Not long ago, the thought of transplanting a kidney into salesman Derek Kee, a heart into statistician Robert Zackin or a liver into playwright Larry Kramer would have defied all reason.
All suffered from HIV infection before their organs went bad, and under the old rules, the drugs needed to protect their transplants would surely have crippled their immune systems even more. Giving scarce organs to patients who didn't have long to live was considered wasteful, even unethical.
Like so many things about AIDS, that view is slowly giving way to another, articulated by Dr. Stephen T. Bartlett, a surgeon at the University of Maryland Medical Center who performed Kee's transplant last month.
"Now, the question is whether we can ethically exclude these patients," says Bartlett.
The unofficial moratorium on transplants for HIV-infected patients, in force since the 1980s, is slowly being lifted as hospital after hospital has found ways to push boundaries once thought inviolable.
Kee, for instance, sought a transplant just as the University of Maryland Medical Center was recruiting patients for a nationwide trial in which 75 HIV-infected patients will receive kidney or liver transplants.
Other hospitals have forged out on their own to test the idea. That was the case with the Cleveland Clinic, which gave Zackin a heart last year, and the University of Pittsburgh Medical Center, which gave Kramer a transplant in December 2001 but has offered livers to infected patients since 1997.
The argument for performing organ transplants on such patients was strengthened by a study presented this year by researchers at the University of California-San Francisco. Among 23 patients who had at least a year of follow-up after their transplants, the survival rate was about 85 percent. Outcomes overall were no different than one would expect among people without the virus.
Several forces are converging to change the prospects for HIV-infected patients needing transplants. For starters, the revolutionary drug combinations introduced in the mid-1990s are enabling many patients to live healthy, robust lives with their virus at undetectable levels.
With their immune systems restored, such patients can often survive a transplant and even the immune-suppressing drugs that prevent patients from rejecting a foreign organ, doctors say.
That some patients with HIV infection even need transplants is testimony to the strides made against the disease, which was once considered a death sentence. Now, some patients are living so long that their organs are succumbing to other diseases or the long-term side effects of anti-AIDS medications.
Larry Kramer, 67, a New York playwright and AIDS activist, suffered liver failure because of his long bout with hepatitis B, an infection that along with hepatitis C plagues many AIDS patients. Derek Kee's kidneys may have been damaged by high blood pressure. Zackin's heart was weakened by drugs that had been used to treat Kaposi's sarcoma, a cancer that sometimes preys upon AIDS patients.
Zackin's quest for a new heart began in 1999, when he started to need 24-hour infusions of a medication to boost his failing heart. An AIDS researcher, the 39-year-old Zackin had colleagues across the country who put out feelers at the institutions where they worked.
Hopkins and Harvard were just two of many institutions that rejected him, saying they had a categorical ban against such transplants. Zackin said two medical centers, which he declined to identify, agreed to present his case to their transplant boards but ultimately turned him down as well.
Finally, the Cleveland Clinic accepted him and gave him a new heart in February 2001. Though he has suffered several bouts of rejection, doctors say he has overcome them and has not had any renewed problems with AIDS.
"In many ways, he's done much better than many transplant patients," said Dr. James Young, a cardiologist who treated Zackin and co-wrote an article with him on the case in the New England Journal of Medicine this month.
Young says he is encouraged that Zackin's immune system was healthy enough to attack the new organ. For his part, Zackin says he quickly returned to work, resumed exercising at the gym, and put on weight and muscle.
"More successes will lead to more people trying, " said Zackin. "I'm not sure it's really an ethical issue anymore. You can't decide who is worthy and who is not worthy."
Kee, a 31-year-old shoe salesman in Clearwater, Fla., almost got a kidney two years ago when Hahnemann University Hospital in Philadelphia offered him one in the middle of the night. Kee, however, knew he couldn't make the trip fast enough, so the hospital gave it to someone else.
Then he began a frustrating search in Florida. "At least three places said they wouldn't even consider it, that they wouldn't touch it," said Kee, who was diagnosed with HIV infection a decade ago but never developed AIDS. "There were many times when I felt I was really being devalued as a human being. "