In an unprecedented case in the history of Brazilian public health, six patients waiting for transplants in Rio de Janeiro tested positive for the virus. HIV after receiving organs from two HIV-positive donors. The circumstances surrounding the incident are still being investigated, and many questions remain unanswered.
What is known
The Public Ministry of Rio de Janeiro, the Ministry of Health, the Civil Police and the Regional Council of Medicine (Cremerj) are leading the investigations. The State Department of Health of Rio de Janeiro (SES-RJ) classified the episode as “inadmissible” and highlighted that, despite the incident, the state has carried out more than 16 thousand transplants since 2006, always with “excellent work”.
The tests that confirmed the health of the organs were carried out by PCS Lab Saleme, a private laboratory contracted in an emergency tender in December 2023. The contract, worth 11 million reais, was signed for the company to carry out serological tests on the organs donated.
PCS Lab Saleme, located in Nova Iguaçu, Baixada Fluminense, belongs to Matheus Sales Teixeira Bandoli Vieira, cousin of the former Secretary of Health and current federal deputy Doutor Luizinho (PP-RJ). During the bidding, Luizinho was still responsible for the portfolio.
The State Transplant Coordination and State Health Surveillance have already closed the laboratory. The inspection revealed that the PCS Lab did not have kits to carry out the tests and did not present documents proving the purchase of the necessary materials — casting doubt on the veracity of the reports issued to the contaminated bodies.
In immediate response, SES-RJ transferred all exams carried out by PCS Lab for new testing at Hemorio. In addition, stored genetic material from 286 donors will be reanalyzed, which will allow for new data verification.
The Minister of Health, Nísia Trindade, released a video on social media stating that the ministry will take all appropriate measures and provide assistance to patients’ families. An emergency audit was also ordered to investigate what happened.
In a note sent to CartaCapitalthe Regional Council of Medicine of the State of Rio de Janeiro reported that it opened an inquiry to investigate the allegations. “The situation is very serious, and Cremerj reaffirms its commitment to rigorously investigating the facts. Patient safety is fundamental to the good practice of medicine in the state”, said Walter Palis, president of the institution. The investigative process runs in secrecy.
The infectious disease specialist and consultant for the Brazilian Society of Infectious Diseases, Lígia Pierrotti, also highlights the seriousness of the case. “Brazil is the fourth largest country in terms of the number of transplants, and this represents a huge advance since the 1960s. Since 2006, more than 16 thousand transplants have been performed, saving many lives and ensuring quality of life for patients”, he highlights.
How the case was discovered
The first case was discovered on September 10, when a transplant patient presented neurological symptoms and, after blood tests, was diagnosed with HIV. He had received a heart in January of this year.
With the suspicion, the authorities revisited the exams of the donated organ and requested a countertest. The collection carried out by the laboratory in January included kidneys, liver, heart and cornea from the same donor, all supposedly negative for the virus. However, other recipients, with the exception of one patient who received the cornea, tested positive for HIV. One of the patients died shortly after the transplant, but his death was attributed to pre-existing complications.
On October 3, another transplant recipient showed symptoms and also tested positive for HIV. This patient had received an organ from another donor, whose examination, carried out on May 25, also did not indicate the presence of the virus.
What still needs to be clarified
Despite emergency actions, many questions remain unanswered. Why was the laboratory responsible for testing the organs hired without the necessary resources to carry out the tests? And how, exactly, did the process of checking contaminated organs fail?
Furthermore, the real impact on transplant patients is still unclear. Pierrotti highlights that the modernization of antiretroviral treatments offers quality of life and does not represent a significant risk for transplant recipients, as long as adequate treatment is followed. Transplantation in people with HIV is also safe, as long as it is carried out with due care and following established protocols.
Another question concerns the chain of responsibility. To date, it is not clear what the role of each inspection and control body was, nor how the reports were approved without due verification. The involvement of a cousin of the former Secretary of Health in the administration of the laboratory also raises questions.
There is also the issue of the 286 donors whose organs were tested by the banned laboratory. Is there a risk that other patients may have been contaminated?
