Lung transplantation in patients with human immunodeficiency virus: a case series and mini-review

Background: Lung transplantation in those with human immunodeficiency virus (HIV) remains uncommon despite modern antiretroviral therapy (ART), which now enables durable viral suppression and improved long-term survival. Ongoing concerns regarding perioperative ART continuity, drug-drug interactions, infection risk, and limited thoracic transplant experience continue to restrict broader adoption. Additional real-world outcome data and practical perioperative management strategies are needed to inform candidate selection and posttransplant care. Although prior case reports, small series, and registry analyses have supported the feasibility of lung transplantation in people with HIV (PWH), detailed patient-level data on perioperative ART strategy, therapeutic drug monitoring, antimicrobial prophylaxis, infectious complications, rejection, and longer-term allograft outcomes remain limited. This series adds consecutive single-center experience with granular perioperative and follow-up data.

Case Description: We retrospectively reviewed all adult lung transplants in PWH at our center from June 2017 to November 2025 and identified four consecutive recipients. Data included HIV history, ART regimen, transplant indication, perioperative support, early postoperative course, infections and microbiology, alloimmune findings, rejection episodes, and longer-term allograft outcomes. Transplant indications were idiopathic pulmonary fibrosis, chronic obstructive pulmonary disease, post-Pneumocystis jirovecii pneumonia fibrotic lung disease, and chronic obstructive pulmonary disease with pulmonary hypertension. Perioperative courses varied: two recipients required brief intraoperative venoarterial extracorporeal membrane oxygenation, one required early postoperative venovenous extracorporeal membrane oxygenation for primary graft dysfunction, and one developed bacterial pneumonia within 30 days. HIV viral suppression was maintained throughout follow-up in all recipients. Posttransplant management included continued or adjusted ART with infectious diseases and transplant pharmacy input, tacrolimus-based immunosuppression with therapeutic drug monitoring, and patient-specific antimicrobial prophylaxis, including cytomegalovirus, antifungal, and Pneumocystis prophylaxis when indicated. Follow-up ranged from 8 to 80 months. At last follow-up, three recipients were alive and one had died without graft failure recorded as the cause of death.

Conclusions: In this consecutive single-center case series, lung transplantation was feasible in PWH who met standard transplant criteria and underwent HIV-specific management review. HIV viral suppression was maintained in all recipients, and early postoperative events appeared to reflect conventional lung transplant risks more than HIV serostatus alone. These findings support considering otherwise appropriate PWH for lung transplantation when ART continuity, drug-drug interaction management, antimicrobial prophylaxis, CD4 interpretation, therapeutic drug monitoring, and infectious diseases and transplant pharmacy expertise are available.