It began with an impossible choice: Watch a 13-month-old girl with the liver condition bilary atresia die, or say yes to allowing her HIV-positive mother to donate a portion of her liver to her child, but almost certainly expose the child to HIV infection.
“The mother kept pleading with us to consider her as a donor. Since 2013 the Wits Donald Gordon Medical Centre has had a living donor liver transplant programme, but our policy, that follows international guidelines, excluded HIV-positive living donation,” says Professor Jean Botha, director of transplantation at the hospital.
Because of the liver’s ability to regrow, living donors can donate a segment of their liver, usually to a child. The liver grows as the child grows and for the donor, their liver regrows completely within eight weeks.
However, for this young patient, her condition worsened every day and the window for a transplant was closing rapidly.
The chronic shortage of organs from living or deceased donors in the country meant she had already been on the waiting list for three times longer than most patients.
“We were compelled to consider other options, including to transplant a portion of liver from the child’s HIV-positive mother. Ultimately after consulting widely we got the approval from the Wits Medical Ethics Committee to go ahead,” says Dr Harriet Etheredge, a medical bioethicists at the Donald Gordon and the Wits Department of Internal Medicine.
Etheredge and her colleagues believe that saving the child’s life was the priority. Also they believe that should the child become HIV-positive, the success of South Africa’s antiretroviral therapy programme to date means that HIV is no longer a death sentence with careful management.
About 4.2 million of the estimated 7.2 million South Africans infected with HIV receive treatment from the state.
Presently, the child’s HIV clinician Dr Francesca Conradie says she’s thriving and continues on antiretrovirals and anti-transplant rejection drugs. Her team continue to monitor her progress and has not taken a decision on if or when they will stop her antiretroviral therapy.
Professor Caroline Tiemessen, of the Wits School of Pathology and head of cell biology in the Centre for HIV and STIs at the National Institute for Communicable Diseases, says this case has shown some quite startling results for understanding HIV within the organ transplant scenario.
Tiemessen says the child received Nevirapine to prevent mother-to-child transmission in utero. She was HIV-negative at the time of her operation and went on to antiretroviral therapy the night before her operation.
After the operation doctors could not detect any sign of the virus in her blood or blood cells with standard and ultrasensitive HIV detection testing. At day 43, though, the child tested positive for HIV antibodies that the body produces to fight disease and infection.
The presence of HIV antibodies is regarded as a sign of HIV infection. However, the child’s HIV antibody count has steadily waned and is presently undetectable. “We have to be cautious because we cannot say that the child does not have HIV.
There are several possibilities the child could be HIV-positive but we haven’t been able to detect it in a transplant scenario and because of the drugs she’s on. Another possibility is that what we are seeing is the child’s liver clearing out the last of the HIV from her system.
We could also be picking up the mother’s antibody response from the segment of transplanted liver. “We will be doing more transplants of this nature that will help us better understand these results.
We will also be able to follow patients pre and post op more carefully and we will be able to set up best practices, because right now this is uncharted territory,” says Tiemessen. DM