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Routine screening of organ donors for human immunodeficiency virus (HIV) infection has made transmission of HIV through organ transplantation rare in the United States. An adult with hemodialysis-dependent renal failure received a kidney transplant from a living donor at hospital A in NYC in 2009. The donor was an adult male who underwent evaluation as a potential living donor for kidney transplantation at hospital A in 2009.
The diagnosis of HIV in both the donor and recipient raised the possibility of transplant-transmitted HIV infection. The donor and recipient each were interviewed in person using a standardized case interview form. During the public health investigation, the donor reported unprotected sex with one male partner during the 1 year before the transplant, including the time between his initial evaluation and organ recovery. Two samples of frozen leukocyte specimens collected from the organ donor 57 and 11 days pretransplant and two frozen serum specimens collected from the recipient 11 days pretransplant and 12 days posttransplant were sent to CDC for HIV testing. On posttransplant day 404, whole blood specimens were obtained from the donor and recipient for phylogenetic analysis at CDC (Figure). This report describes the first confirmed case of HIV transmission through organ transplantation from a living donor reported since 1989 (1) and the first such transmission documented in the United States since laboratory screening for HIV infection became available in 1985.
Reports of confirmed, donor-derived HIV transmission are rare but notable and have important implications for public health when they occur despite screening. Deceased organ donors typically are screened for HIV infection at the time of the donor's cardiac death or brain death, which occurs within hours of organ recovery. In the case described in this report, the donor was screened for HIV infection by EIA 10 weeks before organ procurement but was not rescreened closer to the date of transplant surgery.
Routine laboratory screening of organ donors for human immunodeficiency virus (HIV) infection, introduced in 1985, has made transmission of HIV through organ transplantation rare in the United States.
This report describes the first documented case in the United States of HIV transmission through transplantation of an organ from a living donor, despite screening using serologic testing. All prospective living organ donors should have their initial serologic tests for HIV supplemented with repeat testing with a combination of an HIV serologic test and a nucleic acid test as close to the time of organ donation as possible, but no longer than 7 days before organ donation. Alternate Text: The figure above shows a timeline of events involving HIV transmission from a living organ donor in New York City in 2009. All prospective living organ donors should have their initial serologic tests for HIV supplemented with repeat testing with a combination of an HIV serologic test and HIV NAT as close to the time of organ donation as feasible logistically, but no longer than 7 days preceding organ donation. All living donors should be advised of their obligation to avoid behaviors that would place them at risk for acquiring HIV infection before transplant surgery.
The blood donation network was restructured in its entirety to bring its operating capacity closer to hospitals’ needs.
In towns where centres were closed, blood donation events were launched swiftly and blood donation numbers soon reached the targeted levels. CDC recommends syphilis serologic screening with a nontreponemal test, such as the rapid plasma reagin (RPR) or Venereal Disease Research Laboratory (VDRL) test, to identify persons with possible untreated infection; this screening is followed by confirmation using one of several treponemal tests. Since the 2008 CDC report, confusion has persisted among clinicians, laboratorians, and public health practitioners regarding testing and treatment decisions and partner notification when using the reverse sequence for syphilis screening (3).
For this report, data from five studies of reverse sequence syphilis screening were analyzed to determine whether CDC should provide additional recommendations for serologic testing and patient management when reverse screening is used. CDC continues to recommend that nontreponemal tests be used to screen for syphilis and that treponemal testing be used to confirm syphilis as the cause of nontreponemal reactivity. Additional studies are expected to provide a better understanding of serologic syphilis testing practices.
Treponema pallidum serologic tests: a paradigm shift in syphilis screening for the 21st century. Alternate Text: The figure above shows the recommended algorithm for reverse sequence syphilis screening (treponemal test screening followed by nontreponemal test confirmation). Consistent with the hospital's protocol, a multidisciplinary team (consisting of a living donor coordinator, nephrologist, transplant surgeon, psychiatrist, social worker, and nutritionist) determined the donor's eligibility by assessing his immunologic compatibility with the recipient, his general health, his psychosocial status, and his willingness to donate.
HIV NAT on the donor leukocytes collected 57 days pretransplant was negative; however, DNA sequences for three HIV genes (envelope gp41, polymerase, and group-specific antigen p17) were amplified from donor leukocytes collected 11 days pretransplant and sequenced at CDC.
The donor had initiated antiretroviral therapy 2 weeks before the specimen was obtained, whereas the recipient had not yet initiated antiretroviral therapy.

The time sequence in which HIV was isolated from frozen specimens, tight phylogenetic clustering of HIV sequences from the donor and recipient, and lack of other HIV exposure risk in the recipient confirmed that HIV was transmitted by transplantation of a kidney from a living donor who was infected after screening negative for HIV infection during his initial evaluation.
The annual number of living donors increased from 1,829 to 6,609 during 1988--2009.* Although the Organ Procurement and Transplantation Network (OPTN) sets national policies for organ allocation, including screening potential donors for HIV and other infections, current OPTN policies do not address screening and counseling for HIV infection in living potential donors.
In contrast, living donors undergo a longer and more comprehensive physical and psychological evaluation (2). Despite an initial negative EIA screening and counseling for behavioral risk reduction, living donors can acquire HIV infection between the initial evaluation and organ recovery. Dynamics of HIV viremia and antibody seroconversion in plasma donors: implications for diagnosis and staging of primary HIV infection. Estimated risk of human immunodeficiency virus and hepatitis C virus infection among potential organ donors from 17 organ procurement organizations in the United States. Risk of window period HIV infection in high infectious risk donors: systematic review and meta-analysis. However, no national policy exists for the type or timing of HIV screening tests used for living donors. Clinicians should advise living donors of their obligation to avoid behaviors that would put them at risk for acquiring HIV before organ donation. An adult with hemodialysis-dependent renal failure received a kidney transplant from a living donor at hospital A during 2009. Eight blood service centres were closed by the end of the year and replaced with regular blood donation events. To achieve regular daily donation numbers, the joint planning of blood donation events was improved.
The new syphilis bacterium antibody test identifies both recent infections and patients previously treated for an infection. As a result, serologic testing is the method most often used to diagnose syphilis in patients with suspected disease. Management decisions for patients with discordant sera and nonreactive confirmatory treponemal tests are especially difficult. The traditional algorithm performs well in identifying persons with active infection who require further evaluation and treatment, while minimizing false-positive results in low prevalence populations (8). An assessment is needed of the patient's sexual risk factors and medical history, especially history of previous treatment for syphilis. Syphilis testing algorithms using treponemal tests for initial screening---four laboratories, New York City, 2005--2006.
High throughput laboratory experience using the Trep-Chek EIA as a screening test for syphilis [C-097]. His evaluation revealed a previous diagnosis of syphilis and a history of sex with male partners. HIV DNA sequences from donor and recipient peripheral blood lymphocytes collected on day 404 were amplified and sequenced. This case highlights the need for repeat HIV screening for all living donors using a combination of HIV serology and NAT, as close to the time of organ donation as logistically feasible, to rule out acute or recent HIV infection in living donors before organ donation. In the case described in this report, the time between initial donor evaluation and transplant surgery was 10 weeks. For blood and tissue donation, the combination of HIV NAT and serology is used to screen all donors. To reduce the risk for transplant-transmitted HIV infection, living donors should be rescreened with both HIV serologic tests and NAT as close to the time of organ recovery as logistically feasible, but no longer than 7 days before organ donation (Box). We aim to increase the proportion of blood collected during blood donation events to 50% of all blood collection in Finland.
We sought to select donors among persons able to donate two products at a time in the blood groups most urgently required, and new donors were recruited from the Helsinki region.
To better understand the performance of reverse sequence screening for syphilis, CDC analyzed data from five laboratories that used reverse sequence screening during 2006--2010.
This report summarizes the results of the subsequent public health investigation, which confirmed HIV transmission through transplantation of an organ from a living donor.
Sequences from these two specimens were analyzed phylogenetically together with HIV sequences obtained from the donor's frozen leukocyte specimen collected 11 days pretransplant.

This longer evaluation process for prospective living donors allows potential for acquisition of infections after initial evaluation, emphasizing the need for repeat testing before organ recovery to rule out recently acquired infections. In addition, clinicians should advise living donors of their obligation to avoid behaviors that would put them at risk for acquiring HIV before organ donation. At the same time, the number of blood donations in the remaining ten centres will be increased by about 10–15%, which will be roughly on a par with the figures for 2011. Serodiagnosis of syphilis involves the detection of two distinct types of antibodies: 1) nontreponemal antibodies directed against lipoidal antigens released from damaged host cells and possibly from the treponemes themselves and 2) treponemal antibodies directed against T.
Discordant testing results could be caused by 1) previous syphilis infection, treated or untreated, with persistence of treponemal antibodies but seroreversion of nontreponemal antibodies, 2) a false-positive treponemal test result, or 3) early primary syphilis in a person who has yet to develop nontreponemal antibodies. The report recommended a confirmatory treponemal test for discordant sera (using a test other than EIA or CIA) to identify persons who might require treatment (2). Three sites served patient populations with low prevalence of syphilis (large managed-care organizations), and two sites served patient populations with high prevalence (including men who have sex with men and patients with human immunodeficiency virus infection). The same calculations were performed for the populations with low prevalence and high prevalence of syphilis. If the traditional algorithm is used and the initial nontreponemal test is nonreactive, patients with suspected primary syphilis should be treated and then retested with a nontreponemal test in several weeks. Comparative studies are of particular importance in populations with a low prevalence of syphilis, including pregnant women who are screened as part of routine prenatal care, to guide clinical management of women and infants born to mothers with discordant sera.
To reduce the risk for transmission of HIV through living-donor organ transplantation, transplant centers should screen living donors for HIV as close to the time of organ recovery and transplantation as possible, using sensitive tests for both chronic and acute infections, namely, serology and nucleic acid testing (NAT). The donor's kidney was removed without complication; no blood products were administered around the time of transplant. The gp41, polymerase, and p17 sequences from the donor and recipient were nearly identical, with greater than 98% identity and tight phylogenetic clustering, suggesting that the two viruses are highly related. Because NAT cannot detect HIV infections during the eclipse period, all transplant candidates should be informed during the evaluation process that despite donor screening, a very small risk remains that they could acquire HIV or other infections as a result of transplantation. Additionally, based on the finding that immunoglobulin M (IgM) antibodies are produced within 2 weeks of infection (3), the utility of IgM treponemal testing for diagnosis of primary syphilis and evaluation of infection in asymptomatic, seropositive, untreated persons should be investigated. Furthermore, clinicians should inform transplant candidates of the potential risks for disease transmission and advise donors during evaluation of their obligation to avoid behaviors that would put them at risk for acquiring HIV before organ donation. Therefore, all living donors should be informed about modes of transmission and risk factors for HIV infection and should be counseled to avoid behaviors that would place them at risk for acquiring HIV infection before organ recovery (3). For deceased potential donors who screen negative by HIV serology, NAT can reduce the risk for HIV transmission from an undetected infection during the window period by approximately 68% (7,8). Among discordant sera, the rate of nonreactive confirmatory treponemal tests was 2.9 times higher in a population with low prevalence of syphilis, suggesting that the low-prevalence population had a higher percentage of false-positive test results. Nontreponemal antibody tests can be nonreactive early in the course of infection and in late stages of disease, and often become nonreactive (serorevert) after treatment of early infection (1). Approximately 1 year after the transplant, the donor visited his primary-care physician requesting repeat screening for STIs. Although CDC continues to recommend the traditional algorithm with reactive nontreponemal tests confirmed by treponemal testing, in this report CDC offers additional recommendations if reverse sequence syphilis screening is used. Treponemal antibodies appear earlier than nontreponemal antibodies and usually remain detectable for life, even after successful treatment. The transplant team learned of the living donor's new HIV diagnosis during his follow-up visit 1 year after the transplant. Public Health Service guidelines have recommended serologic screening for HIV infection in potential organ donors since 1994 (3). A forthcoming updated revision to those guidelines, currently in draft form, likely will include consideration of NAT in addition to serology to screen for HIV infection in all potential organ donors, living and deceased.

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