The HIV-positive patient who received Cedars-Sinai’s first HIV-positive donor kidney had previously been listed on the waitlist for more than two years and was not expected to receive an organ offer in the near future. Once listed on the HIV-positive organ list, the patient received an organ offer in less than a week.

This patient and the first HIV-positive liver recipient are doing well following their transplants, which were made possible by the Comprehensive Transplant Center’s new HIV-to-HIV transplant program, currently the only-of-its-kind in the Los Angeles area.

“We brought together a team of liver and kidney transplant surgeons, nephrologists, hepatologists, transplant pharmacists, infectious disease experts, transplant coordinators and more to launch this program,” said transplant surgeon Tsuyoshi Todo, MD, who served as the lead surgeon on both the first HIV-to-HIV-positive kidney and HIV-to-HIV-positive liver transplant at Cedars-Sinai.

New HOPE for Transplant Recipients

Cedars-Sinai’s HIV-to-HIV transplant program represents a dramatic shift from just over a decade ago, when federal law prohibited organs from donors with HIV from being transplanted into any patient, including those where were also HIV-positive.

That changed in 2013 with the passage of the HIV Organ Policy Equity (HOPE) Act, which allowed clinical researchers to study HIV-to-HIV transplants. After years of research documented the safety and effectiveness of HIV-to-HIV transplants, the rule was amended in 2024, removing the strict research requirements, and Cedars-Sinai quickly formed a multidisciplinary committee of experts to bring the institution’s HIV-to-HIV program to life.

“Everyone has an important role to play to help patients through this process,” Todo said.

Support for HIV-Positive Patients

Thanks to advances in antiretroviral therapy, people with HIV are living significantly longer and healthier lives, which opens the chance they experience end organ failure due to other comorbidities.

“The vast majority of patients we see living with HIV have their disease well controlled, often with only one pill a day and minimal side effects,” said Christopher Foltz, MD, lead infectious disease specialist for the HIV-to-HIV transplant program at Cedars-Sinai. “In a sense, it’s almost become easier to manage HIV than it is other chronic conditions like hypertension and diabetes.”

Foltz connects with every potential HIV-positive organ recipient as a pre-evaluation to ensure their HIV is managed and, working with Cedars-Sinai pharmacists, determines whether there are any changes that will need to be made to their HIV medication regimen once they are also taking post-transplant immunosuppressant drugs. He also closely follows each patient after their transplant to monitor their HIV viral load and ensure it remains undetectable.

“The first six months post-transplant is when the immune system is being hit the hardest,” Foltz said. “We will monitor the patient’s HIV closely during this time, but eventually, they’ll be able to get back to monitoring once or twice a year, like they would have been doing before.”

Foltz hopes this program encourages more people to register as organ donors as well.

“If you were to ask most people living with HIV, they probably would assume they’re not eligible to be an organ donor, but that is no longer the case,” Foltz said. “Organ donations are lifesaving, and I think it can be really uplifting to them to know they can support others in their community in this way.”

Reduced Wait Times

More than 95,000 patients are on the kidney transplant waitlist, according to data from the Health Resources & Services Administration (HRSA). Most people will wait three to five years for a deceased donor kidney, but that time frame can significantly increase in densely populated areas with a higher demand.

“In Southern California, many patients are actually looking at eight to 10 years on the transplant waitlist, but for HIV-positive patients, being listed on a separate list for HIV-positive donor organs can drastically reduce their wait,” Todo said. “This translates to several years that these patients will not have to be on dialysis, not only getting them back to their normal life more quickly, but also saving hundreds of thousands of taxpayer dollars.”

While patients with kidney failure can live many years on dialysis, there is no similar treatment for patients with liver failure. These patients are listed on the transplant waitlist based on their Model for End-Stage Liver Disease (MELD) score, a number from six to 40 that predicts a patient’s risk of death from liver failure in three months.

“Patients in the Los Angeles area will typically need to have a MELD score in the low 30s in order to receive a transplant, but by accepting an HIV-positive organ that would have otherwise gone to waste, our HIV-positive patient was able to be transplanted with a much lower score,” Todo said. “In the standard circumstance, they would have had to wait significantly longer and get much sicker before receiving an organ.”

Looking Toward the Future

With the first few HIV-to-HIV transplants successfully completed, the team looks forward to making this option available to more HIV-positive patients moving forward.

“At Cedars-Sinai, we strive to be on the leading edge of medical innovation to provide outstanding patient care and support to as many patients as possible, and our HIV-to-HIV transplant program is an example of that effort,” said Irene Kim, MD, director of the Cedars-Sinai Comprehensive Transplant Center. “To be able to transplant more individuals and help them live longer, healthier lives is an honor.”

Read more from Cedars-Sinai Stories and Insights—Being Patient: The Delicate Timing of Organ Transplantation

The study found that rates of STIs dropped by about two-thirds after the clinic began prescribing DoxyPEP, while testing frequency remained the same.

Foltz, who was not involved in the research, told Medscape the findings were notable because they included people who often struggle to access preventive care.

“The main takeaway is that this study really focused on higher-risk populations that traditionally would likely not have as easy access [to DoxyPEP] for numerous reasons,” Foltz said. “This has long been the challenge with any preventive measure: How do you get in to the people who need it the most?”

Foltz told Medscape that clinics should build clear protocols to make sure everyone at risk is offered DoxyPEP. He said protocols can help “remove any provider bias” and called “for continued efforts to educate high-risk populations.”

He noted that early concerns from the medical community about side effects and bacterial resistance have largely been addressed. The bigger obstacle, he said, is access.

“Unfortunately, high-risk populations typically live in areas with less access to general healthcare,” Foltz told Medscape. He pointed to mobile health clinics and telemedicine as creative ways to expand education and prevention.

The remaining challenge, he added, is determining how to “re-create this on a much larger scale so we can really get the word out about Doxy and make it available to all of those who need it.”

Clinicians recommend that a single dose of doxycycline, taken as DoxyPEP within 72 hours of unprotected sex, can help prevent certain bacterial STIs, but it should not replace condoms.

Read the complete article from Medscape.

Based on results from new clinical trials, the Centers for Disease Control and Prevention (CDC) recently issued proposed guidelines for using doxycycline to reduce the risk of a chlamydia or syphilis—and possibly gonorrhea—infection among sexually active adults. Experts say new preventive approaches are critical to control the widening STI epidemic, fueled in part by the disruption in healthcare services during the height of the COVID-19 pandemic.

“Even before COVID started, we had seen a significant increase in STDs [sexually transmitted diseases], both internationally and here locally in California,” said Christopher Foltz, MD, an infectious disease specialist at Cedars-Sinai. “Syphilis has been climbing at the highest rate with a significant increase among pregnant women and men who have sex with men.” 

Growing Problem

Syphilis cases among men who have sex with men rose 7% from 2020 to 2021, according to the CDC. Syphilis rates among women jumped 55.3% from 2020 to 2021, and 217.4% from 2017 to 2021, which has led to the birth of more babies with the disease.

People with syphilis often don’t have symptoms, Foltz said, and when they finally visit a doctor, they may have been infected for months—or even years—without knowing it. Undiagnosed long-term infections can lead to permanent complications, including blindness and permanent neurologic damage.

“That's what we're trying to prevent—these kinds of catastrophic long-term complications from undiagnosed STIs,” Foltz said. “If we can prevent infections with a relatively safe and easy-to-take antibiotic, the overall number of new infections will ultimately decrease.”

Old Drug, New Use

Doxycycline has long been a go-to treatment for acne, skin infections, illnesses spread by tics and pneumonia. The drug had been on the radar of physicians treating STIs for years, but previous clinical trials hadn’t shown it would be effective as a preventive therapy. Physicians have become increasingly hesitant to prescribe antibiotics when they’re not needed amid a rise in antibiotic-resistant bugs.

“Bacteria can figure out how to avoid being killed by antibiotics,” explained clinical pharmacist Greg Marks, PharmD, coordinator of the Antimicrobial Stewardship program at Cedars-Sinai Medical Center, which closely tracks the use of antibiotics in the hospital. “In general, the more we use antibiotics, the more concerned we are about resistance.”

But new trial results showed doxycycline could be an effective new tool to limit the spread of syphilis and chlamydia if taken as a single 200-milligram dose within 72 hours after unprotected sex, Marks said. Using doxycycline to prevent gonorrhea showed some promise but yielded mixed results.

Only one dose of the antibiotic is necessary in a three-day period to help avoid these bacterial infections, even if having sex with multiple partners. The strategy, dubbed “Doxy on Demand” or “Doxy-PEP” (post-exposure prophylaxis), is similar to taking the morning-after pill to prevent pregnancy after unprotected sex. But this new treatment isn’t a reason to ditch condoms.

“This by no means is a way to offset the use of condoms,” Foltz cautioned. “We absolutely encourage condom use to prevent against other STDs and HIV [human immunodeficiency virus] as an added barrier of protection for prevention.”

Foltz said the people most likely to benefit from this new strategy are those who have had STDs recently, those taking HIV medications or medications to prevent the spread of HIV, and members of the LGBTQ+ community, which tends to experience higher rates of certain STIs.

Pregnant women should generally avoid the drug, Marks said, as well as people allergic to tetracyclines, a class of antibiotics. He and Foltz encouraged patients to speak with a physician about whether doxycycline might be right for them.

“If you're actively having sex and not using condoms 100% of the time, which is the reality out there, this strategy could be appropriate for you,” Foltz said. “It comes down to each person’s individual risk level, something that you should discuss with your physician.”

Read more on the Cedars-Sinai Blog: Gaining Ground on HIV/AIDS