Canadian physicians’ knowledge, attitudes, and beliefs about the risk of HTLV infection in solid organ transplantation

Dear Editor,

Donor screening prior to solid organ transplantation (SOT) includes human T-lymphotropic virus (HTLV) in some jurisdictions, with a positive result deeming that the organ not be used or that it may only be used in exceptional circumstances. Recent guidelines on HTLV in SOT (1) recommend that routine screening not be performed in locations of low seroprevalence in order to reduce organ wastage; however, they support testing of living donors or donors who have risk factors for infection. The low Canadian HTLV seroprevalence of approximately 12 per 100,000 (2) and the low likelihood of causing disease in infected non-transplant individuals (up to 5%) (3), prompted us to examine the attitudes of physicians toward HTLV risk in SOT.

With approval from the Capital District Health Authority/ Nova Scotia Health Authority research ethics board, a web-delivered survey (Opinio, ObjectPlanet Inc., Oslo, Norway) was distributed to approximately 459 physicians across 17 academic medical centres in Canada. The survey was available for 4 months, and assessed physicians’ demographics, HTLV knowledge, and clinical decision-making surrounding HTLV in SOT (survey available in Supplemental Appendix 1). Hypothetical questions regarding SOT with the risk of HTLV were presented using standard gamble (SG) and time trade-off (TTO) methodologies (4,5), which allow the participant to “gamble” accepting an organ infected with each virus, or to “trade” longevity to ensure that an organ is not infected. Descriptive statistics were reported, with the denominator reflecting the number of responses to that individual question, expressed as n.

Participants were contacted via requests to the administrative staff of the relevant specialty programs from Canadian medical schools. Sixty-eight clinicians participated (response rate approximately 14.8%), with participants from the Eastern (18.5%), Central (35.4%), and Western (46.2%) provinces. Overall, 13 medical and surgical specialties were represented, with the largest group being Infectious Diseases physicians (25.8%), followed by Nephrologists (21%), and General Surgeons (9.7%). Approximately 38% of participants reported no clinical duties relating to transplant in the past 12 months. Of those who did report transplant management over the past year, approximately 61% reported that one-quarter or less of their clinical duties were related to transplant. Most respondents correctly identified HTLV’s association with adult T-cell leukemia (ATL) (94.9%, n = 39), and approximately 40% of respondents thought the likelihood of developing ATL was 2% or 5% (n = 37). Most recognized HTLV-associated myelopathy (HAM) (89.7%) as being caused by HTLV (n = 39), and more than half thought the likelihood of developing disease was 2% or less (n = 38). Regarding HTLV seroprevalence in Canada, 25.6% thought that 1 person per 100,000 was correct, and 30.8% chose 10 people per 100,000 (n = 39).

When asked about HTLV risk acceptance in recommending SOT without screening the donor, 26.1% would recommend proceeding with SOT regardless of prevalence in the population (n = 24). At a prevalence of 10 people per 100,000, 45.8% would recommend SOT without testing (n = 25). Just over half of respondents rated donor HTLV screening as important or extremely important in those who use intravenous drugs, those who have had multiple blood transfusions, and those who come from Africa, the Caribbean, and Asia (n = 28–29). For SG and TTO scenarios related to personal acceptance of a risk of HTLV, 41.7%–60.9% of participants (depending on the organ) would accept a SOT regardless of risk, if it were to extend their life by 20 years (n = 23–25) (Figure 1). Over 60% of respondents elected not to exchange any years of longevity to ensure an HTLV-negative organ (n = 22–23).

Figure 1:

Risk acceptance of SOT-related HTLV infection, based on organ. In this figure, (a) shows the proportion of physicians who would accept SOT to extend their longevity by 20 years, based on the likelihood of the organ being HTLV-positive (n = 23–25), and (b) shows the number of years of longevity physicians would sacrifice to ensure an HTLV-negative organ (n = 22–23).

SOT = Solid organ transplantation; HTLV = Human T-lymphotropic virus

These results demonstrate a tendency toward accepting the risk of HTLV infection, but not such that the participant group would completely abandon screening. Although we recognize the study limitation of self-selection bias and relatively low rate of completion, this report echoes our prior work in HTLV risk acceptance in SOT among patients, in demonstrating a reluctance to eliminate HTLV screening of donors (6). A relative lack of data demonstrating the outcomes of SOT recipients who receive non-screened or HTLV screen-positive organs likely contributes to the attitudes and beliefs of the participants. While awaiting further data, these responses provide points of discussion when debating the merits of screening SOT donors for latent viral infections.

Funding Statement

This work was funded by a research grant from the Capital District Health Authority/Nova Scotia Health Authority Research Fund.

Funding:

This work was funded by a research grant from the Capital District Health Authority/Nova Scotia Health Authority Research Fund.

Disclosures:

The authors have nothing to disclose.