BACKGROUND: In 2014, the California Department of Public Health was notified of an acute HIV infection in a male performer (Patient A) employed in the adult film industry. In the week prior to diagnosis, Patient A participated in filmed condomless sex with other men for 2 production companies. An investigation was initiated to identify Patient A’s work and non-work related sexual partners during the 30 days prior to his diagnosis and notify them of their exposure; offer testing for HIV and other STDs; and link partners (if needed) to medical evaluation and treatment.
METHODS: State and local health departments confidentially notified each of Patient A’s work and non-work related sexual partners and recommended immediate HIV-1 RNA nucleic acid amplification testing (NAAT) and follow-up NAAT 30 days after the last exposure. HIV-1 polymerase (pol; 997 base pairs [bp]) and p17 (gag; 411-bp) sequences were PCR-amplified from pre-treatment sera on all patients with newly-identified HIV infection.
RESULTS: As required by many adult film companies, Patient A had a negative NAAT within 2 weeks prior to performing. Patient A had condomless sex with 8 HIV-negative performers during 2 film productions 9 and 11 days after the negative NAAT. One of these performers (Patient B) experienced symptoms consistent with acute HIV infection 4 days after sexual contact and was diagnosed with acute HIV infection 18 days after filming. Patients A and B reported no other common sexual contacts and no non-work related sexual contact with each other. One non-work related sexual partner of Patient A experienced symptoms of acute HIV infection 15 days after sexual contact and was diagnosed with acute HIV infection 1 day after symptom onset (Patient C). Patient A had non-work related sexual contact with Patient D 6 days before Patient A’s negative NAAT; Patient D was subsequently diagnosed with long-standing but previously undiagnosed HIV infection. Phylogenetic analysis showed highly related HIV-1 subtype B sequences in all 4 patients that cluster tightly with strong support; pairwise nucleotide identities were 99.1% in gag and 99.6% in pol.
CONCLUSIONS: We documented occupational HIV transmission among male adult film performers and their non-work sexual partners by phylogenetic analysis. Based on this investigation and previous documented HIV heterosexual transmission in the adult film industry, several public health policy recommendations will be discussed including: the use of condoms; HIV and other STD testing; vaccination for hepatitis A, B and human papilloma virus; and HIV pre-exposure prophylaxis.