Centers for Disease Control and Prevention, National Center for HIV, STD, and TB Prevention, Division of HIV/AIDS Prevention, aBehavioral and Clinical Surveillance Branch, and bHIV Incidence and Case Surveillance Branch, 1600 Clifton Road, Mail Stop E-46, Atlanta, GA 30333, USA; and cCenters for Disease Control and Prevention, Office of the Director, 4770 Buford Highway, Mail Stop K-79, Atlanta, GA 30341, USA.
Received: 21 October 2003; accepted: 12 November 2003.
Up to December 2001, 816 149 patients with AIDS were reported to the Centers for Disease Control and Prevention (CDC) and 256 cases with an unusual transmission mode have been documented . These data provide the largest population-based collection of HIV risk data available. Most individuals initially reported without risk information are subsequently found to have been exposed through sex or needle-sharing. Some individuals remain categorized as no identified risk because of incomplete health department investigations as a result of the patient's death, refusal to grant an interview, or loss to follow-up. Individuals whose HIV exposure category may be unusual have always been a high priority for follow-up because of the potential public health implications (e.g. occupational transmission) . In this report, we document seven cases of intentional self-inoculation with HIV-contaminated needles.
State and local health departments collect surveillance information regarding patient demographics and HIV risk factors and report them to the CDC, based on a mutually exclusive hierarchy of risks . Cases with no identified risk or suspected unusual transmission are further investigated by local or state health departments . These investigations include a review of the available medical records, and when possible, interviews with healthcare providers, case patients or their proxies.
We defined intentional self-inoculation as a self-report from an HIV-infected individual of intentionally inoculating oneself with HIV-contaminated blood, serum or body fluids at least once, before receiving a diagnosis of HIV or AIDS and regardless of other transmission risks. This includes intentionally sticking oneself with a needle used to draw blood or other body fluids from an individual known to be HIV positive. State and local health departments collected information on the circumstances surrounding exposure by reviewing medical records and interviewing patients or their proxies. The protocol for follow-up investigations was reviewed and approved by the Institutional Review Board of the CDC.
We identified seven cases of intentional self-inoculation with HIV-positive material (Table 1). Of these, six are known to have died, and the median time from HIV diagnosis to death was 71 months. All were white and four were women. Five worked in healthcare settings with access to contaminated sharps; one was a caregiver for family members with AIDS, and one had access to HIV-contaminated material through an HIV-positive friend. Five out of the seven had been diagnosed with depression before the inoculation event, and most had other diagnosed psychiatric disorders based on medical record review or patient self-report.
The routine follow-up of cases initially reported with no HIV risk information has allowed documentation of unusual circumstances of HIV transmission [2–4]. However, it is unlikely that HIV/AIDS surveillance data routinely detect self-inoculation cases because individuals are reluctant to disclose or may refuse an interview that could identify self-inoculation as a possible exposure mode. Because these investigations were initiated after the cases were reported to the surveillance system, direct follow-up with patients to allow a more detailed psychological profile was difficult. This is of concern, given that healthcare workers with a diagnosis of depression were highly represented in this case series. Although DNA sequencing was not available to confirm strain relatedness, the self-report and access to infectious material of all affected individuals makes self-inoculation a plausible transmission mode.
Although these may be extreme examples of individuals who deliberately put themselves at risk of HIV, they also illustrate an important challenge for HIV prevention efforts. More common than self-inoculation may be the deliberate practice of risky sexualual or drug-use behaviors among those who seek out HIV infection or are indifferent to its consequences . HIV prevention efforts, like those offered during counselling and testing sessions, or during prevention case management for high-risk HIV-negative individuals, should ideally include an appraisal of psychiatric co-morbidities that are known to impact high-risk behaviors . As HIV-positive individuals are not generally interviewed by HIV surveillance staff, surveillance data cannot document how widespread this phenomenon may be, but all cases of unusual transmission will continue to be a high priority for follow-up investigation.
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