Beyond HIV Status: Accounting for Ethnicity and Socioeconomic Factors in Kidney Transplant Outcomes

The need for solid organ transplantation is rising among people living with HIV (PLWH) as advances in antiretroviral therapy have transformed HIV into a manageable chronic condition and extended life expectancy. As a result, PLWH are now more likely to experience chronic complications such as end-stage kidney disease, where transplantation offers the best opportunity to improve both survival and quality of life.1 However, this growing demand coincides with persistent organ shortages, and PLWH still face unique barriers to transplant access. Prior studies have demonstrated that kidney transplantation in this population achieves comparable long-term survival and graft outcomes when viral suppression and immunologic control are maintained.1,2 Despite this progress, critical gaps remain in understanding how socioeconomic factors and ethnicity affect outcomes, key variables that intersect with HIV status but are rarely rigorously examined in transplant research. In this issue of Transplantation, Gray et al3 present an important national population-based cohort study examining kidney transplant outcomes in HIV-positive versus HIV-negative recipients using UK National Health Service Blood and Transplant Registry data from 2005 to 2022. The authors analyzed 30 013 recipients across 23 UK centers, including 244 HIV-positive individuals. They compared graft and patient survival, delayed graft function, acute rejection, and 12-mo graft function between HIV-positive and HIV-negative recipients. The authors critically adjusted for 2 often-overlooked variables: ethnicity and socioeconomic deprivation, as measured by the UK Index of Multiple Deprivation (IMD). Similar to prior studies comparing HIV-negative and HIV-positive transplant recipients, the demographic composition of these 2 groups was different in some key aspects. For example, among deceased-donor recipients, 73% of HIV-positive individuals were of Black ethnicity compared with only 8% of HIV-negative recipients, and HIV-positive recipients experienced greater socioeconomic deprivation (median IMD 26.2 versus 16.2). After multivariable adjustment, HIV-positive status did not adversely affect 5-y graft or patient survival in this study, a reassuring finding aligned with recent international experiences.1,4,5 However, HIV-positive recipients exhibited higher rates of acute rejection and lower estimated glomerular filtration rate at 12 mo. These findings are consistent with prior reports and likely reflect chronic immune activation, complex interaction between antiretroviral and immunosuppressive drugs, and potential contributions from coinfections that may still influence short-term outcomes. Notably, when ethnicity and deprivation were excluded from the models, the risk attributed to HIV status systematically increased across all outcomes.3 Together, these results underscore how social and structural determinants, rather than HIV infection itself, may drive much of the residual risk. Prior cohorts have similarly demonstrated favorable outcomes in HIV-positive transplant recipients. Stock et al1 reported 74% 3-y graft survival, whereas Locke et al4 found 75% 5-y survival, both showing comparable outcomes between HIV-positive and HIV-negative recipients. Sawinski et al2 observed 71% 5-y graft survival among HIV-positive recipients, with outcomes superior to hepatitis C virus–infected patients. However, none of these studies fully adjusted for socioeconomic factors. The current UK cohort reported 5-y graft survival of 84.2% for first-time transplants and 61.7% for retransplants among HIV-positive recipients, with acute rejection rates ranging from 14.7% to 28.6% depending on donor type. A key contribution of the current UK cohort is demonstrating that incomplete adjustment for confounders in earlier studies likely overestimated the impact of HIV on transplant outcomes. Nevertheless, several important limitations warrant consideration. The study relies on ethnicity categories as recorded in the UK National Health Service Blood and Transplant Transplant Registry, which may limit the ability to evaluate outcomes in mixed-race recipients and to discern the impact of genetic markers linked to certain populations. Second, IMD is a geographical rather than individual-level assessment, as the authors acknowledge, which may misclassify some individuals. Additionally, the index is updated only every 4–5 y, potentially failing to capture demographic changes in those areas, and is not comparable across UK countries. Finally, the analysis did not incorporate measures of organ quality, which could influence outcomes independent of recipient characteristics. From an equity perspective, this work highlights the continued underrepresentation of PLWH among kidney transplant recipients (224/30 013; <1%). Beyond the United Kingdom, international experience similarly shows that access to transplantation for PLWH remains inconsistent. In the United States, despite the HIV organ policy equity Act allowing the use of HIV-positive donors, relatively few transplants have occurred through this pathway, largely due to regulatory complexity and challenges in donor identification. The multicenter study by Durand et al5 provided further evidence that HIV-positive to HIV-positive kidney transplantation is both feasible and safe, with graft and patient survival noninferior to matched HIV-negative donors. In many low-and middle-income countries, transplant remains inaccessible for PLWH, even as access to antiretroviral therapy continues to expand. As the authors highlight, Black individuals represent roughly 29.2% of people diagnosed with HIV in the United Kingdom and are disproportionately affected by end-stage kidney disease, yet they continue to experience longer waiting times and lower referral rates for transplantation.3 Future studies should integrate social determinants with HIV-specific clinical parameters, various genetic variants and pharmacogenetic data to clarify mechanisms underlying higher rejection rates in this population. In the meantime, by illuminating these disparities, which reflect broader global inequities in access to advanced medical care, this study underscores the urgent need for practical strategies to address them.