The HOPE (HIV Organ Policy Equity) Act, enacted November 2013, reversed a decades-long federal ban on use of organs from donors with HIV and authorized development and publication of criteria to research solid organ transplantation from donors with HIV to recipients with HIV (HIV D+/R+).  This review describes HOPE Act implementation and progress to date, as well as ongoing systems- and community-related challenges and opportunities.  As of July 2021, 46 out of 58 Organ Procurement Organizations have evaluated a HOPE donor (this increased from 16/58 in 2017).  35 transplant centers in 21 states, many based in the eastern U.S., are approved to perform HIV D+/R+ transplants: 300 kidney and 87 liver transplants have occurred under approved research protocols.  Early kidney transplant outcomes indicate 100% patient survival and 92% graft survival, and no differences in 1-year mean eGFR, HIV breakthrough, infectious hospitalizations, or opportunistic infections.  Despite 16 states passing new legislation to facilitate HIV D+/R+ transplantation, authors identified policy restrictions in 34 states: this includes scenarios where state laws are “silent”.  HIV-related stigma – including within the health care system—remains an area of concern and opportunity for increasing awareness and information sharing/education, as ongoing stigma may lead to less likely transplant referral/listing, affect PWH’s willingness to donate or accept organs, and may also impair deceased donor evaluation.