São Paulo, Brazil – Six people have been infected with HIV after receiving organ transplants from two different donors at state hospitals in Rio de Janeiro, Brazil.
According to investigators, a private laboratory called PCS Lab Saleme, which was contracted by the Rio de Janeiro government, failed to properly test organ donors. A partner in the lab was arrested on Monday.
The discovery of the infected patients, which was announced last week, has sparked outrage across Brazil.
The Ministry of Health and the Transplant Center in Rio de Janeiro issued statements after confirming the infections and pledged to investigate the case and ensure that such mistakes do not happen again. The Ministry of Health is also offering help to patients whose names are not disclosed for privacy reasons.
A task force was established to review all screening protocols and retest at least 286 patients who received organs tested from the same laboratory. Rio de Janeiro police also opened an investigation and concluded that the laboratory reduced operational control over the quality of HIV tests to maximize profits.
Police did not explain how the reduced control measures boosted the lab’s profits, nor did they clarify whether there was a possibility that the tests had not been carried out at all.
“There was a breakdown in quality control aimed at maximizing profit, disregarding the preservation and safety of health testing,” said investigator André Neves.
In addition to one of the lab’s partners, three other technicians responsible for the test reports were arrested this week. Lawyers representing PCS Lab Saleme stated that the company’s partners “will provide all necessary clarifications to the justice system.”
Under Brazilian law, all organs available for transplant must undergo rigorous testing to rule out the presence of viruses that could infect recipients, such as hepatitis, syphilis and HIV.
According to PCS Lab Saleme’s contract with the state of Rio de Janeiro, the lab had to analyze the blood of every organ donor. To determine whether the donor had HIV, a blood sample is exposed to a reagent, which must be tested for quality before use.
This reagent quality test was supposed to be done every day in the laboratory, but according to the investigation, it has been ordered to be done every week. As a result, according to police, a loophole was created, increasing the possibility of using an ineffective reagent, jeopardizing the test result.
“Reagents had to be systematically analyzed every day and there was a new order, which we are investigating, to reduce this inspection to a weekly basis. This loophole allowed flexibility, increasing the chances of a side effect – this devastating outcome that we are now analyzing,” said Neves.
Rio de Janeiro’s government also pointed to an error in two tests conducted by PCS Lab Saleme, which cleared organs from two HIV-positive donors for the transplant queue. In January, a man’s family authorized the removal of his heart, kidneys, cornea and liver. The heart recipient and two people who received the kidneys became infected with HIV.
The person who received the cornea was not infected, and the recipient of the liver died shortly after the operation. In May, a woman’s relatives donated her liver and kidneys, and all three recipients were HIV-infected.
The six patients were informed of the situation by the Rio de Janeiro government and are being closely monitored by specialist medical teams. They are receiving appropriate treatment with antiretrovirals, which are effective in controlling the infection.
Although HIV is now a manageable condition with antiretroviral treatment, the fact that the virus was contracted due to a medical error has deeply affected both patients and their families. Some have already announced plans to file lawsuits against the state of Rio de Janeiro and the hospitals, citing negligence and serious breaches of safety protocols.
Consequences according to experts
Doctors and transplant specialists were shocked by the incident, which was considered an unprecedented tragedy in the history of transplants in Brazil. According to the Brazilian Association of Organ Transplants (ABTO), this was the first case registered in the country of HIV patients after a transplant.
ABTO stressed that cases of HIV transmission through organ transplants are extremely rare, but that it is essential to review protocols to ensure patient safety. According to the ABTO, additional measures could include performing more advanced tests and reducing the time interval between organ collection and testing.
The Ministry of Health reinforced the importance of following all protocols when testing organs for transplant and assured that the National Transplant System (SNT) is one of the most established, safest and most respected in the world.
“There are strict rules in place to protect both donors and recipients, ensuring that transplants performed locally maintain a high level of reliability. The SNT has regulatory mechanisms that already include specific protocols to minimize risks, such as the transmission of infectious diseases, and is constantly updated to keep pace with medical and scientific advances in this field,” the ministry said.
Although it is an extremely rare situation, there have been other cases of HIV patients after organ transplants. In 2007, in the United States, four patients in Chicago became infected with HIV and hepatitis C after receiving organs from an infected donor. In 2013, a patient in Colombia contracted the virus after a kidney transplant.
