- Email: [email protected]
Safer childbirth: avoiding medical interventions for non-medical reasons
Comment
BB has served as a speaker for Sanofi-Aventis and on advisory panels for AstraZeneca, Bristol Myers Squibb, Lilly, and Sanofi-Aventis. DS has served as a speaker for Glaxo-Smith Kline, Sanofi-Aventis, Servier, and on advisory panels for AstraZeneca, Bristol Myers Squibb, Glaxo-Smith Kline, and Novartis. 1
2
3
4
5
6
The Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008; 358: 2545–59. The ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008; 358: 2560–72. Duckworth W, Abraira C, Moritz T, et al, for the VADT Investigators. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009; 360: 129–39. Ray KK, Seshasai SRK, Wijesuriya S, et al. Effect of intensive control of glucose on cardiovascular outcomes and death in patients with diabetes mellitus: a meta-analysis of randomised controlled trials. Lancet 2009; 373: 1765–72. Turnbull FM, Abraira C, Anderson RJ, et al. Intensive glucose control and macrovascular outcomes in type 2 diabetes. Diabetologia 2009; 52: 2288–98. Mannucci E, Monami M, Lamanna C, et al. Prevention of cardiovascular disease through glycemic control in type 2 diabetes: a meta-analysis of randomized clinical trials. Nutr Metab Cardiovasc Dis 2009; 19: 604–12.
7 8
9 10
11
12 13
Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008; 359: 1577–89. Currie CJ, Peters JR, Tynan A, et al. Survival as a function of HbA1c in people with type 2 diabetes: a retrospective cohort study. Lancet 2010; published online Jan 27. DOI:10.1016/S0140-6736(09)61969-3. Miller CD, Phillips LS, Ziemer DC, et al. Hypoglycemia in patients with type 2 diabetes mellitus. Arch Intern Med 2001; 161: 1653–59. Tzoulaki I, Molokhia M, Curcin V, et al. Risk of cardiovascular disease and all cause mortality among patients with type 2 diabetes prescribed oral antidiabetes drugs: retrospective cohort study using UK general practice research database. BMJ 2009; 339: b4731. Gamble JM, Simpson SH, Eurich DT, Majumdar SR, Johnson JA. Insulin use and increased risk of mortality in type 2 diabetes: a cohort study. Diabetes Obes Metab 2009; published online Sept 24. DOI: 10.1111/j.1463-1326.2009.01125.x. Amiel SA, Dixon T, Mann R, Jameson K. Hypoglycaemia in type 2 diabetes. Diabet Med 2008; 25: 245–54. Amiel SA. Hypoglycemia: from the laboratory to the clinic. Diabetes Care 2009; 32: 1364–71.
Safer childbirth: avoiding medical interventions for non-medical reasons Published Online January 12, 2010 DOI:10.1016/S01406736(10)60055-4 See Articles page 490
3 years ago, The Lancet published the 2005 WHO global survey on maternal and perinatal health,1 which documented the high rates of caesarean sections in Latin America and the association with severe maternal and perinatal morbidity and mortality. That year, a new warning was issued about the dangers of unnecessary caesarean section.2 However, controversy about the ideal rate of caesarean section3 and the place of maternal choice4 has been continuing for so long that many obstetricians have become accustomed to the practice of medical interventions for non-
Panos Pictures
The printed journal includes an image merely for illustration
440
medical reasons. I (Y-SC) was once dumbfounded to overhear a remark at a professional workshop that “the best birth plan any woman can have is to ask for an elective caesarean section”. No doubt that remark was made facetiously, but the inconvenient truth is that physicians are some of the main advocates of this intervention to their patients, themselves, and their relatives.5 In The Lancet today, this situation is highlighted by Pisake Lumbiganon and colleagues in the 2007–08 WHO global survey,6 which provides a careful examination of childbirth practices in nine Asian countries. Acknowledging the difficulties of separating the intrinsic risk of procedures from the underlying medical indications, these authors classified caesarean sections into those with and without indications, and vaginal deliveries into spontaneous and operative deliveries. And the results are surprising and chilling. Although the overall rate of caesarean section was lower than that in Latin America (27% vs 33%), regional practice in the nine Asian countries differed substantially: rates in four countries exceeded 30%, whereas rates in the remaining five were less than 21%. In the country with the highest rate (China, 46·2%), a quarter of caesarean sections were done without medical indications—a rate far higher than that in the other countries surveyed. The reasons for this astonishing difference in practice were www.thelancet.com Vol 375 February 6, 2010
Comment
not specified, but Lumbiganon and colleagues reported that 62% of the hospitals surveyed had financial incentives for doing the intervention. Other studies in east Asia with similarly high rates of caesarean section have noted that physician factors were paramount,7 and that women generally have favourable attitudes towards vaginal delivery compared with caesarean section.8 The 2005 WHO survey noted that the high rates of elective caesarean section in Latin America “reflect a complex social process, affected by clinical status, family and social pressures, the legal system, availability of technology, and women’s role models”.1 Regional differences in medical practice will always exist, often contingent on resource availability. The paradox is that caesarean sections are more resource intensive than are vaginal deliveries1,3,6 but often given to those who need it least,9 since many people consider caesarean section an intrinsically safe operation.2 Lumbiganon and colleagues’ findings certainly do not lend support to this view. For antepartum caesarean section without indication, the risk of admission to an intensive care unit was ten times more likely than it was for spontaneous vaginal deliveries, and 67 times more likely for intrapartum caesarean section done without medical indication. Clearly, caesarean deliveries, even in mothers with no underlying medical issues, can be life-threatening. The WHO surveys have also shown no benefit for perinatal outcomes, apart from, according to today’s report, for babies with breech presentation. A surprising finding by Lumbiganon and colleagues was that the only procedure associated with an increased risk of maternal death was operative vaginal delivery, despite a modest rate of 3·2%. This report provides a sobering reminder of the dangers of operative deliveries. Although most operative vaginal deliveries are high-risk situations that cannot be easily avoided, alternatives should be considered in situations of prolonged second stage of labour with reassuring fetal status. These alternatives include continued expectant management, changes in maternal positioning, increased emotional support, and delayed pushing while reducing neuraxial anaesthesia.10 Present guidelines suggest that the second stage of labour need not be terminated for duration alone.10 Lumbiganon and colleagues’ findings should help us to prioritise our strategies to reduce unnecessary interventions in childbirth. Caesarean section without www.thelancet.com Vol 375 February 6, 2010
medical indication should not be encouraged. Financial incentives for doing these procedures should be removed or kept to a minimum, and both public and continuing medical education should emphasise the risks of unnecessary caesarean delivery. However, caesarean section without indication comprised only 7% of all procedures in the Asian survey.6 Most were done with indications, the most common being previous caesarean section, cephalopelvic disproportion, fetal distress, and malpresentations. Following the Pareto principle,11 investment in training and clearer guidelines for vaginal birth after caesarean section, intrapartum management, fetal monitoring, and external cephalic version12 could have wider effect. A previous randomised trial of mandatory second opinion for caesarean section13 reduced rates by only 7·3%, but the authors acknowledged issues with implementation. Stricter implementation and auditing of this policy might result in greater success. Finally, as operative vaginal delivery rates continue to fall, there should be no compromise in the level of training in the conduct of and careful selection of patients for instrumental deliveries. There is little wrong with medical interventions when indicated, but for those who are still inclined to consider caesarean delivery a harmless option, they need to take a cold hard look at the evidence against unnecessary caesarean section. *Yap-Seng Chong, Kenneth Y C Kwek Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore 119074 (Y-SC); and Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital, Singapore (KYCK) [email protected] We declare that we have no conflicts of interest. 1
2 3 4
5 6
Villar J, Valladares E, Wojdyla D, et al, for the WHO 2005 global survey on maternal and perinatal health research group. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet 2006; 367: 1819–29. Victora CG, Barros FC. Beware: unnecessary caesarean sections may be hazardous. Lancet 2006; 367: 1796–97. The Lancet. What is the right number of caesarean sections? Lancet 1997; 349: 815. Kingdon C, Neilson J, Singleton V, et al. Choice and birth method: mixed-method study of caesarean delivery for maternal request. BJOG 2009; 116: 886–95. Al-Mufti R, McCarthy A, Fisk NM. Obstetricians’ personal choice and mode of delivery. Lancet 1996; 347: 544. Lumbiganon P, Laopaiboon M, Gülmezoglu AM, et al, for the World Health Organization Global Survey on Maternal and Perinatal Health Research Group. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007–08. Lancet 2010; published online Jan12. DOI:10.1016/S0140-6736(09)61870-5.
441
Comment
7 8
9
10
Lin HC, Xirasagar S. Institutional factors in cesarean delivery rates: policy and research implications. Obstet Gynecol 2004; 103: 128–36. Lee SI, Khang YH, Lee MS. Women’s attitudes toward mode of delivery in South Korea—a society with high cesarean section rates. Birth 2004; 31: 108–16. Ronsmans C, Holtz S, Stanton C. Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis. Lancet 2006; 368: 1516–23. Ali UA, Norwitz ER. Vacuum-assisted vaginal delivery. Rev Obstet Gynecol 2009; 2: 5–17.
11 12 13
Koch R. The 80/20 principle: the secret of achieving more with less. London: Nicholas Brealey Publishing, 2001. Walker R, Turnbull D, Wilkinson C. Strategies to address global cesarean section rates: a review of the evidence. Birth 2002; 29: 28–39. Althabe F, Belizan JM, Villar J, et al, for the Latin American Caesarean Section Study Group. Mandatory second opinion to reduce rates of unnecessary caesarean sections in Latin America: a cluster randomised controlled trial. Lancet 2004; 363: 1934–40.
Organ transplantation between HIV-infected patients
Science Photo Library
Organ transplantations between HIV-negative donors and HIV-positive recipients have become more common,1–4 and ethical arguments have been put forward as to why transplantation in HIV-infected patients should be viewed as analogous to transplantation in patients with other chronic illnesses.3 A review of renal transplantation in patients with HIV notes that as demand for organs soars yet the supply of deceased-donor organs remains stable, one strategy to address these problems is to use organs from living donors while another would be to include “infectious high-risk” deceased donors—individuals who tested negative for HIV, HBV, and HCV but, on the basis of social history, could have acquired the infections shortly before becoming kidney donors.5 This strategy does not go far enough. Until September, 2008, transplantations between HIV-infected donors and recipients had not been done anywhere, mainly on the grounds of safety and because recipients were generally expected to have poor prognoses. The kidney transplants in two
442
HIV-infected patients from a single HIV-infected donor in Cape Town in 2008 challenge this tenet.6 In view of the dire shortage of organ donors in most countries, which is being compounded by the shrinking availability of HIV-negative donors, a continued blanket ban on all transplantations between consenting HIV-infected patients is no longer just debatable, but unconscionable, if protective measures can be put in place to mitigate risks to recipient patients. Current policies for organ transplantation in most countries stipulate that organs from HIV-infected donors must be discarded on safety grounds. For example, transplant recipients could acquire a different strain of HIV from the donor, including drug-resistant strains, as well as tuberculosis, hepatitis B, and hepatitis C. In living donors, there is also the risk of HIV-associated nephropathy. Such conditions might not be apparent at the time of screening or donation. Moreover, organs such as the liver and heart could already be damaged because of the donor’s previous exposure to anti-HIV drugs. However, safety checks could be put in place to mitigate or eliminate such risks.7 Such measures could include a pretransplantation biopsy to test for the presence of diseases. In the USA alone, as of October, 2008, more than 100 000 people were on the waiting list for organs.8 In developing countries, living donors provide 85–100% of donations compared with 1–25% in the developed world.9 Although organ shortages in developing countries are largely due to economic stringency and cultural factors,8 rising HIV prevalence in many settings is also translating into shrinking availability of HIV-negative potential donors. Permitting organ transplantation between HIV-infected donors and recipients could give HIV-infected patients a greater chance of receiving new organs than those uninfected because there would be more potential donors.6 www.thelancet.com Vol 375 February 6, 2010
BB has served as a speaker for Sanofi-Aventis and on advisory panels for AstraZeneca, Bristol Myers Squibb, Lilly, and Sanofi-Aventis. DS has served as a speaker for Glaxo-Smith Kline, Sanofi-Aventis, Servier, and on advisory panels for AstraZeneca, Bristol Myers Squibb, Glaxo-Smith Kline, and Novartis. 1
2
3
4
5
6
The Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008; 358: 2545–59. The ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008; 358: 2560–72. Duckworth W, Abraira C, Moritz T, et al, for the VADT Investigators. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009; 360: 129–39. Ray KK, Seshasai SRK, Wijesuriya S, et al. Effect of intensive control of glucose on cardiovascular outcomes and death in patients with diabetes mellitus: a meta-analysis of randomised controlled trials. Lancet 2009; 373: 1765–72. Turnbull FM, Abraira C, Anderson RJ, et al. Intensive glucose control and macrovascular outcomes in type 2 diabetes. Diabetologia 2009; 52: 2288–98. Mannucci E, Monami M, Lamanna C, et al. Prevention of cardiovascular disease through glycemic control in type 2 diabetes: a meta-analysis of randomized clinical trials. Nutr Metab Cardiovasc Dis 2009; 19: 604–12.
7 8
9 10
11
12 13
Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008; 359: 1577–89. Currie CJ, Peters JR, Tynan A, et al. Survival as a function of HbA1c in people with type 2 diabetes: a retrospective cohort study. Lancet 2010; published online Jan 27. DOI:10.1016/S0140-6736(09)61969-3. Miller CD, Phillips LS, Ziemer DC, et al. Hypoglycemia in patients with type 2 diabetes mellitus. Arch Intern Med 2001; 161: 1653–59. Tzoulaki I, Molokhia M, Curcin V, et al. Risk of cardiovascular disease and all cause mortality among patients with type 2 diabetes prescribed oral antidiabetes drugs: retrospective cohort study using UK general practice research database. BMJ 2009; 339: b4731. Gamble JM, Simpson SH, Eurich DT, Majumdar SR, Johnson JA. Insulin use and increased risk of mortality in type 2 diabetes: a cohort study. Diabetes Obes Metab 2009; published online Sept 24. DOI: 10.1111/j.1463-1326.2009.01125.x. Amiel SA, Dixon T, Mann R, Jameson K. Hypoglycaemia in type 2 diabetes. Diabet Med 2008; 25: 245–54. Amiel SA. Hypoglycemia: from the laboratory to the clinic. Diabetes Care 2009; 32: 1364–71.
Safer childbirth: avoiding medical interventions for non-medical reasons Published Online January 12, 2010 DOI:10.1016/S01406736(10)60055-4 See Articles page 490
3 years ago, The Lancet published the 2005 WHO global survey on maternal and perinatal health,1 which documented the high rates of caesarean sections in Latin America and the association with severe maternal and perinatal morbidity and mortality. That year, a new warning was issued about the dangers of unnecessary caesarean section.2 However, controversy about the ideal rate of caesarean section3 and the place of maternal choice4 has been continuing for so long that many obstetricians have become accustomed to the practice of medical interventions for non-
Panos Pictures
The printed journal includes an image merely for illustration
440
medical reasons. I (Y-SC) was once dumbfounded to overhear a remark at a professional workshop that “the best birth plan any woman can have is to ask for an elective caesarean section”. No doubt that remark was made facetiously, but the inconvenient truth is that physicians are some of the main advocates of this intervention to their patients, themselves, and their relatives.5 In The Lancet today, this situation is highlighted by Pisake Lumbiganon and colleagues in the 2007–08 WHO global survey,6 which provides a careful examination of childbirth practices in nine Asian countries. Acknowledging the difficulties of separating the intrinsic risk of procedures from the underlying medical indications, these authors classified caesarean sections into those with and without indications, and vaginal deliveries into spontaneous and operative deliveries. And the results are surprising and chilling. Although the overall rate of caesarean section was lower than that in Latin America (27% vs 33%), regional practice in the nine Asian countries differed substantially: rates in four countries exceeded 30%, whereas rates in the remaining five were less than 21%. In the country with the highest rate (China, 46·2%), a quarter of caesarean sections were done without medical indications—a rate far higher than that in the other countries surveyed. The reasons for this astonishing difference in practice were www.thelancet.com Vol 375 February 6, 2010
Comment
not specified, but Lumbiganon and colleagues reported that 62% of the hospitals surveyed had financial incentives for doing the intervention. Other studies in east Asia with similarly high rates of caesarean section have noted that physician factors were paramount,7 and that women generally have favourable attitudes towards vaginal delivery compared with caesarean section.8 The 2005 WHO survey noted that the high rates of elective caesarean section in Latin America “reflect a complex social process, affected by clinical status, family and social pressures, the legal system, availability of technology, and women’s role models”.1 Regional differences in medical practice will always exist, often contingent on resource availability. The paradox is that caesarean sections are more resource intensive than are vaginal deliveries1,3,6 but often given to those who need it least,9 since many people consider caesarean section an intrinsically safe operation.2 Lumbiganon and colleagues’ findings certainly do not lend support to this view. For antepartum caesarean section without indication, the risk of admission to an intensive care unit was ten times more likely than it was for spontaneous vaginal deliveries, and 67 times more likely for intrapartum caesarean section done without medical indication. Clearly, caesarean deliveries, even in mothers with no underlying medical issues, can be life-threatening. The WHO surveys have also shown no benefit for perinatal outcomes, apart from, according to today’s report, for babies with breech presentation. A surprising finding by Lumbiganon and colleagues was that the only procedure associated with an increased risk of maternal death was operative vaginal delivery, despite a modest rate of 3·2%. This report provides a sobering reminder of the dangers of operative deliveries. Although most operative vaginal deliveries are high-risk situations that cannot be easily avoided, alternatives should be considered in situations of prolonged second stage of labour with reassuring fetal status. These alternatives include continued expectant management, changes in maternal positioning, increased emotional support, and delayed pushing while reducing neuraxial anaesthesia.10 Present guidelines suggest that the second stage of labour need not be terminated for duration alone.10 Lumbiganon and colleagues’ findings should help us to prioritise our strategies to reduce unnecessary interventions in childbirth. Caesarean section without www.thelancet.com Vol 375 February 6, 2010
medical indication should not be encouraged. Financial incentives for doing these procedures should be removed or kept to a minimum, and both public and continuing medical education should emphasise the risks of unnecessary caesarean delivery. However, caesarean section without indication comprised only 7% of all procedures in the Asian survey.6 Most were done with indications, the most common being previous caesarean section, cephalopelvic disproportion, fetal distress, and malpresentations. Following the Pareto principle,11 investment in training and clearer guidelines for vaginal birth after caesarean section, intrapartum management, fetal monitoring, and external cephalic version12 could have wider effect. A previous randomised trial of mandatory second opinion for caesarean section13 reduced rates by only 7·3%, but the authors acknowledged issues with implementation. Stricter implementation and auditing of this policy might result in greater success. Finally, as operative vaginal delivery rates continue to fall, there should be no compromise in the level of training in the conduct of and careful selection of patients for instrumental deliveries. There is little wrong with medical interventions when indicated, but for those who are still inclined to consider caesarean delivery a harmless option, they need to take a cold hard look at the evidence against unnecessary caesarean section. *Yap-Seng Chong, Kenneth Y C Kwek Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore 119074 (Y-SC); and Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital, Singapore (KYCK) [email protected] We declare that we have no conflicts of interest. 1
2 3 4
5 6
Villar J, Valladares E, Wojdyla D, et al, for the WHO 2005 global survey on maternal and perinatal health research group. Caesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet 2006; 367: 1819–29. Victora CG, Barros FC. Beware: unnecessary caesarean sections may be hazardous. Lancet 2006; 367: 1796–97. The Lancet. What is the right number of caesarean sections? Lancet 1997; 349: 815. Kingdon C, Neilson J, Singleton V, et al. Choice and birth method: mixed-method study of caesarean delivery for maternal request. BJOG 2009; 116: 886–95. Al-Mufti R, McCarthy A, Fisk NM. Obstetricians’ personal choice and mode of delivery. Lancet 1996; 347: 544. Lumbiganon P, Laopaiboon M, Gülmezoglu AM, et al, for the World Health Organization Global Survey on Maternal and Perinatal Health Research Group. Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007–08. Lancet 2010; published online Jan12. DOI:10.1016/S0140-6736(09)61870-5.
441
Comment
7 8
9
10
Lin HC, Xirasagar S. Institutional factors in cesarean delivery rates: policy and research implications. Obstet Gynecol 2004; 103: 128–36. Lee SI, Khang YH, Lee MS. Women’s attitudes toward mode of delivery in South Korea—a society with high cesarean section rates. Birth 2004; 31: 108–16. Ronsmans C, Holtz S, Stanton C. Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis. Lancet 2006; 368: 1516–23. Ali UA, Norwitz ER. Vacuum-assisted vaginal delivery. Rev Obstet Gynecol 2009; 2: 5–17.
11 12 13
Koch R. The 80/20 principle: the secret of achieving more with less. London: Nicholas Brealey Publishing, 2001. Walker R, Turnbull D, Wilkinson C. Strategies to address global cesarean section rates: a review of the evidence. Birth 2002; 29: 28–39. Althabe F, Belizan JM, Villar J, et al, for the Latin American Caesarean Section Study Group. Mandatory second opinion to reduce rates of unnecessary caesarean sections in Latin America: a cluster randomised controlled trial. Lancet 2004; 363: 1934–40.
Organ transplantation between HIV-infected patients
Science Photo Library
Organ transplantations between HIV-negative donors and HIV-positive recipients have become more common,1–4 and ethical arguments have been put forward as to why transplantation in HIV-infected patients should be viewed as analogous to transplantation in patients with other chronic illnesses.3 A review of renal transplantation in patients with HIV notes that as demand for organs soars yet the supply of deceased-donor organs remains stable, one strategy to address these problems is to use organs from living donors while another would be to include “infectious high-risk” deceased donors—individuals who tested negative for HIV, HBV, and HCV but, on the basis of social history, could have acquired the infections shortly before becoming kidney donors.5 This strategy does not go far enough. Until September, 2008, transplantations between HIV-infected donors and recipients had not been done anywhere, mainly on the grounds of safety and because recipients were generally expected to have poor prognoses. The kidney transplants in two
442
HIV-infected patients from a single HIV-infected donor in Cape Town in 2008 challenge this tenet.6 In view of the dire shortage of organ donors in most countries, which is being compounded by the shrinking availability of HIV-negative donors, a continued blanket ban on all transplantations between consenting HIV-infected patients is no longer just debatable, but unconscionable, if protective measures can be put in place to mitigate risks to recipient patients. Current policies for organ transplantation in most countries stipulate that organs from HIV-infected donors must be discarded on safety grounds. For example, transplant recipients could acquire a different strain of HIV from the donor, including drug-resistant strains, as well as tuberculosis, hepatitis B, and hepatitis C. In living donors, there is also the risk of HIV-associated nephropathy. Such conditions might not be apparent at the time of screening or donation. Moreover, organs such as the liver and heart could already be damaged because of the donor’s previous exposure to anti-HIV drugs. However, safety checks could be put in place to mitigate or eliminate such risks.7 Such measures could include a pretransplantation biopsy to test for the presence of diseases. In the USA alone, as of October, 2008, more than 100 000 people were on the waiting list for organs.8 In developing countries, living donors provide 85–100% of donations compared with 1–25% in the developed world.9 Although organ shortages in developing countries are largely due to economic stringency and cultural factors,8 rising HIV prevalence in many settings is also translating into shrinking availability of HIV-negative potential donors. Permitting organ transplantation between HIV-infected donors and recipients could give HIV-infected patients a greater chance of receiving new organs than those uninfected because there would be more potential donors.6 www.thelancet.com Vol 375 February 6, 2010