Pharmacotherapeutic management of HIV in transplant patients

ABSTRACT

Introduction: In the last two decades, an increasing number of people living with HIV (PLWH) have undergone solid-organ and hematopoietic cell transplantation as a treatment of end-stage organ and hematological diseases, respectively. Although transplant outcomes are more than satisfactory, transplantation in PLWH is still challenging for clinicians because of concerns regarding potentially higher rates of infective complications, higher risks of allograft rejection, and drug–drug interactions between antiretroviral drugs and immunosuppressive agents.

Areas covered: This review provides an overview of transplantation in PLWH, with focus on the management of combination antiretroviral therapy in this population.

Expert opinion: Solid-organ and hematopoietic cell transplantations should be proposed without any reservation to all PLWH who may benefit from them. Particular attention should be paid to possible drug–drug interactions between antiretrovirals and immunosuppressive agents; moreover, when feasible, integrase strand transfer inhibitor-based antiretroviral regimens should be preferred to protease and non-nucleoside reverse transcriptase inhibitors. Considering the worse prognosis in HIV/hepatitis C virus (HCV) transplant recipients, treatment of HCV with new direct-acting antivirals (DAAs) represents a key issue in the management of this population. However, the timing of treatment (before or early after transplant) should be individualized by considering short-term prognosis, access to transplant, and comorbidities.

KEYWORDS:

• Antiretrovirals
• drug-drug interactions
• hematopoietic cell transplantation
• HIV
• immunosuppressants
• solid-organ transplantation

Article highlights

• The use of solid-organ and hematopoietic cell transplantation is increasing among people living with HIV (PLWH), and the prognosis is similar to that reported for uninfected populations.

• The main concerns regarding transplantation include pharmacological interactions between antiretrovirals and transplant agents.

• Integrase strand transfer inhibitor-based regimens should be preferred in all PLWH candidates and in those who undergo transplantation, when feasible.

• DAA-based regimens have revolutionized the treatment of HCV infection in coinfected transplant recipients; however, optimal timing (before or after transplantation) of HCV treatment in SOT candidates is not clearly defined.

• SOT from an HIV-positive donor to an HIV-positive recipient becomes a reality. In this patient population, outcomes of organ transplantation and risk of superinfection in the recipient with a resistant HIV strain from the donor need to be addressed.

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Acknowledgments

We would like to thank Editage for editing and reviewing this manuscript for English language usage.

Declaration of interest

V Spagnuolo has received speaker’s fees from Gilead Sciences, ViiV Healthcare, Merck Sharp Dohme, and Janssen-Cilag. A Castagna has received consultancy and speaker’s fees from Bristol-Myers Squibb, Gilead Sciences, ViiV Healthcare, Merck Sharp Dohme, and Janssen-Cilag. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

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Funding

This manuscript has not been funded.