Donegan predicted that the New York case would generate considerable discussion about "ways to make sure it doesn't happen again." Given that the New York donor became infected through unsafe sex, she said, "They're going to need to heavily counsel these donors. We're going to have to document that there's a trained counselor counseling these donors, and that they not only counsel them when they agree to donate, but they counsel them again before the actual transplant, giving them a private way to back out of the donation if need be."
The CDC's new recommendation appeared in an account of the New York case published in this week's Morbidity and Mortality Weekly Report. That report said that the donor was screened "10 weeks before organ procurement, but was not rescreened close to the date of transplant surgery."
Dr. Matthew Kuehnert, director of the CDC's Office of Blood, Organ and Other Tissue Safety, said the New York case represented a "sentinel event" that "brought to light that we don't have a national policy" on how to effectively prevent HIV transmission from living organ donors.
Routine antibody screening since 1985 has made HIV infection a rare complication of organ transplantation -- so much so that the New York case represents the first documented incident of HIV being transmitted by a living organ donor in this country since 1985 -- and the first such case documented worldwide since 1989, when a transplant-related HIV case occurred in Italy, Kuehnert said.
However, he said he suspected "there are cases out there that are unrecognized," because they never come to the attention of public health officials. "The nation would benefit from a system to track transplant-related adverse events similar to the surveillance system we have for transfusion-related problems," he said.
"There is no national policy on the type of testing or the timing of testing for living donors in the United States," Kuehnert said. "It's a blind spot for organ donation because the donor pool is increasingly being made up of living donors." The number of living donors has risen steadily in recent years, from 1,829 in 1988, to 6,609 in 2009, according to CDC figures.
To fill in that blind spot, he said the CDC recommended that blood tests at the initial evaluation of potential donors be followed by additional blood tests and nucleic acid testing within 7 days of a transplant operation. That's one day less than the minimum of 8 days scientists believe it takes for a new HIV infection to become detectable with nucleic acid tests.
Speaking by telephone from Varese, Italy, where he was attending a conference on transplant infection, Kuehnert said that right now, transplant centers don't do nucleic acid testing on living donors.
Dr. Michael Shapiro, chief of organ transplantation at Hackensack University Medical Center in New Jersey, explained that part of the reason is that the centers can obtain health histories by interviewing living donors. But, he said, the quality of those histories depends upon full disclosure. "I think what Ronald Reagan said is applicable: 'trust but verify'...No one is doing an adequate job of taking a psychosocial history of a potential donor if they haven't asked about high-risk behavior."