After a rare, high-profile case of HIV

After a rare, high-profile case of HIV transmission through organ transplant, nearly a third of surgeons changed their practice, researchers reported.

But the most common change was to avoid the use of high-risk donors, rather than to institute better ways of detecting the virus before transplant, according to Dorry Segev, MD, PhD, and colleagues at the Johns Hopkins University School of Medicine.

The finding, from a survey of more than 400 transplant surgeons, suggests that fear of legal or regulatory consequences -- rather than patient safety -- was driving changes in practice, Segev and colleagues reported in the January issue of Archives of Surgery.

In 2007, transplants from a single high-risk donor transmitted both HIV and hepatitis C to four organ recipients, despite negative antibody tests before the procedures. The case made national headlines, Segev and colleagues noted, and sparked a debate about informed consent and testing for HIV.

One of the issues was the use of the antibody test for HIV and hepatitis C, which in the first weeks after infection -- 22 days for HIV and 82 for hepatitis C -- cannot detect the presence of the viruses.

After the discovery of the transmission, physicians retrospectively used nucleic acid testing -- which reduces the discovery window to nine and seven days for HIV and hepatitis C, respectively -- and confirmed the donor had been infected.

To see what effect the case had, Segev and colleagues surveyed transplant surgeons across the U.S. between Jan. 17, 2008, and April 15, 2008, getting responses from 422 surgeons in current practice.

Of those, they found, 297 reported using high-risk donors, but 31.6% changed practice after the 2007 event. Specifically:

• 41.7% of those who changed decreased use of high-risk donors.
• 34.5% increased the emphasis on informed consent.
• 16.7% increased use of nucleic acid testing.
• 6% implemented a formal policy.

Surgeons who did not change were in practice longer, the researchers found -- 13.9 years versus 10.7, which was significant at P=0.002. They were also less likely to rank being sued or facing hospital pressure as disincentives (both differences significant at P≤0.001), but both groups saw the medical risks of HIV and hepatitis C in transplants as high (greater than four on a five-point scale).

In multivariate analyses of the reasons for changing practice, the researchers found that ranking the fear of being sued or hospital pressure as important disincentives was associated with higher odds of changing practice. The odds ratios were 2.26 and 2.52, respectively, and both were significant at P<0.05.