Although rates of organ donation and solid organ transplantation have been increasing over the past several decades, the demand for organs still greatly exceeds the supply. Several strategies have been utilized to increase organ supply, including utilization of high-risk donors. Hepatitis C viral (HCV) infection is a major reason for discarded organs, especially in the United States (US), due to the opioid epidemic. While organs from donors with positive HCV antibody have been used in chronic HCV recipients since the early 1990s, more recently the development of safe and highly effective direct-acting antiviral (DAA) therapies and increasing experience treating HCV in the post-transplant setting has led to significant interest in using HCV-viremic organs in HCV-naïve recipients. Preliminary studies based largely in the US have shown excellent outcomes in kidney, liver, heart, and lung transplantation. This practice has the potential to significantly increase transplantation rates and decrease waitlist mortality; however, intentionally transmitting an infectious disease to recipients has important practical and ethical considerations. Further, the generalizability of the US experience to other countries is limited by significant differences in HCV-viremic donor populations. This review summarizes the current data on this practice, discusses barriers to implementation, and highlights areas in need of further study.Copyright © 2020 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.