to be finalized in the coming months.

Looking ahead, experts identified a new frontier in transplantation: The use of organs from HIV-positive donors for HIV-negative recipients. While still controversial, this practice has already been implemented in South Africa under exceptional clinical circumstances — specifically, cases where the lack of a transplant would result in death. In these instances, the immediate benefits are considered to outweigh the potential risks, given that HIV is now a manageable chronic condition. Importantly, these transplants are performed only with the fully informed consent of the recipient.

This evolving field raises important clinical and ethical questions:

• Could HIV transmission be prevented by initiating prophylactic antiretroviral therapy in the recipient?
• Does the principle of “undetectable = untransmittable” apply in the setting of organ transplantation?

Although these approaches are far from standard clinical practice, experts agree that the topic deserves careful consideration and open discussion.

This story was translated from Univadis Spain.