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

Introduction

Life expectancy for those living with human immunodeficiency virus (HIV) has markedly improved with modern antiretroviral therapy (ART), resulting in an aging population with chronic non-AIDS comorbidities, including advanced pulmonary disease that may progress to end-stage respiratory failure (1,2). Lung transplantation is the definitive therapy for select patients with end-stage lung disease; however, HIV was historically considered a contraindication due to concerns regarding opportunistic infections, malignancy, and outcomes under intensive immunosuppression (3).

Over the last decade, solid organ transplantation in patients with well-controlled HIV has expanded, and thoracic transplantation guidance has shifted toward a risk-stratified approach. The International Society for Heart and Lung Transplantation (ISHLT) candidate-selection guidelines no longer consider HIV an absolute barrier when infection is durably suppressed and multidisciplinary expertise is available (4). Accordingly, lung transplantation may be considered for candidates with sustained virologic suppression, ART adherence, and no uncontrolled opportunistic infections using the same transplant risk assessment applied to candidates without HIV.

Despite this shift, utilization remains low. In a United Network for Organ Sharing (UNOS) registry analysis of adult lung transplants from 2016 to 2023, recipients with HIV were rare, yet survival was comparable to that of recipients without HIV, supporting feasibility in recipients with HIV who otherwise meet standard transplant criteria (5).

Although outcomes in people with HIV (PWH) meeting standard transplant criteria appear increasingly acceptable, the evidence base remains limited and heterogeneous. Small cohorts and registry analyses support feasibility but often lack the clinical detail that informs candidacy decisions and early posttransplant management (6). Uncertainty persists regarding immunologic risk, rejection patterns, and optimal induction and maintenance immunosuppression in the setting of HIV (7).

Care is further complicated by drug-drug interactions between antiretrovirals and immunosuppressant medications, which may affect calcineurin inhibitor exposure and require coordinated regimen selection, therapeutic drug monitoring, and dose adjustment. In addition, prophylaxis and surveillance strategies for opportunistic infections are variably reported, limiting reproducibility across programs (8). Practical, transferable guidance on selection thresholds, peritransplant ART strategy, and early posttransplant protocols are therefore needed (9).

Despite existing case reports, small series, and registry analyses, lung transplantation in PWH remains incompletely characterized, particularly with respect to perioperative ART strategy, infectious prophylaxis, therapeutic drug monitoring, rejection, and longitudinal allograft outcomes (6,7). We present a consecutive single-center case series of four lung transplant recipients with HIV and a focused narrative review of the published literature. By combining detailed institutional case-level data with an updated synthesis of prior reports, this study expands the available evidence and provides practical context for candidate selection, ART and immunosuppression management, infection prevention, and posttransplant follow-up in PWH. We present this article in accordance with the AME Case Series reporting checklist (available at https://shc.amegroups.com/article/view/10.21037/shc-2026-0016/rc).

Case presentation

Methods

We performed a retrospective consecutive single-center case series of all adult PWH who underwent lung transplantation at Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona, between June 2017 and November 2025. All adult lung transplant recipients with HIV during the study period were included; no additional study-specific exclusion criteria were applied.

Transplant candidacy was assessed using the standard institutional evaluation applied to all lung transplant candidates, informed by ISHLT candidate-selection guidance, with additional HIV-specific review consistent with American Society of Transplantation Infectious Diseases Community of Practice recommendations (4,8). HIV-specific review included viral suppression, ART adherence and feasibility, CD4 count and percentage trends, history of opportunistic infection, and potential drug-drug interactions.

Clinical data were abstracted from the electronic medical record, including HIV history, ART regimen, transplant indication and type, perioperative support, early graft function, infectious complications, rejection, alloimmune findings, and longer-term allograft outcomes (Table 1). Early postoperative outcomes were defined as events occurring within 30 days after transplantation. Follow-up outcomes were assessed from transplantation through the last available follow-up or death. Follow-up included routine transplant clinic visits, pulmonary function testing, chest imaging, HIV RNA and CD4 monitoring, therapeutic drug monitoring, donor-specific antibody (DSA) surveillance, and clinically indicated bronchoscopy or microbiologic testing.

Early graft dysfunction was assessed using primary graft dysfunction (PGD) grade at 72 hours, assigned according to the ISHLT consensus definition based on oxygenation and chest radiographic findings (10). Use of extracorporeal membrane oxygenation (ECMO) within the first 72 hours after transplantation was recorded separately.

Mini-review search and study selection

A focused PubMed search was performed through March 10, 2026, to identify published reports of lung transplantation in recipients with HIV. Search terms included combinations of “HIV”, “human immunodeficiency virus”, “people with HIV”, “lung transplantation”, and “thoracic transplantation”. Articles were included if they reported lung transplant recipients with HIV and provided extractable lung-transplant-specific recipient data or relevant registry-level outcomes. Articles were excluded if they were not in English, did not include lung transplantation, lacked recipient-level or lung-transplant-specific outcome data, described non-human studies, were review editorials, or did not contain primary clinical data. Registry-level studies are discussed in the text but are not included as individual patient-level rows in Table 2 unless extractable case-level data were available.

Common transplant management

All four recipients underwent bilateral lung transplantation with Infectious Diseases and Transplant Pharmacy involvement in perioperative ART planning. Basiliximab induction was administered as 20 mg intraoperatively and 20 mg on postoperative day 4 in all recipients. Maintenance immunosuppression was tacrolimus-based in all recipients. Tacrolimus trough concentrations were monitored during posttransplant follow-up, and immunosuppression dosing was adjusted according to institutional lung transplant protocols. Posttransplant antimicrobial prophylaxis generally included CMV prophylaxis with valganciclovir or an alternative antiviral strategy, azole-based antifungal prophylaxis with or without inhaled amphotericin, and Pneumocystis prophylaxis with trimethoprim-sulfamethoxazole or an alternative agent when indicated (Table 3). Across the cohort, no severe ART-related adverse reaction requiring ART discontinuation was documented.

Recipient 1

A 68-year-old man with biopsy-confirmed idiopathic pulmonary fibrosis and a 42-year history of HIV underwent bilateral lung transplantation in February 2022. His HIV history included prior AIDS, latent or treated tuberculosis, and remote biopsy-proven pulmonary coccidioidomycosis. Before transplantation, his ART was changed from efavirenz/emtricitabine/tenofovir disoproxil fumarate plus raltegravir to dolutegravir/rilpivirine plus emtricitabine/tenofovir alafenamide after Infectious Diseases evaluation to simplify posttransplant medication management. His CD4 count was 203 cells per µL (27%), before transplantation and 256 cells per µL (32%) at follow-up. HIV RNA was undetectable before transplantation and remained suppressed after transplantation. The recorded operative duration was 3 hours and 27 minutes, with estimated blood loss of approximately 1 L.

His early postoperative course was complicated by PGD grade 2 at 72 hours and the need for venovenous ECMO within the first 72 hours. He had a prolonged critical care course that included plasma exchange, tracheostomy with return to the operating room, and gastrojejunostomy tube placement with subsequent revision. Early respiratory cultures grew yeast and Candida species, which were managed per institutional protocol. Later posttransplant issues included atrial arrhythmias requiring pacemaker placement, coronary artery disease requiring left anterior descending coronary artery stenting, and chronic kidney disease monitoring. Non-melanoma skin cancers requiring Mohs procedures were documented during follow-up, in the setting of prior anal dysplasia and anal squamous cell carcinoma surveillance. At 51 months, he remained alive and clinically stable, with stable pulmonary function and imaging. Mild air trapping was noted on computed tomography, but chronic lung allograft dysfunction (CLAD) was not documented.

Recipient 2

A 64-year-old man with end-stage chronic obstructive pulmonary disease and a 38-year history of HIV underwent bilateral lung transplantation in July 2019. His ART regimen consisted of emtricitabine, tenofovir alafenamide, and raltegravir. Tenofovir was relevant because of hepatitis B core antibody positivity, and the chart documented a long-term nonprogressor phenotype. His CD4 count was 795 cells per µL (41%) before transplantation and 571 cells per µL (61%), at follow-up. HIV RNA was less than 20 copies per mL before transplantation and remained suppressed after transplantation. The recorded operative duration was 3 hours and 9 minutes, with estimated blood loss of approximately 500 mL.

Early allograft function was favorable, with PGD grade 0 at 72 hours, and ECMO was not required within the first 72 hours. Bronchoscopy during the index admission showed purulent secretions, which were managed with intensified airway clearance and inhaled antimicrobial therapy; no clinically significant infections were documented within 30 days. Early noninfectious complications included atrial fibrillation and right internal jugular deep vein thrombosis. Chronic kidney disease was documented during longer-term follow-up. Alloimmune monitoring identified early low-level DSAs to DR4 and DQ8. He subsequently developed recurrent acute cellular rejection and antibody-mediated rejection requiring escalation of immunosuppression, including antithymocyte globulin. De novo DSAs to human leukocyte antigen (HLA)-DP14 were later treated with intravenous immunoglobulin. At 80 months of follow-up, he remained alive with documented CLAD with a bronchiolitis obliterans syndrome phenotype and progressive graft dysfunction requiring intensified immunosuppression.

Recipient 3

A 37-year-old man with fibrotic lung disease attributed to prior Pneumocystis jirovecii pneumonia-associated acute respiratory distress syndrome and a 7-year history of HIV underwent bilateral lung transplantation in June 2017 while receiving abacavir, dolutegravir, and lamivudine. His CD4 count was 212 cells per µL (16%), before transplantation and 393 cells per µL (30%), at follow-up. HIV RNA was less than 20 copies per mL before transplantation and remained suppressed after transplantation.

The operation was technically complex because of dense pleural adhesions and intraoperative hemodynamic instability from systolic anterior motion of the mitral valve with dynamic left ventricular outflow tract obstruction, which improved with volume resuscitation. The recorded operative duration was 5 hours and 27 minutes, with estimated blood loss of 800 mL. He required brief intraoperative venoarterial ECMO support during implantation and was decannulated at the end of the case. Postoperative ECMO within 72 hours was not required, and early allograft function was favorable, with PGD grade 0 at 72 hours.

Within 30 days, he developed bacterial pneumonia involving Pseudomonas aeruginosa and Klebsiella species. His history also included treated hepatitis C and treated syphilis. Later follow-up was complicated by recurrent infections, including soft-tissue infection within the first posttransplant year, complicated cellulitis and myositis requiring debridement and 6 weeks of antibiotics approximately 1.5 years after transplantation, recurrent gastrointestinal infections approximately 2 to 3 years after transplantation, recurrent Escherichia coli respiratory isolates including extended-spectrum beta-lactamase-producing Escherichia coli, and later Pseudomonas pneumonia with concurrent Giardia infection. He died approximately 60 months after transplantation, with no transplant-related cause or graft failure recorded in the registry.

Recipient 4

A 64-year-old man with severe chronic obstructive pulmonary disease and pulmonary hypertension underwent bilateral lung transplantation in October 2025 after HIV was diagnosed during transplant evaluation. He was maintained on bictegravir, emtricitabine, and tenofovir alafenamide. His CD4 count was 622 cells per µL (24%), before transplantation and declined to 70 cells per µL (22%), during early follow-up, later improving to 210 cells per µL (30%). HIV RNA was less than 20 copies per mL before transplantation and remained suppressed after transplantation.

Transplantation was performed without cardiopulmonary bypass. The recorded operative duration was 5 hours and 21 minutes, with estimated blood loss of approximately 2 L and transfusion support. He required brief intraoperative venoarterial ECMO support during implantation and was decannulated at case completion. Postoperative ECMO within 72 hours was not required. Pretransplant alloimmune testing did not detect class I or class II DSAs; an isolated T-cell signal was attributed to non-HLA antibodies.

Early allograft function improved rapidly, with PGD grade 0 at 72 hours, and he was extubated on postoperative day 1. Early postoperative complications included ileus, transient hallucinations, thrombocytopenia, bronchial secretions requiring bronchoscopic clearance, transient transaminitis, and steroid-associated hyperglycemia. Donor cultures grew gram-negative organisms, including Escherichia coli and Klebsiella species, and were managed with protocol-driven antibiotics; no clinically significant infections occurred within 30 days. Hepatitis B serologies were consistent with resolved infection, with positive hepatitis B surface antibody and hepatitis B core antibody. He remained alive at approximately 8 months of follow-up, without evidence of CLAD to date.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Patient consent for publication of this retrospective case series was waived by the Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center Institutional Review Board.

Discussion

In this consecutive single-center case series of four lung transplant recipients with HIV transplanted between 2017 and 2025, transplantation was feasible in patients who met standard transplant criteria with additional HIV-specific review. Perioperative courses were heterogeneous and were largely driven by conventional lung transplant risk factors, including operative complexity, cardiopulmonary support, and early allograft dysfunction. Recipient 3 and Recipient 4 required brief intraoperative venoarterial ECMO and were decannulated at the end of the operation. Recipient 1 developed PGD grade 2 at 72 hours and required early postoperative venovenous ECMO within the first 72 hours. HIV viral suppression was maintained throughout follow-up in all recipients. These cases suggest that posttransplant risk was primarily related to conventional lung transplant factors, while HIV-specific management required attention to ART selection, calcineurin inhibitor monitoring, opportunistic infection prophylaxis, CD4 interpretation, and malignancy surveillance.

Although guidelines now endorse a risk-stratified approach (rather than absolute exclusion) when HIV is durably suppressed and multidisciplinary expertise is available, lung transplantation in PWH remains rare (4). In a national UNOS analysis of adult lung transplants from 2016 to 2023, only 67 of 17,487 recipients had HIV (~0.4%), yet graft and patient survival were similar to that of recipients without HIV (5). Similarly, Ralphs et al. used Organ Procurement and Transplantation Network (OPTN) Standard Transplant Analysis and Research (STAR) data to compare lung transplant recipients with and without HIV and reported comparable survival, including 1-year survival of 91.2% versus 88.6% (P=0.620) and available 3-year survival of 82.6% versus 77.8% (P=0.687) (20). Contemporary single-center experiences likewise suggest favorable medium-term outcomes after thoracic transplantation in PWH; in one 10-year cohort [2013–2023], 8 thoracic transplant recipients with HIV had no HIV-associated complications and 88% survived beyond 1 year (21).

These signals are reassuring when interpreted against baseline outcomes after lung transplantation in the general population, where 1-year survival was ~89% and 5-year survival was ~60% in recent OPTN/SRTR reporting (22). Importantly, available data suggest that HIV serostatus alone does not drive inferior survival. Instead, outcomes appear most dependent on candidate selection (sustained viral suppression, adherence, comorbidity burden) and center capability for coordinated HIV-transplant management (23).

To place our institutional experience in context, we synthesized the published lung transplantation experience in PWH and summarized these reports in Table 2. The reports are predominantly single-center case reports and very small cohorts (6,7,11-15,17-19). Most recipients were transplanted in the contemporary ART era with pretransplant viral suppression, and indications spanned obstructive, fibrotic, and other end-stage lung diseases. Compared with prior reports, our series adds more detailed patient-level information on perioperative ART planning, extracorporeal support, therapeutic drug monitoring, infectious complications, rejection, and longitudinal allograft status. Reported complications largely parallel those seen after lung transplantation in general, including PGD, infectious events, and acute rejection. At the same time, heterogeneity in how HIV metrics and posttransplant infections are reported limits direct comparison across studies.

Because the lung allograft is continuously exposed to the external environment, infectious complications remain a dominant determinant of early and late morbidity after transplantation, irrespective of HIV serostatus. In our series, Recipient 3 developed clinically significant bacterial pneumonia with Pseudomonas aeruginosa and Klebsiella species within 30 days after transplantation and later experienced recurrent infections during follow-up. These observations are concordant with prior thoracic transplantation experience in PWH. In a multicenter cohort of heart and lung transplant recipients with HIV, Koval et al. (7) reported pulmonary bacterial infection in 86% of lung recipients and documented a decline in median CD4 count from 638 cells/µL pretransplant to 280 cells/µL at 1 year, underscoring the vulnerability of this population during intensified early immunosuppression. Similarly, in the largest multicenter lung transplant experience in patients with HIV reported to date, Rouzaud et al. (15) described 22 lung transplant recipients across 25 European centers [2007–2021] and found that infections requiring hospitalization occurred in 40% of recipients during the first posttransplant year, while 1-, 3-, and 5-year survival was 79%. Although these outcomes do not suggest prohibitive infectious risk compared with lung transplantation overall, they reinforce that virologic suppression alone does not eliminate posttransplant susceptibility. Rather, infectious risk in PWH should be managed as a durable, programmatic priority through standardized prophylaxis, surveillance, and rapid diagnostic pathways integrated with transplant and HIV infectious diseases expertise (8,15).

Two HIV-specific points are essential. First, opportunistic infection risk can increase early after transplant as CD4 counts may fall markedly with induction and maintenance immunosuppression (in our series, a nadir CD4 count of 70 cells/µL), supporting CD4-guided prophylaxis and close Infectious Diseases co-management (7,8). Recipient 4 showed the most pronounced early decline in absolute CD4 count, from 622 cells/µL (24%) before transplantation to 70 cells/µL (22%) early after transplantation, followed by recovery to 210 cells/µL (30%). Because HIV RNA remained suppressed, this pattern is most consistent with early posttransplant lymphopenia in the setting of major surgery, transfusion support, and intensified immunosuppression rather than loss of HIV virologic control. Second, prior opportunistic infections are not an absolute contraindication but should trigger pathogen- and region-specific prophylaxis and surveillance (e.g., endemic fungi, mycobacteria). Finally, because lung recipients are among the highest-risk solid-organ transplant groups, Pneumocystis prophylaxis is recommended indefinitely, particularly with profound or prolonged immunosuppression (24,25). Similar posttransplant CD4 lymphopenia has also been reported in lung transplant recipients with HIV, supporting interpretation of absolute CD4 counts alongside CD4 percentage and overall lymphopenia (16).

No AIDS-defining malignancy or posttransplant lymphoproliferative disorder has been documented to date in our small cohort, although non-melanoma skin cancers requiring Mohs procedures were documented in one recipient during follow-up. Nevertheless, malignancy remains a critical long-term consideration because PWH and solid organ transplant recipients both have increased cancer risks, particularly for infection-related malignancies [e.g., human papillomavirus (HPV)-associated anogenital cancers, Epstein-Barr virus (EBV)-related lymphomas, human herpesvirus 8 (HHV-8)-associated Kaposi sarcoma (KS)] (26). Because HHV-8 and CMV seroprevalence may be elevated in some PWH populations, viral serostatus and posttransplant monitoring should inform infectious risk assessment and malignancy surveillance.

In a multicenter HIV lung transplant series, malignancy occurred in 14% of recipients over a median follow-up of 25 months. Although the specific malignancy types were not detailed in the abstract, this signal reinforces the need for structured cancer prevention and screening (15).

In the general solid organ transplant population, overall cancer risk is meaningfully elevated (overall standardized incidence ratio ~2.1) (27). In Transplant Cancer Match analyses, the 5-year cumulative incidence of lung cancer among thoracic organ recipients aged >50 years ranged between 1.2% and 3.9%, and non-Hodgkin lymphoma incidence was highest at extremes of age, particularly among thoracic recipients (28).

KS is a particularly relevant example of viral-immunosuppression synergy: among US transplant recipients, KS incidence is ~60-fold higher than in the general population, and lung transplant recipients have higher KS risk than kidney recipients (incidence rate ratio 2.22 vs. kidney) (29). Because HHV-8 can be transmitted through donor organs, donor-derived pathways should be considered when KS or HHV-8 disease is suspected posttransplant (30).

Given these additive risks, lung transplant care of PWH should incorporate longitudinal prevention strategies: HPV vaccination when eligible, dermatologic surveillance, age-appropriate cancer screening, targeted screening for HPV-associated disease (anal/cervical as applicable), and vigilance for EBV-related disease in the setting of intense immunosuppression. Broader epidemiologic work also highlights that PWH have elevated risk and mortality for several non-acquired immunodeficiency syndrome (AIDS)-defining cancers, including lung and liver cancer, which is particularly relevant for candidates with smoking history or viral hepatitis comorbidity (31).

Pragmatically, transplant programs considering lung transplantation in PWH should formalize: (I) a preferred ART “pathway” that minimizes CYP3A-mediated interactions, when possible; (II) early and frequent therapeutic drug monitoring in the peritransplant period; and (III) explicit contingency plans for renal dysfunction given the nephrotoxic potential of both calcineurin inhibitors and certain antiretrovirals. Notably, a UNOS analysis identified higher posttransplant dialysis rates in recipients with HIV (18% vs. 8.4%) (5).

Limitations

This report is limited by its retrospective single-center design and small sample size, which restrict inference about rare outcomes. Follow-up duration differed between recipients, and granular immunologic and pharmacokinetic data were not uniformly available across the study period. Additionally, selection bias is likely, as candidates were evaluated and transplanted within a program with dedicated HIV Infectious Diseases and Transplant Pharmacy expertise.

Future directions

As lung transplantation in PWH gradually expands, prospective multicenter studies and harmonized registry variables are needed to evaluate optimal selection criteria, perioperative management, and long-term outcomes. Particular priorities include renal outcomes, rejection phenotyping, antimicrobial prophylaxis strategies, and standardized approaches to ART optimization and therapeutic drug monitoring across transplant centers.

Conclusions

Standard lung transplant evaluation combined with HIV-specific review of viral suppression, ART feasibility, opportunistic infection history, drug-drug interactions, and posttransplant prophylaxis can support favorable outcomes after lung transplantation in PWH.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the AME Case Series reporting checklist. Available at https://shc.amegroups.com/article/view/10.21037/shc-2026-0016/rc

Peer Review File: Available at https://shc.amegroups.com/article/view/10.21037/shc-2026-0016/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://shc.amegroups.com/article/view/10.21037/shc-2026-0016/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Patient consent for publication of this retrospective case series was waived by the Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center Institutional Review Board.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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