Six people in Brazil who had organ transplants are now living with HIV because the donated organs were infected with the virus. The transplanted organs were traced to two donors from a Rio de Janeiro organ donation service, Reuters reports.

To ensure no one else has acquired HIV, health officials are screening donor recipients dating back to December 2023, when the lab linked to the error was hired. The city transplant service has been operating since 2006, according to Reuters, with more than 16,000 people receiving donated organs.

“It’s clear that a failure has occurred,” Claudia Mello, Rio’s health secretary, told O Globo, according to The Washington Post. “It’s unacceptable.”

Brazil’s public health care system provides free medical care to over 190 million people and is generally well-regarded across the world, reports the Post. The error in the transplant system has shocked the South American country and left health officials pointing fingers at one another.

Leaders with the Rio de Janeiro public health system blamed the error on PCS Lab Saleme, a private contractor whose lab tests organs for HIV. PCS Lab blamed an employee, who, in turn, implied to the Post that she had nothing to do with the mishap and that her signature had been forged on documents that incorrectly verified the health of the organs.

The state health department has suspended the lab’s license, and two employees are being investigated for fraud and criminal investigation.

PCS Lab Saleme released a statement that read, in part, “This is an episode without precedent in the history of the company, which has worked in this industry since 1969. PCS Lab will give medical and psychological support to the patients infected with HIV and their family members.”

“I didn’t do anything to acquire this,” one of the patients said, speaking anonymously to a Brazilian TV show. “It was the mistake of irresponsible people.”

Another person received a liver infected with HIV and died after the transplant, reports the Post, though it is unclear whether HIV played a role in that death.

In total, nine organs from the two HIV-positive donors were used in transplants on seven people. One person, who received a cornea transplant, has tested negative for HIV.

To be clear, the transplant error in Brazil is an extreme rarity, and it is unrelated to the U.S. transplant system. What’s more, in the United States, the HIV Organ Policy Equity Act (HOPE Act) lifted a ban on research related to transplants between people with HIV. As a result, more people with HIV have been able to safely donate organs to other people living with HIV. To read more about potential policy changes regarding such transplants, see this press release from the Department of Health and Human Services.

To read more about organ transplants and people living with HIV, click #Transplant. You’ll find headlines such as “World’s First HIV-Positive to HIV-Positive Heart Transplant” and “Kidney Transplantation Between Donors and Recipients with HIV Is Safe.”