ACUPUNCTURE SHOULD BE AN UNLIKELY MODE OF TRANSMISSION FOR THE HUMAN IMMUNODEFICIENCY VIRUS (HIV)

Alan I. Trachtenberg, M.D., M.P.H.

     A letter recently published in the New England Journal of Medicine reported a case of acute HIV infection, which may be linked to acupuncture treatments (1). The authors described a previously healthy 17-year-old male in Paris, who had a clinical syndrome compatible with acute HIV infection. HIV-seroconversion was detected three months after the onset of the acute episode. This patient did not have a history of sexual intercourse, did not have hemophilia, and had never had a blood transfusion or other reported risk factors. He had however received acupuncture once a week for six weeks (for tendinitis subsequent to a period of intensive rugby training). The clinical syndrome with fever developed during the week after the end of acupuncture treatments. The authors ascribed the patient's HIV infection to the acupuncture procedure.
     This is the first report in the medical literature of HIV infection possibly related to acupuncture, however it appears that the correlation was drawn on the basis of circumstantial evidence. At a minimum, one would like to know what type of practitioner was performing the acupuncture, what needle sterilization procedure was in use at the time, and whether any breaks in the procedures were observed in the acupuncturist's technique. For a definitive proof of this iatrogenic transmission, a source case (one or more patients known to be HIV infected, or at least in a known risk category receiving acupuncture during the same period as this patient did) would be required to demonstrate the cause of transmission. If acupuncture was thought to be the cause of the infection of this patient, then a comprehensive surveillance of other patients in the same acupuncture practice should have been undertaken to determine if an acupuncture-related outbreak of HIV infection had, indeed, occurred.
     Acupuncture-related outbreaks cf hepatitis B have been described in the medical literature from the U.S.A., Israel and the U.K. (2,3,4,5). All these outbreaks were associated with non-physician acupuncturists and had clear links of transmission. Hepatitis B virus serves as the most useful model for risk cf HIV transmission because it is a bloodborne virus transmitted by modes identical to those for HIV. In addition to these clearly identified outbreaks, Schmid et al. have described 17 cases of hepatitis (16 hepatitis B, and 1 non-A non-B hepatitis) which were "probably, and 4 more cases possibly, traceable to prior acupuncture performed by a non-medical practitioner" over a seven-year period in Germany (6). Until now, the only hepatitis outbreak associated with physician-acupuncturists was reported by Kobler et al. (7), in which three cases of hepatitis B were attributed to a physician performing acupuncture with repeated use of the same needles which were not properly sterilized.
     Despite the existence of such outbreaks, acupuncture has not been demonstrated to be a significant risk factor in population studies of hepatitis B. A large population-based study of Chinese men in Singapore showed an odds ratio of 0.88 (95% CI: 0.71,1.11 ) for the association between acupuncture and hepatitis B surface antigenemia (8). This study confirmed the lack of association between acupuncture and hepatitis B infection in a population with a high prevalence of both. Concordantly, this lack of association hadalso been previously demonstrated in another study in Taiwan (9). These large population-based studies suggested that although breaches in acupuncture technique may lead to an outbreak of infection with a bloodborne virus, such outbreaks should be quite rare, even for non-physician traditional practitioners.
     The suggestion made by Vittecoq et al. (1) that acupuncture might be a route of HIV transmission stemmed from an epidemiological report from the Centers for Disease Control, in which 2 of 148 patients with the acquired immunodeficiency syndrome (AIDS) who had no previously identified risk factors gave a history of acupuncture treatment before the onset of the disease (10). This report however presented "no evidence for new transmission modes" and had no control group to examine the prevalence of a history of acupuncture. In the urban epicenters of the AIDS epidemic, a 1.4 per cent prevalence of acupuncture utilization seems well within the bounds of the expected, and it is too low to establish any significant link to HIV transmission.
     HIV is known to be less easily transmitted by needlestick than hepatitis B virus. In persons without prior vaccination or post-exposure prophylaxis, 6 to 30 per cent of those who have been exposed to hepatitis B by needlestick will become infected (11 ). Of persons similarly exposed to HIV, only 0.5 per cent will become infected (12). It should also be considered that the needlestick cases involved the use of hollow needles for injections, rather than solid needles as used for acupuncture, which as expected may transfer, if any, a much smaller amount of blood.
     The report by Vittecoq et al. (1) gives no indication of the depth of questioning and validation of the patient's sexual history. In addition, there is a lack of epidemiological evidence to support their conclusion. Caution is thus necessary in determining whether acupuncture was the cause of H IV infection in this clinical case.
     Although by no means proving that HIV can be transmitted by acupuncture, Vittecoq et al. have raised an appropriate cautionary note for both physician and non-physician acupuncturists. One hopes that eventually more details of this case will be forthcoming. Whether or not it represents a true case of HIV transmission by acupuncture does not change the need for all practitioners to use appropriate and careful procedures to assure that all used needles, if not disposable, will be properly sterilized. In accordance with CDC recommendations, all blood-contaminated needles should be treated as if they were from a patient with a bloodborne infection (13) and all blood should be treated as potentially infectious, regardless of the clinical status of the patient. Strict adherence to these infection control procedures will insure that neither practitioners nor patients will become infected by HIV or other bloodborne pathogens in the course of acupuncture treatments.

REFERENCES
1. Vittecoq D., Mettetal J.F. et al. Acute HIV infection after acupuncture treatments. New Engl. J. Med. 1989; 320: 250-51.

2. Kent G.P., Brondum J. et al. A large outbreak of acupuncture-associated hepatitis B. Am. J. EpidemioL 1988; 127: 591-98.

3. Slater P.E., Ben-lshai P. et al. An acupuncture-associated outbreak of hepatitis B in Jerusalem. Eur. J. Epidemiol. 1988;

4: 322-25. 4. Stryker W.S., Gunn R.A. & Francis D.P. Outbreak of hepatitis B associated with acupuncture. J. Fam. Pract. 1986; 22: 155-58.

5. Boxell E.H. Acupuncture and hepatitis in the West Midlands, 1977. J. Med. Virol. 1978; 2: 377-79.

6. Schmid E., Hortling G. & Kammuller H. Inoculation hepatitis caused by acupuncture. Clinical cases studied over a 9-year period. Fortschr-Med.1984; 102: 862-65.

7. Kobler E., Schmuziger P. & Hartmann G. Hepatitis following acupuncture. Schweiz Med. Wochenschr. 1979; 109: 1828-29.

8. Phoon W.O., Fong N.P,, & Lee J. History of blood transfusion, tattooing, acupuncture and risk of hepatitis B surface antigenaemia among Chinese men in Singapore. Am. J. Public Health. 1988; 78: 958-60.

9. Beasley R.P., Hwang L.Y. et al. Incidence of hepatitis among students at a university in Taiwan. Am. J. Epidemiol. 1983; 113: 213-22.

10. Castro K.G., Lifson A.R. et al. Investigations of AIDS patients with no previously identified risk factors. JAMA 1988; 259: 1338-42.

11. Centers for Disease Control. Recommendations for protection against viral hepatitis. MMWR 1985; 34: 313-24, 329-35.

12. Centers for Disease Control. Update: universal precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other bloodborne pathogens in health-care settings. MMWR 1988; 37: 377-82, 387-88.

13. Centers for Disease Control. Recommendations for prevention of HIV transmission in health-care settings. MMWR 1987; 36(suppl 25).

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