Immunosuppression in HIV-Positive Heart Transplant Recipients During the Post–COVID-19 Era

To the Editor:

With great interest, we read the article published by Doberne and colleagues¹ regarding heart transplantation outcomes in HIV-positive (HIV+) and HIV-negative (HIV–) recipients. We commend the authors for their important work reporting no differences in survival among these 2 patient populations. Propensity score matching and Cox proportional hazards modeling both supported the conclusion that HIV+ recipient status was not an independent predictor of posttransplant mortality. Additionally, HIV+ recipients experienced higher rates of acute rejection and treatment with antirejection medications before discharge.

Although 5-year posttransplant outcomes suggest similar rates of survival among HIV+ and HIV– recipients, the elevated risk of acute rejection in the former should be highlighted. Regarding this patient population, treatment with more potent immunosuppressants like high-dose corticosteroids has shown efficacy in treating acute organ rejection.² This raises a critical issue that should be emphasized as an additional contraindication to transplanting HIV+ recipients, especially while there remains a risk for coronavirus disease 2019 (COVID-19). Recent studies have demonstrated diminished levels of spike-specific antibodies in immunosuppressed individuals who received the COVID-19 vaccine.³ This is concerning for 2 reasons: 1) protection from COVID-19 is positively correlated with neutralizing antibody titers⁴ and 2) mass vaccination has prompted full reopening and lifting of mask mandates despite underwhelming vaccination rates in several regions across the United States. Immunosuppressed individuals are subsequently placed at greater risk for morbidity and mortality with exposure to SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2). It should be noted that a comprehensive pretransplant evaluation ensures up-to-date vaccination status before initiating immunosuppressive therapy. Nevertheless, given the emergence of several variants of concern capable of escaping polyclonal antibody responses,⁵ enhanced COVID-19 disease continues to be a threat to the immunosuppressed. Whether COVID-19-associated mortality risk influences long-term survival in HIV+ transplant recipients remains to be determined. However, we urge the transplant community to consider these factors when evaluating management strategies for their patients before transplantation.