Brazilian health officials are scrambling to explain how six transplant patients in the country’s well-regarded public health system received organs infected with HIV – and investigating whether there are more cases to come.
The revelation has shocked the South American nation and plunged its health network, a source of national pride, into crisis.
In the days since Brazilian outlet Band News reported the infections last week, those involved have traded blame. The Rio de Janeiro public health system blamed a private laboratory that tests organ donors for HIV. The contractor, PCS Lab Saleme, blamed one of its employees.
That employee told The Washington Post she had nothing to do with the errors and implied the contractor had forged her signature.
Six people, meanwhile, are coming to terms with the news that their new organs infected them with the virus that causes Aids.
“It’s as if the floor opened up; this will change my life completely,” a kidney recipient told the Brazilian television program Fantástico.
“I didn’t do anything to acquire this,” she said. “It was the mistake of irresponsible people.”
A patient who received an HIV-infected liver died soon after. Authorities are investigating whether the virus was a factor. They’re also working to determine whether more organs from HIV-infected people have entered the donor pool.
“It’s clear that a failure has occurred,” said Claudia Mello, Rio’s Health Secretary. “It’s unacceptable.”
The state Health Department suspended PCS Lab Saleme’s licence, and police have opened an investigation. Two lab employees, including one of its partners, were temporarily detained last week. Police say they are being investigated for fraud and criminal association.
PCS Lab Saleme did not respond to a request for comment. In a statement, it said it would co-operate with investigators.
“This is an episode without precedent in the history of the company, which has worked in this industry since 1969,” the statement said. “PCS Lab will give medical and psychological support to the patients infected with HIV and their families.”
Brazil’s public health system, which provides free medical treatment to 190m people, is seen across the developing world as a marvel. In the past 20 years, its Rio state network has performed an estimated 16 000 organ transplants. A key element of the process is verifying the health of the donors.
In Rio, that was the job of PCS Lab Saleme. Since late last year, the company has been asked to test the blood of nearly 300 organ donors, health officials said. At least two who were infected with HIV were reported as negative. Nine of their organs were used in transplants on seven patients.
One of the patients tested negative for HIV. That patient received a cornea.
Rio politician Claúdio Castro, posting on X, said the “state has the duty to assume responsibility” for what he called “an unacceptable situation without precedent”.
Health officials were alerted to the error when one recipient sought medical care for neurological problems. Testing soon revealed the patient had HIV.
Much of the public scrutiny has fallen on one lab employee: Jacqueline Iris Bacellar de Assis, whose name and initials appear on the forms that verified the organs’ health.
The lab has told Brazilian media that she presented herself as a biotechnician. She is not and told The Washington Post that she never claimed to be. The identification number used on the forms corresponds to another person, who lives out of state and no longer practices.
Bacellar said she never served as a biotechnician at the lab. Her job, she said, was strictly administrative. Tests were performed in the Rio suburb of Nova Iguaçu; Bacellar said she worked at a location in downtown Rio.
“I’m not a biotechnician,” she said. “I’m an administrative supervisor. My work was overseeing stock, making spreadsheets, looking at account balances.
“I didn’t physically sign any of the forms,” she said. “But the IT people had access to my passwords.”
The police issued a warrant for her arrest last Monday and she turned herself in on Tuesday.
“I’m beside myself with this situation,” she said. “I keep wondering why the laboratory would do something like this.”
The patient who received the infected kidney said she wanted the laboratory held to account.
“They just weren’t worried about our lives,” she said. “They were looking for profits. There is no justification. I want punishment.”
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SA policy uncertainty a major obstacle to organ donation