Clearing the hepatitis hurdle: Obstacles and opportunities in liver transplantation for people with HIV

Abstract

The early experience of liver transplantation for people with HIV (PWH) was plagued by three issues: hepatitis C virus (HCV), interactions with HIV antiretroviral therapy, and organ rejection. In the first multicenter trials in the United States and Spain, liver recipients with HIV-HCV coinfection had 3-year patient and graft survival around 60%, and acute rejection rates around 40%, significantly worse than in recipients with HCV mono-infection. 1,2 These findings generated concern. Without effective antivirals for HCV, some transplant programs stopped performing liver transplants in PWH. Thus, the hurdle of HCV coinfection was a major barrier to liver transplantation for PWH.

Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation

“…Recently, non-viral liver disease, predominantly NASH and ALD, became the leading indication among HIV-infected LT recipients. This shift signifies the tremendous impact of DAAs, increasing metabolic conditions, and the metabolic effects of ARTs, corticosteroids, and CNIs [864]. HIV-infected LT recipients treated with highly active antiretroviral therapy (ART) have no increase in the risk of opportunistic infections [865].…”

“…Special consideration must be given to HIV/HCV coinfected LT recipients. First-generation DAA treatment became available in 2008; however, protease inhibitors require combination treatment with IFN and ribavirin, which have complex interactions in LT recipients, particularly with HIV [864]. In 2013, IFN-free DAAs were discovered, with cure rates approaching 100%, including in HIV-infected LT recipients.…”

“…In 2013, IFN-free DAAs were discovered, with cure rates approaching 100%, including in HIV-infected LT recipients. Moreover, advanced NS5A inhibitors enabled the combination treatment of DAA, ART, and immunosuppressants, resulting in fewer drug-drug interactions [864].…”