Access to the Kidney Transplant Waitlist for People With HIV

T Advisory Committee on Blood and Tissue Safety and Availability recently voted to remove the statutory National Institutes of Health research criteria and institutional review board requirements for performing kidney transplantation using kidneys from donors with HIV. This policy change may subsequently increase utilization of such organs. Despite excellent kidney transplant outcomes, single-center studies have demonstrated significantly lower kidney transplant waitlist addition rates for people with HIV (PWH) in the United States as compared with those without HIV, a requisite step for deceased donor kidney transplantation. Should adoption of transplantation using kidneys from donors with HIV increase following the implementation of this policy, understanding waitlist addition nationally is imperative. Acknowledging the lack of granularity in HIV-specific data, we used the United States Renal Data System and accompanying Medicare claims data to identify a cohort of PWH (January 1, 2007–December 31, 2016) with end-stage kidney disease (ESKD) and compared waitlist addition rates among PWH with ESKD patients without HIV. This study was approved by the Institutional Review Board at the University of Alabama at Birmingham. Among 602 006 incident patients whose primary payer was Medicare, HIV status was defined using the Chronic Conditions Data Warehouse algorithm (sensitivity: 93.2%; specificity: 99.4%). PWH with claims for an opportunistic infection within 90 d of dialysis initiation were excluded. Cox proportional hazards and Fine and Gray competing risks regressions were used to examine the likelihood of waitlist addition. The 6250 PWH were younger, more commonly African American, and more commonly reported alcohol dependence, drug dependence, and tobacco use. Cumulative incidence of waitlist addition within 5 y of dialysis initiation was 11.1% among PWH and 15.3% among ESKD patients without HIV. Following adjustment for demographics, comorbid conditions, and geography, HIV was associated with 52% lower likelihood of waitlist addition (adjusted hazard ratio: 0.48; 95% confidence interval, 0.43-0.52; P < 0.001; Table 1). After accounting for competing risks of death and living donor kidney transplantation before waitlist addition, a similar inequity was observed (adjusted subdistribution hazard ratio: 0.45; 95% confidence interval, 0.42-0.49; P < 0.001). Letter to the Editor