Is homosexuality a contraindication for organ donation?
Sidney Anthone, MD
There is no prohibition for a homosexual to be an organ donor per se. A person's sexual orientation is only relevant if it might present a medical risk to the recipient. Therefore, the medical and social history of every potential organ donor must be carefully assessed to evaluate the potential risk of transmission of infection to the recipient. The transmission of an infection through a donor organ can result not only in the loss of the allograft, but also in the death of the immunosuppressed recipient. Therefore, despite the shortage of organ donors for organ transplantation, every donor regardless of sexual orientation must be evaluated thoroughly for the potential transmission of any infectious disease.
When the donor or family consents to organ donation, they are also consenting for serologic testing. The determination of an active viral infection in the form of encephalitis or meningitis, varicella zoster, or human immunodeficiency virus (HIV ) is an absolute contraindication to organ donation because of the hazard each of these clinical situations poses for the allograft recipient. It is the responsibility of the organ bank staff to tell the potential recipient if the potential donor has a significant social history that might expose the recipient to an infection.
Serologic screening for HIV, human T-lymphotropic virus, hepatitis B virus, hepatitis C virus, and cytomegalovirus is routinely performed in the United States. HIV has been transmitted from infected cadaver donors to multiple recipients of organs, resulting in the death of the allograft recipients. United Network for Organ Sharing policy states that organs from donors with a positive antibody screening to HIV are not suitable, unless subsequent confirmatory testing indicates that the screening test was falsely positive. However, a confirmatory Western blot test cannot usually be performed emergently before the maximum time of cadaver organ preservation elapses. Therefore, for all practical purposes, a cadaver donor serum testing positive for HIV by the preliminary enzyme-linked immunosorbent assay results in the discard of all donor organs for transplantation.
In contrast, there is ample time to perform confirmatory testing in living donors. All living organ donors should undergo voluntary screening for HIV 2-3 months before the planned transplant. During that interval, donors should be instructed to avoid societal encounters that might endanger an HIV exposure. For example, HIV has been transmitted from an asymptomatic living donor of a renal allograft (whose serology was HIV-negative 8 months before the transplant), after a sexual encounter between the time of the HIV testing and the transplant.
Because of the risk of HIV transmission to blood, tissue, and organ transplant recipients, the Centers for Disease Control and Prevention (CDC) developed guidelines for donor exclusion criteria) for prevention of HIV transmission to organ and tissue recipients. Regardless of their HIV antibody test results, persons who meet any of these criteria listed below should be excluded from donation of organs or tissues unless the risk to the recipient of not performing the transplant is deemed to be greater than the risk of HIV transmission and disease (eg, emergent, life-threatening illness requiring transplantation when no other organs or tissues are available and no other life-saving therapies exist). In such a case, informed consent regarding the possibility of HIV transmission should be obtained from the recipient.
Behavior/History Exclusionary Criteria
men who have had sex with another man in the preceding 5 years
persons who report nonmedical intravenous, intramuscular, or subcutaneous injection of drugs in the preceding 5 years
persons with hemophilia or related clotting disorders who have received human-derived clotting factor concentrates
men and women who have engaged in sex in exchange for money or drugs in the preceding 5 years
persons who have had sex in the preceding 12 months with any person described in the 4 items above or with a person known or suspected to have HIV infection
persons who have been exposed in the preceding 12 months to known or suspected HIV-infected blood through percutaneous inoculation or through contact with an open wound, nonintact skin, or mucous membrane
inmates of correctional systems; this exclusion is to address issues such as difficulties with informed consent and increased prevalence of HIV in this population.
Specific Exclusionary Criteria for Pediatric Donors
Children meeting any of the exclusionary criteria listed above for adults should not be accepted as donors.
Children born to mothers with HIV infection or mothers who meet the behavioral or laboratory exclusionary criteria for adult donors (regardless of their HIV status) should not be accepted as donors, unless HIV infection can be definitely excluded in the child as follows:
--children greater than 18 months of age who are born to mothers with or at risk for HIV infection, who have not been breastfed within the last 12 months, and whose HIV antibody tests, physical examination, and review of medical records do not indicate evidence of HIV infection can be accepted as donors;
--children less than or equal to 18 months of age who are born to mothers with or at risk for HIV infection or who have been breastfed within the past 12 months should not be accepted as donors regardless of their HIV test results.
Laboratory and Other Medical Exclusionary Criteria
persons who cannot be tested for HIV infection because of refusal, inadequate blood samples (eg, hemodilution that could result in false-negative tests), or any other reasons
persons with a repeatedly reactive screening assay for HIV-1 or HIV-2 antibody regardless of the results of supplemental assays
persons whose history, physical examination, medical records, or autopsy reports reveal other evidence of HIV infection or high-risk behavior, such as a diagnosis of AIDS, unexplained weight loss, night sweats, blue or purple spots on the skin or mucous membranes typical of Kaposi's sarcoma, unexplained lymphadenopathy lasting greater than 1 month, unexplained temperature greater than 100.5°F (38.6°C) for greater than 10 days, unexplained persistent cough and shortness of breath, opportunistic infections, unexplained persistent diarrhea, male-to-male sexual contact, sexually transmitted diseases, or needle tracks or other signs of parenteral drug abuse.
Organ bank staff should obtain a social history on all potential organ donors that addresses these criteria. When the social history of the potential donor reveals any of the CDC criteria, the risk of HIV transmission (despite negative serology screening) must be balanced against the benefit contemplated for a particular allograft recipient. Thus, organs may be recovered without restriction for either recipients with life-threatening illnesses (heart and liver) or for those recipients of non-life-saving transplants (lung, pancreas, kidney, bowel). In either circumstance however, the CDC guidelines emphasize a requirement for the transplant center to inform recipients of the potential risk of donor HIV infection, even if that risk is presented only by the behavioral social history.