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# Massive Nosocomial Outbreak of HIV-1 in Rural Cambodia, 2014-2015
# Massive iatrogenic outbreak of human immunodeficiency virus type 1 in rural Cambodia, 2014-2015
###### Authors
Need to enter full author list here.
François Rouet<sup>1</sup> Janin Nouhin<sup>1</sup>, Du-Ping Zheng<sup>2</sup>, Benjamin Roche<sup>3</sup>, Allison Black<sup>4</sup> Sophearot Prak<sup>1</sup>, Marie Leoz<sup>5</sup>, Catherine Gaudy-Graffin<sup>6</sup>, Laurent Ferradini<sup>7</sup>, Chandara Mom<sup>8</sup>, Sovatha Mam<sup>8</sup>, Charlotte Gautier<sup>1</sup>, Gérard Lesage<sup>6</sup>, Sreymom Ken<sup>1</sup>, Kerya Phon<sup>1</sup>, Alexandra Kerleguer<sup>1</sup>, Chunfu Yang<sup>2</sup>, William Killam<sup>9</sup>, Masami Fujita<sup>7</sup>, Chhivun Mean<sup>8</sup>, Didier Fontenille<sup>1</sup>, Francis Barin<sup>6</sup>, Jean-Christophe Plantier<sup>5</sup>, Trevor Bedford<sup>4</sup>, Artur Ramos<sup>9</sup>, Vonthanak Saphonn<sup>10</sup>
<sub><sup>1</sup>Unité VIH/Hépatites, Institut Pasteur du Cambodge (IPC), Phnom Penh, Cambodia
<sup>2</sup>International Laboratory Branch (ILB), Centers for Disease Control and Prevention (CDC), Atlanta, USA
<sup>3</sup>UMR IRD 224-CNRS 5290-Université de Montpellier, Maladies Infectieuses et Vecteurs : Ecologie, Génétique, Evolution et Contrôle (MIVEGEC), Montpellier, France
<sup>4</sup>Fred Hutchinson Cancer Research Center, Seattle, USA
<sup>5</sup>Centre National de Référence (CNR) sur le VIH, Laboratoire Associé, EA2656, Rouen University Hospital, Rouen, France
<sup>6</sup>Centre National de Référence (CNR) sur le VIH and INSERM Unité 966, Tours, France
<sup>7</sup>World Health Organization (WHO), Phnom Penh, Cambodia
<sup>8</sup>National Center for HIV/AIDS, Dermatology and Sexual Transmitted Diseases (NCHADS), Phnom Penh, Cambodia
<sup>9</sup>Division of Global HIV/AIDS, Centers for Disease Control and Prevention (CDC), Phnom Penh, Cambodia
<sup>10</sup>University of Health Sciences (UHS), Phnom Penh, Cambodia</sub>
### Abstract
Need to get finalized abstract from paper.
**Background.** In 2014-2015, 242 individuals aged 2–89 were newly HIV-1 diagnosed in Roka, a rural commune in Cambodia. A case-control study attributed the outbreak to unsafe injections. We aimed to reconstruct the likely transmission history of the outbreak.
**Methods.** We assessed in 209 (86.4%) HIV-infected cases the presence of hepatitis C and B viruses (HCV, HBV). We identified recent infections using antibody (Ab) avidity testing for HIV and HCV, and HBcIgM Ab for HBV. We performed evolutionary phylogenetic analyses of viral strains. Geographical coordinates and parenteral exposure through medical services provided by an unlicensed health care practitioner were obtained from 193 cases and 1499 controls during interviews.
**Results.** Cases were co-infected with HCV (78.5%) and HBV (12.9%). We identified 79 (37.8%) recent (<130 days) HIV infections. Phylogeny of 202 HIV *env* C2V3 sequences showed a 198-sample CRF01_AE strains cluster, with time to most recent common ancestor (tMRCA) in September 2013 (95% highest posterior density, August 2012–July 2014), and a peak of 15 infections/day in September 2014. Three geospatial HIV hotspots were discernible in Roka and correlated with high exposure to the practitioner (P=0.04). Fifty-nine (38.6%) of 153 tested cases showed recent (<180 days) HCV infections. Ninety HCV NS5B sequences formed three main clades, one containing 34 subtypes 1b with tMRCA in 2012, and two with 51 subtypes 6e and tMRCAs in 2002-2003.
**Conclusions.** Unsafe injections in Cambodia most likely led to an explosive iatrogenic spreading of HIV, associated with a long-standing and more genetically-diverse HCV propagation.
### Primary data and analysis

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