Assessment of knowledge, attitudes and practices of HIV post exposure prophylaxis among the doctors and nurses in Princess Marina Hospital, Gaborone: a cross-sectional study

Introduction Botswana is one of the HIV/AIDS hardest hit countries in Sub-Saharan Africa with a prevalence of 17.6 percent while incidence is estimated to be 2.9 percent. The average risk of HIV transmission after a percutaneous exposure to HIV-infected blood has been estimated to be approximately 0.3% posing a threat to health care workers. This has resulted in HIV post exposure prophylaxis (PEP) being very important in the healthcare setting. The aim of this study was to assess knowledge, attitudes and practices of health care workers towards HIV PEP. Methods A cross-sectional study was conducted at Princes Marina Hospital (PMH) in Gaborone from the 26th March-2nd April 2014. Inclusion criteria- registered medical doctors and nurses. Collected sample size was 199. Data was collected using self-administered questionnaires. Results The majority of respondents 70.7% of the respondents had adequate knowledge about PEP, with 191(97.4%) of the study participants being aware of HIV PEP while 82.2% of the respondents had a positive attitude toward PEP. A significant number had been exposed 107(53.7%) to risky exposures. Of the exposed, 80(74.8%) took PEP, while 27(25.2%) did not take PEP. From the respondents that took PEP 21(26.6%) did not complete PEP, with 15(71.4%) quitting because of adverse side effects, 1(4.76%) assuming it was enough treatment and 1(4.76%) doubting drug efficacy. Conclusion The participants were knowledgeable of the existence of HIV PEP and had a positive attitude toward the HIV PEP program. Although the participants were knowledgeable, they showed inadequate practices with regard to HIV PEP.


Introduction
HIV/AIDS is a serious public health problem costing the lives of many people including health care workers. By the end of the year 2002, the world health organization estimated that 42 million people had been infected with the Human Immunodeficiency Viruses. In that year alone, 5 million new infections occurred with 75% of these new infections occurring in sub-Saharan Africa [1]. Therefore HIV/AIDS is probably the most serious disease and causes the highest level of anxiety amongst health care workers (HCWs) in many countries including in Botswana. Health care workers (HCWs) are persons working in health care setting and they are potentially exposed to infectious materials such as blood, tissue, specific body fluids, medical supplies, equipment or environmental surfaces contaminated with these substances [2]. They are frequently exposed to occupational hazards through percutaneous injury such as needle stick or cut with sharps, contact with the mucus membrane of eyes or mouth of an infected person, contact with non-intact skin exposed with blood or other potentially infectious body fluid. The WHO also estimates that overall, 90% of needlestick injuries occur in low and middle-income countries [3]. There are recognized factors which have been associated with increased risk to acquiring HIV post occupational injury. In prospective studies of HCWs, the average risk of HIV transmission after a percutaneous exposure to HIV-infected blood has been estimated to be approximately 0.3% and after a mucous membrane exposure approximately 0.09% [4]. Injury with a hollow-bore needle is the commonest mode of infections. Other risk factors include depth of injury, visible contamination with the source patient's blood, a procedure involving a needle placed directly in the source patient´s vein or artery and exposure to a source patient who died of acquired immunodeficiency syndrome [5]. Although episode of HIV transmission after non-intact skin has been documented, the average risk for transmission by this route has not been precisely quantified but estimated to be less than the risk for mucous membrane exposures [1].
There have been also findings that healthcare workers in Sub-Saharan Africa are at increased risk of infections from blood-borne pathogens because of the high prevalence of the pathogens and increased risk of occupational injuries. Unsafe practices like careless handling of contaminated needles, unnecessary injection on demand, re-use of inadequately sterilized needles and improper disposal of clinical waste increases risk for occupational exposure to blood-borne pathogens [6]. In light of increasing numbers of occupational needle stick injury among the health care workers across the world, World Health Organization has recommended that HIV post exposure prophylaxis should be provided to the affected population. Studies have shown that when administered shortly following exposure, PEP treatment reduces the risk of HIV infection by 81% [7]. WHO recommends that all health care institutions should have an easily accessible system in place available 24 hours a day that allows for reporting and managing the health care worker who experiences an occupational exposure to HIV. In the case of a needle stick injury, the area should be washed with soap and water.
The wound should not be squeezed or milked or exposed to caustic agents such as bleach. For a cutaneous exposure, the area should be treated similarly with soap and water [8]. Since HIV PEP is not 100% effective, WHO/ILO has recommended that occupational safety rules be prioritized to minimize the accident predisposing healthcare worker to HIV [2]. With these recognized recommendations from the WHO, the implementation of the program has had many challenges especially in resource limited sub Saharan Africa where HIV/AIDS is more rampant [7]. Though there is irrefutable evidence supporting the effectiveness of the use of post exposure prophylaxis, African countries still have challenges to implementing the program because of various reasons which include poor resource management of limited resources, improper dissemination of the information about the program, poor program structures in many African countries [2]. In Malawi researchers have found that though the program is well implemented there are health care worker attitudes towards the program which affects their enrollment post exposure, which include fear of stigmatization and adverse side effect of the treatment. They also discovered that major shortcomings were insufficient awareness of the program among HCWs and poor follow up after the first consultation for PEP [6]. Similar results we also replicated in Ethiopia where they found lack of knowledge about PEP and fear of the process as the main factor affecting the enrollment among the HCW. Also literatures evidenced that there is an information gap in the health care setups [2]. For instance a study done in Guy's and St Thomas's hospital in London in 2001 indicated 93% of junior doctors had heard of PEP but fewer were aware that it reduced the rate of HIV transmission [6]. A national study in Kenya also showed, among those who were knowledgeable, only 45% sought HIV PEP. The main reasons for not seeking PEP among this group was lack of sufficient information (35%) followed by fear of the process and what could follow (28%) [9].
Page number not for citation purposes 3 In Botswana, where the prevalence of HIV/AIDS is high, health care workers face the similar challenges faced by HCW elsewhere [10].
This has actuated the implementation of the PEP program for occupational purpose [11]. Though

Operational definitions
Post-exposure prophylaxisis an emergency medical response that can be used to protect individuals exposed to the human immunodeficiency virus (HIV). Healthcare workers (HCWs) in this study will include registered nurses and medical doctors. We chose nurses and doctors because of the limited duration in which the study will be conducted, and because they have direct contact with the patients.

Study area
The research study will be conducted in Gaborone the capital city of

Study design
The study was a cross-sectional study based on health care workers in Princess Marina Hospital the largest referral hospital in Botswana.
We chose a cross sectional study to assess the knowledge, attitudes and practices of HIV PEP amongst HCW in PMH with respect to presence and absence of exposure to HIV contaminated body fluids/equipment. The other reason for our choice is that cross sectional studies are relatively quick to carry out, looking at the limited time we have to carry out the study and limited resources.

Source population:
The source population was the current health care workers in Gaborone.

Study population
The inclusion criteria used for selection of the study population from the source population was as follows: Being a registered nurse at PMH; Being a registered medical doctor at PMH. Exclusion criteria was: all porters and cleaners; being a nursing student or medical student in clinical attachment at PMH; a registered laboratory technicians. We decided to include nurses and doctors because of the limited duration in which the study will be conducted, and because they have direct contact with the patients and are exposed to HIV positive patients blood while carrying out procedures.

Sample size
The study includes medical officers and nurses at Princess Marina Hospital who are 101 and 593 respectively. Thus the total of the study population will be 693. Sample size was calculated using Stat calc within the EPI info application. At 95% CI and the expected frequency of the knowledge about PEP of 50%, with the worst acceptable result set within the limit 45-55% from the sample size was found to be 247.

Sampling procedure
A non-probabilistic sampling (Availability sampling) method was used to enroll the subjects. The researchers distributed the questionnaires to available and consenting individuals. Informed consent in written form (in English or Setswana based on the participant's preference) were obtained from all study participants Page number not for citation purposes 4 before proceeding with data collection. Respondents were then be given questionnaires for self-administration. Questionnaires were dropped into a ballot box in-front of the participants to assure them that privacy was maintained.

Scoring of knowledge, attitudes and practices
Four questions from the questionnaire were used to assess the knowledge of respondents about PEP for HIV and those who scored greater than or equal to 70% were considered knowledgeable.
Fours questions (1-4) from Table 1 were used to assess participants' attitude towards PEP for HIV and those who scored 70% and above were considered as having good attitude. Correct answers to the direct knowledge questions 4, 5, 6, 7, were averaged from Table 2.
Practices were assessed by comparison with other studies.

Ethical approval
The ethical committees that approved the study to be conducted were the University of Botswana Institutional Review Board, (Botswana) Ministry of Health Ethics Committee and the Princess Marina Ethics Committee. All participants took part in the study after informed consent was obtained from the subjects.

Sociodemographic characteristics
Although our calculated sample size was 247, we only managed to get 199 respondents. From the 199 respondents that answered and  Table 1 below.

Knowledge level of the HCWs about PEP for HIV
Knowledge was assessed using the questions represented in Table   2  saying. This information is reflected in Table 3 below.

Practice status of the HCWs towards PEP for HIV
Among all of the respondents 107(53.7%) had been exposed to HIV risky conditions and of these exposed respondents, 80(74.8%) took PEP. On the other hand, 27(25.2%) of the exposed did not take PEP. From the respondents who took PEP, 50(62.5%) reasoned that they took PEP after being exposed to known HIV positive blood, 12(15%) were exposed to blood from a patient whose  Table 4 below.

Discussion
The strengths of this study were that knowledge, attitudes of health Practices A significant number of respondents 107(53.7%) had been exposed to blood, body fluids, sharp objects while caring for patients. Among the exposed, 80(74.8%) took PEP, while 31 (29%) did not take PEP.
The percentage of respondents that were exposed to HIV risky conditions was less as compared to a similar study conducted in the Jimma zone of Southwest Ethiopia, in which 174 (68.9%) HCW had been exposed to HIV risky conditions, and out of the 174 exposed HCWs, 142 (81.6%) did not use post exposure prophylaxis [2]. The results of this study indicate that a higher percentage (72.1%) of  PEP is only used on HIV negative persons that have been exposed; An HIV test is required before starting PEP.  Even with good knowledge and attitudes about HIV PEP, poor practices with regard to adhering to PEP have been exposed by healthcare workers in the study and this is where interventions should be focused.

Competing interests
The authors declare no competing interest.

Authors' contributions
Both