Knowledge, Attitude, and Practice of Postexposure Prophylaxis against HIV Infection among Healthcare Workers in Hiwot Fana Specialized University Hospital, Eastern Ethiopia

Background Postexposure chemoprophylaxis can prevent human immunodeficiency virus (HIV) infection in risk health care workers; however routine adoption of these practices by the workers has been limited. Methods A cross-sectional study was conducted on 311 health care workers of Hiwot Fana Specialized University Hospital between February and March 2016. Data was collected using a structured self-administered questionnaire and analysed using STATA 12. Results In all, 83% of the participants had adequate knowledge of postexposure prophylaxis for HIV. All the respondents had heard about postexposure prophylaxis for HIV; however, only 37 (22.4%) workers know the definition of the postexposure prophylaxis. Among study participants, the majority of them, 272 (87.5%), knew the preferable time to initiate postexposure chemoprophylaxis. A significant number of the workers (43.4%) had an unfavorable attitude towards postexposure prophylaxis. Among 53 workers with a potential exposure to HIV, 38 (71.7%) took postexposure chemoprophylaxis and only 26 (44.8%) completed taking postexposure prophylaxis correctly. Conclusion In all, most of the health care workers had adequate knowledge about postexposure prophylaxis against HIV/AIDS. The result shows that a significant number of individuals had a negative attitude and poor practice with regard to postexposure prophylaxis. Therefore, formal training that aims to improve attitudes and support to improve postexposure prophylaxis implementation and completion are needed. We would recommend the establishment of appropriate guidelines and the supply chain to ensure the availability of postexposure prophylaxis drugs for the protection of healthcare workers with potential high risk exposure to HIV.


Introduction
Acquired Immune Deficiency Syndrome (AIDS) is one of the most serious public health problems costing the lives of many people, particularly in sub-Saharan Africa where even health care workers (HCWs) are at affected and at risk [1,2].
Occupational exposure to blood and body fluids is a serious concern for HCWs and presents a major risk for the transmission of infections such as Human immunodeficiency virus (HIV), Hepatitis B virus (HBV), and Hepatitis C virus (HCV) [3,4]. According to World Health Organization (WHO) report of 2005, about 3 million percutaneous occupational exposures to blood or other bodily fluids occur in health care settings, the majority (90%) of which occurred in developing countries [5,6]. Since the early 1990s, antiretroviral (ARV) drugs have been prescribed for postexposure prophylaxis (PEP) following occupational exposure to HIV for HCWs [7,8]. PEP consists of administering 28 days of antiretroviral therapy (ART) as soon as possible up to 72 hours following high risk exposure to prevent establishment of HIV infection [9][10][11].
Although some studies reported favorable knowledge about PEP, there remains a knowledge gap among health care workers [12][13][14]. In Cameroon, 73.7% [15] and in Zimbabwe, 65% [16] of HCWs had poor knowledge. Similarly, one study had documented inadequate knowledge of PEP in up to 83.9% among HCWs in Ethiopia. Furthermore, among the 2 AIDS Research and Treatment exposed respondents, 81.6% did not use PEP; 33.8% of whom did not use PEP because of lack of information [2].
Currently, there is no data regarding PEP knowledge among HCWs in Harar, Eastern Ethiopia. Thus, this study was conducted to assess knowledge, attitude, and practice on occupational PEP to prevent HIV infection among health care workers of Hiwot Fana Specialized University Hospital (HFSUH), an eastern Ethiopia regional referral hospital.

Methodology
. . Study Period, Setting, and Participants. A hospital based cross-sectional study was conducted from February to March 2016 including 311 health care workers of HFSUH. The hospital is one of the six governmental teaching hospitals in Ethiopia that provides health care service to greater than 300,000 inhabitants. The hospital has 402 healthcare workers. The participants in this study were permanent employees of HFSUH who were routinely involved health care delivery during the study period.
. . Data Collection and Study Procedure. Data collection was conducted using a structured self-administered questionnaires prepared in English based on WHO postexposure prophylaxis guidelines and relevant published articles [4,14,17,18]. Questions assessed knowledge, attitudes, and practices regarding PEP for HIV prevention. Ambiguous and unsuitable questions were modified after the pretest had been conducted. The validity of the developed questions was checked prior to finalizing the survey instrument. The pretest was conducted on 38 HCWs (10% of the study population) and they were excluded from participating in the main study.
. . Sample Size and Sampling Technique. A convenience sampling technique was employed. Of the 342 eligible workers, 311 HCWs were included in the study.
. . Scoring of Knowledge, Attitude, and Practice. Respondents who scored greater than or equal to 6 correct answers (75%) from 8 equitably scored knowledge questions were considered to have "adequate knowledge". Similarly, respondents scored greater than or equal to 75% (6 out of 8 questions) of attitude questions were considered to have "positive attitude". To determine the practice of respondents' , those answered greater than or equal to six out of eight questions (≥ 75%) were considered as practicing PEP for HIV. The practices were evaluated based on correct responses on practices stipulated by guidelines at the time.
. . Data Analysis. Data was cleaned, coded, and entered into the STATA 12 software. The results were summarized in frequencies and percentages.
. . Ethical Consideration. Ethical clearance to conduct this study was secured and obtained from the ethical review board of college of Health and Medical Sciences of Haramaya University. Participants provided an explanation of the study aims and were included in the study after they provided their written and oral consent to the study. The confidentiality of the study participants was maintained by assigning unique study identifiers during data collection and analysis.

Results
.   exposed and 51.8% of the respondents agreed that PEP prevents further infection. However, only 118 (37.9) of the participants believed that PEP should be indicated for any type of sharp object injuries. As indicated in Table 3, only 23 (7.4%) individuals had no trust in PEP effectiveness. One in four workers (24.8%) does not agree that PEP is important if the exposure is not with patient blood of known HIV positive.
. . Practice Status of the HCWs towards PEP for HIV. Of the 53 (17.0%) individuals who had exposures for HIV risky conditions, 42 reported their exposure to program runner and 38 (71.7%) took PEP. However, 15 (28.3%) of the exposed respondents did not take PEP. Among the individuals who took PEP, 21/38 (55.3%) were exposed to blood from patients with known HIV infection, whereas the remaining 15/38 (39.5%) were exposed to blood from source patients of unknown HIV status. Among all the respondents who took PEP, two individuals initiated outside of the ideal time-frame (after 72 hours). Ten (26.3%) individuals started within an hour of exposure. Of the 38 respondents who took PEP, 26 (68.4%) had completed taking PEP correctly, but the rest 12 of the individuals failed to complete PEP. The main reason for the discontinuation of PEP was found to be fear of the adverse effects (7 individuals) and doubt of its efficacy (4 individuals) as shown in Table 4.

Discussion
Adherence to the universal precaution guidelines is fundamental for the prevention of accidental acquisition of HIV infection in healthcare settings. Furthermore, the appropriate management of exposed individuals plays a crucial role in control and prevention of the infection [10,17].
We found that, only 17% of the HCWs had poor knowledge of PEP for HIV. This is lower than similar studies from Gondar University Hospital (36.9%) [14], Nigeria (7-24%) [19,20], and Cameroonian health district (26.3%) [15]. Greater than 90% of our study participants had completed their bachelor or medical degree; this higher level of education may explain the higher knowledge demonstrated by our participants.
In the current study, all the participants had heard about PEP for HIV, 40.48% via training. This level of awareness among our study participants was higher than similar studies from Gondar University Hospital (92.8%) [14], Hawassa University Hospital (67.1%) [21], and Tertiary Hospital of Nigeria (97%) [19].
Data from animal studies suggest that the efficacy of postexposure prophylaxis in preventing transmission is time dependent [19,[22][23][24], and every effort should be made to provide postexposure prophylaxis as soon as possible following exposure. Regarding timing and duration of PEP for HIV, 87.46% of the total respondents stated that PEP should be taken within one hour and 91.32% of them knew the correct duration of PEP against HIV/AIDS (28 days). A study conducted among Interns of a Medical College in West Bengal, India, indicated only 68.5% stated PEP should be started within an hour of exposure and only 46.9% conveyed appropriate duration of PEP (28 days) [25]. The difference might be due to differences in the work experience as greater than 50% of our participants had professional experience of greater than one year. In addition, our result showed greater awareness on timing of PEP among our HCWs than other studies from Uganda (22.3%) [26], Mumbai (64%) [27], and Gondar (50.8) [14].
The majority of our study participants had a positive attitude towards PEP. A study conducted at the Gondar University Hospital [14] indicated that 98.5% agreed on the importance of PEP for HIV, which is greater than our study (92.6%) and 69.5% agreed that PEP guidelines should be available in the hospital which is lower than our study (80.4%).
Of the 311 study subjects, 53 (17.2%) of the participants have been exposed to HIV risky conditions. This finding is less than the result found in the research done in the Jimma zone on government HCWs (68.50%) [2] and Gondar University Hospital (33.8%) [14]. Lower exposure of our study participants to risky conditions might be due to better knowledge in our study group. However, the number of HCWs that have ever been exposed to HIV risky conditions in our study is not considered low.
Among 38 HCWs on ART for PEP, 21 (55.3%) of them exposed to blood of known HIV positive patients, which is comparable to study from the Gondar University Hospital (57.1%) [14]. Even though 71.7% of the exposed respondents took PEP for HIV in this study, only 68.4% of them were able to complete the duration of prophylaxis which requires 28 days. The main reason for nonadherence of these individuals was fear of adverse effects. This indicated that it is lower than the findings of the study conducted among HCWs of governmental health institutions in Mekelle Town, Ethiopia (80.6%) [28]. However, a study conducted in Gujarat, India [29], showed that their respondents had better practice in this regard than our study participants in which more than 94% were able to complete the regimen. This fact alerts that the practice of PEP for HIV in this study area needs improvement. Reasons for the observed difference of findings between different research results might be due to the difference in the level of awareness among the different population, economic difference of the study population, and time difference of the studies.

Limitation of the Study
The expected limitations to this study are unwilling of HCWs in the hospital to participate in the study and the absence of HCWs at the time of data collection. Our statistical analysis was descriptive and we are unable to determine association of independent variables with the outcome. The convenience sampling technique was also the major limitation of the present study.

Conclusion
Most of HCWs have good knowledge about occupational risk of HIV/AIDS exposure and had a good attitude towards occupational risk of HIV infection. The findings of this study revealed the attitude and practice of HCWs towards PEP for HIV is inadequate. A significant proportion of HCWs have had exposure that would warrant the use of PEP. This compounded by low PEP completion rates shows that the practice of PEP for HIV in this study area needs improvement.

Data Availability
The data used to support the findings of this study are available from the corresponding author upon request.

Conflicts of Interest
The authors declare that they have no conflicts of interest.