Despite requirements for periodic testing for HIV infection, work-related transmission between heterosexual adult film performers was documented in 2004. Periodic testing alone, nonetheless, remains the primary attempted means of prevention of HIV transmission by many adult film production companies. The failure of this approach has again been highlighted by the case of a 25-year-old male performer who transmitted the infection despite having had a routine negative nucleic acid amplification test (NAAT) shortly before, with the following overall timeline:
- Day 0: Negative NAAT
- Day 10: Onset acute retroviral syndrome
- Day 22: Patient informed of positive HIV test.
In the 22-day interval between the negative NAAT and the patient learning of the subsequent positive test, he had work-related “condomless” sex with a total of 12 male performers while working for two production companies, as well as more than five male non-work-related encounters in the month before and after his symptom onset.
Contact tracing was complicated by the fact that the contacts, both professional and non-professional, lived in seven U.S. states and four foreign countries, while the production companies were based in two other states and filming occurred in yet another state. Ultimately, contact tracing and viral sequence analysis indicated that, after being infected by a non-performer, the patient subsequently infected both a co-worker and a non-work-related partner in the interval between his negative NAAT and his learning of the subsequent positive test. Of note is that six of the 17 contacts (none of whom used HIV PrEP) had already been chronically HIV-infected prior to exposure to patient A, and one had been exposed prior to patient A being infected. Of the remaining 10, seven had engaged in condomless anal sex with the patient, and two (29%) became infected, an attack rate similar to the 23% rate observed in the 2004 episode.
Safety in the work place is regulated by the Federal Occupational Safety and Health Administration (OSHA) and parallel state OSHAs. Much of the adult film industry is based in southern California, and voters in Los Angeles County passed a law in 2012 requiring that adult film performers wear condoms during vaginal and anal sex. It also required adult film production companies to obtain a permit from the Los Angeles County Department of Public Health, which, in turn, included requirements that adult film directors complete a training course about bloodborne pathogens and that producers submit an exposure control plan. The California Occupational Safety and Health Standards Board proposed further requirements in 2015.
Adult film production companies and their performers, medical providers, and all persons at risk for HIV should be aware that testing alone is not sufficient to prevent HIV transmission and, thus, does not preclude the necessity of condom use, which also provides protection against other sexually transmitted infections. PrEP provides additional protection and should be considered.