Case Review Examines Health Care-Associated HIV Transmission

Health care-associated transmission of HIV is rare, but an investigation of a presumptive case in New York underscores the importance of following standard precautions to prevent the spread of bloodborne pathogens.

The report, published in a recent Morbidity and Mortality Weekly Report from the US Centers for Disease Control and Prevention (CDC), details the case of a young-adult man who was hospitalized in July 2017 with complications of chronic kidney disease before being diagnosed with HIV. Health care officials noted the man had a low risk of HIV infection, including monogamous sex with a female partner who was HIV-negative and no injection drug use.

“This incident serves as a reminder of the importance of strict adherence to standard precautions within health care settings,” the report noted. “It also underscores the utility of sequence analysis to identify transmission to persons with no known HIV risk factors through uncommon health care routes that might otherwise go unrecognized.”

The patient (patient A) was negative for HIV upon hospitalization, an antigen/antibody rapid test revealed. He was readmitted for hemodialysis in October 2017, receiving vascular access placement at a second hospital, and was discharged after 10 days to receive further hemodialysis at an outpatient facility. He developed fever, sore throat, nausea, vomiting and diarrhea and was readmitted to the hospital, where a he received a positive diagnosis of acute HIV infection. Tests—which detected antigen and HIV-1 virus but no detectable antibody—indicated the infection like occurred during the time he was hospitalized.

Investigators from the New York City Department of Health and Mental Hygiene, the New York State Department of Health, and the CDC were prompted to examine the possibility of a health care-associated transmission of the disease. A review of 232 other patients—including 10 with HIV diagnoses—whose treatment overlapped with that of the patient in any of the 2 hospital settings or the outpatient hemodialysis facility.

Of the 10 patients diagnosed with HIV, 1 (patient B) was reported as having an increased viral load and receiving antiretroviral therapy during his hospital stay, while the other 9 were reported to have sustained viral suppression. A nucleotide sequence analysis was conducted, with HIV-1 sequences from the 2 patients sharing >99% identity.

Both patients were in the same inpatient hospital ward for 25 hours. They received hemodialysis in the same unit, but not on the same day nor did the patient A follow patient B on the same machine. Site visits by health officials revealed no lapses in infection control procedures, and were unable to confirm how the infection may have transmitted between the patients. Letters informing 36 other patients of the possibility of exposure were sent and testing offered, with no other cases of health care-associated HIV infection identified.

Patient A died of complications related to chronic kidney disease 66 days after his HIV diagnosis.

Goals to stop HIV include reducing new infections by 75% within five years and by 90% within a decade. A recent study of 6 US cities found that the best strategies included treating opioid users with buprenorphine or methadone; sending electronic HIV testing reminders; nurse-initiated rapid testing; case management; and rapid ART initiation.

Much of the effort on preventing HIV infections has been on pre-exposure prophylaxis (PrEP). Colleen Kelley, MD, MPH, associate professor at the Emory University School, recently discussed the developments in on-demand PrEP and injectable Cabotegravir for PrEP in clinical trials.