Dear Dr. Gonwa:
Thank you for
your letter concerning
the Centers for Disease Control and Prevention (CDC) guidelines
published in the Morbidity and Mortality Weekly Report
(MMWR), Volume 43, Number RR-8, entitled "'Guidelines
for Preventing Transmission of Human Immunodeficiency Virus
Through Transplantation of Human Tissue and Organs.'' I apologize
for the delay in responding to your letter.
Regarding your concern about the
questioning of potential donors and donor families, the issues
surrounding the determination of whether a donor meets behavior/history
exclusionary criteria are quite personal and could be viewed
as intrusive by grieving families considering cadaveric donation.
The CDC guidelines address this by acknowledging the time
constraints and that family members and close friends may
not always be able to provide an accurate social history.
However, the exclusion of HIV-infected but seronegative donors
relies on an accurate social and sexual history and is a
critically important step.
According to the
United Network for Organ Sharing (UNOS) Policy 4.l.l., Organ
Procurement
Organizations (OPOs) shall "obtain a history on each
potential donor in an attempt to determine whether the potential
donor is in a high risk group as defined by CDC." To
our knowledge, OPOs comply with this policy by reviewing
the potential donor's medical record, including the cause
of death; performing a bedside physical examination; and
interviewing the family about the donor's medical and social
history. We are confident that OPOs staff use discretion
in discussing these sensitive issues, and we are not aware
of any evidence suggesting that the family consent conference
discourages a family from donating. According to the Division
of Organ Transplantation, Health Resources and Services Administration
(HRSA), the number of donations has not decreased since the
CDC guidelines were published.
CDC does not agree
with your statement that post-transplant recipient testing
imposes a "significant
cost burden" on transplant programs. Since 1991, UNOS
has received information on 18 cases in which a transplant
recipient tested positive for HIV after a transplant. In
each case, the donor has been ruled out as the source of
infection. This "look-back" procedure reinforces
the safety of our country's organ transplantation system
and provides opportunities for early intervention for recipients.
According to HRSA, about 18,000 transplants are performed
annually; we do not believe that the annual cost of testing
is a significant burden for the transplant community, compared
with the public health benefits of being able to identify
recipients with HIV infection.
I appreciate your sharing the
concerns of the American Society of Transplant Physicians
with CDC.
Sincerely,
David Satcher, M.D., Ph.D.
Director
