In this QHC Case Collective post, I include a case, key points, and resources from Episode 2 of the QHC Podcast, recorded 26 May 2026. I interviewed Dr Olivia Kates to investigate roles of infectious diseases, such as HIV, in liver transplantation decisions.
—Christy Rentmeester, QHC Podcast host
Case
This case was first drafted by Dr Olivia Kates, which I have edited and augmented in what follows.
This is an anonymized, compositized case involving a young patient who has an HIV infection and end-stage liver disease. Without a transplanted liver, they have, perhaps, weeks or days to live. One clinical complexity from this patient’s HIV infection is mold in their lungs, which diminishes likelihood of their successful post-transplantation recovery.
Two ethical complexities posed by HIV in cases like this one are these: (1) a liver transplantation candidate with HIV can agree to accept a liver from a deceased donor who also had HIV, but (2) patients who need a liver from a deceased donor but do not have HIV cannot.
Perhaps surprisingly, if the liver of a deceased donor with HIV is not transplanted into a patient-recipient with HIV, the donor’s liver is not donated to anyone; it is discarded.
Historical Context
Key history moments were first drafted by Dr Kates, which I have edited and augmented in what follows.
One key point of this episode’s conversation is that history should richly inform our clinical and moral reasoning about cases like this one. In the 1980s, widespread panic about human immunodeficiency virus (HIV) transmission led to targeted restriction of who could donate or receive organs in the US. Research continued internationally, however, and HIV-to-HIV transplantation was pioneered in South Africa. Clinical outcomes improved during decades of social and cultural progress, mitigating deeply entrenched negative bias against patients with HIV.
Finally in 2013, the US Congress passed the HIV Organ Policy Equity (HOPE) Act. Thereafter, the Organ Procurement and Transplantation Network (OPTN) and United Network for Organ Sharing (UNOS) forged policies and processes for procuring, transporting, and allocating organs from donors with HIV. By 2016, livers and kidneys were available for transplantation beyond human subject research settings.
Ask 3 questions.
Candidate selection. Health care organizations’ transplantation programs assess their patients’ likelihood of post-transplantation survival when considering whom to select as candidates. Candidates are then “listed” and await an organ.
- When and how should infections be considered in programs’ processes of candidate selection?
Allocation. Organ allocation decisions are made by OPTN and UNOS and informed by a patient’s Model for End-Stage Liver Disease (MELD) Score. Patients who are sickest are prioritized.
- Which roles, if any, should the presence of or likelihood of different kinds of infections–including iatrogenic infections–play in organ allocation decisions?
Survivability, urgency, and scarcity have been cornerstone clinical and ethical concepts used in transplantation decisions.
- How should patterns of clinical or ethical reasoning–especially about solid, deceased donor organ scarcity–change to account for perioperative transplantation infectious disease transmission risks?
One might wonder about the public-private partnership between the US Federal Government and UNOS, so here’s a brief explanation: UNOS operates the OPTN under a contract regulated by the US Department of Health and Human Services’ Health Resources and Services Administration (HRSA), according to the National Organ Transplant Act, which was passed by the US Congress in 1984.
The feature image for this post is available from the Creative Commons Public Domain collection of the Art Institute of Chicago. Learn more about this work here.
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