Needs must: living donor liver transplantation from an HIV-positive mother to her HIV-negative child in Johannesburg, South Africa.

The world's first living donor liver transplant from an HIV-positive mother to her HIV-negative child, performed by our team in Johannesburg, South Africa (SA) in 2017, was necessitated by disease profile and health system challenges. In our country, we have a major shortage of donor organs, which compels us to consider innovative solutions to save lives. Simultaneously, the transition of the HIV pandemic, from a death sentence to a chronic illness with excellent survival on treatment required us to rethink our policies regarding HIV infection and living donor liver transplantation . Although HIV infection in the donor is internationally considered an absolute contraindication for transplant to an HIV-negative recipient, there have been a very small number of unintentional transplants from HIV-positive deceased donors to HIV-negative recipients. These transplant recipients do well on antiretroviral medication and their graft survival is not compromised. We have had a number of HIV-positive parents in our setting express a desire to be living liver donors for their critically ill children. Declining these parents as living donors has become increasingly unjustifiable given the very small deceased donor pool in SA; and because many of these parents are virally suppressed and would otherwise fulfil our eligibility criteria as living donors. This paper discusses the evolution of HIV and transplantation in SA, highlights some of the primary ethical considerations for us when embarking on this case and considers the new ethical issues that have arisen since we undertook this transplant.

A Qualitative Analysis of South African Health Professionals' Discussion on Distrust and Unwillingness to Refer Organ Donors.

INTRODUCTION: South Africa is faced with very low deceased organ donor numbers. Often, sociocultural practices, which are thought to be fundamentally opposed to deceased organ donation, are hailed as the cause. However, other factors such as context, social perceptions, and clinical environment may play a role. AIM: The aim of this article is to present research that explored communication in organ transplant and identified barriers to organ donation decisions in a province of South Africa. METHODS: Qualitative methods were used. Thirty semistructured interviews with transplant professionals and 2 focus groups with transplant coordinators took place across 6 health institutions in Gauteng Province. RESULTS: Barriers that may prevent transplant professionals from referring potential donors were identified: The wider public and transplant professionals may be suspicious of biomedicine and have a perception that people could be killed for their organs. Organ donation was sometimes framed as "murder," "killing," or a "bunch of vultures." Doctors may be unwilling to refer brain-dead patients, as this was seen as failing in one's professional duty to cure the patient. The role of sociocultural practices was inconclusive, with the sample divided based on the extent of their influence. CONCLUSION: Low donor numbers may be a manifestation of barriers to referral in the clinical setting. These barriers interplay in a context of suspicion and are framed by a clinical transplant discourse that is sometimes loaded with negative connotation. Sociocultural practices are influential, but they may not be the overriding cause of low donor numbers.

Communication in Healthcare: Global challenges in the 21st Century.

This article explores the communication challenges brought about by the digital revolution in the 21st century for healthcare professionals internationally. It particularly focuses on the use of content-generating and sharing platforms like social media. Globally, healthcare has been irrevocably altered by digital innovation and health professionals deploy an extensive range of social media and web-based tools on a daily basis. However, many healthcare professionals use these platforms in a regulatory vacuum-where there may not be specific legal or ethical guidance-and without an appreciation of the associated risks. Given the special protections afforded to the practitioner-patient relationship, and the importance of a health practitioners' reputation, it is vital that we understand how to traverse the many ethical and legal challenges of the digital interaction. A comprehensive set of recommendations (see "Guidelines for Good Digital Citizenship in the Health Professions" on page 5 ff.) to keep practitioners out of trouble is provided. These hinge on the notion of being a "good person and a good doctor" as a formative maxim for ethical and legal safety. The constituents of publication, and the consequences of falling foul of acceptable publication standards on social media, are specifically discussed. "Publication" involves sharing content with a third party, or a group of people, and social media refers to platforms on which content can be shared with more than one person. Hence, most information that we post on social media can be considered as "published," and as such may attach liability for health professionals who do not use these platforms with requisite care and sufficient forethought.

Assessing Global Organ Donation Policies: Opt-In vs Opt-Out.

This paper argues that there is little difference between opt-in and opt-out organ donation systems for increasing donor numbers when used in isolation. Independently diverting to an opt-out system confers no obvious advantage and can harm efforts to bolster donations. Rather, it is essential to address barriers to organ donation on several levels along with a switch in system. Moreover, for many countries, it may be more beneficial to adequately capacitate the donation system already in place, rather than entertain a significant change with its attendant resource requirements. For decades, the international transplant community has been involved in vigorous debate as to the merits of moving from default opt-in systems to opt-out policies to grow organ donor numbers and better meet the ever-increasing demand for lifesaving transplants. Opt-out is certainly en vogue, with Wales, England and Nova Scotia recently switching over, Scotland due to become opt-out in March 2021 and Northern Ireland and Canada seriously considering a similar move. Thanks to several countries making the switch from opt-in to opt-out over the last 20-30 years, there are sets of robust longitudinal data that aid in analysing the efficacy of donation systems. However, these data are often contradictory and largely inconclusive, suggesting other factors may be in play. This paper reviews some emerging trends in opt-in versus opt-out organ donation policies and considers recent data that elucidates some of the main contentions across each. Ethical frameworks underpinning donation systems, such as informed consent, trust and transparency, are discussed in detail. Substantial time is also devoted to opt-in vs opt-out systems in developing countries, which tend to be excluded from many analyses, and where the challenges faced are magnified by socio-economic constraints. This constitutes a major gap in recently published literature, as developing countries often lag far behind their developed counterparts in donor and transplant numbers.

Non-referral of potential organ donors in South Africa: insights, challenges and ethical dilemmas.

Traditionally, minimal potential organ donor referrals emanate from general medicine departments. We use a clinical vignette to draw attention to challenges related to referral of potential organ donors from general internal medicine departments. In addition, we provide potential solutions to overcome challenges and reflect on the ethical issues of non-referral of potential organ donors. It is hoped that this paper will increase the awareness of organ donation in the medical fraternity in Africa and thus mitigate critical shortages of organs for transplantation.

Interprofessional communication in organ transplantation in Gauteng Province, South Africa.

BACKGROUND: Communication is essential to the transplant process, but it is challenging in South Africa (SA) because of the complexity of the country and the health system, the nature of transplantation as a technical procedure with inherent psychological considerations, and the large number of professionals involved. Transplant communication has not been explored in SA, and this study was the first to use health communication methods to generate empirical evidence relating to it. OBJECTIVE: To explore communication in transplant settings in Gauteng Province, SA. METHODS: Qualitative methods were used to collect data across six hospitals and transplant centres in Gauteng. State and private institutions were equally represented. Health professionals and transplant co-ordinators participated. Thematic analysis of data was undertaken. RESULTS: Facilitators of interprofessional transplant communication included appreciation of its importance to good practice and cohesive individual transplant teams. Barriers to interprofessional communication were observed when individual teams had to come together in a multi-team, interdisciplinary environment, when interchange became aggressive, and when information was not passed on to other health professionals timeously. These barriers had implications for continuity of care and ethics, which could lead to moral distress. CONCLUSION: Transplantation in Gauteng is characterised by aspects of good teamwork, and the importance of effective communication is acknowledged. Transplantation also faces some challenges in terms of interprofessional communication. Recommendations for mitigating some of the gaps include integrating a health communication specialist into the transplant process, 'knotworking', the use of apology, and an advance warning text-message system for transplant professionals.