The infant’s mother was diagnosed with HIV approximately six months before conceiving, and began antiretroviral treatment with a regimen of efavirenz, tenofovir and lamivudine six weeks prior to conceiving. Her infant received nevirapine prophylaxis for six weeks after birth and subsequently tested HIV negative.
The infant was referred for care at Wits Donald Gordon Medical Centre in Johannesburg at seven months of age. The infant required a liver transplant due to end-stage liver disease resulting from biliary atresia (a childhood disease in which the bile ducts are narrowed or blocked, leading to liver damage when bile cannot drain from the liver).
The average wait time for a paediatric liver transplant at Wits Donald Gordon Medical Centre is 49 days, but after 181 days a liver was still not available for transplant and the infant was admitted to hospital with life-threatening bleeding from varices (enlarged veins supplying the liver).
At this point the clinical team decided to seek ethical approval for the mother’s request to become a living donor. This procedure involves taking a portion of the donor liver rather than the whole liver.
The transplant was approved and took place when the infant was 13 months old. Methylprednisone was given as an immunosuppressant during the operation, and oral corticosteroids for six months after the transplant to prevent organ rejection. Tacrolimus was also prescribed and is still being taken by the infant, again to prevent rejection of the transplanted liver. To prevent HIV transmission, a regimen of raltegravir, lamivudine and abacavir was commenced the day before transplantation.
To monitor the infant’s HIV infection status, testing took place for HIV antibodies, HIV DNA and HIV RNA. The child tested negative in all respects prior to transplantation.
The child tested positive for HIV antibodies 43 days post-transplant on the Architect HIV antigen/antibody test, and continued to test positive to day 379, although antibody titres declined rapidly to almost undetectable levels, indicating a lack of HIV replication to stimulate antibody responses.
No HIV DNA or RNA was detected in plasma at any point. A Western Blot test performed 225 days after transplantation was indeterminate. The assay showed that antibodies to HIV core proteins p24, p40, p55 and p65 were detectable, but no antibodies to envelope proteins could be detected.
No proviral DNA could be detected in peripheral blood mononuclear cells or leukocytes sampled at day 225, suggesting either that no HIV-infected cells persist, or that so few cells had been infected, they were undetectable in the blood samples taken.