Surgeons at Duke University recently performed North Carolina's first transplant of an organ from an HIV-positive donor into an HIV-positive recipient, an operation that until recently wouldn't have been legal in the state.
Their patient, retired Tennessee nurse Stanley Boling, received a new liver in December and is now going through the usual battery of follow-up checks that accompany transplant surgery. So far, his recovery is going according to plan.
"It was the best Christmas present anybody could possibly ask for," Boling said in an interview this week before traveling from Knoxville to Durham for his latest follow-up. "Anyway, for me it was."
Boling's doctors are similarly enthusiastic, not just because he's doing well but because they think a door's opening that will ease some of the bottlenecks that limit the number of kidney and liver transplants they can do.
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Now that HIV-positive donors are able to contribute organs to other people who have the virus, wait lists for everyone who needs a transplant will become that much shorter, said Cameron Wolfe, a Duke School of Medicine infectious-disease specialist who's worked with Boling and his surgeons.
The recovery from a transplant plays out over a "multiple-year timeline, so we're here in the first few months acknowledging that things so far have gone well but we've got a long way to go," Wolfe said. "But he's at home and starting to live his life the way he wants to. That's the goal of this sort of work."
Until recently, however, a transplant like Boling's wouldn't even have been legal. The federal government for many years barred people who are HIV-positive from donating organs. And North Carolina, like many other states, had its own ban on such donations.
Matters began to change in 2013, when Congress passed and then-President Barack Obama signed the HIV Organ Policy Equity Act. Also known as the HOPE Act, it rescinded the outright federal ban on HIV-positive organ donations in favor of allowing them as part of clinical research.
The bill got through Congress in about nine months, and received bipartisan support along the way from legislators who, like Wolfe, noted that it could potentially shorten waiting lists for all organ donations.
By then, doctors in South Africa had shown it was possible to match HIV-positive donors with HIV-positive recipients, work that along with the matching that precedes any transplant also requires a look at how the donor's virus could affect the recipient's and change his or her treatment program.
The South Africans had good reason to forge ahead because the rates of HIV infection there "are so different to not think about HIV patients as donors would leave a lot of transplant science floundering," Wolfe said.
But their work helped show that if a recipient's HIV infection is under control, "their outcomes are really good" after an HIV-to-HIV transplant, he said.
The removal of the Congressional roadblock didn't immediately green-light procedures here, as physicians and regulators also had to remove North Carolina's separate ban on HIV-positive donations. Duke took the lead in lobbying for the change, which took place in 2016 while former State Health Director Randall Williams still worked in the N.C. Department of Health and Human Services.
Williams, who trained at UNC-Chapel Hill, has since moved on to a similar post in Missouri. But while he still worked in North Carolina, he proved willing to use his authority to make the necessary change to the state's administrative code, Duke officials said.
He "thought it was a reasonable place to move forward, particularly given that HIV-to-HIV transplants are still "very much considered clinical research" that receives a lot of oversight both at Duke and the federal level, Wolfe said.
For at least the next two to four years, such transplants will only be performed in "research settings and hospitals" that have an OK from federal regulators, Wolfe said, adding that for the Carolinas at least and likely a couple other states, that's "only Duke."
Boling, who's been HIV positive since 1989, developed liver problems in early 2016. Eventually, his gastroenterologist told him his liver function had fallen to the point he needed a referral for a transplant.
"I said I didn't think I was eligible for one," Boling said. "And he said, 'Oh no, you are.' "
The initial preparations involved signing up to participate in a program sanctioned by the HOPE Act, a process Wolfe and his staff walked Boling through almost line by line. He went on the waiting list for a transplant in September and by mid-November the possibility of actually undergoing the surgery "became very real."
Doctors performed the transplant on Dec. 22, and Boling remained in Durham until the end of January so they could oversee his immediate recovery and rehabilitation. Since returning home to Knoxville, his home-city physicians have begun overseeing more and more of the process.
"He made it through complicated surgery," Wolfe said, summarizing Boling's progress to date. "That's always the first battle. He's immunologically tolerating the transplant well, he's tolerating the medicines and from my perspective, there's been no signs the donor virus has caused us any problems at all."
And the case underscores that it's now possible for someone who's HIV-positive to become an organ donor.
From where it'd "never been something on the table to even discuss, it's kind of an empowering and normalizing discussion for people to have," Wolfe said.