Knowledge, attitude and practices of medical and health science students on the antiretroviral based HIV post-exposure prophylaxis in an Ethiopian hospital: an institutional based cross-sectional study

HIV/AIDS is a leading cause of death in sub-Saharan Africa (SSA) with at least two-third of the world’s HIV infected people living in this region [1]. Ethiopia is among the SSA countries with approximately 800,000 people living with HIV/AIDS. Although antiretroviral therapy (ART) has significantly improved the management and prevention of HIV, early initiation of post-exposure prophylaxis (PEP) reduces the likelihood of sero-conversion of high risk exposure to HIV. A study showed that early administration of a short course of ART (as PEP for 28 days) reduces the risk of HIV transmission by 81% [2].

Healthcare provision, especially in resource-limited settings with profound infectious diseases burden including HIV/AIDS poses a high risk of occupational exposure to Healthcare Workers (HCWs) via different routes. For instance, percutaneous injuries like needle-stick or other sharp injuries, human infected blood, muco-cutaneous injuries (splash of blood or other infective body fluids) or other contacts [3, 4]. As a result of the high prevalence of communicable diseases, HCWs are often exposed to potentially infectious pathogens and increased occupational risk of these pathogens like HIV, Hepatitis B and C virus [5]. The World Health Organization (WHO) estimated 90% of the occupational risk to HIV occurs in healthcare settings of developing countries [6]. In the context of HIV, PEP refers to the set of services that comprises first aid, counselling, risk assessment, relevant laboratory investigations, following short course of PEP for 28 days and monitoring [5]. Since the early 1990s, antiretroviral medicines such as Tenofovir with emtricitabine and protease inhibitors, or Zidovudine with lamivudine and protease inhibitors as alternative regimens were recommended as standard PEP for occupational exposure to HIV [7].

Indeed, studies stated that there is an information gap in the healthcare setups regarding HIV PEP. For instance, a study conducted in Iran indicated that only half of the nursing and midwifery students had good awareness about HIV PEP [8]. Similarly, a study conducted in Ethiopia, Hawassa University showed that one-third of the midwifery and nursing students were exposed to HIV risk factors and among those only 59.3% took PEP [9].

In addition, a study conducted in an Indian medical college demonstrated merely 37.6% had sufficient knowledge regarding HIV PEP and an even smaller number 20.7% had information about the right time of initiation of HIV PEP [10]. Moreover, a Serbian study mentioned that 87% of the HCWs had not been informed about the guidelines regarding protection from HIV, and reported that PEP protocols were not available at their work places [11]. In line with this, 87.5% of the nursing students in Zambia were unaware of PEP services [12]. Evidence from those studies suggests that healthcare students are at high risk of occupational exposures. With this, it is important for healthcare students to have sufficient knowledge to protect themselves while they are in service oriented clinical trainings in healthcare institutions. Furthermore, the important factors that influence the overall risk for occupational exposures to blood borne pathogens include the number of infected individuals in the patient population [13] and this has strengthen the point that in Ethiopia the overall risk for occupational exposure to HIV is high since the disease burden is high in the nation [2].. In addition, a study done in Gondar which is the current study area found quite high prevalence of health care workers exposure to HIV/AIDS risk factors in the health care settings in Gondar city [3]. In addition, in the current set up the existing strategy to prevent occupational HIV infection is through wearing protection gloves. However, some students forgot wearing the protection at all time. A 1 month triple therapy comprised of TDF + 3TC + EFV/NVP/LPV/r as PEP has been also used for the students who are already exposed to the infection. In this regard, there is no information about graduating students’ awareness towards HIV PEP in general although it is remained to be crucial to be informed of it particularly for those early practitioners.

Furthermore, to the best of the authors’ knowledge and search, no previous study explored healthcare students’ knowledge, attitude and practice towards PEP for HIV in the current study area. Thus, this study was aimed to assess the knowledge, attitudes, and practices towards ART based HIV post exposure prophylaxis among medical and health science graduating students who were providing clinical services while practicing on real patients in UOGCSH, Gondar, Northwestern Ethiopia.

An institutional-based cross-sectional study was conducted among Medicine and Health Sciences (MHS) graduating students of Gondar College of medicine and health sciences, University of Gondar from May to July 2015. UOGCSH is a referral hospital with a huge number of beds, serving more than 7 million people living in and around Gondar town. Gondar is found in Amhara region of Ethiopia. According to Demographics and Health survey (DHS) 2005 report, the prevalence of HIV/AIDs in Amhara region was found to be 1.3% in the population. However, the prevalence of HIV/AIDs in Gondar population has not been studied. Instead the prevalence of HIV with visceral leshimaniasis co-infection has been reported to be 17.75% [14].

Generally, since most of the tasks of the MHS graduate class students are potentially risky to the students compared to the previous exposures, great attention and preparation are required to avoid acquiring HIV infection.

A total of 220 MHS graduating students were approached, given a response rate of 100%. The majority of the participants were males (62.7%) with a mean (SD) age of 23.43 ± 2.19 years. Almost all the respondents were single (96.4%) and nearly three-quarter were Orthodox Christians (72.3%). Moreover, the highest number of respondents were medical interns (38.6%) followed by comparable number of respondents from health officers (16.8%) and nursing students (15.9%) (Table 1).

In the present study, the KAP of graduating MHS students on ART based HIV PEP were assessed. The main reason for considering final year graduating students in this study was because they are known to actively involve in patient care at the institutional hospital. In this regard, those students are usually at a greater risk for acquiring blood-borne infections in the workplace as they involve in direct patient care. The paucity of published data on HIV PEP among MHS graduating students in Ethiopia motivated the conception of the current study that aimed to assess the knowledge, attitudes and practices of MHS graduating students on ART based HIV PEP.

In this study, almost all the MHS students had heard of ART based HIV PEP and in this regard, medical students took the lion share. However, none of the laboratory and anesthesia students know anything regarding HIV PEP. In comparison, the current study findings showed higher level of awareness than a study conducted in Hawassa University (67.1%) students [9]. The actual reasons for these differences were not clearly known, but it may be attributed to various awareness levels of experiences in their workplace. Interestingly, nearly 70 % of the medical students in our study got information related to HIV PEP from their medical training.

Nearly, three-fourth (75.5%) of the respondents were aware of the time when PEP is needed to be initiated and correctly reported that it should be done within 2 hours from the instance of HIV exposure. In this regard, the percentage of awareness among participants in this study were higher compared to the result in Hawassa university midwifery and nursing graduating students (48.1%) [9], but much lower than Nigerian health professionals (97%) [15] and Cameroon nurses (83.5%) [15].

Overall, 70 % of MHS graduating students had poor knowledge score on HIV PEP. Comparable results were also noticed among health care workers in Cameroon (73.7%) and Zimbabwe (65%) [16, 17]. Incomparably, higher level of fair and adequate knowledge was noticed among nurses in Nepal (68%) and UOGCSH health professionals (63.1%) in Ethiopia [5, 18].

Indeed, the knowledge on risky body fluids that can potentially transmit HIV was found to be quite poor among the present study population, with more than 90 % of the respondents being unable to identify potentially high risk body fluids. In line with this, only 9.1% correctly identified cerebrospinal fluid as a high risk body fluid for HIV transmission. To the contrary, a multicenter study done in eastern part of Ethiopia stated that very high percentage (97.9%) of healthcare workers mentioned that blood and various body fluids can transmit HIV/AIDS and even claimed that they can correctly identify body fluids that can potentially transmit different diseases. This might be due to their longer experience as the health professional (mean, 8.2 years) that render them learn such health events from their lengthier experiences unlike the current study in which the professionals were still on basic trainings building up experiences [19]. Unlike, the findings of the current study, a study conducted among nurses in Cameron (< 50%) and Nepal (65%) noted as the professionals correctly identified the high risk fluids for HIV transmission [16, 18]. Similarly, high rates of correct identification of risky body fluids were also revealed a study done among Nigerian family physicians revealed that the doctors clearly identified the risky body fluids [20].

On the other hand, less than a 50 % of our study participants believed that HIV PEP is effective in preventing HIV transmission. The major perceived cause of exposure to HIV risk in UOGCSH was lack of protective barrier followed by lack of standard precautions, and work load. Likewise, similar barriers were also reported in other studies done among nurses and midwifery students in Addis Ababa as well as among health workers in southwest Ethiopia, and Malaysia hospitals [5, 21, 22].

Regarding appropriate time for initiation of HIV PEP, three-fourth of the respondents knew how soon to initiate HIV PEP for exposed individual following needle stick injury. In comparison, these findings were much higher than the studies conducted among dental interns and postgraduate dental students in India (20.4% versus 42.2%) [23], Mulago hospital workers in Uganda (22.3%) [24], Gondar health workers in Ethiopia (50.8%) [5], Nepal (60%) [18], Mumbai (64%) [25], and Cameron (66%) [16]. These differences in their knowledge could be attributed to the difference in overall knowledge imparted during their academic training as well as to discrepancies’ in study populations and health care settings.

The current study also uncovered that more than 90 % of MHS graduating students exhibited positive attitude (93.1%) towards HIV PEP. It can be stated that a positive attitude was noticed in almost all the students from midwifery, nurses, medicine, laboratory, health officers and anesthesia. For example, more than 95 % of our respondents revealed as ART based HIV PEP is important and availability of PEP guidelines in the hospital or in their work place is unquestionably crucial. Comparably, our results were much higher than a study conducted in UOGCSH health workers where 88.5% agreed on the need of PEP guidelines in work areas and nearly 70 % believed that PEP can be effective for preventing HIV transmission.

Even though needle stick or short objective injuries are one of the important sources of HIV transmission, only 43.8% of the respondents believed that reporting such injuries was important. Generally, to comment the actual risk of transmission of HIV or hepatitis up on exposure to risky conditions: In our set up, professionals usually get exposure to HIV/Hepatitis while they are shouldering their day to day activities in the hospital as a result of professionals negligence to protect themselves all the time because of their super busy duty. Years later, when professionals are asked on how they got HIV/Hepatitis, they explained that they had exposure to needle injury, blood splash on eye etc. when they provide care to a known HIV/Hepatitis patient. Considering such frequent cases, it can be concluded that the actual transmission have been always true after exposure and is alarmingly high in our set up.

In our study, 37 (16.8%) respondents were in need of PEP for HIV, but only 18 (8.1%) received PEP and 50% of the respondents who started PEP were able to complete 28 days of the PEP regimen. However, the remaining 50% of the students who started PEP failed to complete the full course of PEP. These findings were much higher than a Nigerian study in Abuja teaching hospital where only 6% of exposed participants received PEP [26]. Indeed, our results were in line with other studies conducted in Ethiopia, Cameron, Uganda, Kenya and Tanzania [5, 16, 23, 26, 27]. Furthermore, a study conducted in Gujarat state, India mentioned that a higher number (> 95%) of participants were able to complete the regimen [28]. This might be due to the fact that in the India study the participants had already completed their training and were employed professionals so that they would have better experience to PEP use than the current study in which the participants are still on training that definitely lack experience. In addition, the side effect profile of PEP initiated in the Indian study was minimal with no life threating adverse reaction described so that this further promotes the completion of the prophylaxis. Generally, completion of the initiated PEP is crucial for a better prevention and in our study PEP completion issues still needs effort to be improved.

Previous studies conducted on PEP for HIV in different countries highlighted the importance of formal training on PEP for HIV and that awareness of availability of PEP guidelines in hospitals were significantly associated with good knowledge of PEP. Contradictorily, our study participants received classroom lectures (50.5%), trainings (30%) and personal study (14.1%) but failed to demonstrate adequate knowledge of PEP.

Poor knowledge and practices towards PEP regimen were noticed among medical and health science students, but they had a good attitude towards PEP. To this end, a formal pre-service training for all students regarding PEP for HIV prior to their clinical attachments is of utmost importance. The training should include a brief explanation regarding the bad consequences of non-adherence that primarily include poor treatment outcome and greatest risk of resistance to the only and few donated ART regimens available in Ethiopia to be used for both treatment and prophylaxis of HIV/AIDS. Likewise, as a main driver for non-adherence to PEP, common temporal side-effects of PEP and its managements should be priory informed to healthcare workers to reduce its impact on adherence. Furthermore, the habit of reporting needle stick injury was poor that needs efforts to improve. Most importantly, the effort will be through promoting the culture of reporting and by making the reporting process easy. In fact, reporting such injuries as early as possible will teach others not to commit same problem again and generally, will enable stake holders intervene the issue before it re-occur. Finally, as far as PEP use has left with so many inconveniences, risk reduction is the paramount choice. With this, taking the heightened importance of protective barriers so as to reduce the risk of exposure to HIV, different stakeholders (the hospital equipment supply chain manager, the HIV/AIDS clinic, the hospital director, equipment and supply quality assurance team and other administrative bodies) should work together in co-ordination to secure the supply and assure the quality of those vital protective barriers and to further insist health workers to always wear protective barriers when exposed to HIV risk factors as well as to dispose properly once done. Finally, we recommend future investigators to conduct a prospective multicenter studies with additional objectives (including predictor analysis) for better generalization and outcome.