Self-Flagellation: Possible Route of Transmission of HIV.

In India, HIV prevalence in adults in 2017 was estimated to be 0.22% (0.16%–0.30%).[1] The most common route of HIV transmission is via unprotected sexual intercourse, followed by vertical transmission during pregnancy and childbirth, sharing of contaminated needles, injecting drug use, and transfusion of contaminated blood.

A set of rituals practiced by the Shia Islamic Communities known as “Matam” or act of mourning include public or private ceremonial chest beating (Sineh-Zani) using hands or using certain equipment such as blades, knives, swords, and chains (Zanzeer-Zani).[23] Self-flagellation or “Zanzeer-Zani” practices during mourning of “Muharram” are widely reported by the Indian media. Here, we report a case of HIV infection possibly due to self-flagellation. To the best of our knowledge, this is the first ever-documented case report in scientific literature highlighting transmission of HIV due to such practices.

A 30-year-old male, a resident of suburban Mumbai, presented to the DOTS center of an urban health training center attached to a medical college in Mumbai. Written informed consent was taken from him for furnished details and photographs. He is a freelancer doing works such as painting, plumbing, and electrical repairs. He is educated up to 9th standard.

He came with the chief complaints of generalized tiredness, double vision, and swaying to the left side when walking for 3 months. After taking medications from a general practitioner several times (details not available), he visited a peripheral municipal hospital 1 month back. There, he was diagnosed to have tuberculosis and referred for initiating treatment. He was also detected to be HIV positive. He denied any history of sexual contact with a man or woman outside his marriage. He is separated from his only wife for 8 years and has a 10-year-old daughter. He has never considered remarriage and lives with his mother and daughter. He also denied a history of any blood transfusion, surgery, dental procedure, suturing, or tattooing in the past. He has a habit of chewing tobacco daily since childhood and denies any other addictions such as alcohol, smoking, or narcotic substances. He also denied a history of injecting any drug in the past. He gave a history of being active in social work and youth empowerment in his community. He had allegedly conducted “Nasha Mukti Abhiyan” (antidrug campaign) in his locality and is well aware of the harmful effects of drugs and also the mode of transmission of HIV. He gave a history of being a part of public ceremonies for “Matam” during Muharram since 10 years of age during which he practices self-flagellation using a sword. During childhood, he was a part of private “Matam” ceremony at his home which included using blades and knives. He gave a history of sharing the equipment (sword) with other unknown members of the ceremony and his friends. On probing, he mentioned that a few people who he knows to be injecting drugs are also the part of “Matam.” He fails to recollect all the people he may have shared the equipment with as he did not think it was important. However, due to his ill health, he was not the part of this since a year. Family screening revealed his mother and daughter are nonreactive for HIV.

On examination, he was conscious; oriented to time, place, and person; and moderately built with body mass index of 22.1. His pulse was 78 beats/min and blood pressure was 110/72 mmHg. He had mild ptosis of the left eye. Pupils on both sides were reactive to light. There was no nystagmus. There was no evidence of opportunistic infections such as candidiasis. On inspection, upper chest and back revealed hypertrophic scars from the wounds of self-flagellation [Figure 1]. There were no marks indicating injection of drugs in flexor aspect of the arms and forearms. There were no abnormal respiratory or cardiac sounds. Power and tone were normal. Plantar reflexes on both sides were normal (flexor).

Figure 1

Image showing scars from self-flagellation on the upper chest (a) and back (b) of the patient

At the time of presentation, hemoglobin was 13.7 g/dl and other blood counts were normal; ESR was raised (70 mm at 1 h); urine examination was normal; and liver and kidney function tests were normal. He was nonreactive for hepatitis B antigen (HBsAg) and hepatitis C virus (rapid). His CD4 count was 142 cells/μl. Magnetic resonance imaging brain with contrast revealed a well-defined, ring-enhancing lesion in the right pons, extending to the midbrain and right thalamus suggestive of tuberculoma. Ultrasound abdomen revealed mild splenomegaly and enlarged retroperitoneal lymph nodes. GeneXpert of cerebrospinal fluid did not reveal Mycobacterium Tuberculosis (MTB).

Anti-tubercular drugs (Category I) were started. He was referred to the nearest ART center to start medications after 2–3 weeks of antitubercular drugs. Other symptomatic treatment and dietary advice was given. Importance of medication adherence and completion of full course was explained. He was also explained how the sharing of equipment for self-flagellation may have caused the HIV infection in him. He was also encouraged to motivate his peers who practiced self-flagellation to get themselves tested for HIV.

India has committed to “end the AIDS epidemic as a public health threat” by 2030 under the Sustainable Development Goals. A national strategic plan has also been developed to achieve this goal. It is, therefore, of utmost importance to prevent newer infections and reduce transmission of infection.

This is the first ever-documented case report on HIV attributing the transmission to self-flagellation practice. Our patient has been the part of private and public ceremonial processions involving self- flagellation for more than two decades. The commonly used equipment are swords, knives, and blades. Often, the individuals who are part of such processions share these equipment which are fresh-blood laden. We assume that the sword used by our patient was contaminated with the blood of a HIV-positive individual and this led to transmission of the HIV via percutaneous route. In the past, there are few case reports highlighting transmission of blood-borne pathogens such as hepatitis B and human T-cell lymphotropic virus (HTLV-1) infection due to self-flagellation.[45]

In a case report of a young male from Mumbai suggesting transmission of hepatitis B virus during “Zanzeer-Zani,” the patient had a single exposure and a history of sharing equipment, following which he was detected HBsAg positive after 6 months.[4] In the UK, a case series of ten males having a history of self-flagellation was reported in which all of them had HTLV-1 infection. Eight out of these ten individuals gave a history of sharing of equipment during self-flagellation.[5] Like HIV, even these infections spread through contact with blood and body fluids of the infected persons. Our patient gave a history of multiple exposures and sharing of equipment too, which makes it the more likely route of transmission.

A person infected with HIV may have no symptoms for up to 10 years or more depending on the earlier health status. Therefore, even though the patient has stopped self-flagellation for a year, it is still likely that he has contracted the infection previously.

As public health professionals, it is important to raise awareness regarding spread of blood-borne pathogens, discuss risk elimination strategies, and encourage testing in the communities practicing self-flagellation. It is highly recommended not to share any equipment or materials during public ceremonies for self-flagellation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.