Scalp haircuts, keloids and blood-borne virus transmission risk in South Africa—The SHAKA study

TL;DR

This study in South Africa investigates whether a specific type of haircut that causes bleeding might increase the risk of blood-borne virus transmission, such as HIV and hepatitis.

Contribution

The study introduces a novel hypothesis linking haircut-related bleeding to blood-borne virus transmission risk in a high-prevalence region.

Findings

Haircut-related bleeding was associated with higher HIV and HIV/HCV co-infection rates.

FKN itself was not significantly linked to higher BBI seroprevalence.

HBV risk was not increased and was more likely due to early childhood acquisition.

Abstract

The most frequent transmission modes of blood-borne infections (BBI), including HIV, hepatitis B virus (HBV) and C (HCV), are well documented. South Africa, an HIV epicentre, with HBV endemicity and an additional HCV burden, raises the possibility of novel transmission means. A unique style of close shave haircut that can elicit folliculitis keloidalis nuchea (FKN), may produce bleeding during haircuts and possible BBI transmission. We designed a prospective case control study to evaluate the potential risk of BBI transmission.

Men with FKN and non-FKN controls were recruited from 2 centres in South Africa, Cape Town and Mthatha. The presence of FKN was diagnosed by a dermatologist and clinical photographs independently corroborated by 3 other dermatologists not involved in the study. A comprehensive confidential questionnaire was administered to each participant interrogating risk factors for potential HIV, HBV, and HCV infection. Each participant was screened for HIV 1/2 (Alere Determine), HBsAg (Alere Determine) and HCV antibody (SD Bioline) using point of care tests. Positive HIV screens were confirmed with a second test, Vikia HIV 1/2 test (bioMerieux). Logistic regression analysis adjusting for the relevant confounder was used to assess the associations.

A total of 1163 men, median age 33.4 years [IQR 27.8–42.0], were evaluated. Those who screened positive for any viral infections were significantly older than those who did not, 37.1 [IQR 31.0–44.4) vs. 32.3 [IQR 26.9–41.0] years, p < 0.001, respectively. Overall, the seroprevalence of HIV, HBV, and HCV, was 17.2%, 6.9% and 0.4%, respectively. There was no significant difference in seroprevalence for these potential BBIs between those with FKN and without, p = 0.33, 0.66 and 0.29, respectively. For HIV co-infection with HBV and HCV, findings were similar, p = 0.64 and 0.51, respectively. When controlled for whether participants knowingly bleed during haircuts, HIV seropositivity was significantly more likely in those who regularly bleed, OR = 2.51 [95% CI 1.16–5.42], p = 0.02. Other transmission risk factors for HIV, were also significantly more likely – reported sexually transmitted genital lesions or discharge, aOR = 1.58 [95% CI 1.13–2.22], p = 0.01; and a tattoo/piercing informally done, aOR = 1.84, [95% CI 1.13–2.22], p = 0.01. Similarly, although overall HCV seroprevalence was low, those HIV/HCV co-infection was more likely in those who usually bleed with a haircut, aOR = 2.43; [95% CI 1.13–5.25]; p = 0.02, those with a sexually transmitted genital lesion or discharge, aOR = 1.58 [95% CI 1.13–2.21]; p = 0.01 and those with a tattoo/piercing informally done, aOR = 1.85 [95% CI 1.27–2.72]; p < 0.01. This was not so for HBV mono-infection, p = 0.89. Overall rates of known and recorded HBV vaccination in childhood were low, however in those with no viral infection, the rate of known vaccination was higher, 25.0% vs. 16.2%; p = 0.01 respectively.

Haircut related bleeding but not FKN was associated with a higher prevalence of HIV and HIV/HCV co-infection. HBV risk was not increased and related to either vaccination and/or dominant early childhood acquisition risk of HBV in sub-Saharan Africa. HIV and HBV prevalence remains concerningly high. Risk reduction through public education is key to prevention.

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