SummaryHTLV infection appears to be more common among renal transplant candidates than in the related general population. HTLV‐1‐associated diseases may occur in carriers who are transplanted but there is insufficient evidence to confirm whether these occur more frequently as a result of the associated immunosuppression. Consequently, pre‐existing HTLV‐1 infection should not be considered a contra‐indication to transplantation.The risk of transmission of HTLV‐1 through solid organ transplantation from a confirmed infected donor is unknown. There are anecdotes of multiple infections from a single donor. Biologically due to the significant volume of blood and the lack of storage, transmission would be expected to be higher than following blood transfusion. The rate of subsequent disease is unknown, but there are now 11 reports of HAM and 2 of ATL occurring within 4 years of transplantation associated infection. There are insufficient data to know whether the time from infection to onset of disease and the rate of progression differ from transmission through other routes, but early onset and rapid progression is a concern. Responses to enhanced immunosuppression for the treatment of HAM are variable.The risk of HTLV‐1 associated disease in exchange for a life‐saving major organ transplantation from an infected donor might be considered worth taking by some HTLV‐1 uninfected patients. Peri‐transplantation antiretroviral prophylaxis with zidovudine and raltegravir is biologically sound but therapeutically unproven. The risks related to HTLV‐1 infection appear to preclude the use of any other tissue. All transplant donors should be screened for HTLV‐1 infection regardless of perceived risk.