The issue of postexposure prophylaxis for individuals with blood exposure following percutaneous injury is raised, as this is not routinely recommended in French, European, US, NY State HIV-1 guidelines [1–4] when the source patient's HIV status is unknown.
During the summer 2008 in south of France, a fight with a head injury between a barman and an unknown customer resulted in a superficial wound of the barman's forehead in the form of a scratch with a short exposure to the client's bloody broken nose. The barman, a 49-year-old Caucasian, did not consult a doctor. Four weeks later, he was hospitalized (Toulon Hospital) for fever, lymphadenopathy, weight loss and cutaneous rash. The diagnosis of an HIV-1 acute infection was established with positive HIV-1 ELISA test, negative Western blot; HIV-1 RNA load of 78 million copies/ml, and CD4+ T-cell count of 173 cells/μl (26%). The patient had a discrete scar (0.5 cm length) on his forehead connected with the fight. No other risk factor of HIV transmission was found. His wife was seronegative and he clearly denied homosexual contact, intravenous drug abuse, or contact with prostitutes. After a 3-month inquiry, the patient identified the customer, a 45-year-old Caucasian man previously followed up in our hospital for an HIV-1 infection. He had been contaminated after an intravenous drug injection, always refused any antiretroviral therapy, and had been lost sight of. On July 2007, he presented CD4+ T-cell count of 104 cells/μl with a high viral load of 328 200 copies/ml.
Knowing that the only risk factor for exposure in our patient was the fight, virological investigation was performed to evaluate the homology between the viruses of the patients. They presented the same polymorphism mutations on the reverse transcriptase and protease gene. HIV-1 RNA polymerase sequence from these viruses and a set of control sequences from HIV-1-infected patients, corresponding to their 10 best BLAST hits stored in the local Marseille database , were aligned with Clustal, version 5.0. The trees were inferred through the neighbor-joining method with a Kimura's-two-parameter distance. The tree was generated from the distance matrix on the basis of all pairwise comparisons of sequences. The reliability of tree topology was estimated from 100 bootstrap replicates. Phylogenetic analysis of the polymerase gene indicated that the two patients’ viral sequences belonged to the HIV-1 subtype B and clustered together with bootstrap values of 99%. A high similarity (96%) within the polymerase nucleotide sequence between the index and source patients (96%, 1167/1211 nucleotides) was assessed by BLAST analysis. Furthermore, we searched for the best hits for the HIV-1 RNA polymerase sequences between the two patients in our laboratory nucleotide sequence database (15 000 polymerase nucleotide sequences). ‘Nucleotide identity between sequences recovered from the index and source patients was in a closer range than between these sequences and their best matches in our laboratory database’ (Fig. 1).
Evidence seldom exists of a strong molecular epidemiological link between HIV DNA sequences from the infected person and the suspected infector. A good comprehensive assessment of a possible transmission chain is provided when complete sequences of the envelop gene are analyzed. Other studies have shown that a sequence of polymerase gene fragment may be sufficient for this type of investigation as in our case report [6,7]. The event timing and the molecular characterization of the strains provide strong evidence that HIV-1 was transmitted during the fight.
Few marginal cases of nonsexual, nonprofessional transmission have been reported around the world [8–10], and they emphasize the small but ever present risk to contract HIV-1 infection after percutaneous blood exposure and also reflect the difficulty to collect and authenticate them.
The average risk transmission from nonintact skin exposure to HIV-infected blood has been only documented in studies of healthcare workers which is estimated to be 0.3% [95% confidence interval (CI) 0.2–0.5%] [3,11] and is correlated positively to blood quantity, deep tissue injury, and the source patient's viral load .
Our case report confirms again that HIV-1 transmission through direct blood exposure during a fight is present even in case of superficial cutaneous injury and is probably related to the importance of the viral inoculum. Otherwise, the mode of contamination in France is unknown in 30% of the HIV-1 notifications  and fights are largely present everywhere in the world. In this regard, postexposure prophylaxis should be encouraged in case of brief blood exposure with a source of unknown HIV-1 status. The population should be educated to recognize and report to a physician any unavoidable exposure, as soon as possible, particularly in areas of high HIV prevalence. In terms of individual and public health, this could represent one means of limiting the HIV-1 pandemic.
We would like to thank Professor Christine Rouzioux and Dr Aymeric Pansu for manuscript revisions.
Conflicts of interest
There are no conflicts of interest.
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