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HIV transmission as a result of drug market violence: a case report Small, Will; Kerr, Thomas; Wood, Evan Jul 18, 2008

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ralssBioMed CentConflict and HealthOpen AcceShort reportHIV transmission as a result of drug market violence: a case reportWill Small*1, Thomas Kerr1,2 and Evan Wood1,2Address: 1British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada and 2Department of Medicine, 2194 Health Sciences Mall, University of British Columbia, Vancouver, British Columbia, V6T 1Z3, CanadaEmail: Will Small* - wsmall@cfenet.ubc.ca; Thomas Kerr - uhri-tk@cfenet.ubc.ca; Evan Wood - uhri-ew@cfenet.ubc.ca* Corresponding author    AbstractWhile unprotected sexual intercourse and the use of contaminated injection equipment accountfor the majority of HIV infections worldwide, other routes of HIV transmission have received lessattention. We report on a case of HIV transmission attributable to illicit drug market violenceinvolving a participant in a prospective cohort study of injection drug users. Data from a qualitativeinterview was used in addition to questionnaire data and nursing records to document an episodeof violence which likely resulted in this individual acquiring HIV infection. The case reportdemonstrates that the dangers of drug market violence go beyond the immediate physical traumaassociated with violent altercations to include the possibility for infectious disease transmission.The case highlights the need to consider antiretroviral post-exposure prophylaxis in cases of drugmarket violence presenting to the emergency room, as well strategies to reduce violenceassociated with street-based drug markets.IntroductionHuman immunodeficiency virus (HIV) transmissionamong injection drug users (IDU) represents a significantfactor driving the global HIV epidemic [1], and HIV inci-dence remains elevated among this population in numer-ous settings globally [2]. While the use of contaminatedinjection equipment and unprotected sexual intercourseaccount for the majority of infections worldwide, otherroutes of HIV transmission have received less attention.For instance, few studies have examined less commonroutes of HIV infection [3], and we know of none thathave considered the potential of direct blood-to-bloodcontact via violent altercations among IDU. Although HIVinfection through violent interaction is likely rare, thepotential of antiretroviral post-exposure prophylaxis toof transmission among drug user populations [4,5]. Thismay be particularly important given the high rates of drugmarket violence among IDU [6].Case descriptionWe present the circumstances surrounding the HIV infec-tion of a 39 year old white male who is a participantwithin a prospective epidemiological cohort study of IDUin Vancouver, Canada. In addition to completing a quan-titative survey which assesses HIV risk behavior, study par-ticipants also provide a blood sample for HIV testing atsemi-annual visits. As well, the cohort has a concurrentqualitative component designed to examine HIV serocon-versions among participants. Qualitative interviews areconducted with cohort participants who recently receivedPublished: 18 July 2008Conflict and Health 2008, 2:8 doi:10.1186/1752-1505-2-8Received: 9 June 2008Accepted: 18 July 2008This article is available from: http://www.conflictandhealth.com/content/2/1/8© 2008 Small et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 3(page number not for citation purposes)reduce the risk of HIV transmission under these circum-stances makes it important to examine this potential routea positive HIV test result, to collect additional data regard-ing sexual, and injection behavior in the time prior toConflict and Health 2008, 2:8 http://www.conflictandhealth.com/content/2/1/8seroconversion, as well as details regarding potentialsources of infection. Data from qualitative interviews gen-erate a detailed description of circumstances surroundingeach individual's HIV infection and are triangulated withcohort data and nursing records from pre-test counselling.The present case, to whom we have given the pseudonym'Peter', was defrauded in the street drug market by an indi-vidual who had sold him "bunk" [counterfeit drugs]instead of $50 worth of heroin he sought to purchase.When he next encountered the person who had defraudedhim at a focal point of the local drug market, Peterattempted to obtain re-imbursement of his $50. When re-imbursement was refused, a physical altercation ensued,and the man who defrauded Peter was severely beaten.The assault was committed using his fists and no bitingwas involved. Peter came into contact with large volumesof the other man's blood, and reported that the skin onhis own hands was broken in a number of places as aresult of punching the victim. Peter reported having beenaware that the victim was possibly HIV infected and thathis open wounds posed potential for infectious diseasetransmission. However, he did not seek medical attentiondue to his fear of being identified by police.Early in 2006, approximately 3 months after the incident,Peter presented to our research office for his semi-annualHIV test. Reviews of this participant's pre-test counselingnursing records from this study visit revealed that he sus-pected that he had been exposed to the HIV virus throughthe incident detailed above. In the six months prior to hispositive test result, the present case was injecting drugs buthis questionnaire data revealed that he denied any injec-tion-related HIV-risks as he primarily injected alone anddid not share syringes or ancillary equipment. Similarly,while the present case was sexually active in the 6 monthsprior to his seroconversion, he reported consistently usingcondoms and did not report any unprotected sex.DiscussionWe have described a case of an individual whose HIVinfection appears to be attributable to blood-to-bloodcontact which occurred during a violent encounter. Theassault that likely resulted in this infection was sparked bya conflict in the local street-based drug market. Althoughthis individual recognized that he had come into contactwith the blood of a person he thought to be HIV positive,and was cognizant that there was potential for infectiousdisease transmission, he did not seek medical assistance.Although violent encounters, particularly fistfights,involving HIV positive individuals have previously beenidentified as a mode of HIV transmission [3,7,8], thisamong IDU. The present case suggests that the potentialfor HIV exposure should be explored among individualsinvolved in violent encounters in high HIV prevalence set-tings, especially among IDU, since the level of violenceinvolved in this case is not unique [9,10]. This episodeindicates that the dangers of violence among IDU extendbeyond the immediate physical trauma associated withviolent altercations to include the possibility for infec-tious disease transmission. The potential for high levels ofviolence among IDU to create opportunities for HIV trans-mission merits consideration of measures to provideantiretroviral post-exposure prophylaxis to individualswho have been involved in a violent encounter involvingdirect blood contact.Within illegal drug markets violence is endemic and isemployed for the purposes of punishment and conflictresolution [9-11], as persons buying or selling drugs inthese markets have no recourse to legitimate authority toresolve disputes [12,13]. Therefore, effective practicalinterventions are needed to reduce the prevalence of drugmarket violence and mediate the negative health impactsthat result. Substitution therapies (e.g., methadone, her-oin prescription) and strategies to regulate or decriminal-ize particular illicit substances may hold potential toreduce violence among drug users and community levelsof violence in neighborhoods where street-based drugmarkets currently operate [14].Since the current study did not undertake phylogeneticanalysis, it is not possible to be absolutely certain that thedescribed assault on an HIV-positive male was the sourceof this individual's infection. However, given that bloodcontact resulting from violence has previously been docu-mented as a route of HIV transmission, the details of thiscase do support the conclusion that an assault was verylikely the source of infection. Additionally, comparison ofdata from study records and the qualitative interviewrevealed a high level of consistency in reported behaviorand agreement between data sources.Authors' contributionsWS conducted the analyses of the interview data and pre-pared the first draft of the article. All authors contributedto the design of the study as well to the drafting and revi-sion of the manuscript. All authors have approved thefinal manuscript.AcknowledgementsThe authors wish to thank the study participants for their time and partic-ipation. We also thank the administrative staff at the B.C. Centre for Excel-lence in HIV/AIDS, as well as the VIDUS and SEOSI study staff for their research assistance.Page 2 of 3(page number not for citation purposes)potential route of transmission has not been commonlyreported, and as far we know, has never been reportedPublish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central Conflict and Health 2008, 2:8 http://www.conflictandhealth.com/content/2/1/8Funding for this research was provided by the Canadian Institutes of Health Research (CIHR) operating grant, "Exploring the natural history of injection drug use: social and environmental influences".Mr Small is supported a Michael Smith Foundation for Health Research (MSFHR) Senior Graduate Studentship and a CIHR Doctoral Research Award. Dr Kerr is supported by a MSFHR Scholar Award and a CIHR New Investigator Award.References1. Joint United Nations Programme on HIV/AIDS (UNAIDS): Reporton the Global AIDS Epidemic by the Joint United NationsProgramme on HIV/AIDS.  , UNAIDS; 2006. 2. Aceijas C, Stimson GV, Hickman M, Rhodes T: Global overview ofinjecting drug use and HIV infection among injecting drugusers.  Aids 2004, 18:2295-2303.3. Gilbart VL, Raeside F, Evans BG, Mortimer JY, Arnold C, Gill ON,Clewley JP, Goldberg D: Unusual HIV transmissions throughblood contact: analysis of cases reported in the United King-dom to December 1997.  Commun Dis Public Health 1998,1:108-113.4. Mackie NE, Coker RJ: Post-exposure prophylaxis following non-occupational exposure to HIV: risks, uncertainties, and eth-ics.  Int J STD AIDS 2000, 11:424-427.5. Omrani AS, Freedman A: Prophylaxis of HIV infection.  Br MedBull 2005, 73-74:93-105.6. Kerr T, Small W, Wood E: The public health and social impactsof drug market enforcement: A review of the evidence.  Inter-national J Drug Policy 2005, 16:210-220.7. Emerson CR, Quah SP: Transmission of HIV-1 infection due toa fist fight.  Int J STD AIDS 2008, 19:131-132.8. O'Farrell N, Tovey SJ, Morgan-Capner P: Transmission of HIV-1infection after a fight.  Lancet 1992, 339:246.9. Singer M, Simmons J, Duke M, Broomhall L: The challenges ofstreet research on drug use, violence, and AIDS risk.  AddictionResearch & Theory 2001, 9:365-404.10. Fagan J, Chin K: Violence as regulation and social control in thedistribution of crack.  In Drugs and Violence: Causes, Correlates, andConsequences Edited by: De La Rosa M, Lambert EY and Gropper B. ,NIDA; 1990:8-42. 11. Maher L: Sexed Work: Gender, Race, and Resistance in aBrooklyn Drug Market.  , Oxford University Press;  2000. 12. Sterk CE, Elifson K: Drug-related violence and street prostitu-tion.  Drugs and Violence: Causes, Correlates, and Consequences1990:208-220.13. Parker RN, Auerhahn K: Alcohol, drugs, and violence.  Annu RevSociol 1998, 24:291-311.14. Erickson PG: Drugs, Violence and Public Health: What doesthe harm reduction approach have to offer.  , Fraser Institute;2001. yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralPage 3 of 3(page number not for citation purposes)

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