a survey on knowledge & practice of requestig hiv tests among intern medical officers (imos)

Getting the testing message across: A survey on knowledge and practice of

requesting HIV tests among intern medical officers (IMOs).

Premadasa PS*, Karawita DA**

* Registrar in venereology ,**Consultant venereologist. National STD/AIDS control Programme, Ministry of Health, Sri Lanka.

1

Introduction

• Sri Lanka is a low HIV prevalence country.

• Number attends for VCT is low.

• Large proportion was detected through PIT

• Adults detected at ward setting were significantly immunocompromised at the time of diagnosis.

• Mean CD4 count of the inward diagnosed HIV cases in 2012 was 92.1cells/ul indicating late diagnosis (N = 19).

2

Introduction ctd;

• Late diagnosis is associated with increased mortality, morbidity and impaired response to ART

• Health care providers should recommend HIV testing early for patients presenting with signs and symptoms of illness that could be attributable to HIV.

• To offer HIV tests , health care providers in ward setting should have an adequate knowledge on HIV.

3

Recommendations for HIV testing at health care institutions

• WHO

– For persons presenting with signs and symptoms of illness that could be attributable to HIV, it is a responsibility of a health care provider to recommend HIV testing and counseling.

• BHIVA

– Patients with specific indicator conditions should be routinely recommended to have an HIV test by the clinicians.

4

Objectives

I. To assess the knowledge of intern medical

officers regarding the clinical indications to

request an HIV test.

II. To describe their current practice of requesting HIV testing.

III. To assess the knowledge on HIV testing procedure.

5

Methodology

• A descriptive cross sectional study was carried

out among 100 (total 103) IMOs attached to 4

tertiary care hospitals in Colombo.

• Key outcomes assessed by using a self administered questionnaire: – Knowledge on clinical indications for HIV testing .

– Knowledge on HIV testing procedure.

– Assessment of current practice of HIV testing,

– Obstacles encountered .

• Data analysis: SPSS V 16 6

• UK national guideline indications for HIV testing in adults (2008) was used to assess knowledge as it is a;

– comprehensive list which also includes all the clinical conditions defined in WHO staging i - iv .

7

Results - knowledge on clinical indications

72

72

76

77

78

79

79

79

80

83

84

85

88

91

99

0 20 40 60 80 100 120

Extra pulmonary tuberculosis

Cryptosporidiosis diarrhea

Weight loss of unknown cause

Oesophageal candidiasis

Cryptococcal meningitis

Hepatitis B infection

Unexplained lymphopenia

Unexplained persistent generalized lymphadenopathy

Multidermatomal or recurrent herpes zoster

Lymphadenopathy of unknown cause

Pneumocystis jirovecii pneumonia

Kaposis sarcoma

Chronic diarrhea of unknown cause

Pyrexia of unknown origin

Diagnosed or suspected sexually transmitted disease

Indications with a good response rate (> 70 %) (N= 100)

Diagnosed or suspected STI




99

91

77

72

Persistent generalized lymphadenopathy 79

9

Results - knowledge on clinical indications

40

44

44

45

46

50

51

62

66

66

67

68

69

0 10 20 30 40 50 60 70 80

Peripheral neuropathy

Cytomegaloviral retinitis

Generalized maculopapular rash with fever

Progressive multifocal leucoencephalopathy

Oral candidiasis

Aspergilosis

Unexplained thrombocytopenia

Recurrent Bacterial pneumonia

Cerebral toxoplasmosis

Hepatitis C infection

Recurrent oral ulcers

Oral hairy leukoplakia

Unexplained neutropenia

HIV testing indications with satisfactory response rate (41 % - 69 %) (N= 100)

Oral candidiasis


46

44

10

Results - knowledge on indications

3

3

4

9

10

10

18

24

24

25

27

27

28

30

30

30

31

33

34

36

37

39

0 5 10 15 20 25 30 35 40 45

Salmonella , shigella or campylobacter infections

Seminoma

Lung cancer

Guillain-Barre syndrome

Head and neck malignancy

Angular chelitis

Non Hodgkins lymphoma

Severe or recalcitrant (uncontrolled or refractory) psoriasis

Vaginal intraepithelial neoplasia

Dementia

Aseptic meningitis/encephalitis

Anal cancer or anal intraepithelial neoplasia

Transverse myelitis

Primary CNS lymphoma

Cerebral abscess

Leucoencephalopathy

Pulmonary tuberculosis

Space occupying lesion of unknown origin

Cervical intraepithelial neoplasia

Unexplained retinopathy

Severe or recalcitrant (uncontrolled or refractory) seborrhoeic dermatitis

Cervical cancer

HIV testing indications with poor response rate (<40 %) (N=100)

18

31

34 Cervical intraepithelial neoplasia


Non Hodgkin lymphoma

Transverse myelitis

Guillain- Barre syndrome 9

28

11

9 18

25 27

30 33

31 34

40 44 46

62 72

77 80

91 99

0 20 40 60 80 100 120

Guillain-Barre syndrome


Dementia

Aseptic meningitis/encephalitis

Cerebral abscess

Space occupying lesion of unknown origin


Cervical intraepithelial neoplasia

Peripheral neuropathy


Oral candidiasis






Diagnosed or suspected sexually transmitted disease

Summery of the knowledge on clinical indications (N= 100)

Good

Poor

12


18

30

39

44

45

62

66

72

72

77

78

84

85

0 10 20 30 40 50 60 70 80 90



Cervical cancer

Cytomegaloviral retinitis

Progressive multifocal …


Cerebral toxoplasmosis


Cryptosporidiosis diarrhea


Cryptococcal meningitis

Pneumocystis jirovecii pneumonia

Kaposis sarcoma

Identification of WHO stage 4 clinical conditions as indications for HIV testing (N= 100)

Progressive multifocal lecoencephalopathy

Cytomegaloviaral retinitis


Cervical cancer


45

44

39

18

30

13


31

30

46

68

88

51

69

91

0 10 20 30 40 50 60 70 80 90 100


Cerebral abscess

Oral candidiasis

Oral hairy leukoplakia

Chronic diarrhea of unknown cause

Unexplained thrombocytopenia

Unexplained neutropenia


Identification of WHO stage 3 clinical conditions as indications for HIV testing (N=100)

Oral candidiasis

Cerebral abscess


46

30

31

14


10

37

67

76

80

0 10 20 30 40 50 60 70 80 90

Angular chelitis

Severe or recalcitrant (uncontrolled or refractory) seborrhoeic dermatitis

Recurrent oral ulcers

Weight loss of unknown cause


Identification of WHO stage 2 clinical conditions as indications for HIV testing (N = 100)

15


79

0 10 20 30 40 50 60 70 80 90

Unexplained persistent generalized lymphadenopathy

Identification of WHO stage 1 clinical conditions as indications for HIV testing (N =100).

16

Poor knowledge on WHO clinical conditions (N= 100)

18

30

39

31

30

10

37

0 5 10 15 20 25 30 35 40 45



Cervical cancer


Cerebral abscess

Angular chelitis

Severe or recalcitrant seborrhoeic dermatitis

stag

e 4

st

age

3

stag

e 2

17

51%

4%

45% average

good

poor

Knowledge on clinical indications for HIV testing

• 50 indications 2 marks for each correct answer. • Good knowledge : >70 marks

• Average knowledge : 41 – 69 marks

• Poor knowledge : < 40 marks

18

Results - knowledge on procedure

83%

8% 9%

Knowledge on the specimen required for HIV testing (N = 100)

Serum

Anticoagulated blood

bone marrow aspirate

19

Results - knowledge on procedure

88%

9% 2% 1%

knowledge on specimen collection (N= 100)

Plain tube

EDTA bottle

Heparin tube

Don't know

20

10%

66%

24%

Knowledge on the required volume of the specimen (N = 100)

1.6ml

2ml

5ml

21

2% 7% 3%

9%

69%

1% 6% 3%

knowledge on the venue in which HIV testing is carried out (N=100)

NHSL

Infection control unit

Hospital main lab

MRI

STD clinic

Blood bank

Don't know

microbiology lab

31 %

22

Results- Practice of HIV testing

• 85% of the respondents have requested an HIV test at least once during the past 6 months.

– 57 % have decided on their own.

– 28 % as instructed by the seniors

– Average number of tests requested by one respondent - 3.35

23

Results- Practice of HIV testing

72%

17%

6% 5%

Reason for requesting HIV testing (N = 285)

Clinical indications

Percieved or real high risk behaviours

Prior to the invasive procedures/surgeries

Needle prick injury

24

23

4

4

4

4

5

5

7

7

14

15

19

19

39

0 5 10 15 20 25 30 35 40 45

others ( =<3)


Genital ulcers

Multidermatomal herpes zoster

Unresolving or poorly resolving pneumonia

Generalized lymphadenopathy

Thrombocytopenia

weight loss

Oral candidiasis

Immunodeficiency screening


Patients with recurrent pneumonia



Common clinical conditions where HIV tests were requested (N = 100)

39 (21.8%)

19 (10.6%)

19 (10.6%)

7(3.9%)

4 (2.2%)



Recurrent pneumonia

Oral candidiasis


25

Results- Knowledge vs practice

9.84

2.25

5.67

0.00

2.00

4.00

6.00

8.00

10.00

12.00

average good poor

Association of mean number of testing with the level of knowledge

26

Results- obstacles encountered

3 (6.6%)

6 (13.3%)

7 (15.6%)

7 (15.6%)

10 (22.2%)

12 (26.6%)

0 2 4 6 8 10 12 14

Stigma to the patient from the staff once the test is requested

Difficult to trace reports as STD lab is not located inside the hospital

Getting the consent is time consuming

Non consenting patients

Explaining the relevance of the test to the patient in getting the consent

Reports delayed

Obstacles encountered during HIV testing (N = 100)

12 (26.6%)

10 (22.2%)

Reports delayed

Explaining the relevance in getting the consent

27

Conclusion

• There is a missed opportunity for detection of HIV in the ward setting as the understanding of common clinical indications for HIV testing is low.

• The practice of ordering HIV testing by the intern medical officers in the ward setting remains unsatisfactory.

• Report delay and difficulty in explaining the relevance of HIV testing to the patients, were the common problems encountered in testing.

28

Limitations

• Data cannot be generalized as it only represents four tertiary care hospitals in Colombo.

• Number of HIV testing assessed asking the respondents to recall (recall bias).

29

Recommendations

Reducing the high number of late diagnoses is a clinical and public health priority. To achieve this, it is recommended to;

• Set clinical guidelines for HIV testing in ward setting and policy dispersal.

• To develop and display posters containing HIV testing indications in the ward setting .

• CME/in service training of health care providers to upgrade the knowledge on HIV testing.

• To explore the possibilities to expand the content related to HIV testing in the medical curriculum.

30

References

• Evan Hunter,Meghan Perry, Clifford Leen, Nikhil Premchand 2011,A survey of knowledge , attitudes and practice among non HIV specialist physicians, Postgrad Med J 2012;88:59e65.doi:10.1136/postgradmedj-2011-130031.

• Smith RD, Delpech VC, Brown AE, et al. HIV transmission and high rates of late diagnoses among adults aged 50 years and over. AIDS 2010;24:2109e15.

• BHIVA, BASHH, BIS. UK National Guidelines for HIV Testing. 2008. http://www.bhiva.org/files/file1031097.pdf (accessed 29 Dec 2010).

• Krentz HB, Auld MC, Gill MJ. The high cost of medical care for patients who present late (CD4 < 200 cells/microL) with HIV infection. HIV Med 2004;5:93e8.

• WHO, Guidance on provider initiated HIV testing and counseling in health facilties, 2007, ISBN 978 92 4 159556 8.

• Country progress report Sri Lanka (2010-2011), 2012. Available from:http://aidsreportingtool.unaids.org/116/sri-lanka-report-ncpi.

• National STD/AIDS control programme of Sri Lanka. HIV quarterly update reports (WWW) NSACP.Available from: http://www.aidscontrol.gov.lk/web/index.php?option=com_content&view=article&id=154&Itemid=123&lang=en

• Guideline for intern medical officers 2012, Ministry of health. 31

http://www.aidscontrol.gov.lk/web/index.php?option=com_content&view=article&id=154&Itemid=123&lang=en

http://www.aidscontrol.gov.lk/web/index.php?option=com_content&view=article&id=154&Itemid=123&lang=en

Acknowledgement

• Dr C D Wickramasuriya, consultant venereologist, National STD/AIDS control programme.

• All the intern medical officers attached to NHSL, CSHW, DMH & LRH.

32

a survey on knowledge & practice of requestig hiv tests among intern medical officers (imos)

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