Data presented at the Conference on Retroviruses and Opportunistic Infections (CROI 2026), held last week in Denver, showed comparable long-term liver transplant outcomes for people with and without HIV after 15 years. 

“These results are encouraging and support liver transplants in people with HIV when clinically indicated,” José Miró, MD, PhD, of the Hospital Clinic of Barcelona, told attendees.

End-stage liver disease and liver cancer are recognized complications of hepatitis B or hepatitis C coinfection, as well as fatty liver disease and heavy alcohol use, that may necessitate a liver transplant.

Previously, short- and mid-term data comparing liver transplant outcomes among HIV-positive and HIV-negative people have been reported, but long-term data are scarce, with no European studies having been done. Prior research from a cohort in San Francisco only included a single center in the study, with no comorbidity data. Thus, Miró and colleagues set out to compare long-term outcomes while also accounting for comorbidities that may have an impact.

The researchers performed a retrospective case-control study of 340 people, 85 of whom had HIV, from four Spanish centers. They received liver transplants between 2003 and 2012 and were followed until mid-2025. Of note, the transplants were done before the advent of interferon-free direct-acting antiviral therapy, which cures more than 90% of patients. Possible outcomes included surviving with no further transplants, graft failure requiring re-transplantation and death.

Participants with HIV were closely matched in a 1:3 ratio to those without HIV to ensure fair comparisons. This included matching by sex, calendar year of transplant (±1 year), age (±12 years), hepatitis B and C coinfection and the presence of liver cancer.

The median age of people in both groups was similar, with an overall median of 48 years, and there were many more men in the study (82%).

In terms of coinfections, most people in both groups had hepatitis C only (85% to 96%); very few had either hepatitis B only or both viruses. In terms of hepatitis C virus (HCV) genotypes, most people had genotype 1. But here, the groups were significantly different. For instance, while 21% of people with HIV had HCV genotype 4, only 4% of HIV-negative people did. At the time of their liver transplant, most participants (83% to 90%) tested positive for HCV RNA, indicating active infection. In both groups, approximately 30% had liver cancer. Most people with HIV (72%) acquired it through injection drug use.

Comparable Number of Survivors

Participants were followed for a median period of approximately 12 years, with some followed for as long as 16 years. About half of all participants died, and this was similar in both groups: 46% of people with HIV and 52% of HIV-negative people died after receiving their transplant. Very few—less than 5%—underwent re-transplantation followed by death.

Around 40% of deaths in both groups were caused by the recurrence of underlying disease—either hepatitis C relapse or a recurrence of liver cancer. Overall, there was no statistically significant difference in causes of death between the groups.

The introduction of direct-acting antivirals in 2015 significantly reduced deaths caused by hepatitis C relapse. Prior to 2014, this was the cause of 33% of deaths among HIV-negative transplant recipients, but this fell to 16% after 2015. People with HIV appeared to derive the most benefit from the introduction of these medications, as deaths due to hepatitis C relapse fell from 56% to 6% after 2015. What’s more, all active hepatitis C infections were cured after 2015. But as hepatitis C decreased as a cause of mortality, liver cancer rose, accounting for nearly a third of deaths after 2015.


The proportion of survivors was not statistically different. Projected survival rates at 15 years were 50% in the HIV-positive group and 46% in the HIV-negative group. Very few had re-transplantation, around 2.5% of all participants. There was also no significant difference in liver graft survival between the two groups (47% and 43%, respectively, at 15 years).

Predictors of Death, Graft Failure and Comorbidities

Few factors stood out as predicting either death or liver graft failure when considering the full picture. For death, these were male sex, positive HCV RNA pre-transplant and having HCV genotype 1. People with positive HCV RNA were at nearly three times greater risk of dying—the strongest risk factor.

The pattern was fairly similar for graft failure, except male sex was not a significant predictor when accounting for other factors. Here, positive HCV RNA pre-transplant was associated with nearly twice the risk of experiencing graft failure.

In terms of comorbidity profiles, many people in both groups presented with infections (around 45%). Approximately a third had a non-AIDS-defining cancer, including 10% in both groups with liver cancer. Over half of all participants had heart disease—55% in the HIV-positive group and 64% in the HIV-negative group. Comorbidity profiles did not differ significantly between the groups, except for prediabetes and diabetes, with more HIV-negative people having both.

Among people living with HIV, most gradually moved onto integrase inhibitor antiretroviral regimens after their liver transplant. Most continued to maintain HIV viral suppression over time, with a viral load below 200. CD4 counts tended to rebound over time from a post-transplant low—likely due to antirejection medications—but the mean CD4 count of all participants did not exceed 500 over the study duration.

The results of this study indicate that people with HIV should not automatically be deemed poor candidates for liver transplants. Instead, factors such as untreated hepatitis C or relapse should be of chief concern when it comes to predicting outcomes.
 

A version of this report was also published by aidsmap.


Krishen Samuel, PhD, is a queer scholar and medical writer currently based on Johannesburg, South Africa.

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