|Year : 2020 | Volume
| Issue : 1 | Page : 32-39
Healthcare workers' knowledge, attitude and practice of HIV postexposure prophylaxis in a South-Eastern Nigerian tertiary hospital
Appolus C Mmeremikwu1, Obinna I Ekwunife2, Ekene S Mefoh3, Chioma C Mmeremikwu3, Chiedozie Kingsley Ojide4
1 Antiretroviral Therapy Clinic, Alex-Ekwueme Federal University Teaching Hospital Abakaliki, Awka, Nigeria
2 Department of Clinical Pharmacy and Pharmacy Management, Faculty of Pharmaceutical Sciences, Nnamdi Azikiwe University, Awka, Nigeria
3 Department of Pharmaceutical Services, Alex-Ekwueme Federal University Teaching Hospital Abakaliki, Abakaliki, Ebonyi, Nigeria
4 Department of Medical Microbiology, Alex-Ekwueme Federal University Teaching Hospital Abakaliki, Abakaliki, Ebonyi, Nigeria
|Date of Submission||26-Oct-2019|
|Date of Acceptance||10-May-2020|
|Date of Web Publication||31-Jul-2020|
Dr. Chiedozie Kingsley Ojide
Department of Medical Microbiology, Alex-Ekwueme Federal University Teaching Hospital, Abakaliki, Ebonyi
Source of Support: None, Conflict of Interest: None
Background: HIV postexposure prophylaxis (PEP) is an integral aspect of preventive management of HIV/AIDS. Timely provision of HIV PEP after exposures to HIV risky conditions can reduce significantly the possibility of HIV transmission. Objective: To determine the knowledge, attitude and practice of HIV PEP among healthcare workers (HCWs) in a Nigerian tertiary health facility. Methods: Standardized questionnaires designed to assess knowledge, attitude and practice of HIV PEP were administered to 343 HCWs randomly selected from various clinical specialties in the hospital. Their responses were coded, collated and analyzed using SPSS version 24. Simple descriptive statistics was used in the overall analysis and Chi-square statistics for bivariate analysis. Results: Twenty eight (8.2%) of the 343 HCWs had adequate knowledge of HIV PEP. The uptake of HIV PEP among the eligible HCWs was 60% and the provision of HIV PEP to eligible victims of rape was 67.9%. The general attitude on the attitude index was 93.8%. Conclusion: The study revealed a very poor level of knowledge and poor practice of HIV PEP among the HCWs. The attitude towards the HIV PEP intervention was however generally positive.
Keywords: Abakaliki, healthcare workers, HIV, postexposure prophylaxis, tertiary institution
|How to cite this article:|
Mmeremikwu AC, Ekwunife OI, Mefoh ES, Mmeremikwu CC, Ojide CK. Healthcare workers' knowledge, attitude and practice of HIV postexposure prophylaxis in a South-Eastern Nigerian tertiary hospital. Niger J Exp Clin Biosci 2020;8:32-9
|How to cite this URL:|
Mmeremikwu AC, Ekwunife OI, Mefoh ES, Mmeremikwu CC, Ojide CK. Healthcare workers' knowledge, attitude and practice of HIV postexposure prophylaxis in a South-Eastern Nigerian tertiary hospital. Niger J Exp Clin Biosci [serial online] 2020 [cited 2020 Oct 27];8:32-9. Available from: https://www.njecbonline.org/text.asp?2020/8/1/32/291195
| Introduction|| |
HIV postexposure prophylaxis (PEP) is the immediate but short term anti-retroviral preventive treatment recommended by World Health Organization (WHO) to reduce the risk of HIV infection following accidental exposure to an infectious or potentially infectious blood and/or body fluids such as semen and vaginal secretions. It refers to the use of antiretroviral (ARV) drugs within 72 h of exposure to HIV in order to prevent infection. It involves counseling, first aid care, HIV testing and then the administering of a 28-day course of ARV drugs with follow-up care.,,
Adequate knowledge of HIV PEP, and its importance, by healthcare workers (HCWs) will aid optimal implementation of the intervention. HCWs are frequently exposed to a wide range of infectious body fluids including HIV infected blood in the course of providing care to their patients. These pose the risk of HIV infection from these occupational activities. Furthermore, in the events of accidental nonoccupational exposures to potentially risky sources, as seen in cases of rape, HCWs like the doctors and nurses in the hospitals are usually the first port of call by these patients/victims. PEP following these risky exposures to HIV has been shown to significantly reduce the risk of acquiring HIV.
Unfortunately, there appears to be some knowledge gaps among HCWs on HIV PEP despite the fact that they are at risk of infection at work places and are also in pivotal positions of saving their patients from HIV infections following risky exposures. A knowledge-practice gap related to HIV PEP among Nigerian family physicians has been underscored to be a very wide one. Similarly, knowledge and practice of PEP against HIV infection among HCWs in a tertiary hospital in Abuja, Nigeria have also been rated very poor.
Occupational exposures to HIV can give rise to a variety of serious and debilitating consequences like extreme anxiety, low productivity at work and overt infections. Percutaneous injury, usually inflicted by a hollow bore needle is the most common mechanism of occupational HIV transmission. The World Health Report estimates that universally 2.5% of HIV cases among HCWs are as a result of occupational exposures. Some studies outside south eastern Nigeria have shown that exposure to blood borne infections in health care settings are most frequent with nurses and followed by the doctors when compared to the other health care workers, but virtually little has been done to ascertain the levels of knowledge and practice of HIV PEP among these different groups of health care workers in south eastern, Nigeria.
More than a decade ago, the Human Rights Watch (2004) identified poor government support and lack of adequate information and training by public health system as major barriers to PEP implementation in rape cases in South Africa. However, by the year 2014, the WHO reported that survivors of sexual assault in South Africa are increasingly aware that it is essential to receive HIV prevention medication quickly. Unfortunately, Nigeria is still lagging behind in this regard. Recent studies have still shown a low level of PEP uptake among medically and nonmedically informed population. This often results to inappropriate management of sexual assault cases in health facilities. The first point of contact for sexual assault victims is usually an emergency centre and thus emergency HCWs should have the requisite knowledge and training to take care of these patients.
The main objective of this study was to determine the level of Knowledge, Attitude and Practice of HIV PEP among HCWs in the tertiary health institution in Abakaliki, south eastern Nigeria. Secondary objective was to ascertain the level of exposure to occupational risks among the HCWs with respect to blood and other infectious body fluids and also ascertain the level of provision of HIV PEP to rape victims that present in the hospital.
| Methods|| |
This was a cross-sectional study conducted at Alex-Ekwueme Federal Teaching Hospital, Abakaliki, located in Ebonyi state, south eastern Nigeria. It is a 700 beds capacity federal tertiary health facility in the state and provides medical services to the people of the state and beyond. The study lasted for 13 month, from July, 2017 to August, 2018 and the study population was the HCWs at the Hospital. The study was backed by ethical clearance obtained from the institution's Research and Ethics committee.
A total of 356 HCWs were surveyed. Random sampling technique was used in selecting the various respondents across the different wards and clinical departments of the hospital.
A standardized and validated structured questionnaire with the usual socio demographic information and adequate questions that could assess the level of knowledge, the attitude and practice related to HIV PEP was designed. The questions were developed in line with the current WHO HIV PEP guideline and the current Nigerian national HIV PEP guideline.
Pilot study was first conducted for feasibility. In the pilot study, 10.0% of the total sample size not to be included in the study was pretested with the questionnaires. Some questions were further modified accordingly after the pretest to enhance comprehension and elicit the desired responses from the prospective study sample. Then the pretested and modified questionnaires were finally administered to the 356 health care workers randomly selected from different wards and clinical departments of the hospital.
The questionnaire comprised ten item questions (each with multiple choice answers) prepared to assess the level of knowledge of respondents about HIV PEP. Scores of ≥70.0% in this section were adjudged adequate knowledge. The questionnaire had another five item questions (which elicited only 'Yes' or 'No' answers) prepared to assess participants' attitude towards HIV PEP. Among the attitude based questions, concurrent affirmative responses by participants (≥90.0%) were adjudged positive attitude and <90.0% were adjudged negative attitude. The attitude assessment was on a general note and not individualized. The questionnaire also had another four-item questions (which elicited “Yes”, “No” or “Don't know” answers) prepared to assess the practice of HIV PEP among the respondents. Actual PEP uptake (with completion) of ≥90.0% among the eligible group in the study population together with Actual PEP provision of ≥90.0% to eligible rape victims (attended to in the hospital) were adjudged good practice and outcomes <90.0% were adjudged poor practice. The practice assessment was also on a general note and not individualized.
Only 343 questionnaires out of 356 distributed had adequate information and were the ones included in the analysis. Data was coded, entered, cleaned and analyzed using SPSS version 24 computer software (IBM Statistical package for social sciences (SPSS) version 24, chicago Illinois, USA). Simple descriptive statistics was used in the overall analysis and Chi-square Statistics was used for bivariate analysis. Results were summarized in frequencies and percentages and presented in tables.
| Results|| |
Out of 343 respondents that participated in the study, 202 (58.9%) were female and 141 (41.1%) were males. The mean age (standard deviation) of the respondents was 37.9 ± 1.60, with the highest number (169, [27.4%]) of respondents belonging to age group 30–39 [Table 1]. Staff with 6–10 years working experience were in the majority (132, [38.5%]) More than half (57.4%) of the respondents were working in the wards while a little less than half (48.1%) were nurses/midwives. Most of the study participants, 216 (63.0%) had bachelor's degree as their highest educational qualification.
Knowledge level related to HIV postexposure prophylaxis
Most of the respondents 315 (91.8%) in the study expressed poor knowledge of HIV PEP [Table 2]. A total of 304 (88.6%) of the study participants are aware the availability of HIV PEP services in the study facility, but only 71 (20.7%) had knowledge of the recommended best time for commencement of HIV PEP after risky exposures. A total of 219 (63.8%) of the respondents had the knowledge of the maximum time lag outside which HIV PEP is considered ineffective, while 155 (45.2%) knew that 4 weeks was the duration over which HIV PEP is taken.
|Table 2: Knowledge level of the respondents on HIV postexposure prophylaxis|
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From our rating, only 28 (8.2%) persons had adequate knowledge of HIV PEP, while majority 315 (91.8%) had poor knowledge [Table 3]. The degree of association between some of the demographic data and knowledge level of PEP is shown in [Table 4]. Gender (P = 0.003), profession (P = 0.001), years of experience (P = 0.021) and highest educational qualification (P = 0.037) showed significant association with knowledge level of PEP. Only professional type and years of experience still maintained statistical significance in the regression model [Table 4].
|Table 3: General knowledge level of the respondents about HIV postexposure prophylaxis|
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|Table 4: Degree of association between some demographic data and the level of knowledge of the respondents|
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Attitude towards HIV postexposure prophylaxis
Majority of the respondents have heard of HIV PEP (90.7%) and believed that it reduces the risk of HIV transmission following exposures (96.2%). Similarly majority are willing to be trained on HIV PEP (91.0%). A total of 328 (95.6%) of the participants have been screened for HIV and only 323 (94.2%) where will to have HIV PEP in event of hazardous occupational exposure [Table 5].
|Table 5: Attitude of the respondents towards HIV postexposure prophylaxis|
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Practices related to HIV postexposure prophylaxis
Washing the affected portion thoroughly under a running tap with soap and water as a first aid measure to institute following needle stick injury was subscribed to by 188 (54.8%) of the respondents. Half of the participants (171 [49.9%]) have been exposed to sharp injuries or blood splash into the eyes during medical procedures on patients in the past; out of which 79/171 (42.2%) admitted exposure once, 36/171 (21.1%) twice, 8/171 (4.7%) thrice and 48/171 (28.1%) more than thrice. Of all those that have been exposed for more than thrice, dentists were the most (56%), followed by medical doctors (21%) and laboratory scientist (5%).
Out of these 171 respondents exposed to these potentially hazardous sources, 127 (74.3%) took a further step of ascertaining the patients HIV status (source). Of these 171 respondents exposed to the potentially hazardous sources, only 50 (29.2%) of them reported the incidence for appropriate PEP procedure. A total of 30 (8.7%) of all the respondents have taken HIV PEP before the study. Out of this number only 12 (40.0%) did not completed the course of prophylaxis. Only 156 (45.5%) of the respondents have attended to rape cases in the facility before. On whether the rape victims were offered any PEP intervention, 106/156 (67.9%) of the HCWs answered in the affirmative whereas the rest 50/156 (32.1%) of them answered “No” or “Don't know” [Table 6].
| Discussion|| |
This study exposed poor knowledge of HIV PEP among HCWs (91.8%). Similar Nigerian studies in the past showed a mean score of 46.5% ± 14.1% on knowledge assessment of HIV PEP among pediatricians, and 68.5% of dental surgeons had inadequate knowledge of PEP. Another study among healthcare providers in a tertiary hospital in Nigeria indicated that only 30.9% of them are knowledgeable on PEP drugs and dosing considerations. However, the finding in the present study is in contrast with the outcomes of the survey among Nigerian family physicians, where the majority of the physicians surveyed (79.4%) had adequate knowledge of HIV PEP and the study among medical interns in India with majority of them (62.7%) having adequate knowledge of HIV PEP.
In respect of the specific questions that assessed knowledge in this study, only 20.7% of the respondents could identify “within 1 h” as the best time to commence HIV PEP. This is lower compared to the findings at Gondar Ethiopia, where >50.0% of the respondents got that correctly and the study at Benin City, Nigeria where a commendable majority, 88.9% of participants also had knowledge of the best time, plus the study among family physician where up to 93.9% of the participants also knew it is “within 1 h.”
In this study <50% of the study participants (45.2%) could correctly identify 4 weeks as the duration over which HIV PEP is taken. This is much lower when compared to the findings in Ethiopia where up to 72.8% of participants and the study among Nigerian family physician where up to 83.3% of the respondent knew correctly the duration of the treatment course. However a similar study at Lagos University Teaching Hospital Nigeria, reported that only 15.3% of the HCWs knew the correct duration of HIV PEP. This is much lower than that obtained in this present study. These differences might be due to the disparity in the levels of awareness of HIV PEP among the different study population.
In this present study, 39 (11.4%) of the participants indicated they are not even aware that HIV PEP services are offered in the study facility where they themselves are working. This is however less compared to 60.0% obtained in a similar study in India. It is worthy of note that PEP services have been going on in the present study facility, for well over 8 years before the study.
In this study also, some demographic variables like gender (P = 0.003), profession (P = 0.001), years of experience (P = 0.021) and highest educational qualification (P = 0.037) showed statistically significant association with the level of knowledge. But only professional type and years of experience maintained statistical significance in the regression model. This is at variance with the findings in the survey among Nigerian family physicians where no single factor (among the demographic variables) was independently predictive of adequate knowledge on multivariate analysis after being male was associated with adequate knowledge (P = 0.050) on bivariate analysis. The regression analysis in this present study was done to eliminate confounding factors.
It is surprisingly noteworthy that the HCWs in the HIV clinic of the present study facility showed no better knowledge of HIV PEP compared to those in the other clinics and wards. Those in the Emergency unit also showed no better knowledge, even though they constitute the first port of call in cases of both occupational and nonoccupational exposures. On analysis, there was no statistically significant association between area of practice and level of knowledge of HIV PEP (P = 0.277).
Generally the study participants had a positive attitude towards HIV PEP. This was corroborated in their responses to questions that demanded if they believe PEP reduces the risk of HIV transmission following occupational and nonoccupational exposures, if they would like to receive formal training (lectures) on HIV PEP and also if they would accept to take HIV PEP if they fall victim to any hazardous exposure such as needle stick injury. To the question on willingness to receive formal training (lectures) on HIV PEP, 91.0% of the HCWs answered in the affirmative and to the question on willingness to accept PEP following a hazardous exposure, a commendable 94.2% of them also answered in the affirmative. In addition, an overwhelming 96.2% of them believe PEP reduces the risk of HIV transmission following occupational and nonoccupational exposures. All these are congruent with the study at Gondar, Ethiopia where 98.5% of the participants agreed on the importance of PEP for HIV and 78.5% of them had strong belief that it can reduce the probability to be infected. The outcome of this present study is also consistent with the findings in a similar study at Benin City, Nigeria where it was reported that majority (81.5%) of the dental surgeons who participated in the study had good attitude towards PEP for HIV/HBV. Good attitude towards HIV PEP was also underscored in the study among medical interns in a teaching hospital in India, with an overall 96.8% of them having good attitude towards this subject matter.
It is remarkable that most previous studies on attitude towards HIV PEP among heath workers have revealed good or positive attitudes among the participants. Though good or positive attitude towards HIV PEP is commendable, it can only be relevant and appreciated when it translates to good knowledge and practice.
In the aspect of practice, in this present study, only 54.8% of the participants identified washing off the injured portion thoroughly with water and soap under a running tap as a first aid measure to adopt after a needle stick injury, in line with best practice. This number is lower compared to the 60.9% and 70.2% of participants studied in India and Iran.
Virtually half of the study population (49.9%) have had a history of sharp instruments/needle stick injury NSI (or blood splash into the eye) in the course of their practice. This figure is higher than those obtained in most studies among HCWs in tertiary institutions in Nigeria; 30.9% in Abuja, 47.3% in Lagos and 46.3% in Benin city. It is however lower compared to the 60.7% obtained in the study among Nigerian pediatricians. Similarly, the 28.0% of the exposed HCWs in our study that have had >3 exposures is also higher compared to the study in Abuja, Nigeria, which recorded only 8.4% for HCWs with >4 exposures and 18.7% for Nigerian pediatricians, with >5 exposures.
The 25.7% of exposed HCWs that did not confirm the source HIV status in our study is however lower compared 33.0% and 35.2% recorded among Nigerian paediatricians and HCWs in Abuja, Nigeria respectively. All these are really alarming as the concerned HCWs stood the risk of being infected.
Again, the 40.0% that did not complete the PEP from our study is lower compared to what obtained in the study in Lagos, Nigeria, and India, where up to 62.5% and 100.0% respectively of those that started PEP did not complete the course. The reason for not completing the course of PEP could possibly be attributed to the side effects of the ARV drugs used and possible stigmatization. However another study in a tertiary hospital in Nigeria discovered a complete 100.0% adherence for 4 weeks among those placed on HIV PEP.
A worrisome total of 32.1% (50/156) of HCWs indicated that rape victims they attended to were not provided with any HIV PEP or they were not aware of any such provisions for rape victims. This means that 32.1% of rape victims in the hospital stand at risk of being infected with HIV if they were raped by someone harboring the virus. This proportion is high compared to that which obtained in a similar study in Lagos, Nigeria, where most of the sexual assault victims (90.3%) received HIV PEP. This figure (32.1%) is however lower compared to that obtained in another study in Lagos, Nigeria, where up to 70.6% of the eligible sexual assault victims did not receive any PEP against HIV infection.
Furthermore, it is alarming to note that up to 21% of the medical doctors and 75% of the dentists involved in this present study have had what were considered relatively significant occupational risks (>3 consecutive exposures), ranging from sharp instrument injuries, needle stick injuries, to blood splash into the eyes in the course of their practice. On analysis a statistically significant association (P = 0.001) was found between professional type and risk of occupational exposures to hazardous sources. This really calls for urgent attention by policy makers.
| Conclusion|| |
Majority of the HCWS in this study exhibited an unacceptably poor knowledge of HIV PEP and their practice pattern and disposition towards it was also poor. However, far reaching majority of them had positive attitude towards this HIV PEP.
This study also revealed that rape victims are not sufficiently provided with the possibly needed HIV PEP intervention, an observation that requires urgent attention. The level of uptake of HIV PEP among the eligible HCWs (when they fall victims to hazardous sources) is also poor. Some of the HCWs especially the dentists are appreciably exposed to significant occupational risks. Regular training and re-training of HCWs on HIV PEP is therefore recommended.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]