We have described a case of an individual whose HIV infection appears to be attributable to blood-to-blood contact which occurred during a violent encounter. The assault that likely resulted in this infection was sparked by a conflict in the local street-based drug market. Although this individual recognized that he had come into contact with the blood of a person he thought to be HIV positive, and was cognizant that there was potential for infectious disease transmission, he did not seek medical assistance.
Although violent encounters, particularly fistfights, involving HIV positive individuals have previously been identified as a mode of HIV transmission [3, 7, 8], this potential route of transmission has not been commonly reported, and as far we know, has never been reported among IDU. The present case suggests that the potential for HIV exposure should be explored among individuals involved in violent encounters in high HIV prevalence settings, especially among IDU, since the level of violence involved in this case is not unique [9, 10]. This episode indicates that the dangers of violence among IDU extend beyond the immediate physical trauma associated with violent altercations to include the possibility for infectious disease transmission. The potential for high levels of violence among IDU to create opportunities for HIV transmission merits consideration of measures to provide antiretroviral post-exposure prophylaxis to individuals who have been involved in a violent encounter involving direct blood contact.
Within illegal drug markets violence is endemic and is employed for the purposes of punishment and conflict resolution [9–11], as persons buying or selling drugs in these markets have no recourse to legitimate authority to resolve disputes [12, 13]. Therefore, effective practical interventions are needed to reduce the prevalence of drug market violence and mediate the negative health impacts that result. Substitution therapies (e.g., methadone, heroin prescription) and strategies to regulate or decriminalize particular illicit substances may hold potential to reduce violence among drug users and community levels of violence in neighborhoods where street-based drug markets currently operate .
Since the current study did not undertake phylogenetic analysis, it is not possible to be absolutely certain that the described assault on an HIV-positive male was the source of this individual's infection. However, given that blood contact resulting from violence has previously been documented as a route of HIV transmission, the details of this case do support the conclusion that an assault was very likely the source of infection. Additionally, comparison of data from study records and the qualitative interview revealed a high level of consistency in reported behavior and agreement between data sources.