Healthcare practitioners and students’ PEP knowledge, attitude and adherence in Southern Africa

Background There is a high prevalence of occupational exposure among health care practitioners (HCPs) around the globe. One of the risk factors of HIV infection among HCPs is occupational exposure to human immunodeficiency virus (HIV) infection through blood or fluid from HIV-infected individual. Therefore, because of this prevalence, there is a need to have sufficient knowledge and information regarding post-exposure prophylaxis (PEP). Sufficient PEP knowledge assists individuals in utilising PEP in case of exposure to HIV. Aim This study aims to assess the level of knowledge, attitude and adherence to PEP in HCPs in Southern Africa. Setting The systematic review included studies conducted in Southern Africa. Methods A systematic review was conducted. Search engines employed in this study included Google Scholar, Science Direct, PubMed, Ebscohost and JSTOR. From these, 3572 articles emerged after removing duplications, and article screening was guided by inclusion and exclusion criteria and outlined on a PRISMA flow chart. Ultimately, the study included 13 articles. A critical appraisal skills programme was applied for the quality assessment of the eligible studies. Results Studies included in this review revealed that most participants have adequate knowledge regarding PEP (n = 6). However, it was revealed that poor adherence occured because most HCPs did not complete PEP. Conclusion Health care practitioners have adequate knowledge of PEP with varying levels of adherence to PEP. Therefore, more awareness illustrating the importance of adhering to PEP is needed. Contribution There is an adequate level of knowledge regarding PEP found in the included studies although not satisfactory in Southern Africa given the participants are HCPs, and marked inappropriate practices affect adherence.


Introduction and background
Global statistics show the prevalence of possible occupational human immunodeficiency virus (HIV) exposure and infection within one's (Health Care Practitioner [HCP]) career to be 56.2%, and considering sociodemographic factors, the prevalence is about 54.8% (Mengistu, Tolera & Demmu 2021). Because of the manner of work, it is common for HCPs to be exposed to blood, needle stick injuries or the possibility of infection. Annually, 35.7 million HCPs are subject to percutaneous exposures (Shil & Upashe 2020). In Africa, the prevalence of occupational exposure is approximately 92% among HCPs depending on the year (Mossburg et al. 2019). Post-exposure prophylaxis (PEP) was designed as a 'reactive' method to prevent HIV infection, serving the same purpose as preexposure prophylaxis (PrEP), which may be considered a 'proactive/preventative' measure. Postexposure prophylaxis is a measure provided to minimise the risk of infection following potential exposure to bloodborne pathogens (Smoot 2021;Tekalign et al. 2022). Post-exposure prophylaxis includes counselling, risk assessments, relevant laboratory investigations and 4 weeks of antiretroviral treatment with follow-up and support. Thus, in the event of occupational exposure, HCPs who wish to take PEP should have adequate information and a counselling session that would assist them in fully benefiting from PEP and preventing HIV transmission (Adebimpe 2018).
prevalence of infection, other factors affect the efficacy of PEP. These factors include pill burden, side effects and psychological distress that may influence completion rates (Sultan, Benn & Waters 2014). However, Beekmann and Henderson (2014) suggest that frequency, severity, duration and reversibility of side effects are essential considerations in formulating a prophylactic treatment regimen.
Given that Southern Africa has the highest impact of HIV and AIDS, for it to meet the sustainable development goal (SDG), goal number 3 good health and well-being target 3.3 indicating the ending of the epidemics of AIDS and other communicable diseases that by the year 2030 (World Health Organization 2022), there must be evidence of knowledge and adherence to universal precautionary measures and PEP. The description of the level and nature of HCPs' attitudes towards PEP is also of paramount importance. Hence, an improved understanding of PEP's knowledge, attitudes and adherence among HCPs in Southern Africa has the potential to inform researchers and policymakers to increase safety and decrease occupational infection rates. This systematic review aims to assess knowledge, attitudes and adherence to PEP among HCPs in Southern Africa. The specific objective was to review the available literature to determine the level of knowledge regarding PEP, attitudes toward PEP and the level of adherence to PEP.

Systematic review question
What is the knowledge, attitudes and adherence to PEP among HCPs in Southern Africa?

Methods and approach
The systematic review was conducted following a systematic review and meta-analysis guidelines (Moher et al. 2015). This type of review was selected based on its strength in identifying, appraising and synthesising all available research relevant to this study's review question. The review methods included search strategy, inclusion and exclusion criteria, study selection and abstraction, critical appraisal and thematic analysis.

Inclusion and exclusion criteria
This study included studies on knowledge, attitudes and adherence to PEP among HCPs (nurses/midwives and medical doctors) and students training in nursing or medicine. Furthermore, the studies included were between 2014 and 2021. Only studies conducted in Southern Africa/ sub-Saharan Africa were included in the review. Only articles that were published in English were included. Articles not on knowledge, awareness or practices of PEP among HCPs were not considered for this review.

Study selection
The researchers used the PRISMA flow chart described by Moher et al. (2009) (see Figure 1; Haddaway et al. 2020) to outline the study flow in the search results. A total number of 6849 articles emerged from the search engines. From these articles, the researchers did the topic screening, abstract screening and full-text, which resulted in duplications being removed and studies that did not meet the inclusion criteria. In the end, 13 studies were found eligible to be included in this review as they met the inclusion criteria and responded to the study's review question, aim and focus.

Critical appraisal of eligible studies
These included studies were critically appraised using the critical appraisal skills programme (CASP) checklist to ensure that the included studies are of good quality and conform with the research rigour of their respective approaches. Eight studies were subject to the cohort study checklist, three went through the systematic review/literature review checklist and one went through the qualitative checklist. The majority of the included studies (n = 11) scored above 70%, and only two studies fell below 70% in the critical appraisal (see Table 1).

Characteristics of the included studies
With all the studies in this review, information abstracted from the articles included the following characteristics: author and year of publication, objective/aim, country, study design, population and sample size, outcomes and limitations. Refer to Table 2 for the characteristics of the included studies.

Thematic analysis of selected studies
Thematic analysis was adopted as the method of analysis, using Caulfield's method (Caulfield 2019). Reading the abstracts and full articles helped the researchers familiarise themselves with the data. Following this, the researchers highlighted common words, expressions and findings in the data during coding. From these, the researchers developed themes, as illustrated in Table 3, leading to the results and discussion. The analysis yielded the following themes: •

Ethical considerations
This article followed all ethical standards for research without direct contact with human or animal subjects.

Results
From the data, two major themes emerged: knowledge of and attitude towards PEP and adherence to PEP (see Table 3).
Six studies included here show that most participants in the studies have been previously exposed, some even more than twice. For this reason, it is essential to have adequate knowledge and adherence to PEP. The study found that HCPs and students in training have somewhat sufficient knowledge of PEP; however, adherence to PEP-related protocols is low.

Theme 1: Knowledge of post-exposure prophylaxis
The included studies commonly found that having adequate knowledge of PEP was characterised by having heard about PEP and having information concerning PEP. On the opposite side, inadequate understanding of PEP would entail never having heard about PEP and having little knowledge and more misconceptions than truths relating to PEP. Furthermore, it was found that among the nine studies on knowledge and awareness of PEP, many of the studies (n = 6) reported that most of the participants had adequate knowledge of PEP, with over 60% of their participants having heard of PEP (either formally or informally   One region hospital was used; findings cannot be generalised.

Rasweswe and Peu (2020a)
To determine the occupational exposures and use of HIV (PEP).

South Africa
Descriptive study Nurses in Gauteng. Ninety-four participants.
There is a gap in occupational exposure reporting and attaining PEP.
The study was conducted in one hospital in Gauteng. Nondespondence bias as some participants did not answer some questions.

Theme 2: Attitudes towards post-exposure prophylaxis
Reports on attitudes towards PEP correlate with the suggested satisfactory level of knowledge. Of the included studies that reported on attitudes on PEP (n = 4), they reported that people have positive attitudes toward PEP. Most HCPs understood its importance and appreciated reducing HIV contraction during practice to support this conclusion. However, it is unclear if HCPs have a positive attitude because of having a good understanding of PEP or knowing PEP to relieve the possible threat of infection. In this regard, the accuracy of the positive attitude towards PEP may be questionable because of HCPs' practices toward PEP.

Theme 3: Adherence towards and practice of post-exposure prophylaxis
As these studies presented themselves, there is little information on procedures that should follow the blood and bodily fluid exposure hence the expressed need for education. Harmful practices towards PEP were mostly characterised by the urgency of taking treatment post-exposure and not knowing where to report exposure. Moreover, being misinformed about the availability of PEP treatment in the facility, ignorance of exposure, and starting treatment late contributed to harmful practices. The common thread in these cases is the inconsistency of treatment availability, accountability and knowledge-sharing concerning the PEP procedure. These may be the determening factors for good PEP practice. One study reported a shortage of PEP medication. Even when they wanted to, they could not get access to treatment. With this said, in most studies, practices towards PEP were characterised by adherence.
In the included studies, four out of nine did not reflect good adherence practice because of insufficient knowledge concerning PEP. However, about six of the included studies showed that HCPs often started PEP treatment postexposure, with an average percentage completing the course of treatment (55.6%). Some reasons for not adhering to or completing treatment included experiencing side effects, HIV stigma, fear of reporting and HCPs not thinking they needed PEP. In some instances, HCPs stopped PEP treatment because they tested negative, which excused the need to continue treatment. These may result in a lack of overall adherence and momentousness regarding PEP treatment.   Moreover, general awareness and knowledge within medical facilities are pivotal. Some HCPs may not know the correct protocols to avoid exposure or actions after exposure and treatment to take (Prathapasinghe & Dharmarathne 2018). This study suggests that although HIV stigma, lack of available treatment and fear of exposure may influence adherence, these factors may also influence seeking information regarding post-exposure protocols. As shown in a study by Chalya et al. (2015) in Tanzania, HCPs do not report occupational accidents in fear of the side effects.

Discussion
As most studies suggested, there is a need for formal education for students as they are more at risk of occupational exposure (Aigbodion et al. 2019;Hada et al. 2018;Matos et al. 2021;Triassi & Pennino 2018). The lack of experience during practicals and the beginning of their careers may be why they are at high risk for exposure. This education will clarify practices, reduce anxiety, increase positive attitudes and decrease misconceptions and stigma associated with HIV among HCPs. This case would assist in knowledge sharing and adherence if information about PEP was already publicised. Although the more significant majority completed the course of the PEP treatment, a high number of HCPs does not finish treatment because of several reasons that are somewhat justified (Aigbodion et al. 2019;Bareki & Tenego 2018;Makhado & Seekane 2020;Ncube et al. 2014;Sultan et al. 2014;Chimoyi et al. 2022). The ill knowledge of PEP procedures shows the importance of follow-ups. It may result in more adherence and decreased side effects of exposure because of provided support, such as psychological support (Vedhanayagam, Sengodan & Rajagopalan 2016;Beekmann & Henderson 2014). A study conducted by Chalya et al. (2015) in Tanzania also discovered that HCPs do not report occupational accidents because of fear of the side effects, as 50% showed that participants knew when and where to report, which medication to take and which protocols to follow in case of exposure. Although knowledge of relevant PEP processes may align with the levels of adherence, most HCPs do not complete the recommended 28-day course of therapy.

Limitations
This study only included HCPs and students in the Southern African region training. Many of the studies included were quantitative, and perhaps more data would have emerged should there have been qualitative studies within the inclusion criteria. The findings of this study may not be generalised as the included studies may not accurately represent health HCPs (in practice and training) in Southern Africa.

Conclusion
This review aimed to assess PEP's knowledge, adherence and practices in Southern Africa. It was found that there is a somewhat reasonable level of PEP, especially regarding whether HCPs have ever heard about PEP. On the other hand, although reports showed adequate knowledge of what PEP is, there is insufficient knowledge regarding PEP processes that may play a role in adherence and measures employed postoccupational exposure.

Recommendations
It is recommended that the HIV programme managers and supervisors employ follow-ups and accountability measures to increase adherence and completion of PEP. Furthermore, the formal education (pre-service) and HIV training should include PEP protocols and adherence to PEP emphasis. It is also recommended that researchers should consider PEP with fewer side effects than those available to aid adherence and completion. Further research can be done focusing on the relationship between adherence and level of knowledge on PEP. Health institutions should always have PEP available and accessible for all HCPs.