Canadian study highlights need for equity for people with HIV in kidney transplantation

Aleksandr Lupin/

People with HIV in need of a kidney transplant in Canada’s most populous province were more likely to die before receiving an organ than people without HIV between 2007 and 2020, highlighting the need for greater equity in kidney transplantation, say Canadian researchers in a study published in the journal Open Forum Infectious Diseases.

People with HIV have a higher risk of end-stage kidney disease than the rest of the population. A study which compared the Danish national HIV cohort to the Danish population found that the risk of end-stage kidney disease requiring dialysis was at least three-and-a-half times higher for people with HIV.

Antiretroviral treatment reduces the risk of kidney damage caused by HIV (nephropathy) but doesn’t eliminate it. People who have been living with HIV for many years may have experienced a progressive decline in kidney function. Older age or South Asian, African or Afro-Caribbean heritage also raise the risk of chronic kidney disease.



Dialysis is a type of treatment that is used when the kidneys are not working properly. The dialysis machine acts as an artificial kidney, filtering excess fluid and waste products from the blood.


The presence of one or more additional health conditions at the same time as a primary condition (such as HIV).

end-stage disease

Final period or phase in the course of a disease leading to a person's death.


The result of a statistical test which tells us whether the results of a study are likely to be due to chance and would not be confirmed if the study was repeated. All p-values are between 0 and 1; the most reliable studies have p-values very close to 0. A p-value of 0.001 means that there is a 1 in 1000 probability that the results are due to chance and do not reflect a real difference. A p-value of 0.05 means there is a 1 in 20 probability that the results are due to chance. When a p-value is 0.05 or below, the result is considered to be ‘statistically significant’. Confidence intervals give similar information to p-values but are easier to interpret. 

boosting agent

Booster drugs are used to ‘boost’ the effects of protease inhibitors and some other antiretrovirals. Adding a small dose of a booster drug to an antiretroviral makes the liver break down the primary drug more slowly, which means that it stays in the body for longer times or at higher levels. Without the boosting agent, the prescribed dose of the primary drug would be ineffective.

Dialysis can filter out waste products and fluid if kidney function fails but people receiving dialysis have reduced life expectancy and will usually need a kidney transplant, especially if they are older.

Obtaining a transplant depends on the supply of organs and the opinion of doctors regarding the likelihood of transplant rejection, survival after a transplant and the potential for interactions between the medication used to enable the transplant and other medicines. All of these factors can make some doctors reluctant to offer a kidney transplant to a person with HIV.

Yet if people with HIV receive a kidney transplant, they are no more likely to experience organ rejection or die after transplantation than people without HIV, a study looking at 15 years of kidney and liver transplants at the University of California San Francisco found.

The extent to which people with HIV fail to receive kidney transplants, and the comparative outcomes of people with HIV and others after transplantation, are unclear.

To investigate these questions, transplant specialists and epidemiologists in Canada looked at all people who received kidney dialysis in the province of Ontario between 2007 and 2020, to assess the likelihood of receiving a kidney transplant, the risk of death and post-transplant outcomes according to HIV status. Half of all organ transplants in Canada take place in Ontario, the country’s most populous province.

Between 2007 and 2020, 40,686 people received dialysis. Of these, 173 were living with HIV. People with HIV were significantly younger (55 vs 68 years) and less likely to be female (22% vs 38%) than people without HIV.

The frequencies of five common conditions associated with end-stage kidney diseases (cancer, chronic obstructive pulmonary disease, type 2 diabetes, hypertension and heart failure) were lower in people with HIV than people without HIV. People with HIV had a higher burden of comorbidities than people without HIV (46% had at least five, compared to 33% of people without HIV).

Thirteen percent of people with HIV and 12% of people without HIV received a transplant during the follow-up period. There was no significant difference in the incidence of kidney transplant between people with and without HIV (40 vs 35 transplants per 1000 person-years of follow-up). When the analysis was confined to people on dialysis who had no contraindication to kidney transplant (26,107 people), there was no significant difference between people with and without HIV in the incidence of transplantation (55 vs 36 per 1000 person-years, p=0.07).

There was no significant difference in the pre-transplant death rate (57% vs 52%, p=0.12).

However, when the investigators compared the likelihood of transplant, that is, receiving a transplant before dying of any cause, they found that after controlling for age, sex, income and city of dialysis, people with HIV were over 50% less likely to receive a transplant (hazard ratio 0.46, p<0.001).

The lower likelihood of people with HIV receiving a transplant after entering dialysis did not appear to be related to place of residence, as a higher proportion of people with HIV lived in the greater Toronto area near major transplant centres. And although the proportion of people with HIV who had five or more comorbidities was higher, comorbidities associated with poorer transplant outcomes were less common in people with HIV.

"Concerns about interactions between immunosuppressive drugs used to prevent organ rejection and HIV medications may provide one explanation.

The researchers suggest that concerns about interactions between immunosuppressive drugs used to prevent organ rejection and drugs used in the treatment of HIV or related comorbidities may provide one explanation for why people with HIV had lower chances of receiving a transplant.

Most immunosuppressive drugs are either contraindicated or need to be used with careful monitoring alongside boosted protease inhibitors, boosted elvitegravir or the non-nucleoside reverse transcriptase inhibitors doravirine and efavirenz.

The researchers say that surveillance of access to transplantation is needed to reduce the gap between people with and without HIV. They note that recent studies in the United States and Central and Eastern Europe also show barriers to access and lower rates of transplantation.


Hosseini-Moghadem SM et al. Renal transplantation in HIV-positive and HIV-negative people with advanced stages of kidney disease: equity in transplantation. Open Forum Infectious Diseases, published online 16 April 2024 (open access).