Writer and activist Larry Kramer, who has AIDS and hepatitis B, has joined 18,646 patients on the national liver transplant waiting list. Like Kramer, a significant number of people with HIV are also infected with hepatitis B or C or both. A few years ago, organ transplants for people with HIV were unthinkable, since they were not expected to live long enough to justify receiving a scarce donor organ. But things changed when the 1996 arrival of combination drug therapy markedly improved the prognosis for people with HIV. Initial reports of HIV-positive people who underwent the procedure also indicated that they tolerated the required immune-suppressing drugs better than doctors had anticipated.

As a result, many surgeons say it is not ethical to deny transplants to HIV patients; however, some doctors say such transplants should be done only as part of rigorously designed studies to determine whether the procedure is truly effective.

University of Pittsburgh transplant surgeon Dr. John Fung said that 14 liver transplants have been performed on HIV-positive patients at Pittsburgh and the University of Miami during the last four years. Twelve patients are still alive. One-year survival approaches 90 percent, which is comparable to that for recipients without HIV.

Paying for the expensive procedure is another matter entirely. Boston AIDS activist Belynda Dunn, who has HIV and hepatitis C, was denied coverage for the operation by her HMO. Boston Mayor Thomas M. Menino started a fund and helped to raise several hundred thousand dollars to help Dunn and others in her situation; it enabled her to sign up for the Pittsburgh transplant list.

Dr. Michelle E. Roland, an HIV specialist at the University of California at San Francisco, said that calling liver transplants for HIV-positive people either "experimental" or "routine" glosses over a host of complications and subtleties. "When insurers say there are no efficacy studies of liver transplantation for people with HIV, that is an absolutely true statement," she said. At the same time, "We want insurers to reimburse for the clinical costs of transplanting these patients."

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