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About 1% of all patients with end-stage renal disease in the United States are infected with HIV. With the introduction of highly active antiretroviral therapy (HAART), HIV death rates have declined 80%, and chronic diseases resulting from HIV have replaced opportunistic infections as the leading cause of death among HIV-infected patients. Traditionally, HIV infection has been considered an absolute contraindication to solid-organ transplantation. However, in the context of improved survival, the role for kidney transplantation among HIV-positive patients is currently being revisited. This article discusses long-term outcomes after kidney transplantation in the HAART era and management strategies for the HIV-positive kidney transplant recipient.

Approximately 9% of deceased kidney donors are classified by the Centers for Disease Control as high infectious risk donors (HRDs), donors thought to be at increased risk for having HIV infection. While the use of HRDs expands the organ supply, there is a small risk of infectious transmission. All donors are tested for antibodies to a variety of viral infections including HIV, hepatitis C virus (HCV), and hepatitis B virus; however, infections acquired in the weeks to months before death may not be serologically detectable, but will likely be transmitted to the recipient. Nucleic acid testing (NAT) shortens the window between acquisition of infection and serologic detectability, from approximately 22 days to 9 days for HIV and from 66 days to 7 days for HCV. Nucleic acid testing has not been universally adopted because it is expensive, time consuming, and has a higher rate of false positives compared with an enzyme-linked immunosorbent assay (ELISA), which might lead to discarding viable organs. Further studies are needed to quantify the risk of infectious transmission from HRDs, identify patients on the waitlist who would most benefit from HRD receipt, and guide NAT policies.