SCHOOL OF MEDICINE

Knowledge, attitude, and practices of medical students towards post exposure

prophylaxis of HIV/AIDS at University Teaching Hospital in Lusaka, Zambia

A Research Dissertation submitted in Partial Fulfillment for the Bachelor of

Medicine & Bachelor of Surgery at the Cavendish University, Zambia

Stanley Mugowe Samusodza

Student No: 001-169

Supervisor: Mr G Mwalungali

2021

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 Certification

This dissertation titled ‘Knowledge, attitude and practices of medical students towards post
exposure prophylaxis of HIV/AIDS at University Teaching Hospital in Lusaka, Zambia’ is
submitted with my approval as Cavendish University, Zambia supervisor.

Signature…………………………………….Date……./………/2021

Mr G. Mwalungali.

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 Declaration

I hereby declare that this dissertation is the original research undertaken by me under the
guidance of my supervisor. No part of the study has been presented in any form for any degree or
certificate in another institute of study. I also declare that, all references and assistance received
from various people have been duly acknowledged.

Stanley Mugowe Samusodza (001-169)

Signature…………………………………….Date……./………/2021

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 Dedications

This dissertation is dedicated to my wife Caroline and daughter Alexandria, who have endured
countless days and moments without husband and father at home, all in pursuit of knowledge.
Thank you Caroline for believing in my abilities and possibilities, even where mere mortals
would generally not. Thank you for all the support and love during difficult times, I will forever
cherish each and every moment of this journey.

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 Acknowledgement

I would like to thank my supervisor Mr. G. Mwalungali for his guidance, encouragement and
patience during the course of the study. His comments and contributions were very insightful and
helpful in shaping this dissertation. I would love to thank all the medical students from
Cavendish University Zambia, Lusaka Apex Medical University and University of Zambia who
took time out of their busy study schedule to participate in this study. I am forever grateful for
their support. Lastly, thank you Mr. M.H Samusodza for all the assistance, it is greatly
appreciated.

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 Abstract

The prevalence of HIV remains high in Sub-Saharan Africa, and Zambia is not spared.
Uninfected medical students have an increased risk of contracting HIV due to exposure during
training and as such, strategies like adequate utilization of PEP are effective measures that can
help in prevention of new HIV infections. It is imperative for medical students to be aware and
knowledgeable of the risks of contracting HIV as well as have proper attitudes to prevent
contracting HIV.

The purpose of this study was to assess the knowledge, attitudes and practices of medical
students towards PEP of HIV/AIDS at University Teaching Hospital in Lusaka, Zambia. A
quantitative cross-sectional study was conducted with 66 medical students from Cavendish
University Zambia (23), University of Zambia (21) and Lusaka Apex Medical University (22).
Data was collected by means of a structured questionnaire and analysed using SPSS version
16.0.

Results were presented using tables. Among the 66 participants, 58% were males and 42% were
females. Fifty two percent were in the age range 25-29 with 73% being single. Sixty percent
were straight from grade 12 with the rest having worked as a clinical officer, nurse or laboratory
scientist.

Fifty three percent knew of PEP during clinical training, with 48% knowing the maximum delay
for PEP and 61% stating the preferable time to take PEP as within one hour. All the participants
had never attended any training on PEP with 58% of the participants not aware of PEP
guidelines. Eighty-two percent agreed that PEP was important with 79% indicating that they
would use PEP if they get exposed to HIV risky conditions. Respondents exposed to HIV risk
conditions were 64% and 68% of the exposed individuals had not taken PEP. Fifty-seven percent
of the exposed participants took PEP within 2-6 hours of exposure.

Knowledge about PEP was high and good practices towards PEP were noted among medical
students. Attitude towards PEP was positive although it was not statistically significant
according to the t-test done. Training of pre-clinical medical students on PEP guidelines,
protocols as well as the principles of universal precautions before they start their clinical
rotations is recommended so that they get acquainted on what to do when they are exposed to
HIV risky conditions.
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 Table of Contents

Certification ................................................................................................................................................... ii
Declaration ................................................................................................................................................... iii
Dedications ................................................................................................................................................... iv
Acknowledgement ......................................................................................................................................... v
Abstract ........................................................................................................................................................ vi
Table of Contents ........................................................................................................................................ vii
List of Tables .................................................................................................................................................. x
List of Figures ................................................................................................................................................ xi
List of Acronyms .......................................................................................................................................... xii
CHAPTER ONE: INTRODUCTION .................................................................................................................... 1
1.1 Background .......................................................................................................................................... 1
1.2 Problem statement .............................................................................................................................. 3
1.3 Study justification ................................................................................................................................ 4
1.4 Research question ............................................................................................................................... 5
1.5 Objectives ............................................................................................................................................ 5
1.5.1 Main objective .............................................................................................................................. 5
1.5.2 Specific objectives ........................................................................................................................ 5
1.6 Significance of the study...................................................................................................................... 5
1.7 Organization of the dissertation.......................................................................................................... 6
CHAPTER TWO: LITERATURE REVIEW ........................................................................................................... 7
2.1 Introduction ......................................................................................................................................... 7
2.2 Overview of HIV Post exposure prophylaxis (PEP) .............................................................................. 7
2.2.1 What is HIV Post Exposure Prophylaxis (PEP)? ............................................................................ 7
2.2.2 Indications for HIV post exposure prophylaxis (PEP) ................................................................... 8
2.2.3 Rationale for HIV post exposure prophylaxis (PEP)...................................................................... 8
2.3 Knowledge levels of post exposure prophylaxis (PEP) of HIV/AIDS .................................................... 9
2.3.1 Global perspective ........................................................................................................................ 9
2.3.2 African perspective ................................................................................................................... 133
2.4 Attitude towards post exposure prophylaxis (PEP) of HIV/AIDS..................................................... 155

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 2.4.1 Global perspectives .................................................................................................................. 155
2.4.2 African perspectives ................................................................................................................... 16
2.5 Practices towards post exposure prophylaxis (PEP) of HIV/AIDS ................................................... 188
2.5.1 Global perspectives .................................................................................................................. 188
2.5.2 African perspective ................................................................................................................... 199
2.6 Knowledge, attitude and practices towards post exposure prophylaxis (PEP) of HIV/AIDS in Zambia
............................................................................................................................................................... 211
2.7 Conclusion ....................................................................................................................................... 222
CHAPTER THREE: MATERIALS AND METHODS .......................................................................................... 244
3.1 Introduction ..................................................................................................................................... 244
3.2 Study design .................................................................................................................................... 244
3.3 Study site ......................................................................................................................................... 244
3.4 Population and sampling ................................................................................................................. 244
3.4.1 Study Population ...................................................................................................................... 244
3.5 Target population ............................................................................................................................ 244
3.5.1 Sample size determination and sampling method................................................................... 255
3.6 Inclusion and exclusion criteria ....................................................................................................... 266
3.6.1 Inclusion criteria ....................................................................................................................... 266
3.6.2 Exclusion criteria....................................................................................................................... 266
3.7 Data collection tools and techniques .............................................................................................. 267
3.8 Data analysis .................................................................................................................................... 277
3.9 Ethical considerations...................................................................................................................... 277
3.9.1 Informed consent ..................................................................................................................... 277
3.9.2 Privacy and confidentiality ....................................................................................................... 288
3.9.3 Ethical clearance and permission ............................................................................................. 288
CHAPTER FOUR: RESULTS .......................................................................................................................... 299
4.1 Introduction ..................................................................................................................................... 299
4.2 Research findings............................................................................................................................. 299
4.2.1 Socio-demographic characteristics of respondents ................................................................. 299
4.2.2 Knowledge of medical students about PEP ................................................................................ 31
4.2.3 Attitudes of medical students about PEP ................................................................................. 322
4.2.4 Practice of PEP among medical students ................................................................................. 344
4.3 Conclusion ....................................................................................................................................... 366

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CHAPTER FIVE: DISCUSSION ...................................................................................................................... 377
5.1 Introduction ..................................................................................................................................... 377
5.2 Discussion of research findings ....................................................................................................... 377
5.2.1 Socio-demographic data........................................................................................................... 377
5.2.2 Knowledge of medical students about PEP .............................................................................. 388
5.2.3 Attitudes of medical students about PEP ................................................................................... 40
5.2.4 Practice of PEP among medical students ................................................................................... 41
5.3 Study limitations .............................................................................................................................. 422
5.4 Conclusions ...................................................................................................................................... 433
CHAPTER SIX: CONCLUSION AND RECOMMENDATIONS .......................................................................... 444
6.1 Conclusion ....................................................................................................................................... 444
6.2 Recommendations ........................................................................................................................... 444
REFERENCES............................................................................................................................................... 455
ANNEXURE 1 ................................................................................................................................................ 52
ANNEXURE 2 .............................................................................................................................................. 577
ANNEXURE 3 .............................................................................................................................................. 588
ANNEXURE 4 .............................................................................................................................................. 655
ANNEXURE 5 .............................................................................................................................................. 666
ANNEXURE 6 .............................................................................................................................................. 677

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 List of Tables

TABLE 4.1 : SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE STUDY SAMPLE ................. 30

TABLE 4.2: KNOWLEDGE OF MEDICAL STUDENTS ABOUT PEP ............................................... 31
TABLE 4.3: ATTITUDES OF MEDICAL STUDENTS ABOUT PEP ................................................... 333
TABLE 4.4: PRACTICE OF PEP AMONG MEDICAL STUDENTS .................................................... 355

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 List of Figures

FIGURE 1: KNOWLEDGE OF MEDICAL STUDENTS ABOUT PEP................................................. 322

FIGURE 2: PRACTICE OF PEP AMONG MEDICAL STUDENTS ..................................................... 336

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 List of Acronyms

AIDS Acquired Immune Deficiency Syndrome

ART Antiretroviral therapy

ARVs Antiretrovirals

HIV Human Immunodeficiency Virus

MOH Ministry of Health

PEP Post Exposure Prophylaxis

UNAIDS United Nations Program on HIV/AIDS

WHO World Health Organization

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 CHAPTER ONE: INTRODUCTION
1.1 Background

HIV remains the scourge of our times and has proved to be a significant public health disease

globally, with the Sub Saharan Africa being the most affected region (Adebimpe, 2018). Zambia

ranks among the countries with the highest burden of HIV/AIDS (WHO, 2018).With

approximately 3% of global HIV cases being due to occupational exposure among health care

workers, the figure may looks small, but it is quite significant when it comes to the risk of

transmission of HIV and other blood borne infections among health care workers (Adebimpe,

2018).

Post exposure prophylaxis (PEP) refers to the use of short term anti-retroviral drugs to reduce the

risk of HIV acquisition (WHO, 2002). Indeed it may require three days from exposure for the

virus to be detected in the lymph nodes, and up to five days for it to be detected in the blood

(Sagoe-Moses et al, 2001). This offers a limited window of opportunity during which acquisition

of HIV following exposure can be prevented through PEP which inhibits viral replication and

stops the irremediable establishment of the infection (Jagger et al, 2008).

World Health Organization recommends post exposure prophylaxis (PEP) use for both

occupational and non-occupational exposures, and for adults and children (WHO/ILO, 2004).

PEP treatment has been shown to reduce significantly the risk of HIV infections (Karen et al,

2004). Occupational exposure refers to potential blood borne infections that may occur in health

care settings during the performance of duties (Phillips et al, 2012).

Post exposure prophylaxis (PEP) is a comprehensive medical management to minimize the risks

of infections among health care workers following potential exposure to blood borne infections.

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It includes counseling, risk assessment; relevant laboratory investigations based on informed

consent of the source and the exposed person, first aid and depending on the risk assessment, the

provision of anti-retroviral medications with follow up and support (Dulcie et al, 2017).

Although significant progress has been made over the last decades in reducing workers exposure

risk in industrialized countries like the United States of America, where for example needle

safety legislation has been implemented resulting in significant decline in sharps injuries (Jagger

et al, 2008). The progress witnessed by some western countries in reducing the numbers of sharp

injuries has not been achieved in economically challenged countries, especially in Sub Saharan

Africa. Health care providers continue to be at increased risk of occupational HIV acquisition,

contributing the bigger share of the three per one thousand(3/1000) injuries resulting in HIV

transmission after percutaneous exposure from an HIV infected patient in the health settings

(Pruss-Ustun et al,2003).

Medical students form an integral part of the health care team and are at increased risk of

acquiring HIV and other blood borne infections during their clinical rotations (Mesfin et al,

2013). The health care setting in which medical students work potentially expose them to

infectious materials such as blood, tissues, specific body fluids, medical supplies, equipment and

environmental surfaces contaminated with these substances. They are exposed to occupational

hazards through percutaneous injury such as needle stick, or cut with sharps, contact with

mucous membranes of eyes or mouth of an infected person, contact with non-intact skin exposed

with blood, or other potentially infected body fluids (Dulcie et al, 2017).

In 2006, Zambia through the Ministry of Health recommended procedures to prevent the

transmission of HIV among the health care workers by formulating the following strategies for

the provision of PEP for all health care workers:

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• Make PEP available to all health care workers whether they work in government, mission or

private hospitals and also victims of sexual violence at all levels of the healthcare systems.

• Print and distribute current PEP Information, Education and Communication (IEC) materials to

all health facilities in appropriate languages.

• Train healthcare providers in the provision of PEP services, inclusive of routine counseling and

testing.

• Promote the development of workplace policies and implementation of workplace programs for

health workers in public and private health facilities (MOH & NAC, 2009).

1.2 Problem statement

Of approximately 35 million health care workers worldwide, the World Health Organization

estimates that nearly 3 million people experience percutaneous injuries every year (WHO, 2002).

It is further estimated that through occupational exposure,0.5% of health care workers are

exposed to HIV annually and this equates to approximately 175 000 HIV infections worldwide

(Thapa & Gurung,2018).

In Africa, health care workers suffer two to four needle stick injuries per year with almost half of

the admitted patients being HIV positive due to the high prevalence rates of HIV (Pruss-Ustun et

al, 2003), and as such Zambian health care workers are not spared from the statistics. Zambia has

a population of approximately 17 million people with 1.1 million people living with HIV and

11.5% adult (15-49 years) HIV prevalence (UNAIDS 2018).

Medical students must have knowledge about PEP and the risk of transmission of HIV as they

are most commonly exposed health care workers to needle prick injuries and contact with

infectious body fluids as they practice procedures like venipuncture and cannula insertion.

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It is therefore important to train them to protect themselves from professional health hazards

prior to starting their life long careers (Aminde et al, 2015 & Dhital et al, 2017).

According to Lungu (2013), There is not much information available in Zambia about the

knowledge, attitude and practices of health care students towards post exposure prophylaxis

(PEP) of HIV/AIDS, hence there is need for the same to be explored so that appropriate

recommendations can be done towards curriculum design and implementation as well as

continual medical education on PEP to medical students who are the future medical officers.

1.3 Study justification

For most medical students, fifth year is their first year of clinical rotations and a number of them

have had needle stick pricks. A number of these fifth years have taken Post Exposure

Prophylaxis anti-retroviral drugs. This study sorts to look at the knowledge, attitudes and

practices of sixth year medical students because these students have had at least a year of clinical

experience, hence they are able to share the knowledge, the attitudes as well as the practices they

have been carrying out towards PEP of HIV/AIDS when they were in their fifth year.

HIV prevalence is high in Sub Saharan Africa, and Zambia is not spared accordingly. The

burden of HIV has been so huge on the local population and it is imperative that the medical

students who are the future frontline fighters of HIV and AIDS are protected from it during

training, hence this study looks at knowledge, attitudes and practices of PEP of HIV/AIDS

among sixth year medical students from three different medical schools at University Teaching

Hospital in Lusaka, Zambia.

There has been no research to date that has looked at knowledge, attitudes and practices towards

PEP of HIV/AIDS among sixth year medical students in Zambia from the reviewed literature,

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hence this study may lay the foundation for future studies as well as contribute to the general

body of knowledge of PEP of HIV/AIDS in Zambia.

1.4 Research question

What is the level of knowledge, the attitude and practices of medical students towards PEP of

HIV/AIDS at University Teaching Hospital in Lusaka, Zambia?

1.5 Objectives

1.5.1 Main objective

To determine the knowledge, attitude and practices of medical students towards PEP of

HIV/AIDS at University Teaching Hospital in Lusaka, Zambia

1.5.2 Specific objectives

1. To determine the level of knowledge towards PEP of HIV/AIDS among medical students

at University Teaching Hospital in Lusaka, Zambia.

2. To ascertain the attitude towards PEP of HIV/AIDS among medical students at

University Teaching Hospital in Lusaka, Zambia.

3. To identify the practices towards PEP of HIV/AIDS among medical students at

University Teaching Hospital in Lusaka, Zambia.

1.6 Significance of the study

The study is significant as it focuses on HIV/AIDS which is a global pandemic and has affected

countries in the Sub Saharan Africa and Zambia is a part of that geography.

The study also focuses on knowledge, attitude and prophylaxis towards Post Exposure

Prophylaxis of HIV/AID among medical students in sixth year, which is a first in Zambia.

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Also this study will have a sample from three medical schools in Lusaka, Zambia hence the

results will be fairly representative of all the sixth year medical students.

The results of this study will be significant in coming up with recommendations for possible

improvements towards education, awareness and utilization of Post Exposure Prophylaxis among

pre-clinical medical students so that the incidents of needle stick injuries among fifth year

medical students are drastically reduced.

The findings will also add to the existing body of knowledge with regards to HIV PEP.

1.7 Organization of the dissertation

Chapter one looks at the background, the problem statement, study justification, research

question, objectives as well as the significance of the study. Chapter two will focus on reviewed

relevant literature on knowledge, attitude and practices towards PEP of HIV/AIDS among

medical students. Chapter three will provide a detailed discussion on research design and

methodology. More detailed information will be provided on study site, population and

sampling, data collection and analysis as well as ethical considerations and ethical clearance and

permission. Chapter four will present the study results in the form of tables of graphs. Chapter

five will present discussion of findings as well as study limitations. Chapter six will present

conclusions of the study as well as recommendations.

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 CHAPTER TWO: LITERATURE REVIEW

2.1 Introduction

In the previous chapter, the research problem that inspires the study was stated. As such,

Zambia’s HIV prevalence remains high despite extensive decentralization and dissemination of

HIV services and information on preventive measures among them being Post exposure

prophylaxis (PEP). An assumption is thus made that knowledge, attitude and practices towards

Post exposure prophylaxis (PEP) may be some of the contributing factors to increased cases of

HIV among health care professionals.

About 2.5% of the global number of people living with HIV resulted from occupational exposure

among health professionals (Singh et al, 2015). This is significant because the Zambian setting

has health professionals among them novice students who are looking after people who are

infected with the HIV virus every day. This chapter will critically review existing literature on

knowledge, attitudes and practices towards Post exposure prophylaxis (PEP) among medical

students thus guiding and directing the study in order to evince or negate the aforementioned

assumptions.

2.2 Overview of HIV Post exposure prophylaxis (PEP)

2.2.1 What is HIV Post Exposure Prophylaxis (PEP)?

Antiretroviral Post Exposure Prophylaxis (PEP) is short-term antiretroviral therapy initiated soon

after suspected or known exposure to HIV virus and it aims to prevent the establishment of HIV

infection in the exposed person. The medications are started immediately after exposure that is

within 72 hours of exposure in order to prevent HIV seroconversion (UNAIDS, 2013). Post

exposure prophylaxis has become the standard of care for the prevention of acquisition of HIV

7
infection after occupational exposure (when someone working in a healthcare setting is exposed

to materials infected with HIV) (Jagger et al, 2008).

According to Shevkani et al (2011), PEP services are a set of comprehensive services that are

aimed at preventing HIV infection in persons exposed occupationally and non-occupationally,

and a provision of short term (28 days) provision of ARV drugs depending on the risk

assessment. Services include first aid care, HIV testing, counseling and follow up care (WHO,

2016).

2.2.2 Indications for HIV post exposure prophylaxis (PEP)

The risk of acquiring HIV infection after occupational exposure to HIV infected blood is low

(1:300 after percutaneous exposure to <1:1000 after mucocutaneous exposure). When the skin is

intact there is no risk. Factors associated with increased risk include deep injury, visible blood on

the device that caused the injury, injury with large bore needle from artery or vein and

unsuppressed viral load in a source patient. Materials and body fluids that pose a risk to HIV

transmission are amniotic fluid, cerebrospinal fluid, human breast milk, pericardial fluid,

peritoneal fluid, pleural fluid, saliva in association with dentistry, synovial fluid, unfixed human

tissues and organs, vaginal secretions, semen, any other visibly blood stained fluids and fluids

from burns or skin lesions (MOH,Zambia,2018). If a health professional is exposed to the above

mentioned body fluids and materials, then post exposure prophylaxis ARVs are a must if the

source patient is HIV positive.

2.2.3 Rationale for HIV post exposure prophylaxis (PEP)

After exposure to HIV, there is a small window of opportunity to use anti-retroviral drugs to

prevent systemic infection from establishing itself.

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Effectiveness of HIV PEP in preventing the establishment of HIV infection is dependent on a

number of factors namely route and dose of exposure, efficacy of drug(s) used ,interval between

exposure and initiation of drug(s) and the level of adherence to treatment(Volberding et al,2012).

The aim of HIV PEP is to give a person’s immune system a chance to provide protection against

the virus and to prevent HIV from being established in the human body (USAID, 2013). After

percutaneous or mucosal exposure to HIV, viruses replicate locally in tissue macrophages or

dendritic cells and host cytotoxic T cells will kill infected target cells. If infection cannot be

contained at this stage, within 2 to 3 days there will be replication of HIV in regional lymph

nodes. Viraemia will follow within 3 to 5 days of virus inoculation (Lebona, 2016).

The sequences of events do carry significant implications. Given the rapid appearance of infected

cells following the introduction of the virus, regimes with the most rapid onset of action,

multiple sites of anti-viral action and greatest potency are more likely to be effective. The

irreversible establishment of HIV infection is stopped or suppressed with the use of PEP by

utilizing the very short window of opportunity given that it takes 3 days (72 hours) from

exposure for HIV to be detected in the lymph nodes and up to 5 days to be detected in the blood

(Aminde et al,2015).

2.3 Knowledge levels of post exposure prophylaxis (PEP) of HIV/AIDS

2.3.1 Global perspective

In their study in India, Gupta et al (2017) noted that most of the health care workers were casual

and non-serious about consequences of occupational injuries. In this study, students pursuing

medical degrees, doctors on training, nursing staff and other supporting staff were part of the

study.

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They elude the ignorance towards screening and PEP treatment to the high work load, social

stigma and also the fear of having HIV infection. They noted that health care workers were

poorly equipped with knowledge of the management of occupational hazardous injuries hence

there being a need to upscale on training more the health care workers.

In another study in India, Kata et al (2014) looked at the knowledge, attitudes and practices

towards PEP for HIV among dental students. They found that the majority of the participants

were aware of the concept of HIV/PEP (68%), although very few students knew the details of

when to start PEP, which drugs to use and for how long the drugs are taken. In this study it

shows that just being aware of the existence of PEP is not enough, as the implementation which

comes into play by being aware of the specific medicines to be taken is of paramount importance

as there will be a high likelihood of adherence even when someone is to be commenced on PEP

ARV regime.

Moderate degree of awareness (57.94%) of PEP for HIV among dental students in Dehli was

also noted by Bakshi et al (2015). On an item with question “should more emphasis be given to

teaching about PEP in curriculum?” 77% of the subjects strongly agreed and realized the need to

be informed enough by their teachers. The findings by Bakshi shows the need for input into

existing curriculum of medical student training of PEP uptake by medical students as the

responses by the participants shows a great need, revealing a potential area for interventions to

be made in increasing the likelihood of uptake of PEP ARVs after exposure among the same

medical students.

In a study by Shaghaghian et al (2013) in Iran on dentist knowledge about PEP, They found out

that knowledge level about PEP was inadequate. Doctors who had attended infection control

seminars had higher levels of knowledge.

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Of the participants, only 38% had attended the seminar. They also noted that dentist with more

years of practice needed further education and they suspected the fact that infection control was

not previously taught in detail in school in Iran being the reason for that score.

In the study to describe the prevalence and characteristics of needle stick injuries and adherence

to infection prevention among students in Taiwan, they found out that of the 61.9% of

individuals who had needle stick injuries, only 14.2% made a formal report to the PEP services

unit. Reasons for not reporting were noted as students not being aware of the universal

precautions as well as post exposure prophylaxis modalities (Shiao et al, 2002).

Resnic and Noerdlinger (1995) in their study on occupational exposure at a New York City

Medical Centre of students and house staff members found out that few students and house staff

members reported their exposure at the time of injury. Only 29% of the exposed respondents

reported on the incident and some of the reasons for not reporting were lack of knowledge on

how to report on the exposure.

Resnic and Noerdlinger (1995) study as well as that of Shiao et al (2002) are in agreement that

quite a number of students do not report their injuries with sharps in the hospital and fear is one

of the factor that may be the reason behind students not reporting the same incidents.

In a descriptive cross sectional study in Nepal involving 65 health professionals who were

assessed on different knowledge variable on PEP towards HIV, 6% had good level of knowledge

and 68% had fair knowledge and 26% had poor knowledge levels. Conclusion drawn at the end

was that knowledge level among respondents was fair (Lamichanne et al, 2012). In an almost

similar study in Madrid Spain, Fernandez-Balbuena et al (2012) found out that only 22% of the

respondents were aware of PEP with only 2% having used PEP before.

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Awareness averaging below 50% is of great concern generally as the risk for transmission will

also be expected to be high as well.

In Lahore, Pakistan, Singh et al (2015) assessed health care workers on knowledge, attitude and

practices of HIV PEP; they found that almost half of the respondents had never heard of PEP.

The results of Singh et al echoed well with those of Chen et al, (2001) in a study on “Post

exposure prophylaxis for human deficiency virus: knowledge and experiences of junior doctors

in United Kingdom” where they found that more than half of the respondents had never heard

about PEP.

Russi et al (2000) in a study of antiretroviral prophylaxis of health care workers at two urban

medical centers in the United Kingdom, they noted that among the respondents aware of PEP,

the majority were aware that it reduces the transmission of HIV following occupational exposure

although knowledge on the doses and drugs that are given, they noted that the knowledge level

was low.

In China, Chang et al (2008) conducted a study at a Chinese medical university in which students

in all academic years from different programs were interviewed. Of all the sharps exposures that

occurred, only 34% were reported to the supervisor and the students displayed a general lack of

knowledge on occupational exposure standard and post exposure prophylaxis

Global trends on knowledge level of post exposure prophylaxis (PEP) among health care

workers as well as health care students (nurses, dental students and medical students) is generally

low especially from European, middle east and Asian countries. Most of the studies showed

awareness barely above fifty percent with almost all studies scoring below fifty percent on

knowledge levels of PEP as well as the treatment regimens which are taken upon exposure.

12
2.3.2 African perspective

Some data from developing countries shows that adherence to the “standard precautions” and

adequate documentation of occupational exposures are sub optimal and knowledge of post

exposure prophylaxis (PEP) among health care workers was poor (Kuhar et al, 2013).

Good awareness but poor knowledge of PEP was found among respondents in a study done by

Adebimpe (2017), the researchers noted that the findings were consistent with what other studies

had concluded on that inadequate knowledge exists despite high awareness.

In Cameroon, a study done by Aminde et al (2015) on occupational post exposure prophylaxis in

a health district focusing on nurses showed that knowledge of PEP among nurses in Cameroon

was low. About 73.7% of the participants had poor knowledge about PEP for HIV and 12.5%

had received formal training on PEP for HIV, with 30% knowing the correct drug regime for the

anti-retroviral drugs used in PEP and 25% knowing the duration of the treatment for PEP.

Okoh & Saheeba (2017) in their study of dental surgeons found out that 68.5% of dental

surgeons had inadequate knowledge about PEP for blood borne viral infections and 94% had

heard about PEP from clinical training. About 88.9% of the respondents knew when to initiate

PEP and 33.3% knew about the efficacy of PEP. Of all the participants, 63% knew how long an

exposed individual should be on PEP. Regarding attending training about PEP, 22.2% of the

respondents had received some. In their study, they noted that the majority of the respondents

were exposed to the risk of HIV and only a few of them had used PEP due to fear of

stigmatization.

In a study of doctors and nurses with regards to their knowledge, attitude and practices towards

HIV PEP in Botswana, the participants were found to have good knowledge about the existence

of HIV PEP and had a positive attitude towards HIV PEP program. Although knowledgeable,
13
they showed inadequate practices with regards to HIV PEP (Bereki & Tengo, 2018). The

findings of Bereki & Tenego (2018) are similar to those obtained by Rotimi et al (2012) in

Nigeria in their study of health workers in a tertiary institute where most health care workers

(83%) had adequate knowledge about post exposure prophylaxis against HIV/AIDS.

In a study to determine knowledge and uptake of occupational post exposure prophylaxis among

nurses caring for people living with HIV in South Africa, Makhado & Davhana-Maselesele

(2016) found that the majority of nurses (60%) knew about PEP. Their concern was that 40% did

not know anything about PEP and they opined that such ignorance in the area of work they

operate in can have disastrous outcomes on the health worker.

According to Eticha & Gumeda (2019) in their study in eastern Ethiopia among health care

workers, they found that 83% of the participants had good knowledge about PEP for HIV.

Although the entire respondents heard about PEP for HIV, only 22.42% of the workers knew the

meaning of PEP. Main source of information was training. Most of the respondents knew the

preferred time for initiation of PEP as well the maximum acceptable delay prior to initiating PEP

for HIV.

Health care professionals by virtue of their training are expected to practice continuously

universal precautions. In the study by Ajibola et al (2014) in Nigeria, the majority of respondents

(83%) were aware of HIV PEP as is expected of their educational background. Despite high

levels of awareness, participants showed inadequate knowledge about PEP.

Only 54% knew when to commence PEP and less than half of the participants (15.3%) knew the

correct duration for use of HIV PEP.

14
A cross sectional survey by Monera & Ncube (2014) in Zimbabwe at a referral hospital where

they assessed knowledge, attitude and practices on occupational post exposure prophylaxis, the

results showed that more than 65% of the participants scored below 50% on knowledge level of

occupational HIV PEP. Their results were in harmony with other studies that had been done in

other countries like Nigeria and Ethiopia were low level of specific knowledge about HIV PEP

had been noted despite generalized awareness on PEP.

2.4 Attitude towards post exposure prophylaxis (PEP) of HIV/AIDS

2.4.1 Global perspectives

Shaghaghian et al (2014) in their study in Iran focusing on dentist attitudes towards PEP, they

found out that 13.1% of the dentist considered PEP ineffective in reducing the risk of acquiring

AIDS. None of the dentist believed that PEP is completely effective in preventing AIDS. Dentist

who had attended the infection control seminars had a more desirable attitude towards the

effectiveness of the immediate washing of the contaminated body area with water in preventing

AIDS. In another study by Gupta et al (2014) in a study that involved medical interns and post

graduate students in India, 98.4% of the interns and 100% of the post graduate students had a

positive attitude towards HIV patients as well as PEP. None of the interns and 3.2% of the post

graduate students had attended lectures, workshops or seminars about post exposure prophylaxis

(PEP).

Another Indian cross sectional study by Rangari (2015), the researcher found that the majority of

the respondents were unaware of PEP, thus having a casual/careless approach and attitude

towards PEP. Careless attitude predisposes people to higher incidents of occupational injuries

and this can directly contribute to the risk of being exposed to HIV infections or even any other

blood borne infections.

15
Gupta et al (2017) in their study of health professionals at a tertiary hospital, their study results

showed misconceptions, negative attitudes and risk perceptions towards HIV/AIDS of health

care workers. As a result of the negative attitude, they noted that there was increased numbers of

non-reporting of occupational injuries with potential exposure of HIV infections. Understanding

of the misconceptions that people have will enable precise health education, incentives and

coaching being tailored to the specific population hence increasing the chances of having a

positive attitude.

Among health care professionals in Pakistani, Singh et al (2015) noted that among the

respondents 47.2% believed that PEP was not protective against HIV. The figure was huge given

that these are health care professionals who work in high risk environments. Provision of

information and evidence of PEP use are needed in order to address the lack of awareness and

improve on the attitudes of health care workers.

In another study by Dulcie et al (2017), majority (98%) and 95.5% respectively agreed on the

importance of PEP for HIV and the availability of PEP guidelines in their work place.76.5% of

the participants had a strong belief that HIV-PEP can reduce the probability of being infected

and 52% of the participants agreed that PEP prevents further infections.

2.4.2 African perspectives

Eticha & Gumeda (2019), in their study in Eastern Ethiopia, greater than 56.6% of the study

participants had a positive attitude about PEP. The majority (92.6%) and 80.4% respectively

agreed on the benefit of PEP and availability of PEP guidelines in their work place. The majority

of participants (72%) strongly believed that PEP can reduce the likelihood of acquiring HIV after

being exposed. Only 37.9% of the participants believed that PEP should be indicated for any

type of sharp object injuries.

16
In a study by Rotimi et al (2012) in Nigeria, they noted that in spite of the high exposure rates

among the study participants, only about 6% sought PEP. The findings of poor attitude were

clearly seen by the fact that of the 13 respondents who had accidental exposure, and whom the

source patients were HIV positive, more than three quarters of them did not receive PEP either

because they did not appreciate the risk involved or they did not have an idea of what actions to

take at the time of the incident.

Bereki & Tenego (2018) in their study in Botswana, they found that the majority of study

participants (82.2%) had a positive attitude towards PEP which was a very good indicator given

the fact that the HIV prevalence in Botswana was one of the highest in the Sub Saharan region.

The findings were similar to those of Ajibola et al (2014) who also noted that the majority of

study participants had a positive attitude.

In another Nigerian study by Agbulu et al (2010), the attitude of doctors in the study towards

PEP was generally positive and very receptive. The findings corroborate findings in the other

parts of the world where despite the cost effectiveness of PEP it is still advocated for so much.

As to the respondents towards PEP, of the 15 % who reported ever taking PEP, 56% felt that it

had too many side effects while 43% felt it was helpful in helping transmission.

The 56% had a negative attitude due to the fear of the side effects in the study by Chagani et al

(2011) in Tanzania.

Aschale et al (2017) in their study in North West Ethiopia, noted that the majority of participants

(69.8%) had a favorable attitude towards PEP for HIV and 80.7% of the participants strongly

agreed that PEP was important for HIV with 68.3% strongly agreeing that training of PEP was

important for behavior change. The effectiveness of PEP for HIV prophylaxis in Lagos Nigeria

17
was accepted by the respondents with 73% of them accepting to use PEP if the need arises. This

was a good indication of good attitude by the respondents according to Ajibola et al, (2014).

2.5 Practices towards post exposure prophylaxis (PEP) of HIV/AIDS

2.5.1 Global perspectives

In a study by Shaghaghian et al (2014) in Iran, the studied dentist who had been exposed to

potentially infectious HIV, only a few of them received PEP. Immediate washing of the

contaminated skin (hand and face) and mucous membranes (eyes, nose and mouth) was done by

62% and 37% respectively. Only 5% of the dentist evaluated the contaminated skin for any

existing erosion, ulcerations or dermatitis. Of the dentist who experienced mucosal

contamination with blood, 64% did not receive any preventative measures. It is clear that the

participating dentists did not manage their occupational exposures adequately as if expected from

local guidelines or universal precautions point of view.

A study in India by Mukherjee et al (2013), a considerable gap was revealed between knowledge

and practice among the respondents who were 130.The study showed that education on HIV and

its prevention should start in health schools to ensure more knowledgeable future professionals.

When reasons were asked for non-reporting of needle stick injuries, it was found that 34% of the

interns were too busy to report the incident and 43.6% of them thought it was only a minor

injury.

In Brazil, Garcia & Blank (2008) did a study on management of occupational exposures among

dentists. They found that 44% of the dentist after sharp injury and 14% of them after mucosal

contamination with potentially infectious fluids investigated whether the source patient was a

carrier of blood borne virus or not. Only 11% of them sought medical care after exposure. In

18
another Iranian study, a low level of knowledge and concomitantly less likelihood of PEP uptake

was noted (Askarian et al, 2007).

2.5.2 African perspective

Adebimpe et al (2018) in their study in Nigeria, they found that PEP was not observed by a

significant population of the participants who had occupational exposure through needle stick

injuries. Despite the fact that national guidelines which give holistic guide of what the health

care worker should do in the event of occupational exposure were in place, the rate of uptake was

too low showing a negative practice.

In Ethiopia, among 106 participants, 33.8% were exposed to HIV risky conditions and of those

participants 89.7% took PEP. Of the 10.3% who did not take PEP, the reason for not doing so

was found to be fear of its efficacy in 33.3% and the adverse effects in 66.7 %( Habib et al,

2018).

Approximately 69% of the exposed health care workers in Tanzania cleaned their wounds and

sought professional help, thus indicating that the majority of the health care workers were aware

of the risk of HIV transmission via occupational exposure.

However of the exposed, only 24% used PEP. The low use of PEP was attributed to the

likelihood of poor knowledge about PEP, fear of using PEP due to concerns of side effects, fear

of HIV testing as well as perception of lack of availability of PEP drugs (Chagani et al, 2011).

In a study by Aschale et al (2017) in Ethiopia, the major reasons for individuals who did not take

PEP following exposure were those whose source patient was HIV negative. Among the

participants who took PEP, 65.5% completed the prescribed PEP. The major reason for not

finishing PEP was fear of the adverse effects (50%) and negligence (30%).In another Ethiopian

19
study by Eticha et al (2019), the same conclusion was drawn on the reasons for non-completion

of PEP with an addition of doubt of its efficacy being the addition.

Ajibola et al ( 2014) in their study in Lagos Nigeria, they noted low level use of PEP despite

participants displaying good acceptance of PEP as only 6.3% of the participants who had needle

stick injury accepted to use PEP. Dulcie et al (2017) also found the majority (54.9%) of

participants who were medical, nursing and paramedical students not taking up PEP. The results

were worrisome as it showed that there was a need for improvement.

The findings of Monera & Ncube (2014) in Zimbabwe were similar to what was obtained by

Okoh & Saheeba (2017) in Ethiopia where a low uptake of PEP was noted. This was despite

having been exposed to the risk of HIV through various ways among them needle stick injuries.

The major reason was fear of stigmatization and discrimination among health care workers at the

central referral hospital.

In Botswana, 72.1% of the exposed health care workers were initiated on HIV PEP. The

researchers attributed this to increased knowledge levels as compared to other studies which

were showing low uptake of PEP which was corresponding to low knowledge levels (Bereki &

Tenego, 2018).

In Malawi, there was a reported underutilization of PEP with less than half of the exposed health

care workers initiating PEP as is expected from the protocol. One of the reasons for the low

uptake was lack of awareness and fear of getting tested for HIV (van Oosterhout et al, 2007).The

trend in Malawi was also noted in South Africa by Makhado & Davhana-Maselesele (2016)

where they noted a low uptake of PEP among nurses looking after HIV positive patients who had

been exposed through needle stick injuries.

20
2.6 Knowledge, attitude and practices towards post exposure prophylaxis

(PEP) of HIV/AIDS in Zambia

Medical students are involved in the collection, transportation and processing of blood samples,

human tissues and body fluids as well as heavily involved in the invasive procedures that may

predispose them to deep percutaneous injuries, hence there is need for awareness and knowledge

of what to do when they are exposed to HIV infected body fluids and materials (Mesfin et al,

2013).

In Zambia due to the acute shortage of staff in health institutions which are also learning centers,

medical students are not just observers but also assist in some areas as they learn hands on. In a

study by Chanda (1996) in Zambia on the role of operational research in needle stick injuries at

the work place, it was noted that 59% of the respondents had sustained needle stick injuries

within the course of the year and no formal reporting had been done.

Phillips et al (2012) in their study on “the risk of blood borne pathogen exposure among

Zambian health care workers”, the average sharps injuries rate per worker was 1.3 per year

which was more than 8 times higher than that of the United States of America. The issue of not

reporting injuries was also noted in the study. The study included service workers,

nurses/midwives, physicians, security and laboratory workers.

No medical students were included in the study showing that there is a gap when it comes to data

concerning medical students in Zambia just as in the rest of Africa and the world as almost

nonexistent literature exist save for a few concerning dental students.

In a study by Lungu (2013) among nursing students at Ndola School of Nursing in Zambia, 87 %

of nursing students were not aware of PEP services which is in line with the general trend

globally and in Africa where knowledge level is generally low on PEP.

21
In a prospective study done at St Francis Hospital, Katete on “the risk of exposure to HIV during

surgery in Zambia” the risk of contracting HIV for a surgeon practicing in Zambia for 5 years

was noted to be 1.5% as compared to 0.1% for those practicing in the western worlds (Constern

et al, 1995) which was very high as compared to those in the Western worlds. This shows the

need for exploration into this disparity hence such a study on knowledge, attitude and practice of

PEP towards HIV/AIDS is paramount.

2.7 Conclusion

The reviewed literature shows that knowledge level about PEP was poor from studies globally,

in Sub-Saharan Africa as well regionally and locally in Zambia. The findings are worrisome

especially for Sub-Saharan Africa, where more than half the burden of HIV lies is. It is

imperative for health care workers to have a higher level of knowledge of PEP as they are

expected to know as well as implement PEP when the need arises in their work places since they

work in high prevalence areas. According to Aminde et al (2015), adequate knowledge and

practices on HIV PEP among health care workers are very important in the prevention of HIV.

Attitude towards PEP was poor from reviewed studies globally, and African studies showed

good attitude among health care workers. The good attitude towards PEP is a good thing among

African health care workers as it can potentiate good practices if harnessed well.

Practices towards implementation of PEP were poor from studies both from Africa and globally.

In order to prevent HIV, knowledge and attitude alone are meaningless if there is no positive

preventive practice from the health care workers. Poor practices are of concern in Africa given

the high prevalence rates of HIV and the limited number of health care workers.

Almost all the reviewed studies used the cross sectional survey methodology and they were

mostly on knowledge, attitude and practices towards post exposure prophylaxis of HIV/AIDS
22
among health care workers. No study was specific to Zambia on the same, save for one by Lungu

(2013) which focused on knowledge level of PEP among student nurses at Ndola School of

Nursing. Also almost none focused on medical students specifically both in Africa and globally.

In light of the reviewed literature, this research will determine the knowledge, attitude and

practices towards post exposure prophylaxis (PEP) of HIV/AIDS among medical students at

University Teaching Hospital in Lusaka, Zambia. It is envisioned that this study will bridge the

identified gaps and contribute to the general body of knowledge as well as come up with

recommendations with regards to post exposure prophylaxis (PEP) education and awareness

among medical students in Zambia.

23
 CHAPTER THREE: MATERIALS AND METHODS

3.1 Introduction

This chapter will discuss the methodology that was used to conduct this study. The study design,

study site, population and sampling, target population, inclusion and exclusion criterion, data

collection tools and techniques, data analysis ethical consideration and ethical clearance and

permission will also be looked at.

3.2 Study design

Cross sectional study using a standardized structured questionnaire was used. Cross sectional

study design entails looking at data from a population at one specific point in time. The

participants in this type of study are selected based on particular variables of interest.

3.3 Study site

The study was conducted at University Teaching Hospital in Lusaka, Zambia.

3.4 Population and sampling

3.4.1 Study Population

The study population was medical students from Cavendish University Zambia, University of

Zambia and Lusaka Apex Medical University.

3.5 Target population

The target population was sixth year medical students from Cavendish University Zambia,

University of Zambia and Lusaka Apex Medical University who were attached at University

Teaching Hospital in Lusaka, Zambia.

24
3.5.1 Sample size determination and sampling method

The sample size was determined by using the single proportion formulae.

n= (Z value) 2 X Standard deviation (1-Standard deviation)/ (margin of error) 2

With confidence interval (CI) of 90%, Z value is 1.645

Standard deviation of 0.5

Margin of error of 10%

The sample size (n) was thus 69 participants.

The 90% Confidence Interval (CI) was used as it would enable a sample of 69. A higher

Confidence Interval of 95% would result in a sample of 384 participants. Although 384

participants would have been more representative as compared to 69, the challenge would be

coming up with approximately 128 students from each school of medicine that are in sixth year.

As for Cavendish University Zambia School of Medicine, the total number of sixth year medical

students is way less than that, hence the lower confidence interval of 90% selected by the

researcher will result in a total sample size of 69 participants which is achievable and more

representative for all the three medical schools.

The sample size of 69 was distributed evenly among the students from the three medical schools

with each providing 23 participants. Probabilistic simple random sampling method was used in

this study to select the 23 participants from each of the three medical schools represented at

University Teaching Hospital in Lusaka, Zambia. The 23 participants were selected by

alternatively picking the 6th year students as they were entering the gate on a particular day for

each of the three medical schools.

25
3.6 Inclusion and exclusion criteria

3.6.1 Inclusion criteria

Medical students who were in sixth year from Cavendish University Zambia, University of

Zambia and Lusaka Apex Medical University who are attached at University Teaching Hospital

Lusaka, Zambia.

3.6.2 Exclusion criteria

Sixth year medical students from Cavendish University Zambia, University of Zambia and

Lusaka Apex Medical University who were not attached at University Teaching Hospital were

excluded from the study.

3.7 Data collection tools and techniques

The study used a structured questionnaire adapted and modified from Aschale et al (2017) to

collect data from the participants. In addition to the questionnaire being a source of primary data,

it has some other advantages which are;

1. Less time consuming

2. It is cost effective

3. It assumes greater anonymity

4. Absence of the interview means minimal to no biases.

The questionnaire elicited responses that were relevant to the area of study which was to

determine the knowledge, attitude and practices towards post exposure prophylaxis (PEP) of

HIV/AIDS among medical students at University Teaching Hospital in Lusaka, Zambia. The

questionnaire included multiple choice questions, true or false questions and Likert type scale

questions. The questionnaire was composed of four sections. Section A was for socio-

26
demographic data of the medical students, section B focused on knowledge of medical students

about post exposure prophylaxis (PEP), section C focused on attitudes of medical students about

post exposure prophylaxis (PEP) and section D focused on practice of post exposure prophylaxis

(PEP) among medical students.

3.8 Data analysis

All returned questionnaires were checked for completeness, inconsistences of responses and was

manually coded and entered into statistical software for analysis. Appropriate descriptive

statistics and analytics were used to determine the knowledge, attitude and practices. T-test was

used on attitude for statistical significance.

3.9 Ethical considerations

Ethics is defined as “a system of moral values that are concerned with the degree to which

research procedures adhere to professional, legal, and social obligations”(Polit & Back, 2012).In

this study, the following ethical aspects were considered:

3.9.1 Informed consent

The researcher ensured that participants were not coerced into taking part in the study.

Participants decided on their own voluntarily on whether to take part in the study or not. Before

signing the consent form, participants were informed about the purpose of the study, the

procedures involved, and how the study findings would be utilized. Participants in addition of

not being coerced were guaranteed of their anonymity, confidentiality of records, and assurance

that they would retain their right to refuse participation or withdraw from the study at any time

should they feel the need to do so without any prejudice, penalty or castigation.

27
3.9.2 Privacy and confidentiality

Codes were used for example “P1” for first participant instead of real names being used. All

other information which was obtained remained strictly confidential and anonymous.

3.9.3 Ethical clearance and permission

Ethical clearance was obtained before commencing the study from ERES Converge in Zambia

before the study was commenced.

28
 CHAPTER FOUR: RESULTS

4.1 Introduction

The previous chapter looked at the study design, the research instrument and data analysis. This

chapter presents the research findings. The data was analyzed using SPSS version 16.0. The

main sections of the questionnaire were highlighted. The response rate was 96% as 66

questionnaires out of 69 were retrieved and analysed. The percentages in the tables are presented

as received from the data analysis software. The t-test was done to determine the attitudes of

medical students towards PEP. Results were presented in tables and figures and interpretations

were made.

4.2 Research findings

The main objective of this study was to determine the knowledge, attitudes and practices of

medical students towards PEP of HIV/AIDS at University Teaching Hospital in Lusaka, Zambia.

The results have been organized around the three specific objectives which focus on knowledge,

attitudes and practices inclusive of the demographics.

4.2.1 Socio-demographic characteristics of respondents

The socio-demographic characteristics were described according to gender, age, marital status,

religion, occupation before studying medicine. Table 4.1 below shows the percentage

distribution for each of the socio-demographic variables.

On being asked on their age ranges, 52% of the respondents indicated that they were in the 25-29

years age range. Fifty eight percent of the participants were males and 42% were females. The

least represented age range was the 35-39 years age range at 3%. On their marital status, 73% of

the respondents indicated that they were single while 3% were divorced and separated

respectively.
29
TABLE4.1 : SOCIO-DEMOGRAPHIC CHARACTERISTICS OF THE STUDY SAMPLE

DEMOGRAPHIC PERCENT
INFORMATION DESCRIPTION Frequency (%)
Gender Male 38 58
Female 28 42
Age 18-24 18 27
25-29 34 52
30-34 8 12
35-39 2 3
>40 4 6
Marital Status Single 48 73
Married 14 21
Divorced 2 3
Separated 2 3
Other 0 0
Religion Christianity 50 76
Islam 10 15
Hinduism 2 3
African Traditional 4 6
Other 0 0
Occupation Before studying
medicine Nurse 8 12
Clinical Officer 10 15
Grade 12 40 61
Lab Scientist 8 12

Seventy six percent of the respondents indicated that they were of the Christian religion while

3% were of the Hindu religion. On being asked on their occupations prior to joining studies in

Medicine, 61% indicated that they had joined studies in medicine straight from secondary school

Grade 12 while 12% were Nurses and Lab Scientist respectively.

30
4.2.2 Knowledge of medical students about PEP

This section presents data collected on knowledge levels of medical students about PEP. Table

4.2 and Figure 1 below shows the percentage distribution of knowledge level of respondents to

the knowledge questions.

TABLE 4.2: KNOWLEDGE OF MEDICAL STUDENTS ABOUT PEP

Description of knowledge on PEP High Knowledge Low knowledge

Knowledge on Maximum Delay for
32 (48)
PEP 34 (52%)
Knowledge on preferable time to
take PEP 40 (61%) 26(39%)

Knowledge on Effectiveness of PEP 42(64%) 24(39%)

Knowledge on length of time to
take PEP? 48(73%) 18(27%)

The research indicated that 32 (48%) of the respondents had high knowledge on the maximum

delay for intake of PEP while 34 (52%) showed low levels of knowledge. It was also noted

through this research that 40 (61%) of the respondents had high knowledge on the preferable

time to take PEP while 26 (39%) had low levels of knowledge on the preferable time to take

PEP. On the effectiveness of PEP, results of the research indicated that 42 (64%) they had low

levels of knowledge on the effectiveness of PEP. On being asked on the length of time to take

PEP after exposure, 48 (73%) showed high levels of knowledge while 18 (27%) had low levels

of knowledge.

31
 Knowledge of PEP

73
80 64
70 61
52
60 48
50 39 36
40 27
30
20
10
0
Knowledge on Knowledge on Knowledge on Knowledge on
Maximum Delay for preferable time to Effectiveness of PEP length of time to
PEP take PEP take PEP?

High Knowledge Low knowledge

FIGURE 1: KNOWLEDGE OF MEDICAL STUDENTS ABOUT PEP

On being asked on whether they had attended any form of training on PEP, all respondents

(100%) indicated that they had not received any training on PEP and 58% noted that they knew

about PEP guidelines. On being asked on their sources of PEP knowledge, 53% of the

respondents indicated that they had acquired their knowledge from clinical training while 3%

stated that they had acquired their knowledge from Journals, friends and books respectively.

Twenty six percent of the respondents indicated that they relied on mass media for their

knowledge on PEP while 12% indicated that they had acquired PEP knowledge from attending

seminars.

4.2.3 Attitudes of medical students about PEP

This section presents collected data on medical student’s attitudes about PEP. The questions

were multiple-choice type, and they had options on whether the respondent, agreed, disagreed or

not sure. Table 4.3 below shows the response distributions in relation to the questions asked. The

collated mean scores were used to calculate the t value.

32
TABLE 4.3: ATTITUDES OF MEDICAL STUDENTS ABOUT PEP

NOT
QUESTION AGREE SURE DISAGREE
PEP is Important 54 (82%) 10(15%) 2(3%)
Training is important for behaviour Change 44(67%) 16(24%) 6(9%)

There should be PEP guidelines in the hospital? 28(42%) 38(58%) 0(0%)

PEP reduces the likelihood of being positive 44(67%) 12(18%) 10(15%)
PEP helps prevent further Infection 24(36%) 30(45%) 12(18%)
PEP is not important if exposure is not with person
of known HIV positivity 20(30%) 12(18%) 34(52%)
I will use PEP if you had to 52(79%) 0(0%) 14(21%)
Total Scores 266 118 78
Mean Scores 38 17 11
Overall mean score expected 66

On the attitudes of medical students towards PEP, the overall impression was that 81% of the

respondents agreed that PEP was important and 78% indicated that they would use PEP if they

had to.

The mean of responses who agreed was m=38, for n=7 and, with sample standard deviation

s=14. The established suitable null and alternative hypotheses were thus:

• Null Hypothesis H0: μ = μ0 (There is no difference between the sample mean agreeing

and the expected mean)

• Alternate Hypothesis HA: μ ≠ μ:

The test statistic was then calculated from the equation:

33
The calculated t value was 5.2915 and the t critical was 3.707

Since tcal>tcrical, the H0 was rejected and hence concluded that respondents attitude towards PEP

was generally of people who are not sure and disagreeable to the relevance of the importance of

PEP. Thus, the responded attitudes tended to place them to risk associated with failure to use

PEP.

The overall attitude of respondents to PEP is that of being not sure to one of being agreeable to

the importance of PEP, the need for behaviour based training, guidelines on use of PEP and the

general risk factors associated with exposure that may demand PEP. It is, thus, concluded from

the t-test carried out above that, while there is an overall positive attitude towards PEP, it is not

statistically significant, thereby, requiring that there be further interventions that improve

students attitude to PEP.

4.2.4 Practice of PEP among medical students

This section presents data collected on practice of PEP among medical students. The questions

were multiple-choice questions and the respondents had to choose the best response. The

percentage distribution of each response to each question is shown in table 4.4 and Figure 2

below.

On being asked whether they have previously been exposed to HIV risky exposure in practice,

64% of the respondents indicated that they had been exposed while 6% did not remember. Of

the 64% respondents who indicated that they had been exposed, 68% indicated that they had not

taken PEP while 32% had taken PEP. Seventy percent of the respondents who did not take PEP

after exposure indicated that they did not do so because the patient had tested negative to HIV.

Six percent of those who did not take PEP indicated that they did not do so for fear of stigma and

discrimination and a lack of understanding of the value of reporting exposure respectively.

34
TABLE 4.4: PRACTICE OF PEP AMONG MEDICAL STUDENTS

Practice of PEP Good Practice Bad practice Neither good

nor bad
practice
Exposure to HIV risk conditions like 20 (30%) 42(64%) 4(6%)
(Blood, patient’s body fluids, needles,
sharps) at hospital
Tested for HIV after exposure to risk 24 (70%) 19 (30%) 0%
conditions
Took PEP after exposure? 14 (32%) 30 (68%) 0%
Took PEP within recommended time 14 (100%) 30 (68%) 0%
Took PEP for the recommended duration 10 (71%) 4 (29%) 0%

Results of analysis on the PEP practice among medical students indicated that 42(64%) had bad

practices that led to exposure to HIV risky conditions while 20 (30%) practiced good practices.

On being asked on the whether they had been tested to HIV after exposure, results of analysis

noted that 24 (70%) had good practice while 19 (30%) had bad practice. The study also revealed

that 30(68%) practiced bad practices by not taking PEP after exposure while 14 (32%) took their

PEP after exposure. The results also indicated that 10 (71%) of the medicals students sampled

tool PEP for the recommended duration while 4 (29%) did not take PEP for the recommended

time.

35
 Practice of PEP
100
100 64 70 68 68 71
80
60 30 30 32 29
40 6 0% 0% 0% 0%
20
0

Good Practice Bad practice Neither good nor bad practice

FIGURE 2: PRACTICE OF PEP AMONG MEDICAL STUDENTS

4.3 Conclusion

This chapter presented the results of data analysis using tables as well as the t-test using SPSS

version 16.0. No comparisons were made between variables as the study sought to ascertain the

knowledge, attitudes and practices towards PEP among medical students. The next chapter will

discuss the results as well as highlight the study limitations.

36
 CHAPTER FIVE: DISCUSSION

5.1 Introduction

In the previous chapter, results of the study were presented. In this chapter, the same results are

discussed with regards to the knowledge, attitudes and practices of medical students towards PEP

of HIV/AIDS. The study limitations are also discussed in this chapter.

5.2 Discussion of research findings

Significant research findings are interpreted and summarized in a manner conforming to the

main study objectives which are:

• To determine the level of knowledge towards PEP of HIV/AIDS among medical students

at University Teaching Hospital in Lusaka, Zambia.

• To ascertain the attitude towards PEP of HIV/AIDS among medical students at

University Teaching Hospital in Lusaka, Zambia.

• To identify the practices towards PEP of HIV/AIDS among medical students at

University Teaching Hospital in Lusaka, Zambia.

5.2.1 Socio-demographic data

In the study, 58% of the participants were males with females constituting the remaining 42%.

The ratio of males to females is comparable to the ratios in the study done by Aschale et al

(2017) where 59.4% of the participants were males versus 40.6% being females. A similar trend

was shown by Thapa & Gurung (2018) where fewer females took part in the study. However, in

a Tanzanian study by Chagani et al (2011), 68% of the participants were females with males

constituting only 32%.

37
Fifty two percent of the study participants were in the age range of 25-29 years while in another

study by Aschale et al (2017), 20-30 years range constituted the majority of the participants.

Overall, all age groups were represented from eighteen years to those above forty years old.

Seventy three percent of the participants were single, while twenty one percent were married.

The majority of the participants were Christians by religion at 76%. The demographics on

religion and marital status are comparable to those of Aschale et al (2017) in their study in

Ethiopia.

The majority of the participants were direct school leavers from grade twelve at 61% followed

by clinical officers at 15% and nurses and laboratory scientist equally at 12%. The background of

nursing, laboratory science as well as clinical officer training and practice may have exposed

these participants with awareness of universal precautions as well as knowledge of PEP which

may have influenced their practice and attitude towards PEP as compared to direct school leavers

(grade 12s). These results show how imperative it is for all medical students to have training on

PEP before they embark on their clinical rotations so that the grade 12s who may have had no

opportunity to learn about universal precautions they can do so.

5.2.2 Knowledge of medical students about PEP

The main source of knowledge for PEP was from clinical training for fifty three percent of the

participants which was in agreement with Aminde et al (2015) where the majority of the

participants at 73.7% had learned of PEP from clinical training. In contrast, Dulcie et al (2017)

found that 82% of the participants in their study indicated textbooks as the source of their

knowledge.

On the maximum delay for PEP, the majority of respondents (48%) indicated 72 hours. In as

much as the majority scored correctly, it is worrying as less than half of the total respondents
38
indicated otherwise meaning there is a higher probability of the same respondents not taking PEP

thinking that the maximum delay has lapsed before the seventy two hours has been reached.

Thapa & Gurung (2018) findings showed slightly higher correct response on the maximum delay

for PEP with 52.2% of the respondents indicating seventy two hours as the maximum delay with

research findings of Aschale et al (2017) showing much higher correct response at 82.7%.

With regards to the time when PEP for HIV can be started, 61% of the respondents gave the

correct response which was within one hour of exposure. The findings showed a correct response

rate higher than that found by Thapa & Gurung (2018) where the majority of those who

responded correctly constituted only 43%.

On effectiveness of PEP, 64% of the respondents answered correctly as 80-100%. This was

higher than the findings by Okoh (2016), where 33.3% of the respondents answered correctly

that it is 80-100% whilst findings by Aschale et al (2017) showed that much higher percentage of

75.2 was achieved on the correct response on effectiveness of PEP as compared to findings of

this study.

The majority of the respondents at 73% answered correctly on the length of time PEP is

supposed to be taken. The findings of the study are higher than those obtained by Okoh (2016)

were 63% knew the correct duration PEP is supposed to be taken, however findings by Aschale

et al (2017) showed a much higher knowledge level with 94% knowing the correct duration of

PEP treatment.

All the respondents in the study indicated that they had never attended any training about PEP.

This was poor in comparison to findings in a study by Okoh (2016) where at least 22% of the

dental surgeons had attended training about PEP. The majority of the respondents at fifty eight

percent were not aware of the existence of PEP guidelines which was moderately high and
39
comparable to findings by Okoh (2016) where 59.3% knew about the existence of PEP

guidelines in their respective hospitals.

Overall, the knowledge about PEP was high medical among students at University Teaching

Hospital in Lusaka, with three of the four questions which sought to elicit directly knowledge

level of medical students about PEP being responded to by more than 50% of the respondents.

Low knowledge level was noted on maximum delay for PEP whilst high knowledge levels were

noted for preferable time to take PEP, effectiveness of PEP and length of time to take PEP

5.2.3 Attitudes of medical students about PEP

Eighty two percent of the respondents agreed that PEP is important in the study and the results

are comparable though much higher than those obtained by Ajibola et al (2014) where 73%

believed that PEP is important. The positive responses are good as they are indicators of the

likelihood of an individual to take PEP after exposure and an indicator of good attitude towards

PEP.

The majority of the respondents believed that training is important for behaviour change with

67% being in agreement. The findings were comparable to those of Aschale et al (2016) where

68.3% strongly agreed although both were lower than the findings by Okoh (2017) where 88.9%

agreed that training is important for behaviour change in Nigeria.

On being asked if they think PEP guidelines should be in the work place, 58% were not sure with

42% agreeing that they should be available in the workplace. These research findings were lower

as compared to those obtained by Dulcie et al (2017) in India where 88% of the students agreed

that guidelines should be in the work place.

When asked whether they believed that PEP can reduce the likelihood of being HIV positive,

67% of the respondents agreed that it does. A similar trend was noted by Dulcie et al (2017) in
40
their study where 72% of the respondents agreed that PEP can reduce the likelihood of being

HIV positive.

On being further asked whether they believed PEP helps in the prevention of further infections,

45% of the respondents who constituted the majority were not sure as compared to findings by

Dulcie et al (2017) and Okoh (2016) which had 56% and 64.8% agreed response respectively.

The findings of the study show that there is potential room for the respondents to be sure and

agreeable if appropriate interventions are made.

Overall, positive attitude towards PEP was noted although it was not statistically significant

according to the t-test done hence there is need for further interventions that has the potential of

improving the attitude towards PEP to significant levels.

5.2.4 Practice of PEP among medical students

With regards to practice among medical students in the study, 64% agreed to have been exposed

to HIV risk conditions such as blood, patient’s body fluids and needle sharp injuries at the

hospital, with 6% not remembering. Out of the 64% who were exposed, 68% did not take PEP

after exposure with the major reason being that the patient had tested negative in 70% of the

respondents. The number of those exposed in this study was significantly high in comparison to

46.6% who were exposed with 11.1% of the respondents not remembering and 64% of the

exposed respondents not taking PEP with fear of stigma being the major reason for not taking

PEP in 93.6% of the respondents in a study by Okoh (2016).

In a similar study by Aschale et al (2017), 66.8% had never been exposed to HIV risky

conditions, and out of those exposed (33.2%), 56.7% did not take PEP with the major reason

being that the source patient had tested negative to HIV infection.

41
For those who were exposed to risky conditions in the study and took PEP (32%), the major

reason why they took PEP was due to injury with a sharp object with a similar trend being

observed by Okoh (2016). Fifty seven percent of the participants started PEP after 2-6 hours of

exposure and this figure was lower than findings by Okoh (2016) in Nigeria where 77.8% of the

respondents started PEP 2-6 hours post exposure. Mean time to start PEP was 13.5 hours in a

study by Chagani et al (2011).

Seventy one percent of the respondents in the study took PEP for the recommended 28 days and

out of those who did not complete the course, patient testing negative and fear of the side effects

were the two equal reasons for non-completion. In a study by Aschale et al (2017), of those

participants who took PEP, the majority (44.8%) did so within an hour and these findings are

quite high than findings in this study were no participant who took PEP within an hour. Also out

of those who took PEP in the study by Aschale et al (2017), 65.5% completed their twenty eight

day course and the remainder did not finish the PEP course due to fear of adverse effects.

Overall, good practices were noted among medical students with regards to PEP of HIV/AIDS.

Good practices were noted with regards to getting tested for HIV after being exposed to risky

conditions, taking PEP within recommended time frames as well as taking PEP for the

recommended duration with some bad practices being noted only with regards to being exposed

to risky conditions in the first instances. The mere fact that seventy percent of the exposed took

effort to report and only to find out that the patient was negative is a good indicator of good

practices among medical students.

5.3 Study limitations

The study was conducted at one teaching hospital in Lusaka, Zambia hence the findings cannot

be generalised to all the teaching hospitals in Zambia. The participants were from only three

42
medical schools in Zambia out of about eight in Zambia. The results of the study cannot be

generalised to all the medical schools in Zambia.

The study was conducted during the COVID-19 global pandemic hence it was difficult to locate

some of the respondents for physical filling of questionnaires in the presence of the principal

investigator at the specialty clinics where they are normally found in sixth year since they do

rotations in subspecialties. Some of the clinics were closed and as a result some students had to

respond to the questionnaires remotely. Mutual influence among medical students could not be

ruled out.

The researcher failed to achieve the intended equal representation of male and female genders

mainly due to the COVID-19 as well as the unequal rations from their respective medical schools

where males were more than females in general.

5.4 Conclusions

This chapter discussed the findings of the research with regards to socio-demographic data, the

knowledge of medical students about PEP, the attitude of medical students about PEP and

practice of PEP among medical students. The results of the study were noted to be corroborative

with other studies done in Africa and globally. The study limitations were also expounded in this

chapter.

43
 CHAPTER SIX: CONCLUSION AND RECOMMENDATIONS

6.1 Conclusion

This study explored the knowledge, attitude and practice of medical students towards PEP of

HIV/AIDS at University Teaching Hospital in Lusaka, Zambia. Knowledge about PEP was high

and good practices towards PEP were noted among medical students. The number of students

who reported having been exposed to HIV risk conditions at the hospital was worrisome as more

than half of the study participants had been exposed. Despite being exposed, the PEP practice

was good generally. Attitude of medical students towards PEP was positive although it was not

statistically significant according to the t-test done.

6.2 Recommendations

Based on the findings of this study, the researcher proposes the following recommendations:

• Training of pre-clinical students on PEP guidelines, protocols as well as the principles of

universal precautions before they start their clinical rotations is recommended so that they

get acquainted on what to do when they get exposed to HIV risky conditions.

• Encourage and emphasize vaccinations against blood borne infections like Hepatitis B as

new students are at high risk of being exposed to these infections if they get in contact

with body fluids of infected individuals.

• Similar studies should be done in other University Teaching Hospitals among medical

students from other medical schools so that a national baseline can established.

• Studies to determine knowledge, attitude and practice of not only medical students, but

also other professional health care workers are encouraged in order to ascertain if ever

there are any gaps.

44
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 ANNEXURE 1
INFORMATION SHEET

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 ANNEXURE 2
INFORMED CONSENT

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 ANNEXURE 3
QUESTIONNAIRE

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 ANNEXURE 4

WORK PLAN (GANTT CHART)

Proposal Writing 27/10/19-

20/01/20

Ethical Approval 27/02/20-

31/07/20

Data Collection 01/08/20-

14/08/20

Data Analysis 15/08/20-

31/08/20

Completion 01/09/20-

30/09/20

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 ANNEXURE 5

BUDGET

No: Description of item Quantity Unit Cost Total

1 Ream of paper 2 K60 K120

2 Pens 20 K5 K100

3 Lunch 10 K30 K300

4 Printing & Binding 3 K210 K630

5 Incidentals 1 K100 K100

Grand Total K1250

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 ANNEXURE 6
INTRODUCTORY LETTERS

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