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Nigerian J Paediatrics 2016 vol 43 issue 3

Nigerian J Paediatrics 2016 vol 43 issue 3

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Post exposure prophylaxis against human immunodeficiency virus Awareness knowledge and practice among Nigerian Paediatricians
Niger J Paediatr 2016; 43 (3): 193 – 196
ORIGINAL
Odinaka KK
Post exposure prophylaxis against
Edelu BO
Nwolisa CE
human immunodeficiency virus:
Amamilo IB
Awareness knowledge and practice
Amamilo IJ
among Nigerian Paediatricians
DOI:http://dx.doi.org/10.4314/njp.v43i3.7
Accepted: 23rd November 2015
Abstract : Objective: To deter-
(45.1 ± 14.8%), p = 0.21, t =1.26.
mine the level of awareness,
Ninety one (60.7%) of the respon-
Odinaka KK (
)
knowledge and practice of human
dents had been exposed to percuta-
Department of Paediatrics,
immunodeficiency virus post ex-
neous injury during work. Thirty
Madonna University Teaching Hospital
Elele, Rivers State, Nigeria.
posure prophylaxis (HIV PEP)
(33%) of the exposed paediatri-
Email : kellymed112@yahoo.com
among paediatricians in Nigeria.
cians did not know the
Methodology: The study was a
patient’s HIV status and only 10
Edelu BO
cross
sectional questionnaire-
(11%) received PEP, with only 7
Department of Paediatrics,
based survey conducted among
(7.7%) of them completing the
University of Nigeria Teaching
paediatrcians that attended the
PEP for 4 weeks
Hospital, Enugu, Enugu State, Nigeria.
Paediatric association of Nigeria
Conclusion: Despite the high level
annual scientific conference in
of HIV PEP awareness, there was
Nwolisa CE, Amamilo IB
2015.
an unacceptable high rate of occu-
Department of Paediatrics,
Federal Medical Centre Owerri, Imo
Results: Most of the respondents
pational exposures and
poor
State, Nigeria.
(96%) were aware of the concept
knowledge of HIV PEP among
HIV PEP. The scores on knowl-
Paediatricians. Additionally, there
Amamilo IJ
edge of PEP for all the respon-
was a low uptake of HIV PEP ser-
Clinton Health Access Initiative,
dents ranged from 18% to 91 %
vices amongst exposed Paediatri-
Maitama, Abuja.
with a mean score of 46.5 ±
cians in Nigeria. There is need for
14.1%. There was no significant
urgent action to curb this trend.
difference between the perform-
ance of those who had received
Key Words : HIV PEP, Paediatri-
training on HIV PEP (48.0 ±
cian, Nigeria
13.2%) and those who had not
Introduction
tressing consequences ranging from extreme anxiety to
chronic illness and premature death for the individual
involved.
6
Paediatricians practicing in developing countries are
frequently exposed to a wide range of blood borne
Post exposure prophylaxis (PEP) following occupational
pathogens including human immunodeficiency virus
exposure to HIV has been shown to significantly de-
crease the risk of acquiring HIV infection.
5
(HIV) during the course of providing care for their pa-
Animal
tients. With this comes the attendant risk of acquiring
models have shown that after initial exposure, HIV rep-
HIV infection from occupational exposure. Several
licates within dendritic cells of the skin and mucosa be-
measures to prevent blood exposure through safe prac-
fore spreading through the lymphatic vessels and devel-
oping into a systemic infection. This delay in systemic
1
tices have been documented,
1,2
but in spite of these pre-
cautionary measures, occupational exposures still con-
spread leaves a “window of opportunity” for PEP using
tinue to occur and are often under-reported .
3
antiretroviral drugs designed to block replication of
HIV. PEP is thus aimed at inhibiting the replication of
1
The risk of acquiring HIV infection following percuta-
the initial inoculum of virus and thereby prevent estab-
lishment of HIV infection. HIV PEP procedure in-
7
neous exposure to HIV infected blood in the healthcare
setting has been documented to be 3 per 1000 injuries.
4
volves initial first aid and counseling, followed by an
Certain factors are known to increase the odds of HIV
immediate risk assessment, conduct of relevant labora-
transmission after percutaneous exposure and they in-
tory investigations based on the informed consent of
clude a deep injury, the presence of visible blood on the
exposed person and source patient, short term antiretro-
instrument causing the exposure, injury via a needle that
viral drug administration for 28 days, and follow-up
evaluation.
8
was placed in a vein or artery of the source patient, and
terminal illness in the source patient. Occupational ex-
5
posure to HIV can result in a variety of serious and dis-
Unfortunately, many healthcare workers including doc-
194
tors do not appear to have adequate knowledge about
Table 1: Age and Cadre of the respondents
PEP in spite of being at risk of acquiring the infection.
9
Age
Frequency (n= 150)
Percentage (100%)
This study was done to assess the level of awareness,
knowledge and practice of HIV PEP among Paediatri-
25 – 29
07
4.7
30 – 34
46
30.7
cians in Nigeria.
35 – 39
44
29.3
40 and above
53
35.3
Cadre
Consultant
46
30.7
Materials and Methods
Senior registrar
41
27.3
Registrar
45
30.0
This was a across sectional study conducted among
Did not indicate
18
12.0
paediatric residents and consultants during the 46th an-
nual general and scientific conference of the Paediatric
association of Nigeria that held at Abakaliki, Ebony
Practice of PEP
state from January 21st – 23rd, 2015. Approval for the
study was obtained from the research and ethics com-
Ninety one (60.7%) of the respondents had been ex-
mittee of Federal Medical Centre Owerri, Imo State.
posed to percutaneous injury during work. Most (92%)
A two-part structured questionnaire was formulated,
of the exposures were from needle stick injury, while 12
field-tested, reviewed and subsequently distributed to
(8%) were from blood splash into the eyes. Seventeen
the resident and consultant Paediatricians at the confer-
(18.7%) of the exposed doctors had more than five ex-
ence. The first part of the questionnaire obtained demo-
posures while 41 (45.0%) and 33 (36.3%) were exposed
graphic information such as age, sex, cadre and place of
2 – 5 times and once respectively. Thirty (33%) of the
paediatric practice. In addition, information regarding
exposed paediatricians did not know the patient’s HIV
exposure to percutaneous injury and patient’s blood as
status and only 10 (11%) received PEP, with only 7
well as action taken was obtained. The second part of
(7.7%) of them completing the PEP for 4 weeks. Rea-
the questionnaire assessed PEP awareness and knowl-
sons for not receiving PEP included unavailability, fear
edge of basic information regarding PEP and respon-
of drug side effects, patient was unlikely to be positive,
dents performance scored over 100%.
fear of stigma and one was pregnant. Three doctors
stated that they just didn’t want to receive it.
Data collected was inputted into IBM SPSS version 20
(IBM Corp. 2011). Analysis was mainly descriptive.
Awareness and Knowledge of PEP
The means and standard deviations of the various vari-
ables were calculated where applicable. The perform-
Most (96%) of the 150 respondents have heard of PEP
ance of those who had received previous training on
but less than half (71, 47.3%) admitted to having had
PEP was compared with those who did not using stu-
any formal training on PEP. One hundred and twenty
dent’s t -test. A p-value of 0.05 was considered signifi-
eight (85.3%) have a protocol for PEP established at
cant. Results were documented as prose, tables and fig-
their workplace, 16 (10.7%) do not have any, while 6
ure.
(4.0%) were not aware of such protocol.
The score for all the respondents ranged from 18% to 91
% with a mean score of 46.5 ± 14.1%. There was no
significant difference between the performance of those
Results
who had received training on PEP (48.0 ± 13.2%) and
Socio-demographic characteristics of the respondents
those who had not (45.1 ± 14.8%), p = 0.21, t =1.26.
A total of 180 questionnaires were distributed but only
Among the 3 cadres of respondents, the senior registrars
156 respondents returned their questionnaires. Six were
performed better than the consultants and the registrars
excluded because they did not complete the second part.
with mean scores of 52.1%, 45.7% and 44.8% respec-
Of the 150 respondents who returned their completed
tively, (figure 1). This difference was not statistically
significant (p = 0.444, χ = 16.12)
2
questionnaires, there were 69 males and 81 females giv-
ing a male to female ratio of 1: 1.2. Their ages are as
Fig 1: Performance of the different cadres of paediatricians on
shown in Table 1.
Among the respondents were 46
knowledge of PEP
consultant paediatricians, 41 senior registrars and 45
registrars.
Eighteen (12%) of the respondents did not
indicate their cadre. One hundred and thirty three
(88.7%) practice in government hospitals while only 17
(21.3%) practice in private hospital setting.
195
Table 2 : Response to questions on PEP among the paediatricians
S/N
Question
Percentage(%) of respondent that answered correctly
Consult.
Snr. Reg
Reg
Others
Overall
n = 46
n = 41
n = 45
n = 18
N=150
1
How soon after needle stick injury should HIV post exposure prophylaxis
41.3
24.4
17.7
22.2
28.0
be commenced?(A)within 1Hour (B) within 24 hours (c) within 72 hours
(D) don’t know
2
What is the maximum delay to take PEP?
52.2
85.4
77.8
38.9
67.3
(A) 12hours (B) 24 hours (c) 48 hours (D) 72hours
3
What is the duration of HIV post exposure prophylaxis?
67.4
68.3
64.4
27.8
62.7
A) 2 weeks (B) 4 weeks (C) 3 months ( D) 6 months.
4
What proportion of needle stick injury results in HIV/AIDS transmission?
8.7
14.6
8.9
22.2
12.0
A)1/100 cases B) 1/1000 cases (C) 3/ 100 cases (D) 3/ 1000 cases
5
What percentage of mucosa exposure to HIV infected fluids results in
4.3
0
2.2
0
2.0
HIV/AIDS transmission
(A) 0.9% (B) 0.09% (C) 0.3% (D) 0.03%
6
Should HIV post exposure prophylaxis be administered for accidental
87.0
97.6
95.6
72.2
92.7
non – occupational exposure to HIV
( a) Yes ( B) No
7
The first aid measures to institute following needle stick injury include:
i
Promote active bleeding of wound by squeezing. (A) Yes
(B) No
39.1
51.2
35.6
27.8
40.0
ii
Wash thoroughly with soap and water
( A) Yes
(B) No
97.8
90.2
84.4
72.2
89.3
iii
Cleansing the skin with bleach
(A) Yes
(B) No
69.6
26.8
15.6
11.1
22.7
Consult. = Consultants, Snr. Reg. = Senior Registrars, Reg. = Registrars, Others = Cadre not indicated.
Concerning the drugs used for PEP, there were several
ideal antiretroviral drug combination for PEP for HIV.
combinations provided. Sixteen (10.7%) of the respon-
As much as 42.7% wrongly listed Nevirapine as one of
dents stated a monotherapy, while about one third
the drugs used for PEP. It is noteworthy that Nevirapine
(34.7%) did not provide any answer. Table 3 summa-
is not used for PEP for HIV owing to its side effects in
rizes the drugs listed by the respondents.
individuals with normal CD4 count. The World health
Organization currently recommended drug combination
Table 3: Drugs listed by respondents as used for PEP
for HIV PEP includes: Tenofovir with lamivudine or
emtricitabine plus ritonavir-boosted lopinavir.
13
Drugs
Frequency
Per-
Zi-
(n =150)
centage
dovudine is reserved for children ten years and below, in
Zidovudine + Lamivudine + Nevirapine
32
21.3
combination with lamivudine and ritonavir-boosted lopi-
navir.
14
Zidovudine + Lamivudine + Efavirenz
12
8.0
Tenofovir + Lamivudine + Efavirenz
4
2.7
Zidovudine + Stavudine + Efavirenz
2
1.3
Although it was observed that senior registrars were
Tenofovir + Emtricitabine + Efavirenz
2
1.3
more knowledgeable than the other cadres of Paediatri-
Zidovudine + Nevirapine
18
12.0
cians and a plausible explanation could be their active
Zidovudine + Stavudine
8
5.3
reading in preparation for fellowship exams, this finding
Zidovudine + Lamivudine
2
1.3
was not statistically significant. No significant differ-
Tenofovir + Efavirenz
2
1.3
ence was noted between the performance of respondents
Nevirapine alone
14
9.3
Zidovudine alone
2
1.3
who had received training on PEP and those who had
No drug listed
52
34.7
not. This obviously underscores the need for HIV PEP
training on a periodic and regular basis rather than the
one-off type of training usually funded by non-
governmental organisations.
Discussion
The prevalence of percutaneous injury among Nigerian
Paediatricians is 60.7% with majority having multiple
This study shows that majority of Paediatricians in
exposures. This high prevalence of percutaneous injury
Nigeria are aware of PEP for HIV. This corroborates the
would appear to suggest that there is a failure or inade-
findings of Agaba et al. However, while there is
10
quate adoption of universal precautions methods among
awareness, the knowledge of HIV PEP among Paediatri-
Paediatricians during the course of discharging their
cians is poor. This differs from other studies which
clinical duties. Although the risk of transmission of HIV
documented good knowledge of HIV PEP.
10,11,12
This
following occupational exposure is low, the price to be
difference may be due to differences in the tool used for
paid in the event a Paediatrician acquires HIV following
the assessment of HIV PEP knowledge. A standardised
occupational exposure is enormous. The frequent percu-
and universally acceptable tool for assessment of knowl-
taneous exposures and the need to access PEP services
edge would allow for better comparison and assessment
thereafter would constitute a drain on scarce health re-
of knowledge.
sources and reduce availability for those with actual
HIV infection. It is noteworthy that beyond HIV infec-
Majority of Paediatricians (85.3%) did not know the
196
tion, there are other blood-borne pathogens such as
Conclusion
Hepatitis B and C viruses, which can be transmitted fol-
lowing percutaneous injury. The need for training and
There was an unacceptable poor knowledge and low
retraining of Paediatricians on universal precautions
uptake of HIV PEP among exposed Paediatricians in
methods cannot be overemphasized.
Nigeria. We recommend that there should be concerted
It is worrisome that 33% of the Paediatricians exposed
efforts geared at regular training and re-training of Pae-
to percutaneous injury did not know the patient’s HIV
diatricians in Nigeria on HIV PEP and universal precau-
status and only 11% received PEP. Furthermore, only
tions. The Paediatric Association of Nigeria should in-
7.7% that commenced PEP completed the 4-week
corporate HIV PEP sessions at her annual and scientific
course despite the fact that most sampled institutions
conference. Hospitals should have established protocols
had existing HIV PEP policies and protocols. This poor
for HIV PEP which should be routinely communicated
practice of HIV PEP is in keeping with the findings of
to all health workers and antiretroviral drugs should be
Agaba et al who also observed that majority of doctors
10
made readily available for exposed health workers.
that had been exposed to needle stick injury did not ac-
cess HIV PEP. The reasons for this would need to be
further explored because it would be pathetic to believe
Author's contributions
that doctors are careless about issues bothering on their
OK conceived and designed the study. EB, NE, AI and
health and general wellbeing.
They are preoccupied
IA also participated in the design. OK and AI partici-
with rendering help to others and neglecting their own
pated in the acquisition of data. OK, EB, and IA partici-
health. Other researchers have also documented low
pated in interpretation of data and the statistical analysis.
uptake of HIV PEP among exposed health workers.
All authors participated in the drafting of the manuscript
Challenges faced by Pediatricians who accessed HIV
for important intellectual content, read the final draft and
PEP include: unavailability of antiretroviral drug, fear of
gave approval.
side effects of drug, stigma among others. These chal-
Conflicts of Interest: None
lenges are surmountable. The findings of this cross sec-
Funding: None
tional study can be generalised because it was a nation-
wide survey of Paediatricians from all over Nigeria.
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