September 23, 2005
The first identified case was in a man aged 40 years (index patient) who tested HIV-negative on February 12, 2004, and on March 17, 2004, through regular monthly testing of blood samples, but subsequently tested HIV-positive on April 9, 2004. HIV testing was performed through the Adult Industry Medical Health Care Foundation, a private nonprofit clinic in California, in a Clinical Laboratory Improvement Amendments (CLIA)-approved laboratory by using a polymerase chain reaction (PCR) test for HIV DNA (AmplicorTM HIV-1 Detection Kit, Roche Diagnostics); this clinic has provided voluntary monthly HIV testing to adult film industry workers since 1998. The nucleic acid testing method is approved only for screening blood products and not for individual human testing; however, the method has been used by the private nonprofit clinic for testing adult film industry workers because possible infection can be detected earlier than with standard serologic methods (i.e., enzyme-linked immunoassay [EIA] or Western blot). For blood transfusions, nucleic acid testing methods can detect HIV infection an estimated 10-15 days sooner than antibody-based tests; nucleic acid methods are highly sensitive but less specific than less costly serologic assays and thus are well-suited for screening of blood products but not for definitive diagnosis.1
On April 20, 2004, LACDHS initiated an investigation regarding the HIV-transmission events to assist with partner elicitation and notification and with medical referral for persons with newly diagnosed HIV infection. Cal/OSHA received an official request for an investigation from LACDHS on April 20, 2004. On April 29, 2004, LACDHS sought technical assistance from CDC to investigate concerns regarding HIV transmission.
During the time between his two negative tests, the index patient performed in film productions in Brazil, engaging in unprotected sexual acts. While in Brazil, he experienced an influenza-like illness that resolved before his return to California on or around March 10, 2004. According to LACDHS investigators, upon the return of the index patient to California, he participated in film productions in which he engaged in unprotected sexual acts with 13 female partners. Three of these 13 female partners subsequently tested HIV-positive by PCR after having tested HIV-negative during the preceding 30 days (attack rate: 23%). HIV PCR testing was conducted by the laboratory used by the nonprofit clinic; the HIV status of all four infected film workers was subsequently confirmed by PCR, enzyme-linked immunosorbent assay (ELISA), and Western blot testing at a separate laboratory.
According to field interviews with LACDHS and Cal/OSHA, two of the three HIV-infected female partners engaged in unprotected sex with the index patient during film production on March 24, 2004. Of these two female partners, one tested HIV-negative on March 20, 2004, and positive on April 13, 2004; the other tested HIV-negative on April 13, 2004, and positive on April 25, 2004. The third female partner engaged in unprotected sex with the index patient on March 30, 2004; she tested HIV-negative on April 12, 2004, and positive on May 5, 2004. During film production, all three of the infected female partners had engaged with the index patient in specific acts associated with increased possibility of mucosal tears. None of the other adult film industry workers or private partners with whom these three women had contact during the 30 days before their diagnoses subsequently tested HIV-positive. As of May 20, 2004, the index patient reported having had no sex partners outside of work since February 12, 2004. The person who was the source of HIV infection for the index patient is unknown.
The index patient and two of his three HIV-infected sex contacts subsequently provided whole blood samples to LACDHS, from which HIV DNA was sequenced at CDC. The third sex contact declined to provide a blood sample for sequencing. Using standard techniques, the HIV p17 region of gag and the C2V3C3 and gp41 regions of env from each of the three persons was amplified and sequenced by two different CDC laboratory scientists on separate days. All sequences were identical and supported the epidemiologic conclusion that the male index patient was the source of HIV infection and had transmitted HIV to these two women through sexual exposure.
After identification of the HIV outbreak cases, the organization operating the nonprofit clinic providing the HIV PCR testing identified a total of 25 first-generation partners (i.e., workers who had direct sexual contact with the four outbreak patients) and 36 second-generation partners (i.e., workers who had direct sexual contact with a first-generation partner). By June 30, 2004, a total of 24 of the 25 known first-generation partners had received HIV counseling and PCR testing at the nonprofit clinic after their exposure to a known HIV patient; of these 24 partners, 23 were tested at least 1 month after their direct sexual contact with an outbreak patient, and one was tested 3 weeks after the contact. All tested HIV-negative. The one first-generation partner for whom postexposure HIV test results were not available was a female partner of one of the infected female workers. In addition, 35 of 36 known second-generation partners had received HIV counseling and testing at the clinic as of June 30, 2004; among those tested, all were HIV-negative. The one second-generation partner for whom no postexposure testing data were available was a female partner of a male first-generation partner, who did receive postexposure HIV testing and was HIV-negative.
On June 4, 2004, Cal/OSHA opened an inspection of the producer(s) involved in these recent incidents of presumed workplace infection with HIV. On September 15, 2004, Cal/OSHA issued citations to two employers of some of the adult film industry workers with newly diagnosed HIV infection for failing to comply with the state's bloodborne pathogen standard,2 failing to report a serious work-related illness, and failing to prepare and follow a written occupational injury and illness prevention program.
Many producers and workers in the heterosexual segment of the adult film industry participate in a voluntary program of periodic HIV and STD testing, with results shared among workers and producers.* However, as demonstrated by the recent incidents of HIV transmission in this industry, screening alone is not adequate to prevent transmission of HIV or other STDs because infected persons can transmit these diseases for a period before their infection can be diagnosed. For HIV infection, the period after infection until virus is detectable by methods such as PCR is called the "eclipse period," and the period until antibodies to the virus are detectable by serologic methods is called the "window period." On the basis of the limited data available, the average eclipse period for HIV infection is estimated to last 10-15 days but can be longer.1,3 The index patient described in this report tested negative by HIV PCR twice during the 2 months before engaging in sex acts with the three women who subsequently became infected, including a negative test only 1 week before encounters with two of these women. This negative test likely occurred during the eclipse period when the index patient was able to transmit HIV but before the PCR test could detect the virus.
In addition to the testing program being inadequate as the sole source of protection from HIV transmission, the costs of testing are typically borne by the workers themselves. The cost burden of health services could cause some workers to reduce the range and frequency of HIV and STD screening or to avoid or delay pursuing vaccination for hepatitis B virus (HBV).
Similar episodes of HIV transmission have been identified previously in the heterosexual segment of the adult film industry. In addition to HIV, adult film industry work practices can result in transmission of other STDs. During June 2000-December 2001 (the most recently available prevalence data for this group of workers), before voluntary monthly STD screening was instituted, prevalences of chlamydial infection and gonorrhea among heterosexual adult film industry workers in California were 5.5% for males and 7.7% for females for chlamydial infection and 2.0% for both males and females for gonorrhea.4 By comparison, an analysis of a nationally representative sample of young adults aged 18-26 years during April 2001-May 2002 revealed prevalence of chlamydial infection among males and females to be 3.7% and 4.7% respectively, and, similarly, prevalence of gonorrhea to be 0.4% and 0.4%, respectively.5
These instances of HIV transmission in the adult film industry underscore the hazards associated with unprotected sex among workers in this industry and the importance of implementing an effective health and safety program at adult film industry worksites and production agencies, as required by Cal/OSHA.6 In issuing citations, Cal/OSHA made the determination that existing occupational health and safety regulations apply to employers in this industry, including development and implementation of a written injury and illness prevention program and compliance with the Cal/OSHA Bloodborne Pathogens Standard.6 This standard requires that employees be protected from hazards associated with blood and other potentially infectious substances (including semen and vaginal fluid). Protections include measures such as simulation and use of condoms and other barriers where needed to prevent exposure. Other provisions include employee training and vaccination for HBV. The citations are currently under appeal to the Cal/OSHA Appeals Board. Cal/OSHA, LACDHS, the California State Department of Health Services, and other agencies are also currently collaborating to develop an appropriate model exposure-control plan (ECP) for this industry that is consistent with the existing Cal/OSHA Bloodborne Pathogens Standard2 and the California Injury and Illness Prevention Standard.7
Findings from this investigation emphasize the need to review current health and safety policies in the adult film industry and ensure that they are designed in accordance with Cal/OSHA requirements. This review should involve all of the various industry, employee, policy, and public health organizations. Workers in this industry need to be made aware of the risks associated with participation in various acts,8 to be able to participate in decision-making about their health and safety at work, and to benefit from prevention practices.9 These recommendations are consistent with existing CDC guidelines for health and safety practices and primary prevention of disease.10
H. Rotblatt, J. Montoya, Ph.D., P.R. Kerndt, M.D., R. Kim-Farley, M.D. and J. Fielding, M.D. are with the Los Angeles Dept. of Public Health. E. Daar, M.D. is with the Harbor-UCLA Medical Center, Torrance. T. Bustamante is with the California Dept. of Health Svcs. B. Bernard, M.D. is with the Div. of Surveillance, Hazard Evaluations, and Field Studies, National Institute for Occupational Safety and Health. J.T. Brooks, M.D., M. Kalish, Ph.D. and K. Robbins are with the Div. of HIV/AIDS Prevention. K. Kenney, L. Laubacher and M. Taylor M.D. are with the Div. of STD Prevention, National Center for HIV, STD, and TB Prevention, CDC.
* Additional information is available at http://democrats.assembly.ca.gov/members/a42/pdf/afi.pdf (PDF).