People with HIV fare as well as those without it after liver transplants

Data presented at the Conference on Retroviruses and Opportunistic Infections (CROI 2026) held in Denver, US showed comparable long-term liver transplant outcomes after 15 years between people with and without HIV. 

“These results are encouraging and support liver transplants in people with HIV when clinically indicated,” Dr José Miró, from the Hospital Clinic of Barcelona, Spain, told the audience.

End-stage liver disease and liver cancer are recognised complications of advanced hepatitis C and/or hepatitis B co-infection and may necessitate a liver transplant. Previously, short- and mid-term data comparing outcomes to those without HIV have been reported, but long-term data are rare, with no European studies having been done.

Prior research from a cohort in San Francisco only included a single centre in the study, with no co-morbidity data. Thus, Miró and colleagues set out to compare long-term outcomes, while also accounting for co-morbidities that may have an impact on outcomes.

The study

Researchers performed a retrospective case-control study including 340 people (85 with HIV) from four Spanish centres. They had received liver transplants between 2003 and 2012 and were followed until mid-2025. Possible outcomes included surviving with no further transplants, graft failure requiring re-transplant, and death.

Participants with HIV were closely matched in a 1:3 ratio to those without HIV to ensure fair comparisons. This included by gender, calendar year of transplant (±1 year), age (±12 years), hepatitis C and B co-infections, and the presence of liver cancer.

The median age of people of both groups was similar, with an overall median of 48, with many more men in the study, at 82%. In terms of hepatitis C and B co-infection, most people in both groups had hepatitis C only (85% to 96%), very few presented with either hepatitis B only, or both viruses. In terms of hepatitis C genotypes, most people presented with genotype 1. Here, the groups were significantly different. For instance, while 21% of people with HIV had genotype 4 hepatitis C, only 4% of HIV-negative people did. At the time of their liver transplants, most participants tested positive for hepatitis C RNA (83% to 90%). As groups were matched on liver cancer, in both it was at approximately 30%. Most people with HIV in the sample acquired it through injecting drug use (72%).

Comparable number of survivors

Participants were followed for a median period of approximately 12 years, with some followed for as long as 16 years. Half of all participants died over this period. This was similar across groups: 46% of people with HIV died, while 52% of HIV-negative people died after receiving their transplants. Very few – under 5% – had re-transplantation followed by death.

Around 40% of deaths in both groups were caused by the recurrence of underlying disease – either hepatitis C relapse, or a recurrence of liver cancer. Overall, there were no statistically significant differences for cause of death between the groups.

The introduction of direct-acting antivirals in 2015 significantly reduced deaths caused by hepatitis C relapse. Prior to 2014, this was the cause of 33% of deaths in HIV-negative people, but fell to 16% after 2015. People with HIV appeared to derive the most benefit from the introduction of these direct-acting antivirals, as deaths due to hepatitis C relapse fell from 56% to 6% before and after 2015. In addition, all active hepatitis C infections were eradicated after 2015.

The numbers of survivors were not statistically different: 47% in the HIV group and 42% in the HIV-negative group. Very few had re-transplantation, around 2.5% of all participants. There was also no statistically significant difference in graft survival between the two groups.

Predictors of death and graft failure and co-morbidities

There were very few factors that stood out as predicting either death or graft failure, when considering the full picture. For death, these were: male sex, positive hepatitis C RNA pre-transplant, and having hepatitis C genotype 1. People with positive hepatitis C RNA were at a nearly three times greater risk of dying – the strongest risk factor (Hazard Ratio, HR, 2.75, 95% Confidence Interval, CI, 1.43-5.28).

This pattern was fairly similar for graft failure, except that male sex was not a significant predictor when accounting for other factors. Here, positive hepatitis C RNA pre-transplant was associated with nearly twice the risk of experiencing graft failure (HR 1.92, 95% CI 1.08-3.42).

In terms of co-morbidity profiles, many people in both groups presented with infections (around 45%). Approximately a third presented with a non-AIDS defining cancer, including 10% of both groups who had liver cancer. Over half of all participants had heart disease – 55% in the group with HIV and 64% in the HIV-negative group. None of the co-morbidity profiles differed significantly between groups, except for pre-diabetes and diabetes, with more HIV-negative people presenting with both.

Among people with HIV, most gradually moved onto integrase inhibitor regimens after liver transplant. Most remained undetectable over time, with over 85% with viral loads below 200. CD4 counts tended to rebound over time – from a post-transplant low, likely due to anti-rejection medications – but the mean CD4 count of all participants did not exceed 500 over the study duration.

The results of this study indicate that people with HIV should not automatically be deemed poor candidates for liver transplants. Instead, factors such as untreated hepatitis C or relapse should be of chief concern when it comes to predicting outcomes.
 

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