HIV, HCV, organ transplants and surgery - Henry Bauer is utterly clueless

IN EARLY 2007 IN CHICAGO a 38 year old man was brought into hospital suffering unspecified traumatic injuries. Sadly, attempts at resuscitation failed and he died. The one apparent positive from his death was that he was an organ donor, and that the organs which were now useless to him could be used for transplantation to provide a new lease of life for a number of otherwise seriously ill people with organ failure such as in severe kidney, liver or heart disease.

There was a problem though. The donor screening questionnaire revealed he was in a “high risk group” for HIV – he was sexually active with other men. Although donor organs are routinely screened for blood borne viruses such as HIV and hepatitis C through antibody testing, such tests are not absolutely failsafe: antibodies may not be detectable for up to three months after initial infection, (although with modern HIV antibody tests they are generally reliable some weeks sooner than that). Donations from “high risk” individuals can therefore be in the early stages of infection with HIV or hep C without this showing on the usual screening tests, during the “window period”. The chances of that happening are very small, but still there. Even among people with no identified “risk” for HIV this can potentially happen: in the US there are now almost as many people infected heterosexually with HIV each year as males infected homosexually: an increasing proportion of new HIV infections occur in people outside the traditional “risk groups”.

The routine antibody tests for HIV and hep C were done on our Chicago man, and they came up negative. The four transplants went ahead.

Since 2004 there has been a second type of screening test (nucleic acid testing) which looks for the viral RNA or proviral DNA rather than antibodies, and which reduces the false negative period still further, but which is again not quite failsafe, as there is still a short period of several days between infection and the test becoming reliable – the “eclipse period”. Another issue is that the test takes time to perform – several hours – which can be critical in the time frame required for organ transplantation. Nucleic acid testing wasn’t done for the four organs donated by our Chicago man.

Organ transplantation carries risks – it’s major surgery – as well as often lifesaving benefits. As well, the supply of suitable organs is very limited and many people die on the waiting list for transplants. It’s not altogether unreasonable to use organs from a “high risk” individual: after all the chances that a donor would die within 22 days or so of becoming infected with HIV are pretty slim. So slim, in fact, that not a single case of HIV transmission through organ transplantation was known to have occurred since 1986 in the US, among hundreds of thousands of transplants, including from an unspecified number of donors fitting the “high risk groups” for HIV.

Of course, ethically and medico-legally there is a principle that consent for a medical procedure is accompanied by information of any salient risks. The transplant coordination team say they told the three hospitals involved of the donor’s risk status. What is not clear is whether the hospitals informed the four organ recipients. Which could become problematic on the very slim chance anything went wrong.


SEVERAL MONTHS LATER, one of the recipients was undergoing assessment for re-transplantation – the organ was apparently failing. As part of the assessment s/he was routinely screened for HIV and hepatitis C – and came up positive for both viruses. As part of the epidemiological investigation, stored samples from the donor were tested – this time with the more sensitive nucleic acid tests that can identify HIV and HCV during much of the window period where the antibody tests will miss a recent infection. He was positive for both. The three other organ recipients were then tested, and they too tested positive for both viruses. The dreaded but very unlikely event – almost a freak occurrence - had happened, and left four people with dual blood borne virus co-infections to add to their other health problems.

This case raises numerous technical and ethical issues, not the least of which is whether consent for the transplants was truly informed if, as at least one recipient claimed, she was not told of the donor’s risk status, and would have refused the kidney had she known. And how, exactly, should the transplant teams have quantified such a risk, which was at the time only theoretical? How much do recipients have the right to know about the donor? Should organs from “high risk” donors even be used? Who, exactly, is “high risk” these days? Should nucleic acid testing be part of the routine donor screen, given the low probability that any given donor will have infections not picked up by standard screening, and the potential for the extra delay to compromise the viability of the transplant?

However, raising those important issues was not the point of this post. This is a blog about Henry Bauer’s bizarre theories about HIV and AIDS, and his take on this case , “HIV”, organ transplants, surgery is a fine illustration of his hopelessly confused, contradictory and downright ignorant pontification about the significance of HIV test results.

FOR OBVIOUS ETHICAL REASONS, deliberately conducted experiments to demonstrate the transmissibility of HIV in humans can never be done. While some of us might take a certain secret pleasure in seeing some of the more prominent denialists publicly demonstrating the courage of their convictions by injecting themselves with a reliably infectious dose of blood from an HIV positive person, it’s not going to happen. Well, actually it kind of did once. A barking mad Florida doctor called Robert Willner stuck himself with a needle coated in allegedly HIV positive blood in several media stunts during the 1990s.  This was some time after he had been struck off for repeated infractions amounting to gross professional misconduct, including claiming to cure people with HIV/AIDS by injecting them with… ummm… ozone.

Unfortunately, we will never know the results of Willner’s publicity stunts, because he died a few months later, apparently from causes unrelated to HIV. [Incidentally, also of interest would be an explanation from denialists about how pumping ozone (a highly oxidative chemical) into people’s veins is supposed to treat a condition that according to the most currently popular denialist account is supposedly the result of “oxidative stress”. But I digress.]

The Chicago cases provide a kind of “natural experiment” that demonstrates the transmissibility not only of HIV but also HCV. It was a tragic and unfortunate series of events that modern medicine does its damnedest to try to prevent, usually successfully, which is why this case was so singular. If you were an evil scientist trying to test the transmissibility of HIV, it would be hard to come up with a better “experimental design”.

So what does Henry say about it?

This sad story illustrates the sorts of tragedies that follow from regarding a positive HIV-test as proof of infection by a pathogenic virus. What those tests (ELISA, Western Blot) actually detect is a variety of antibodies to a whole range of proteins, or (PCR test) bits of RNA and DNA, none of which have ever been shown to constitute part of an authentic virion of HIV. On the other hand, there is copious evidence that a great range of conditions can deliver a “positive” on an HIV test. In the present context, most pertinent are the reports that TRAUMA is associated with positive tests — see for example reports from emergency rooms and autopsies, p. 85 in The Origin, Persistence and Failings of HIV/AIDS Theory. When a person who has had surgery subsequently tests HIV-positive, it’s immediately assumed that infection resulted from blood transfusion or infected instruments; but perhaps the positive test merely reflects the trauma of the surgery or whatever manifest illness later ensues, as with a 65-year-old Indian patient .

The 65-year-old Indian patient, by the way, was a guy who believed that he was infected with HIV through blood transfusions during cardiac bypass surgery. The news article provides few clues as to whether this was or wasn’t the case, but there’s nothing implausible about it. One thing you can be fairly sure of is that in large countries such as India or China it is inevitable that there will be occasional cases of HIV transmitted by transfusions. The probability that any single unit of blood will carry HIV missed by standard antibody screening is extremely small, but in countries with populations of the order of a billion where there are many hundreds of thousands of such donations every year, you can be certain just on statistical probability that someone is going to be unlucky. And you can bet that sometimes this will make the news.

Snout posted a comment for Henry on this post, and – you guessed it – Henry deleted it. Never mind, here it is:

Snout
said
Your comment is awaiting moderation.
Friday,
10 July 2009 at 9:09 am

Henry, don’t you think it’s odd that out of 400,000 transplants since 1986 in the US that only four recipients (0.001%) are known to have acquired HIV through the procedure? Surely if it were the trauma of surgery itself causing HIV antibodies to appear as a “non specific reaction” you would expect more, wouldn’t you?

And don’t you find it odd that those exact same four recipients also seroconverted for hepatitis C – the only known cases ever of post transplant HIV/HCV coinfection in the US?
And that those four recipients all received organs from the one donor in February 2007. No transplants from any other donor have resulted in post transfusion HIV seroconversion since 1986*, or HIV/HCV coinfection ever.

And strangely, when the donor’s stored serum was tested for HIV and HCV by nucleic acid testing he was positive for both viruses?

Far from supporting your theory of HIV antibodies indicating a “non-specific response to stress”, this tragic freak occurrence is virtually iron-clad evidence that what is detected by both HIV and HCV testing are transmissible agents.

“Standard testing” for organ donation at the time (early 2007) was antibody testing. The limitation of this is that antibody tests are not reliable until the window period following infection has passed: up to about 3 months for both viruses. The very small risk of a donation during the seroconversion period is well known, which is why blood banks refuse “high risk” donors despite the fact the samples are tested for HIV. Unfortunately, the demand for transplantable organs far exceeds supply, and transplant teams sometimes take a calculated risk. The medico-legal issue in this case was that the recipient says she was not informed of the risk status of the donor, and would not have agreed to the transplant had she known.

In the last few years many blood banks have added nucleic acid testing to the screening regimen. This reduces, but does not entirely eliminate, the risk of infected donation being missed by the screening process. Nucleic acid testing for HIV and HCV has also recently been introduced for cadaveric transplants in many parts of the world, partly in response to the 2007 events in Chicago.

I’m staggered that you can read this story as confirming rather than utterly refuting your “non-specific response to stress” theory.

Notes: an article about this case was published in November 2008 in Liver Transplantation:
Transmission of human immunodeficiency virus and hepatitis C virus through liver transplantation. 

Other media reports include a series of articles from November 2007: 

4 transplant patients infected with HIV Experts: Case signals patients’ need for more information on donors

Nov. 13, 2007Transplant patient a ‘mess’ after HIV diagnosis Woman was not told her kidney was high risk, attorney says 

Nov. 16, 2007 Federal officials investigate tainted transplants
At issue is what hospitals knew and told four patients about high-risk donor

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*Since this was written in July 2009, there has been another case reported, this time from a living donor in New York.