Editorial Note: The 2026 International AIDS Conference (AIDS 2026) was held in Rio de Janeiro, Brazil. Long-term prognosis of liver transplantation in people living with HIV (PLWH) emerged as a key topic in the hepatology track of the conference. Dr. Adriana Cervo from the University Hospital of Modena, Italy, presented a specialized study at the conference, systematically analyzing long-term survival, rejection episodes, hepatocellular carcinoma (HCC) recurrence and metabolic complications following liver transplantation in PLWH. Her work provides evidence-based references for transplant diagnosis and treatment in this special patient population.Decades ago, PLWH were long regarded as a high-risk cohort for liver transplantation. However, iterative advances in antiretroviral therapy and anti-hepatitis C virus (HCV) medications have drastically reshaped the landscape of transplant care. To clarify prevailing clinical challenges and summarize cutting-edge research findings, our journal conducted an in-depth interview with Dr. Cervo. The discussion covered survival prognosis, tumor recurrence, post-transplant metabolic management and other clinically critical concerns, with a focus on sharing study data and multidisciplinary care frameworks.
Infectious Disease Frontier: Historically, people living with HIV were regarded as a high-risk group for liver transplantation. What key conclusions have been drawn from this study regarding patients’ long-term survival rates and trends in rejection episodes? Compared with liver transplant recipients without HIV who have liver diseases, what significant differences exist in the features of immune rejection and long-term survival outcomes among HIV-positive liver transplant recipients?
Dr. Cervo: As we all know, research on liver transplantation for PLWH began in the early 2000s. Back then, major doubts lingered about the feasibility and safety of transplant surgery for this population. Even so, the medical community has always upheld the principle that PLWH deserve equal access to transplant surgery and treatment just like the general population.
Over the past several decades, HIV therapeutics and liver transplantation techniques have undergone tremendous refinement, which has meaningfully improved transplant outcomes for PLWH—an observation validated by our research.
We carried out this study at an Italian transplant center, enrolling all HIV-positive liver transplant recipients and matching them with HIV-negative liver transplant recipients to compare survival rates, rejection events and other clinical endpoints across the two cohorts. Our core finding is that overall survival rates are comparable between HIV-positive and HIV-negative transplant recipients, with no statistically significant disparity.
The data revealed that HIV-positive recipients demonstrated slightly lower survival rates in the first year post-transplant, a trend most likely driven by active HCV replication. Nevertheless, long-term follow-up demonstrated nearly overlapping survival curves at 10 and 15 years after transplantation—this constitutes one of the landmark conclusions of our research.
With regard to rejection episodes, the study confirmed that HIV-positive recipients experience a substantially higher rejection risk: their odds of rejection are 3.5 times greater than those of HIV-negative counterparts. Multivariate analysis indicated that HIV seropositivity itself and active HCV infection each independently elevate post-transplant liver rejection risk by more than twofold.
That said, separate analysis of cases treated from 2015 onward showed comparable rejection rates between the two groups. This meaningful shift can be attributed to the advent of direct-acting anti-HCV agents and optimized modern antiretroviral regimens. Newer therapies exhibit far fewer drug-drug interactions with immunosuppressants, effectively mitigating the historically elevated rejection risk seen in PLWH undergoing liver transplantation.
Collectively, these findings deliver robust research evidence supporting equitable access to liver transplantation for people living with HIV.
Infectious Disease Frontier: HCC constitutes a major indication for liver transplantation in patients living with HIV and liver disease, as well as a critical challenge due to post-transplant tumour recurrence. Based on your research data, what are the recurrence patterns and high-risk influencing factors of HCC after liver transplantation among people living with HIV? What clinical interventions can effectively reduce the risk of recurrence?
Dr. Cervo: HCC is indeed one of the leading underlying etiologies prompting liver transplantation for PLWH. Our study data showed that half of all transplant recipients underwent surgery primarily due to HCC. Our observational analysis found no intergroup differences in post-transplant survival among recipients with concomitant HCC; survival outcomes remained favorable for both HIV-positive and HIV-negative patients with HCC.
Our research identified active HCV infection as the dominant risk factor for HCC recurrence. Approximately one-tenth of all recipients in our cohort experienced tumor relapse, which drastically impairs overall survival—yet HCC recurrence rates showed no meaningful variation based on HIV serostatus.
We also uncovered a notable secondary finding: recipients with metabolic dysfunction-associated steatotic liver disease (MASLD) did not develop HCC more frequently than those without MASLD. This carries profound clinical significance and aligns with the shifting paradigm of liver transplant indications: HCV infection is no longer the sole leading cause of end-stage liver disease requiring transplantation, as MASLD and other fatty liver disorders have emerged as major contributors.
Infectious Disease Frontier: This report places particular emphasis on patients’ post-transplant metabolic outcomes. Could you outline the characteristics of metabolism-related complications in people living with HIV following liver transplantation? In light of long-term follow-up findings, what recommendations do you have to optimise comprehensive post-transplant management and improve overall long-term prognosis for this patient population?
Dr. Cervo: Survival data across transplant cohorts reveal a steadily aging recipient population burdened with an increasing prevalence of multimorbidity. Our study demonstrated that most patients already carry substantial comorbidity burdens prior to liver transplantation.
Head-to-head comparison of HIV-positive and HIV-negative recipients revealed that PLWH face higher risks of dyslipidemia and hypertension. Meanwhile, the prevalence of diabetes (approximately 20%), obesity, cardiovascular disease and chronic kidney disease was equivalent across both groups.
Longitudinal follow-up data demonstrated similar overall incidence rates of most comorbidities after transplantation, with dyslipidemia being the sole metabolic disorder disproportionately prevalent in HIV-positive recipients. Final follow-up assessments confirmed that PLWH carry a heavier multimorbidity burden: nearly half of HIV-positive recipients live with three or more concurrent chronic conditions, compared with only one-third of HIV-negative recipients.
Notably, MASLD prevalence was identical between the two cohorts at final follow-up, standing at 20% for both groups. This is a vital clinical takeaway. On one hand, clinicians must recognize the complex multimorbidity profile of transplant patients, as one in five individuals develops MASLD either intraoperatively or post-transplant—mandating routine screening and lifelong surveillance. On the other hand, despite a heavier overall comorbidity burden, PLWH do not exhibit a higher risk of MASLD than HIV-negative transplant recipients.
This balanced MASLD outcome is partially attributable to proactive comorbidity screening delivered through our dedicated metabolic outpatient clinic for HIV-positive transplant recipients at the Modena center. Our institution implements annual comprehensive follow-up visits for PLWH post-transplant, with universal screening for all chronic comorbidities paired with timely targeted interventions to slow disease progression.
In summary, our study underscores that this patient cohort requires lifelong continuous monitoring supported by a multidisciplinary collaborative framework to deliver standardized, integrated post-transplant care, with cross-specialty medical teams coordinating to optimize long-term transplant outcomes.
