Investigation of Presumptive HIV Transmission Associated with Receipt of Platelet-Rich Plasma Microneedling Facials at a Spa Among Former Spa Clients — New Mexico, 2018–2023

Investigation and Results

NMDOH and CDC investigated cosmetic injection services as a possible transmission route for HIV. The period for active case finding was from spring 2018, when the initial patient received the procedure, to fall 2018 when spa A closed. Spa A’s owner operated without appropriate licenses at multiple locations and did not have an appointment scheduling system that stored client contact information. Investigators compiled and cross-referenced names and telephone numbers from spa A client consent forms, handwritten appointment records, and telephone contacts to create a list of potentially affected clients. The investigative team was not permitted to collect specimens from spa A at the time of the inspection in September 2018, because the inspection was conducted under the purview of the New Mexico Regulation and Licensing Department, which did not have authority to collect specimens. This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy.^§

Identification of Clients at Risk

The investigative team identified 59 clients at risk for exposure, including 20 who received PRP with microneedling at spa A, and 39 who received other injection services (e.g., onabotulinumtoxinA [botox]) during the case-finding period. Investigators cross-referenced the client list with the New Mexico state HIV registry and identified one spa A client who received a diagnosis of HIV in 2012.

During 2018–2023, current and former spa A clients who received new HIV diagnoses were reported to NMDOH from clinical providers throughout the state. During this period, a spa A–related HIV case was defined as a new HIV diagnosis in a patient with previous receipt of blood product or any injection services provided by spa A’s owner^¶ from 2017 until closure of the unlicensed operation in fall 2018, or who had sexual contact with a person who received such spa services. Cases were included only if an HIV nucleotide sequence demonstrated molecular linkage to other HIV sequences from persons with infections associated with spa A.

Characteristics of Patients

By spring 2023, five patients had been identified, including four women and one man who was a sexual partner of one of the four women patients and never received any services from spa A. Blood specimens from the five patients and a former client with a 2012 HIV diagnosis were submitted to CDC for nucleotide sequence analysis to ascertain cluster association and determine case status; all five patients were confirmed to have spa A–related cases. Medical record reviews and clinician interviews were conducted for all confirmed patients. Three patients were interviewed by NMDOH. Patients ranged in age from 40–60 years. HIV diagnoses occurred during summer 2018 through spring 2023 (Figure 1) (Table). Two patients had stage 1 disease, and three had stage 3 disease at the time of diagnosis** (2). All four female patients had received PRP with microneedling at spa A.

Four of the five patients with confirmed spa A–related HIV infections received at least one PRP with microneedling facial treatment at spa A during May–September 2018. Two of the patients in this cluster (a man and a woman) were engaged in a sexual relationship before and after their diagnoses. Sexual partners of two other patients received negative HIV test results after their partners’ diagnoses, and the remaining patient reported having no sexual partner at the time of diagnosis. Before receiving a diagnosis of confirmed HIV infection, two of the five patients had previously received a positive rapid HIV test result during routine evaluations for life insurance, one in summer 2016, and the other in fall 2018; however, only one patient reported being notified of the positive screening test result and subsequently had their HIV diagnosis confirmed by a primary care provider in winter 2019. The other patient received a confirmed HIV diagnosis after hospitalization with an AIDS-defining illness in fall 2021. One patient received their HIV diagnosis in spring 2023 after hospitalization with an AIDS-defining illness.

The two patients who were engaged in a sexual relationship had stage 3 or chronic HIV infections, indicating that their infections were likely attributed to exposures before receipt of cosmetic injection services. The other three patients in this cluster had no known social contact with one another, and no specific mechanism for transmission among these patients was confirmed. Evidence suggests that contamination from an undetermined source at the spa during spring and summer 2018 resulted in HIV-1 transmission to these three patients.

Evaluation of HIV Sequences

Whole blood specimens collected from all patients and the former client living with HIV since 2012 were used to generate HIV-1 polymerase (pol), gag, and envelope (env) sequences to evaluate sequence relatedness using established protocols (3,4). HIV-1 subtype B was determined using the online subtyping tool COMET (5). Maximum likelihood phylogenetic analysis was employed to compare the pol, gag, and env sequences from this investigation with genetically similar sequences from GenBank, the National Institutes of Health genetic sequence database (https://www.ncbi.nlm.nih.gov/genbank), and with 46 local control sequences from routine HIV surveillance in New Mexico in 2018 and 2023 for pol. Additional pol sequences derived from blood specimens collected by commercial laboratories from three patients within 3 weeks of diagnosis were included in phylogenetic analyses. HIV-1 subtype J sequences were used as an outgroup^†† for the phylogenetic analyses. Phylogenetic analyses showed that gag, pol, and env sequences from all patients clustered together strongly in a monophyletic clade with high confidence (Figure 2). Sequences from the former client living with HIV, who was not receiving antiretroviral therapy at the time of specimen collection, did not cluster with any New Mexico sequences.

Investigation of Spa A

In fall 2018, on-site inspection of spa A revealed multiple unsafe infection control practices. A centrifuge, a heating dry bath, and a rack of unlabeled tubes containing blood were located on a kitchen counter. Unlabeled tubes of blood and medical injectables (i.e., botox and lidocaine) were stored in the kitchen refrigerator along with food. Unwrapped syringes were found in drawers, on counters, and discarded in regular trash cans. An autoclave (steam sterilizer) was not found on the premises. Procedure equipment was surface cleaned using ammonium chloride disinfecting spray and benzalkonium chloride disinfecting wipes after each client visit, and disposable electric desiccator tips were cleaned by alcohol immersion and reused.