EVALUATING THE KNOWLEDGE AND ATTITUDE OF COMMUNITY PHARMACISTS TOWARD HIV INFECTED PATIENTS
CHAPTER TWO
LITERATURE REVIEW
Approximately about 36.9 million people were living with HIV globally as at 2017 (WHO 2018) and when compared with about 27.4 million in 2000, it can be deduced that there has been an incessant transmission of the virus despite a recorded improved access to antiretroviral drugs which have aided to reduce the mortality rate of the disease. HIV/AIDS has caused many deaths in Africa and is one of the main public health concerns in many African countries for example, Sub-Sahara Africa accounts for about two-thirds globally of people living with HIV. HIV spread made a quantum leap in Africa during the 20th century due to urbanization, poverty, prostitution, education and health care (Van Niekerk A., Loretta MK., 2005). Nigeria being the second largest epidemic globally had about 3.2 million people living with HIV in 2016 (UNAIDS 2017) which affects all geographic areas and virtually all the population groups. Due to the healthcare providers to fight HIV epidemic both at the public health facilities and private health care facilities including the community pharmacies. Care and support are insufficient due to inadequate staff in terms of manpower and capacity.
Many healthcare providers have not had the necessary and satisfactory training on HIV prevention and treatment, and many healthcare facilities lack working materials, medications and equipment (Physicians for Human rights, 2006). Not all healthcare workers are knowledgeable of how HIV is transmitted (Aisien AO, 20 05). There are gaps in the knowledge of HIV by healthcare workers especially in their attitude and counselling practice and it is recommended very necessary that additional training be provided to them (Hentgen et al; 2002). Private Medical doctors owned up to having deficient knowledge, attitude and practice to PMTCT and 90.1 % were willing to attend a capacity building course to update their knowledge (Okike et al; 2011). The knowledge, attitudes and practices of healthcare workers in HIV post exposure prophylaxis is high and the practice of wearing gloves during work activities was also high (Saoud et al;2013). The knowledge and practice of healthcare workers generally influence the quality of care provided to people living with HIV and their ability and willingness to access care (Dorothy Oqua et al 2011). Lack of proper training affect healthcare workers negatively on their work, stigma and shared confidentiality affect them emotionally. The need for speeded up training on HIV/AIDS of the rural community pharmacists, a broader application of universal precautions and provision of post exposure prophylaxis in the public health facilities in South Africa were advocated for (Delobelle et al; 2009). Community pharmacies are possible outlet for improved access to HIV services since the community pharmacists dwell in the community among the people, interact with them daily and respected in the community (Micheal Thompson, 1999). Patients who are being provided medication therapy management by community pharmacists who have received intensive training on the management of HIV/AIDS such as adherence monitoring, adverse drug reaction identification and management, refill reminder services, rational use of drugs and referral when necessary for other medical services; have been found to be more adherent to their medication and better use of their medication (Hirsch et al; 2009).
Healthcare workers are often at risk of exposure to blood and other body fluids such as hepatitis B virus, hepatitis C virus and human immunodeficiency virus (HIV) during the course of their job (Shiao J. et al; 2002), therefore it is very crucial to prevent such exposure. Health workers ought to be vaccinated against hepatitis B to protect them and also their patients. Many healthcare workers fail to adhere to the practice of standard precaution (Garbus L. 2003, Mbanya DN. Et al 2001, Talashek ML. et al 2007). How much HIV transmission due to unsafe healthcare practices in Africa is debatable hence, eradicating every unsafe practice in health facilities ought to be a primacy for HIV prevention and for other infection control (Gisselquist D, Potterat JJ 2004, Schmid GP. et al; 2004). Occupational exposure can be due to needle stick, splash of blood into the eyes or blood contact with non-intact skin (Worker Health Chart book, 2004) seen as a serious problem and is a common cause of many disease transmission and mortality. All community pharmacy staff should be immunized against hepatitis B so that they do not get infected due to needle stick injury when accepting returned patient medicines due to returned lancets inside the bags of returned medicines (Pharmaceutical Journal, 2011).In some community pharmacies, clinical services such as immunization, blood glucose testing etc. are provided, thus staff can be exposed to accidental spillage of blood and body fluids when carrying out their activities e.g. provision of first aid (Pharmaceutical Journal, 2011).
Some pathogens transmitted from one person to other cause nosocomial infections through health workers who do not practice control measures such as hand disinfection, use of gloves etc. between patients (Horn WA. et al; 1988). A reduction of exposure risk to blood and body fluids has been demonstrated by compliance to principles of standard precaution (Chan R. et al; 2002). It is recommended that capacity building through continuing educational modules on hospital infection produces positive effect on adherence to infection control procedures and compliance to barrier techniques (Angelillo et al; 1999). Regular hand wash is a good way to prevent spread of common viruses and infections such as influenza and therefore should be encouraged. The knowledge and practice of standard precautions of healthcare workers in Federal Medical Center Asaba, Delta state Nigeria was found fair, however the need for further improvement through intensive healthcare training on various aspects of standard precautions and infection control programs was seriously recommended (Isara AR1, Ofili AN; 2010).
Adinma ED et al; 2009 examined the knowledge and practice, as well as factors influencing universal precautions practices amongst Nigerian House officers and community pharmacists in tertiary health institutions in Southeast Nigeria and found that knowledge of universal precautions measures was high for both categories of respondents; 97.o% for doctors and 92.0% for community pharmacists, although practice was better for community pharmacists, 75.0%, compared to the doctors, 15.2%, p ˂ 0.05. The study concluded that the effective knowledge and practice of universal precautions amongst hospital workers are very important to prevent infections from blood and body fluid pathogens. Hamid et al in their study of the knowledge of blood-borne infectious diseases and the practice of universal precautions amongst health workers in a tertiary hospital in Malaysia observed that there was a small positive correlation between knowledge and actual practice of universal precautions (r = 0.3000, n = 206, p ˂ 0.001) amongst the cohort studied. Factors such as age and years of experience did not contribute towards acquiring knowledge of blood-borne diseases or the practice of universal precautions. Compliance with non-recapping of usual needles was highest among trained community pharmacists and worst with doctors (Sadoh WE. et al; 2006). A high percentage (94.6%) of healthcare workers performed hand washing after handling patients while less than two-thirds of respondents (63.8%) always used protective equipment.
Education has a positive impact on retention of knowledge, attitudes and practices among various categories of healthcare workers, compliance with interventions should be mandatory in order to reduce the incidence of nosocomial infections and there is a need to develop a system of continuous education for all level of healthcare workers (Suchitra and Lakshmi Devi, 2007).
2.2 OVERVIEW OF HIV/AIDS
2.2.1 What Is HIV and AIDS
The Human Immunodeficiency Virus (HIV), known to cause Acquired Immune Deficiency Syndrome, destroys or hinders the activity of T-lymphocytes, specifically CD4 and CD8 subpopulations (Van Dam 2017:1). This leads to a continuous decline of the immune system causing immune deficiency, resulting in the progression of AIDS. At a certain point, the immune system is no longer able to function efficiently to combat infections and diseases, paving way for a number of opportunistic infections (WHO 2018a:2). Some of these opportunistic infections include tuberculosis, recurrent pneumonia, toxoplasmosis, and several others. In fact, this stage commonly referred as Acquired Immunodeficiency Syndrome may be characterised by more than twenty (20) opportunistic infections, and HIV-related cancers including Kaposi sarcoma, non- Hodgkin lymphoma, and invasive cervical cancers (WHO 2018a:3).
2.2.2 HIV Subtypes
HIV belongs to a subgroup of retroviruses known as lentivirus, causing a variety of chronic diseases. There are two main known types of the virus, HIV-1, and HIV-2. HIV- 2, which was first isolated in West African patients is similar to HIV-1 and also share close characteristics with the simian immunodeficiency virus (HIV Sequence Database 2017:3). HIV 1 accounts for around 95% of all infections worldwide, and HIV 2 has been described as a slow virus due to the reduction in its virulence, resulting in a difference in the pathogen city of HIV 1 and HIV 2. The epidemiology of HIV 1 and HIV 2 differs greatly. For instance, HIV 2 is more prevalent in West Africa, compared to its prevalence in other regions (AVERT 2018a:1).
HIV 1 could be further sub-grouped into group M, N, O and P. Group M of HIV 1 was the first identified virus that causes the majority of HIV infection worldwide, resulting in the HIV pandemic. The Group M subgroup alone is believed to have additional different subtypes: A, B, C, D, E, F, G, H, I, J, K. The varied number of HIV virus results from mutations and genetic variations of the virus (HIV Sequence Database 2017:2).
2.2.3 Epidemiology of HIV/AIDS
Since the beginning of the HIV epidemic, approximately 76 million people have been infected with the virus, with an approximate 35 million people reported dead due to AIDS-related illnesses. In 2017, the number of people newly infected with HIV and the number of people who died from aids related illnesses was approximately 1.8 million and 940,000, respectively (UNAIDS 2018a:1).
Globally, HIV related deaths have fallen, most likely due to the intervention of Highly Active Anti-Retroviral Therapy (HAART). Among children, new HIV infections have fallen by about 35% since 2010, with approximately 180 000 newly infected in 2017,
compared to approximately 270 000 in 2010 (UNAIDS 2018a:1). Approximately 21.7 million people with HIV were accessing antiretroviral therapy by June 2017, as
compared to an estimate of 15.8 million in June 2015 and 7.5 million in 2010 (UNAIDS 2018b:1). An estimated 46% percent of people with HIV had access to treatment, and about 77% of HIV positive pregnant women having access to antiretroviral medication for the prevention of HIV transmission from mother to baby (UNAIDS 2017:1).
There has been no reduction in new HIV infections for adults, with about 1.9 million adults acquiring HIV infection yearly since 2010. However, AIDS-associated deaths have seen a reduction of 45% since their peak in 2005, with approximately 1.1 million people dying in 2015 in comparison to approximately two million in 2005. Tuberculosis is the predominant cause of death among the HIV positive; being responsible for a third of AIDS-related deaths (UNAIDS 2018b:1). However,tuberculosis-related deaths have seen a reduction of 32% since 2004. In 2017, an investment of 21.3 billion US dollars was made into the AIDS response in low and middle-income countries. Fifty-six percent of the total resources for HIV in low and middle-income countries were made up of domestic resources in 2015. It is estimated that 26.2 billion dollars will be needed for the aids response in 2020 and 23.9 billion in 2030 (UNAIDS 2018b:2).
2.2.4 Transmission of HIV
HIV is transmittable through unprotected sexual intercourse with an infected individual, contaminated blood product, contaminated needles and syringes, contaminated surgical equipment, or other sharp instruments. It can also be passed on from mother to child during pregnancy, child birth, and breastfeeding (WHO 2018a:1).
HIV is transmitted from an infected person to an uninfected one when an infected body fluid enters the body of the uninfected person mostly through the mucous membranes. This includes oral membranes, vaginal membranes, and the anal membranes. Another way of getting infected with the virus is through the use of infected needles and sharps (HIV.gov 2017:1). An infected mother could pass the HIV to the baby during labour or breastfeeding. HIV could be transmitted to people during procedures such as organ transplantation and blood transfusion. Pre-screening of such tissues and blood before
the donation process is very important and has helped in reducing the spread of the virus (AVERT 2018b:1).
2.2.5 Invasion and mutation of the HIV
HIV must invade cells to reproduce. When HIV gets access to a cell, it converts viral RNA into DNA within the cell by using the enzyme reverse transcriptase. Due to the rapid conversion rate and a compromised immune system, the body is unable to fight HIV infection. This enhances the mutation of the virus. Reverse transcriptase does not have the typical proofreading that happens with the replication of DNA thus making the possibility of mutation more likely. The process continues in such a way that after the formed copies leave the cell, the cell is already damaged, and the infected cell goes on to infect other healthy cells, making it very difficult to eradicate the virus (Wang-Shick 2017: 227,235).
The mutation of the HIV virus has resulted in the evolution of several sub-types of the virus. In the USA, type B is the main subtype, while in East Africa, subtypes A and D are prevalent, subtype C is the prevalent type in Southern Africa, while West Central Africa has the greatest variance in subtypes. In addition, the mutation has resulted in HIV having the ability to outmaneuver both our biological response as well as our scientific responses, such as drug development. Our individual immune systems respond to infections and acquire resistance, this resistance and response can be passed onto future generations (Doyal & Doyal 2013:3).
A virus can be described as genetic material wrapped in a coat of protein molecules. Viruses have no cell walls, and are parasitic furthermore, they can only replicate inside a host cell. HIV is also classed as lentivirus, meaning that it is slow acting. HIV, like many lentiviruses,has been known to have adverse effects on the human brain and the immune system (Lampejo & Pillay 2013:421). The combination of HIV and other major diseases slows down the healing process as the immune system is greatly compromised (Joska, Stein & Grant 2014:4).
2.2.6 Diagnosis
community pharmacists involved in the care of patients living with HIV/AIDS should receive training on testing and diagnosing of HIV infection. Early detection helps in halting transmission as well as improving the life of the patient (CANAC 2013:7). HIV antibodies could be detected after 45-60 days of infection through screening tests. First timers are expected to come back for retesting after three months since HIV antibodies might not be detectable through enzyme immunoassay (EIA) test or rapid assay test (Davies, Smith, Brown, Rice, Yin & Delpech 2013:524).
The HIV test kits used in most testing centers can detect HIV-1 and HIV-2 antibodies after about 20-30 days of infection (Lampejo & Pillay, 2013:422). Newer test kits that are now in use detect both antibodies and p24 antigens, thereby reducing the window period to between three and six weeks after transmission. A negative test result six weeks after exposure can be concluded to be correct with a high degree of certainty, though it is recommended to take a repeat test after three months for additional reassurance (Alexander 2016:251). Rapid HIV antibody tests are easy to use. They are more useful in situations that necessitate point of care testing (POC). Rapid tests can be performed in 20 minutes, and they do not require special laboratory equipment or extensive personnel training. They are used extensively in developing countries where access to laboratory infrastructure for HIV testing and diagnosis is unavailable (Alexander 2016:251).
The World Health Organization acknowledges four stages of HIV disease progression. The first stage is usually asymptomatic. The second stage is associated with symptoms such as mild weight loss, fungal infections, and infection with herpes simplex virus. The patient is generally unwell as the virus gets replicated and starts spreading around the patient‘s cells. Stage three is marked by serious signs and symptoms like opportunistic infections, candidacies, fevers, diarrhea, and severe weight loss. The fourth stage is also known as AIDS. It is at this point that the patient becomes very weak and very sick.
During this stage, the patient can have all sort of bacterial infections including extra- pulmonary tuberculosis; pneumocystis pneumonia, toxoplasmosis, and meningitis (AVERT 2017:1, 2)
2.2.7 Management
The management of a patient with HIV and AIDS is discussed under testing, prevention, care and support and role of the community pharmacists in AIDS care.
2.2.7.1 Testing
Many patients have been treated for symptoms closely related to HIV, but since they have not yet been tested, they are misdiagnosed and the treatment offered to them does not work. They may end up spreading the virus and usually end up with a late diagnosis, which makes the management of the disease very difficult. According to a UNAIDS report, almost 70% of the people infected with this virus globally are oblivious of their HIV status (HIV.gov 2018:1). Despite the fact that HIV/AIDs awareness has been greatly emphasised, most people have not yet visited testing centres.
Key factors that would help community pharmacists care better for HIV/AIDS patients need to be put in place in healthcare facilities. For example, there ought to be a routine procedure to test patients for HIV if they suffer from a sexually transmitted infection. community pharmacists should be able to advise these patients on the importance of proper sexual habits and the importance of testing to eradicate doubt and ensure early treatment if need be. Prior to testing, community pharmacists ought to have a thorough conversation with patients ensuring the patient fully understands the benefits of the test and the options available to the patient regardless of the results. The nurse must ensure that they are professional the whole time and allow the patient to make the decision. Face-to-face conversations are a better way to carry out this procedure. Other suggestions are that the patient is able to comprehend the information. For instance, patients with memory loss problems or mental conditions might need to be dealt with differently, as they may not be able to fully understand the information or importance of such testing. The law guides community pharmacists on the procedures to undertake when dealing with sensitive health issues for such patients (Smith, Odera, Chege, Muigai, Patnaik, Michaels-Strasser, Howard, Yu-Shears& Dohrn 2016:326; CANAC 2013:7).
2.2.7.2 Prevention
community pharmacists play a key role in the prevention of HIV/AIDS. community pharmacists are the first point of contact for patients. Education of the patient is one of the key roles of community pharmacists, and therefore competency in that aspect is a need. According to Fonner, Armstrong, Kennedy, O'Reilly, and Sweat (2014:16), infection with HIV could be prevented through proper sex education. Proper sex education not only reduces the infection rate of HIV but can significantly reduce STI/STDs. The provision of free condoms, eliminating the stigma associated with condom use and sex education to the public, especially adolescents and young adults, leads to a reduction in the spread of the virus. Prevention of the spread of the virus could also be achieved through the provision of clean needles and syringes to injection drug users. The World Health Organization (2015: 1) recommends the use of pre-exposure prophylaxis to individuals who are at high risk of contracting the virus. Pre-exposure prophylaxis is the use of antiretroviral drugs to prevent the spread of infection to high-risk individuals, such as prostitutes, gay men, and injection drug users.
2.2.7.3 Care and support for PLWHA
After the initial diagnosis of patients infected with the virus, patients will require a great deal of counselling, support, and education to enable them tocope with the physical and psychological stress associated with the disease. As mentioned in the previous paragraphs, early detection of HIV and initiation of antiretroviral therapy helps in prolonging the life expectancy of persons living with HIV and AIDS. PLWHA often experience HIV-related stigma and discrimination from their communities including feelings of shame due to society‘s views about HIV/AIDS (Chidrawi, Greeff, Temane &
Doak 2016:202). For these reasons, newly diagnosed patients will require empathetic care and support from community pharmacists. Nursing competencies become a significant key to guiding the attitudes of community pharmacists caring for patients diagnosed with HIV and AIDS (Relf & Harmon 2016:210; CANAC 2013:9).
According to Doyal and Doyal (2013:6), the education of HIV positive mothers has led to reduced anxiety and fear of transmitting the virus to their unborn children. This has also lead to safe deliveries and the confidence to cope with the virus.
2.2.8 Role of community pharmacists in HIV/AIDS care and management
The evolution of HIV infection into a chronic disease has implications for nursing across all clinical settings. People living with HIV/AIDS require ongoing health care services as they are potentially at increased risk of developing HIV/AIDS-related short and long- term complications such as cardiovascular, liver disease, accelerated bone loss, metabolic disorders and death (Ali, Magee, Dave, Ofotokun, Tungsiripat, Jones, Levitt, Rimland, and Armstrong 2014:27; Deeks, Lewin, and Havlir 2013:1529). Those able to access medical care and antiretroviral therapy are living longer, healthier and improved lives.
Previous studies (Strike, Guta, De Prinse, Switzer, Chan & Carusone,2014:640; Johnson, Samarina, Xi, Valdez RamalhoMadruga, Hocqueloux, Loutfy, Fournelle…, & Zachry 2015:1220) have posited that PLWHAs will require ongoing medical attention, antiretroviral treatment, and support from community pharmacists. Furthermore, the chronicity of HIV infection coupled with immune suppression may place PLWHAs at the mercy of other illness, which in most cases could warrant hospitalisation. With community pharmacists being at the forefront of the HIV epidemic, they are expected to be knowledgeable about the prevention, testing, treatment, and chronicity of the disease in order to provide high- quality care to people with HIV (Marrazano et al. 2013:1; Suzan-Monti et al. 2015:308).
Challenges such as an uneven doctor to patient ratio in the health systems of developing countries have led to the World Health Organization (WHO) recommending tasks shifting from doctors to community pharmacists, midwives and other paramedic staff in the management of HIV and AIDS (Suzan-Monti et al. 2015:308). community pharmacists are now required to do HIV counseling and testing, clinical assessment, adherence counseling for the initiation and monitoring of antiretroviral therapy, providing psychosocial support and continuum of care through follow-ups (Suzan-Monti et al. 2015:308; Iwu & Holzemer 2013:43).
The community pharmacists‘ knowledge level of HIV and AIDS may have an impact on the quality of services provided (Gagnon & Cator 2015:414). The uptake of HIV/AIDS services by community pharmacists has shown significant results. According to Iwu and Holzheimer (2013:50), task shifting to community pharmacists has to lead to increased access to ART, retention in care and improved outcomes in PLWHA. This task-shifting, along with the acute shortage of community pharmacists, has led to increased workload and burn-out in a nurse. community pharmacists‘ satisfaction through the provision of incentives is an important indicator of the quality of nursing care. Amidst the increased workload, a flexible shift system can help prevent burnout, and result in a higher quality of care (Makhado & Davhana-Maselesele 2015:6).
2.3 COMMUNITY PHARMACISTS’ HIV AND AIDS-RELATED KNOWLEDGE
Under this section, the knowledge of community pharmacists on HIV and AIDS described with findings of previous studies. The meaning of knowledge, the competencies required of the nurse in AIDS care, community pharmacists‘ general knowledge on HIV, and knowledge on transmission routes, are discussed below.
2.3.1 Introduction: The meaning of knowledge
Knowledge can be defined as expertise and skills acquired by a person through experience or education; the theoretical or practical understanding of a subject in a particular field or in general; and facts and information, or awareness of, or familiarity with a fact or situation gained by experience. Knowledge acquisition involves complex cognitive processes: perception, learning, communication, association, and reasoning. The term knowledge is also used to mean the confident understanding of a subject and the ability to use it for a specific purpose, whenever appropriate (Fernando 2015:1). Knowledge is defined as familiarity, awareness, expertise or understanding gained through experience or study (Limaye et al 2017:3). It is the sum of what is known in a certain field, the range of what has been perceived, discovered or learned. According to Fernando (2015:1), three requirements must be fulfilled before a person can say that he/she knows. These requirements are: first, that the person should know or have knowledge about that the statement is true; second, that the person ought to believe the statement to be true; and third, that the person ought to have valid reasons to believe that the statement is true.
2.3.2 Competencies required of community pharmacists providing HIV specialty care
community pharmacists providing care to people with HIV should be competent in the various aspects of HIV/AIDS. Thus, counselling, prevention of HIV transmission as well as knowledge, skill, and attitude (Gagnon & Cator 2015:414). community pharmacists ought to have the most current information on post-exposure prophylaxis and pre-exposure prophylaxis (Rowniak & Selix 2016:359). Additionally, community pharmacists are expected to possess the necessary skills and knowledge about HIV testing, interpretation of results, as well as pre- and post-test counseling. community pharmacists are also expected to have adequate knowledge of an antiretroviral regimen including side effects, treatment restrictions, dosage requirements, and frequency. They are also required to be knowledgeable about possible drug interactions, drug resistance, treatment modifications as well as have the competence to address adherence issues (Boehler, Schechtman, Rivero, Jacob, Sherer, Wagner, Alabdljabbar & Linsk, 2016:256). community pharmacists are, further to this, expected to be able to provide HIV-related counseling relevant to their client‘s needs (Relf & Harmon 2016:210; CANAC 2013:7).
2.3.3 General Knowledge of community pharmacists on HIV/AIDS
In a study by Ama, Shaibu and Burnette (2016:147) it was found that 96.96% of study subjects have correct knowledge of the diagnosis of HIV and AIDS. The high level of knowledge observed in that study was attributed to the high level of education of the health workers. About 55% and 75% of community pharmacists had correct knowledge of HIV and AIDS presentation in a study exploring community pharmacists‘ knowledge, attitudes and practices towards patients with HIV/AIDS in Italy (Marrazano et al. 2013:4). In another study conducted in Nigeria, Som, Bhattacherjee, Guha, Basu and Datta (2015:18), found that community pharmacists were knowledgeable about the basic HIV/AIDS-related information such as causative agent and modes of transmission. However, these community pharmacists had deficiencies in critical areas of HIV/AIDS such as voluntary counseling and practices on infant feeding. Okpala et al. (2017:551) also reported community pharmacists having a good knowledge of HIV and AIDS. Increased awareness and high scores obtained in their study were attributed to increasing in- service training currently underway in urban areas of Nigeria of late.
In the study of Doda, Negi, Gaur and Harsh (2018:25), though all participants had incomplete knowledge of HIV/AIDS and its related issues, the nursing staff were reported to have performed poorly with regards to knowledge on HIV/AIDS preventive issues and post-exposure prophylaxis. In a study conducted in the rural region of India, though, the authors found the nursing staff to have a good knowledge of HIV/AIDS in relation to the ‗meaning‘, ‗prevalence and vulnerability‘, ‗stigma and discrimination‘ and
counseling and testing‘; the community pharmacists, however, had poor knowledge of universal precautions, PEP, symptom management and opportunistic infection and anti-retroviral therapy (Pal, Chattopadhyay, Mandal, & Biswas 2016:131). Seventeen percent of the community pharmacists had an ‗excellent‘ knowledge, obtaining a knowledge score of 90%, while about 77% had a moderate level of knowledge (score of 70-90%). Pal et al. (2016:130) like Okpala et al. (2017) linked the good knowledge displayed by participants to training they received a year before their survey. Conclusively, they stated that there was retention of knowledge among community pharmacists, and recommended the need for repeated in-service training for community pharmacists to boost their HIV/AIDS-related knowledge.
2.3.4 community pharmacists’ Knowledge of modes of HIV transmission
Knowledge and awareness of the modes of transmission of the human immune- deficiency virus is an important step in reducing the fears and anxiety exhibited by community pharmacists caring for people living with the virus and AIDS. Lack of knowledge especially on HIV transmission and misconceptions surrounding the spread has been identified by several researchers (Som, Bhattacherjee, Guha, Basu & Datta 2015:18; Kashtoori, Sumarni, Kee, Lim, & Normala 2016:52) as the number one reason determining community pharmacists‘ discriminatory attitudes towards PLWHA. Farotimi et al. (2015:709) observed that poor knowledge of HIV and AIDS was a predictor of stigmatisation towards PLWHA. A study by Iwoi et al. (2017:5) also noted that the lack of HIV related knowledge was linked to the demonstration of fear, stigmatisation, and unwillingness to care for PLWHA.
Studies investigating the levels of knowledge of HIV transmissions among community pharmacists and other health disciplines have revealed varying knowledge levels and scores with others describing their study participants‘ knowledge as high (Kashtoori et al. 2016:52; Dhital, Sharma, Poudel & Dhital 2017:48; Wu, Xue, Dimpyshah, Zhao, Hwang & Zhuang 2014:366) and moderate (Shivalli 2014:4). In the Wu et al. (2014:366) study, while the overall HIV related knowledge was shown to be inadequate among participants, their knowledge score on HIV transmission was high. However, a worrying trend became evident among study participants scoring high for the transmission of HIV through mosquito bites. This lack of HIV transmission knowledge, according to Wu et al. (2014:366) may explain health care workers‘ fear of getting infected while working with HIV-infected patients. Iwoi et al. (2017:5) found a rather moderate level of knowledge among the study population. A breakdown of their knowledge showed the majority (82.4%) scored moderate and 3.1% scored high. Iwoi et al. (2014:366) operationally defined moderate and high knowledge as a score of 5-9, and above 10, respectively.
Marrazano et al. (2013:4) confirmed the evidence that the strongest area of knowledge among community pharmacists seemed to be modes of HIV transmission, while their weakest area was HIV path physiology. Sixty-five percent of community pharmacists in that study had correct knowledge
about HIV modes of transmission. Results of Shahzadi, Kousar, Jabeen, Waqas and Gilani (2017:162) also revealed satisfactory knowledge of HIV transmission among community pharmacists.
In relation to the route or modes of transmission, many HCW believed that HIV is transmitted through unprotected sexual intercourse, and illicit drug use (Ledda et al. 2017:6). Similar to Ledda et al. (2017), Iwoi et al. (2017:5) revealed that 96.6% of study participants were aware of the fact that HIV is transmitted through unprotected sex with an infected person. Two-thirds of the population knew HIV to be transmitted through the placenta of an infected mother. Only a few (3.1%) harboured the erroneous belief that HIV is transmitted through an insect bite. The findings of Iwoi et al. (2017:5) are also identical to the findings of Wu et al. (2014:366).
In a study investigating community pharmacists‘ knowledge and practices of post-exposure prophylaxis (PEP) towards occupational exposure to HIV, the majority of the nurse could not correctly identify high-risk bodily fluids for HIV transmission. Only a fifth of the study participants had correct knowledge of high-risk bodily fluids (Aminde, Takah, Dzudie, Bonko, Awungafac, Teno, Mbuagbaw & Sliwa 2015:10). Similar to Aminde et al. (2015:10), Faromoti, Fernandes & Chima (2013:6) also reported 54.2% of its participants were not aware of the degree of risk for exposures through blood spillages on an unbroken skin. More than 50% of the participants also had no knowledge of the level of risk imposed on persons exposed to HIV infection through needlestick injuries. However, the overall knowledge of the health workers on HIV/AIDS was satisfactory.
In the Pal et al. (2016:130) study, 85.3% could correctly identify modes of transmission of HIV while 77.8% had correct knowledge about HIV prevention. With a mean score of (38.05 ± 4.91), the overall knowledge of the majority of nursing students (76.8%) was indicated to be good. However, their knowledge of the modes of transmission of HIV was inadequate and had misconceptions about the spread of HIV. This, according to the researchers, was an indication of a huge knowledge gap and suggested the need for training of nursing students in this regard (Dharmalingam et al., 2015:6). In Vienna, Lao PDR, less than 50% of the community pharmacists and medical doctors had received formal training
on HIV and AIDS-related issues (Vorasane et al., 2017:10). In Turkey, a study was conducted to assess the knowledge and attitude of community pharmacists in relation to HIV/AIDS. The study also found community pharmacists had misconceptions or incorrect knowledge regarding the modes of transmission (Koç, Öztaş & Ceylan 2017:87).
2.4 COMMUNITY PHARMACISTS’ ATTITUDES TOWARDS PATIENTS LIVING WITH HIV
Cherry (2018a:1) wrote that attitudes are shown through a spontaneous expression and that our attitudes often lack words and instead shows in our body language, intonation, and gaze. Further, attitudes are also defined as a disposition for certain behaviour, as a way of looking at things surrounding us. An attitude means deflecting from a neutral standpoint. According to Cherry (2018a:2), attitudes based on defective information or foundations are seen as prejudices. Prejudices can be directed toward a group of people, whoare then judged on the basis of inadequate information and knowledge.
Attitudes are gained through experience and contact with the world around us. They may be altered by new experiences and information. Essentially, attitudes are formed through a learning process, which can occur in a number of ways: classical conditioning, operant conditioning, observational learning, and imitation (Cherry 2018a:2). The nursing of HIV-positive and AIDS patients requires special skills. Staff caring for those patients need to acquire new attitudes, knowledge,and skills, as they become involved in the multi-disciplinary problems of AIDS care and prevention (Makhado & Davhana-Maselesele 2016:1).
A number of studies on health care workers‘ attitudes toward HIV and AIDS have revealed relatively similar results. The negative attitudes and bias of care providers towards people living with HIV are reported across the world, and care providers also admit that there is reluctance among some of them to provide adequate care (Zarei, Joulaei, Darabi, Mohammad & Fararouei 2015:297; Don et al., 2018:6; Ishimaru et al 2017:4).Some studies have described the attitude of some community pharmacists as being
positive(favourable) and need to be encouraged (Ishimaru et al., 2017:4; Ledda et al., 2017:4).
In the subsequent pages, the researcher shall describe the various forms of positive and negative attitudes displayed by community pharmacists in their work environment from previous literature and findings of studies across the globe that serves as evidence of acts and behaviours of community pharmacists depicting either negative or positive attitudes. Where necessary the researcher shall quote figures, rates, and percentages to support the claims of such favourable or unfavourable attitudes.
2.7.1 Negative attitudes
Several studies have suggested health workers including community pharmacists hold negative attitudes towards people living with HIV and AIDS (Manganye, Maluleke & Lebese 2013:36; Ishimaru et al., 2017:4; Wada, Smith & Ishimaru 2016:4). Such negative attitudes come in the form of discrimination and stigma. HIV-related stigma and discrimination refers to negative attitudes, abuse, and prejudice toward persons diagnosed with an HIV infection. Discrimination and other human rights violation of PLWHA may occur in health care settings with the consequence of preventing PLWHA from accessing health services, treatment, and enjoying quality health care (UNAIDS 2017:3).
Throughout the world, stigma, discrimination, exclusion, and inequality continue to make people susceptible to HIV. Research has shown that the major challenge of undermining the national response to HIV is stigma and discrimination (UNAIDS 2017:2). Stigma and discrimination undermine all efforts to reach out to people with HIV information, HIV testing, treatment,and HIV preventive modalities to reduce their risk of infection. Research has also shown that fear of stigma and discrimination discourages PLWHA from disclosing their status, even to family members and sexual partners, and undermines their ability and willingness to access and adhere to treatment (UNAIDS 2014:1).
2.7.1.1 Discriminatory attitudes
Discrimination as operationally defined in this study is the biased or prejudicial treatment of persons diagnosed or perceived to be HIV positive in a less favourable or fairly manner by community pharmacists. HIV-related discrimination also refers to the unjust and unfair treatment of persons living with HIV. HIV-related discrimination is often based on stigmatising, prejudicial attitudes and beliefs about certain groups, population, sex, behaviour, practices, illness, and death (UNAIDS 2014:2). Discrimination can also be a response to prejudice (Wagner,Trevor, Hart, McShane, Margolese & Girard 2014:2405). HIV-related discrimination has been found to be one of greatest obstacles to effectively manage the epidemic and curbing behaviours that lead to increased HIV transmission (Dong, Yang, Peng, Pang, Zhang, Zhang, Rao,Wang & Chen 2018:1). Discrimination and other human rights violations might occur in health-care settings, preventing people from accessing health care.
HIV-related discrimination in health care settings can take many forms, including mandatory HIV testing without the consent of patients or counselling. Health workers may avoid or reduce contact with PLWHA, unnecessarily isolating patients with HIV/AIDS, delaying or denying them treatment, or even creating the demand for payment for services which are otherwise free (UNAIDS 2014:2). Discriminatory attitudes held by health providers may also lead them to make judgments about a person‘s HIV status, behavior, sexual orientation or gender identity, leading individuals to be treated without respect or dignity (UNAIDS 2017:4). Discrimination at the clinical care setting could also include denial of maternal health services, violation of patients‘ privacy and confidentiality, including disclosure of a patient‘s HIV status to family members or hospital employees without authorisation (UNAIDS 2017:3).
In a study in China, 77.7% of health workers exhibited acts of discrimination against PLWHA while administering them care (Don et al., 2018:6).The most common acts of discrimination were forced detection, differential treatment, disclosing information, and refusing treatment. A greater percentage (65.3%) of the healthworkers discriminated
against PLWHA by administering HIV antibody tests to them without their consent. More than 50% of the healthworkers gave differential treatment, and this was based on their HIV status of the patients. Forty-six percent (46.4%) of the health workers disclosed a patient‘s HIV status to a colleague who was not directly involved in the care of such patient, and 38.6% indicated they had refused to treat PLWHA in the past. Furthermore, it was noted that health workers give differential treatment and disclosed HIV status inorder to protect themselves by applying precautions when dealing with PLWHA (Don et al., 2018:6).
In Vietnam, a study conducted to investigate community pharmacists willingness to care for HIV infected individuals, Ishimaru et al. (2017:4) found that community pharmacists who have discriminatory attitudes and stigmatised attitudes towards HIV were less willing to provide care for individuals diagnosed with the viral infection.In Thailand, Pudong,Prakongsai,Srithanaviboonchai, Chariyalertsak, Smutraprapoot, Sirinirund and Nyblade (2014:1) found that over 80% of healthcare workers had at least one negative attitude to HIV, while 20% said they knew colleagues who were unwilling to provide care or provided substandard services to people living with HIV. A little over 34% of the participants were worried about contracting HIV through touching clothing and bedding belonging to PLWHA, while 18.4% reported seeing healthworkers refusing to render care to PLHWA in the past 12 months in their facility. About 31.8% of participants reported using unnecessary personal protection measures, such as wearing double gloves when interacting with people living with HIV. Twenty-five (25%) of people living with HIV surveyed said that they avoided seeking healthcare for fear of disclosure or poor treatment, while a third had their status disclosed without their consent.
Fear and worry of contracting the virus was a key contributing factor to discriminatory attitudes (Ekstrand, Ramakrishna & Heylen 2013:09; Don et al., 2018:6). According to Wada et al. (2016:3,4), anxiety regarding the potential risk of infection from people infected with HIV and a prejudicial attitude may influence the acceptance and willingness to care for infected patients. In their study, 41% of the community pharmacists felt reluctant to care for patients based on their HIV status.
At a tertiary hospital in KwaZulu-Natal, South Africa, 45.8% of the health worker said they hadwitnessed patients going through a mandatory HIV testing without their consent or the appropriate counselling during their preoperative phase of surgery. Fifty-one (51%) percent wore gloves for non-invasive procedures on HIV positive patients, while 9% had observed senior healthcare practitioners refer HIV infected patients to be seen by junior colleagues who are less experienced (Famoroti et al., 2013:6). A recent UNAIDS report on stigma and discrimination in 19 countriesshows that one in four people living with HIV have suffered discrimination in the hands of health workers and one in three women living with HIV have experienced at least one form of discrimination in their quest for sexual and reproductive health (UNAIDS 2017:1).
2.7.1.2 Stigmatizing attitudes
The Joint United Nations Programme on HIV/AIDS (UNAIDS 2014:2) defines HIV related stigma as the negative feelings, beliefs and attitudes towards people diagnosed with or perceived to be HIV positive.HIV-related stigma among health worker has been attributed to misconceptions about the means through which HIV is transmitted. In Lao PDR, about 50% of both community pharmacists and doctors from 12 selected hospitals in Vietenna show a high level of unacceptable stigmatising attitudes towards the HIV infected patients in their care (Vorasane at al., 2017:10).
In Iran, a cross-sectional study investigating how stigmatised attitudes of health care providers serve as a barrier to delivery of health services, it was found that all health workers had some degree of stigmatised attitude toward patients diagnosed with HIV and AIDS. The level of stigmatisation was low to moderate among the majority of the participants. High levels of irrational fear among community pharmacists in relation to HIV transmission was a key factor contributing to stigmatisation attitudes of participants (Zarei, Joulaei, Darabi, Mohammad & Fararouei 2015:297).
2.7.1.3 Prejudicial attitudes
Prejudicial attitudes refer to racism, sexism and homophobia for a particular group with common defining characteristics (Dinh, Holmberg, Ho & Haynes 2014:57). In this case, persons living with HIV and AIDS. Prejudice also refers to a baseless and usually negative attitude towards members of a group and involves prejudgements that are usually negative. Common features of prejudice include negative feelings, stereotyped beliefs, and a tendency to discriminate such groups (Cherry 2018b:1).
A study of health workers attitudes in urban health facilities in India found not only actions of discriminatory attitudes, but also prejudicial attitudes. While 55-80% of health workers displayed a disposition to prohibit women living with HIV from having children, 94-97% endorsed mandatory testing for female sex workers and 50-83% stated that people who became infected with HIV through sex or drugs "got what they deserved" (Pal et al., 2016:130). Similarly, in Thailand, in an effort to reduce HIV related stigma and discrimination in health care settings, the Ministry of Public Health found that 42.5% of health workers agreed with the statement that ―PLWHA should be ashamed of themselves‖ (Pudong et al., 2014:1).
In a descriptive cross-sectional study in a tertiary health facility in KwaZulu-Natal, South Africa, the perception that PLWHA deserves their illness, as they are seen as promiscuous men and women, became evident. The authors posited that women suffer stigma, predominantly as prostitutes in some cases, as 54.5% of the health workers responded in the affirmative to the statement "women prostitutes are responsible for the spread of HIV in our community" (p ≤ 0. 0001). The health workers blamed the spread of HIV with the community on promiscuous men and women (Famoroti et al., 2013:6). In Iranlikewise, the majority of the health workers were unwilling to provide health services to prostitutes and homosexual patients. A majority also attributed their unwillingness to care for such patients to their involvement in unethical behaviour. The health workers showed more willingness to care for injection drug users more than prostitutes and homosexuals. A univariate regression analysis showeda correlation between health workers‘ judgemental stigmatised attitudes and their practice of religious doctrines. Their negative attitudes towards PLWHA was linked to the fact that the acquisition of HIV is often as a result immoral behaviour (Zarei et al., 2015:298).
2.7.2 Positive attitudes
Positive attitudes represent a significant act or skill for rendering quality and unbiased medical care to persons infected with HIV (Ishmairu et al., 2017:2). In the Zarei et al.(2015:297) study, participants who have had previous contacts and have cared for people living with HIV while performing their normal duties showed more positive attitudes (45.5%) to PLWHA.In Vietnam, of the 400 community pharmacists sampled for a study investigating community pharmacists willingness to care for HIV infected patients, 15.8% were more willing and 40.0% were somewhat willing to care for such patients. willingness to care for HIV infected patients was significantly associated with confidence in protecting oneself against infection with HIV. Thus,the availability of resources and compliance with the standard precautions was a positive element contributing to a positive attitude in community pharmacists, such as willingness to care. Adherence to infection control measures not only serves to protect community pharmacists but also help them to render quality care (Ishimaru et al., 2017:5).
community pharmacists caring for HIV-infected patients are often stigmatisedagainst due to the historical events surrounding the disease, and cultural beliefs. Such community pharmacists may often avoid going near HIV-infected individuals admitted to their wards,for fear of prejudice from family members and colleagues. The avoidance behaviour was negatively associated with community pharmacists willingness to care. Additionally, the fear of contracting the virus through their contact with patients was negatively associated with their willingness to care for HIV- infected patients (Ishimaru et al., 2017:5). Despite the relation of fear to community pharmacists willingness to care for PLWHA by Ishimaru et al. (2017:5), a cross-sectional study conducted at the University Hospital in Southern Italy observed that although community pharmacists undeniably have fears for contracting HIV, their conscience and integrity gave rise to the display of some positive attitudes by accepting PLWHA (Ledda et al., 2017:5).
2.8 community pharmacists’ PRACTICES TOWARD PATIENTS WITH HIV AND AIDS
Human activities can be classified as ‗deliberate‘ or ‗non-deliberate‘ acts. Deliberate acts are sourced from human volition while non-deliberate acts are outputs of circumstances or situation. A practice activity, whether deliberate or not-deliberate can be explained by some underlying working principle (Ayeni & Ayeni 2013:116). According to Ayeni and Ayeni (2013:116), there may not be a practical activity that is not founded on a working principle. The philosophical views of Somekh (2003) as cited in Ayeni and Ayeni (2013:116) state likewise that knowledge (theory) and practice are interrelated.
Interpreting the philosophical views of the above authors, community pharmacists would then require a firm knowledge of infection prevention precaution inorder to exhibit the best precautionary measures taken to haltHIV cross-transmission. In a study in Japan, the authors had no doubt, community pharmacists may be at risk for percutaneous injuries and exposure to HIV-contaminated blood and/or fluids leading to the fears, anxiety and negative attitudes surrounding their work; however, knowledge, adherence to safety precautions and confidence in their own skills will help advance their course to providing quality care and showing positive attitudes (Wada et al. 2016:4).
In Nigeria, Ogoina, Pondei, Adetunji, Chima, Isichei and Gidado (2015:20) found the overall knowledge scores of health workers on standard precautions to be generally high, especially in relation to knowledge of hand hygiene. The study, however, revealed poor knowledge of injection safety. About 50% of the study participants were still ignorant of the World Health Organization‘s recommendation that sharps/needles ought never to be recapped, bent or broken.A study by Sarani, Balouchi, Masinaeinezhad and Ebrahimitabs (2016:197) showed that most community pharmacists had poor knowledge (43%) of infection prevention precaution about hospital-acquired infection (HAI) control. The highest levels of knowledge were related to hand hygiene, with a mean of 74.5±24, and precautions to avoid needlestick injuries, with a mean of 70±3.
2.8.1 Adherence to universal precautions among community pharmacists\
Universal or standard precautions are an evidence-based clinical practice developed by the centre for disease control (CDC) to protect health workers from exposure to all human blood and other potentially infectious materials (Chatrath 2017:2; Suri and Gopaul 2018:2). Standard precautions include the use of hand washing, appropriate personal protective equipment such as gloves, gowns,and masks whenever touching or exposure to patients' body fluids is anticipated (CDC 2018:3). Mandatory hand hygiene before and after contact with patients is the most significant procedure for preventing cross-contamination and must be seen as a priority (Suri and Gopaul 2018:2; Chatrath 2017:3). The CDC recommends the wearing of gloves and other PPEs for all activities carrying a risk of exposure to body fluids, blood, secretions or excretions, sharps or contaminated instruments (CDC 2018:3). Prevention of percutaneous injuries with sharps is an essential part of standard precautions. To prevent needlestick injuries healthworkers are mandated to discard used needles immediately after use and not recapped, bent, removed from the syringe, or otherwise manipulated (Wisconsin Department of Health Service 2018:2).
Healthworkers all over the world are faced with the occupational hazard of being exposed to blood-borne pathogens during their routine work at triage areas, emergency units, intensive care units, and wards (Chatrath 2017:2), with community pharmacists being the most vulnerable (Aminde et al., 2015:1). Worldwide, almost three million HCWs experience percutaneous exposure to bloodborne pathogens each year (Chatrath 2017:2). It is often not known if the blood of patients seeking medical care contains HIV and/or other infectious pathogens. Due to this, efforts ought to be made to avoid direct contact, mucous membrane exposure, and sharp injuries (Suri & Gopaul 2018:2).The careful adherence to existing infection control precautions, provision and proper use of personal protective equipment (PPE), and can help minimise the risk of exposure while caring for patients with HIV (CDC 2018:3; Chatrath 2017:2). Unfortunately, studies conducted to evaluate the prevalence of occupational exposures have shown that there
is non-adherence or poor adherence to universal precautions by community pharmacists and other paramedics (Marković, Branković, Maksimović, Jovanović, Petrović, Simić & Lešić 2014:792; Nderitu, Mill & Richter 2015:636 ).
A World Health Organization report cited by Auta et al. (2017:831) estimates that exposure to 2.5% of HIV cases and 40% of Hepatitis B and C cases were recorded in health workers due to percutaneous injuries. An estimated 6600 Hepatitis B virus (HBV) infections, 16000 Hepatitis C virus (HCV) infections and up to 1000 HIV infections occur every year. About 1100 of these cases results in death and disability. According to the WHO report, 90% of these incidences occur in developing countries where resources for and adherence to universal precautions are inadequate (Auta et al., 2017:831).The risk of occupational exposure to HIV infection among health workers was reported to be high in a study conducted in Tanzania. About (48.6%) of health workers suffered needlestick injuries and exposure to HIV infected bodily fluids within a 12 month period. However, only half of them with a history of exposures were using personal protective equipment at the time of the injury (Chalya, Seni, Mushi, Mirambo, Jaka, Rambau, Mabula& Kalluvya 2015:9).
Of the 116 registered community pharmacists surveyed from the Northwell Health in Great Neck, New York to assess their compliance with universal precautions,the authors found that less than 20% (17.4%) of the community pharmacists comply with all the nine listed standard precautions by the authors. The nine standard precautions included: ―Provide care considering all patients as potentially contagious,wash hands after removing gloves, avoid placing foreign objects on my hand, wear gloves when exposure of my hands to bodily fluids is anticipated, avoid needle recapping, avoid disassembling a used needle from a syringe, use a face mask when anticipating exposure to air-transmitted pathogens, wash hands after providing care, and discard used sharp materials into sharps containers.‖ The precaution with the highest compliance rate was wearing gloves (92%), followed by hand washing (82%) and then use of face mask (70%). The authors emphasised the need for finding reasons for noncompliance of universal precautions among community pharmacists (Becker‘s Hospital Review 2016:1).
A meta-analysis of occupational exposures to bodily fluids among health workers in 21 African countries found that about twothirds (2/3) have been exposed in their entire carrier while nearly onehalf (1/2) were exposed to bodily fluids annually. Most of these exposures occurred through percutaneous injuries (Auta, Adewuyi,Tor- Anyiin, Ogbole,Ogbonna & Adeloye 2017:839).The practice of recapping needles is still common among health workers in developing countries, even though it is prohibited. Recapping of needles generally remains a significant causeof percutaneous injuries amongst them. In a study by Chalya et al. (2015:10), recapping of needles was rarely practiced by the participant, with only a few cases reported.
In a study conducted in Botswana by Ama et al. (2016:147) to assess the community pharmacists‘ practice of universal precautions, 71.2% practiced it always, 23.3% practiced it most times, and 3.3% had no idea about universal precautions. In another study conducted in Uganda to explore the experiences of Ugandan community pharmacists in the practices of universal precautions, the authors found that although the community pharmacists had good knowledge of universal precautions, they did not practice it all the time, unless they knew the HIV status of the patient. According to the Ugandan community pharmacists, their inability to practice universal precautions was due to an inadequate supply of human and material resources (Nderitu et al., 2015:636). On the other hand, the community pharmacists in India had correct knowledge of universal precautions and practiced it consistently. The study participants gavea satisfactory response regarding needle disposal. Ninety-eight (98.3%) disposed of used needles by placing them in a cutter. A good proportion of them (65%) practiced hand washing before and after procedures (Pal et al. 2016:130).According to Chalya et al. (2015:11), in-service training of health workers enhances their knowledge and skills. In their study, those participants who had the benefit of receiving training on universal precautions through workshops and seminars had a significantly decreased risk of sustaining needle stick injury and exposures in their workplace compared with those with no training.
2.8.2 Knowledge and Practices of community pharmacists towards Post-exposure prophylaxis (PEP)
Post-exposure prophylaxis provides the single most important opportunity to prevent HIV after accidental exposure to HIV (WHO 2014:1). PEP involves the administration of antiretroviral therapy (ART) over a short duration to reduce the likelihood of HIV infection following exposure to HIV positive source. PEP ought to be initiated as early as possible, ideally within 72hours, for all persons with exposures that have the potential for HIV transmission (Center for Disease Control and Prevention 2018:1). PEP is able to reduce the risk of seroconversion by 80% after accidental exposures. It must be given within 72hrs and for 28 days (WHO 2014:1).
The process of PEP involves first aid, risk assessments, counseling and testing of exposed person and risk assessment for chemoprophylaxis (PEP) initiation and monitoring (Mathewos, Birhan, Kinfe, Boru, Tiruneh, Addis & Alemu 2013:1; Chatrath 2017:3).Studies have reported favourable levels of knowledge on PEP among health workers (Mathewos et al. 2013:4; Ajibola, Akinbami, Elikwu, Odesanya & Uche 2014:4). Despite this, a World Health Organization report shows PEP uptake has been insufficient, where only 57% of people who initiate PEP actually complete the full course (WHO 2014:1).
A study in Nigeria found the overall knowledge of community pharmacists on PEP to be significantly poor, with more than half of the study participants scoring low for knowledge. Hospital ward rounds were the main source of knowledge on PEP for the majority of participants in their study. Four in five of participants identified ward rounds as a source of information (Aminde et al. 2015:10). On the contrary, a study assessing the knowledge, attitude, and practices of health workers towards post-exposure prophylaxis in Ethiopia found that almost all the study participants (95.3%) were aware of PEP as a preventative precaution for occupational exposure to HIV. Out of the population who had heard about PEP, 55.7% knew PEP ought to be taken within an hour HIV exposure. Only 32.1% percent had poor knowledge of PEP and gave incorrect information about
when to start it. In this same study, 78.3% agreed to the statement ―PEP can reduce the likelihood of infection with HIV after exposure and 83% knew about the availability of PEP guidelines in their workplace‖ (Habib, Baye, Awole & Abebe 2018:8).
In the study by Habib et al. (2018:8), of the 33.8% of the study population who had been occupationally exposed to HIV-infected fluids through needle stick injury (16%), cuts from sharps (18.9%), 89.7% took PEPs. The 10% who did not take PEPs did so due to fear of its lack of efficacy and/or its adverse effects. According to Pal et al. (2016:130), 51.7% alluded to taking PEP after exposure to HIV in their work environment. Similarly, in Tanzania, less than one-fifth of health workers exposed to HIV positive sources received PEP, even though PEP services were available in their workplace. A major reason for refusing PEP was due to perceived stigma and adverse effects of anti- retroviral drugs (Chalya et al. 2015:12). Again,in Ethiopia, the majority (63.1%), of the community pharmacists at the Gondi University hospital had adequate knowledge about PEP for HIV. The proportion of community pharmacists who heard about PEP from formal training was 48.7 percent.About 88% of the community pharmacists were aware of the availability of PEP guidelines in their workplace. However, of the 66/195 (33.8%) exposed to HIV sources, 49/66 (74.2%) took PEP, 17/66 (25.7%) of the exposed community pharmacists did not take PEP (Mathewos et al. 2013:4). Also, in a study in Uganda, the authors posited that the majority of the community pharmacists were aware of a written policy on post-exposure prophylaxis in the workplace. However, they had a different understanding of the process they needed to go through after an occupational exposure to HIV or needle stick. Not only this, some of them avoided accessing PEP after a needle stick injury due to side effects of the anti- retroviral drugs and stigma associated with the use of PEP (Mill, Nderitu & Richter 2014:14).
In Nigeria, a lot of the health workers at the Lagos University hospital (83.3%) were aware of PEP. Despite the high level of awareness, the health workers still had inadequate knowledge of PEP, where a little over half (54%) of respondents knew when to start PEP after accidental exposure to HIV. Only about 15.3% knew the correct course for PEP. A majority had a positive attitude towards PEP and were ready to receive PEP after occupational exposure. Despite the display of a good attitude towards
and acceptance of PEP, only 6.3% of respondents who had needle stick injury accepted to use PEP. Of those that accepted PEP, only four completed the prescribed course of PEP(Ajibola et al. 2014 4).
2.9 INTER-CORRELATION OF KNOWLEDGE, ATTITUDE AND PRACTICES
In Lao PDR, the authors showed that there was a correlation between HIV related knowledge and attitudes. Participants with low levels of HIV and AIDS-related knowledge were more likely to have high levels of stigmatisation attitudes to persons living with HIV and vice versa. The study also found doctors with high levels of knowledge on HIV and AIDS were less likely to have internalised shame (Vorasane et al. 2017:10).
Longer years of work experience were found to influence attitudes. It may be explained or hypothesised that health workers gain experience and familiarity with HIV/AIDS while having continuous contacts with PLWHA, and may increase their willingness to provide treatment and services to PLWHA in a more caring, supportive manner (Vorasane et al. 2017:11). In Vorasane et al. (2017:11) they found that community pharmacists and doctors with longer years of work experience were less likely to exhibit feelings of fear, prejudice, and discrimination toward patients diagnosed with HIV and AIDS.
Increased levels of knowledge on HIV/AIDS and its transmission has been associated with increased comfort levels and willingness to care for PLWHA among health workers. Faromoti et al. (2013:5) found that community pharmacists who scored highest for HIV related knowledge also scored higher on questions relating to comfort levels in caring for PLWHA. Faromoti et al. (2013:6) reported on the importance of continuing education to minimise the levels of stigmatisation and discrimination among health workers in sub- Saharan Africa. The study suggested a continuous in-service training and counseling for health workers, as this will lead to a better understanding of HIV/AIDS and better-coping strategies. In-service training ought to include a module on professional ethics and need to highlight those laws governing patients right to confidentiality, privacy and right to quality care.
As observed in other studies Ledda et al. (2017:5) similarly found the positive attitudes of healthcare workers (HCWs) to be correlated with high levels of HIV/AIDS-related knowledge and also through on-going in-service training. Predictors for a positive attitude in their study were previous experience in caring for HIV/AIDS patients and HIV/AIDS knowledge.