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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.

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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.

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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

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• 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 .

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Results - knowledge on clinical indications Indications with a good response rate (> 70 %) (N= 100) 99 99

DiagnosedDiagnosed or suspectedor sexually transmitted suspected STI disease

Pyrexia of unknown origin origin Pyrexia of unknown

91 91

Chronic diarrhea of unknown cause

88

Kaposis sarcoma

85

Pneumocystis jirovecii pneumonia

84

Lymphadenopathy of unknown cause

83

Multidermatomal or recurrent herpes zoster

80

Unexplained generalized lymphadenopathy Persistentpersistent generalized lymphadenopathy

79

Unexplained lymphopenia

79

Hepatitis B infection

79

Cryptococcal meningitis

78

OesophagealOesophageal candidiasis candidiasis

77

Weight loss of unknown cause

76

79

77

Cryptosporidiosis diarrhea

72

Extra pulmonary tuberculosis Extra pulmonary tuberculosis

72

72 9

0

20

40

60

80

100

120


Results - knowledge on clinical indications HIV testing indications with satisfactory response rate (41 % - 69 %) (N= 100) Unexplained neutropenia

69 68 67 66 66 62

Oral hairy leukoplakia

Recurrent oral ulcers Hepatitis C infection Cerebral toxoplasmosis Recurrent Bacterial pneumonia Unexplained thrombocytopenia

51 50 4646 45 44 44 44 40

Aspergilosis

OralOral candidiasis candidiasis Progressive multifocal leucoencephalopathy Generalized Generalizedmaculopapular maculopapularrash rashwith withfever fever Cytomegaloviral retinitis

Peripheral neuropathy

0

10

20

30

40

50

60

70

10

80


Results - knowledge on indications HIV testing indications with poor response rate (<40 %) (N=100) Cervical cancer Severe or recalcitrant (uncontrolled or refractory) seborrhoeic dermatitis Unexplained retinopathy Cervical intraepithelial neoplasia Cervical intraepithelial neoplasia Space occupying lesion of unknown origin Pulmonary tuberculosis Pulmonary tuberculosis Leucoencephalopathy Cerebral abscess Primary CNS lymphoma TransverseTransverse myelitis myelitis Anal cancer or anal intraepithelial neoplasia Aseptic meningitis/encephalitis Dementia Vaginal intraepithelial neoplasia Severe or recalcitrant (uncontrolled or refractory) psoriasis NonNon Hodgkin lymphoma Hodgkins lymphoma Angular chelitis Head and neck malignancy Guillain- Barre syndrome Guillain-Barre syndrome Lung cancer Seminoma Salmonella , shigella or campylobacter infections

39 37 36

34

34 33

31

28 28 27 27

31 30 30 30

25 24 24 1818 10 10 9

9

4 3 3 0

5

10

15

20

25

30

35

40

11

45


Summery of the knowledge on clinical indications (N= 100) 99

Diagnosed or suspected sexually transmitted disease Pyrexia of unknown origin Multidermatomal or recurrent herpes zoster Oesophageal candidiasis Extra pulmonary tuberculosis Recurrent Bacterial pneumonia Oral candidiasis Generalized maculopapular rash with fever Peripheral neuropathy Cervical intraepithelial neoplasia Pulmonary tuberculosis Space occupying lesion of unknown origin Cerebral abscess Aseptic meningitis/encephalitis Dementia Non Hodgkins lymphoma Guillain-Barre syndrome

91

80 77 72

Good

62 46 44 40 34 31 33 30 27 Poor 25

18 9

0

20

40

60

80

100

120

12


Results - knowledge on indications Identification of WHO stage 4 clinical conditions as indications for HIV testing (N= 100) Kaposis sarcoma

85

Pneumocystis jirovecii pneumonia

84

Cryptococcal meningitis

78

Oesophageal candidiasis

77

Cryptosporidiosis diarrhea

72

Extra pulmonary tuberculosis

72

Cerebral toxoplasmosis

66

Recurrent Bacterial pneumonia

62 4545

Progressive multifocalâ&#x20AC;Ś Progressive multifocal lecoencephalopathy

Cytomegaloviral Cytomegaloviaralretinitis retinitis

44

44

Cervical Cervicalcancer cancer

3939

Primary CNS lymphoma Primary CNS lymphoma

3030 1818

Hodgkins lymphoma NonNon Hodgkins lymphoma 0

10

20

30

40

50

60

70

80

90

13


Results - knowledge on indications Identification of WHO stage 3 clinical conditions as indications for HIV testing (N=100) 91

Pyrexia of unknown origin

69

Unexplained neutropenia

51

Unexplained thrombocytopenia

88

Chronic diarrhea of unknown cause

68

Oral hairy leukoplakia

4646

Oral candidiasis Oral candidiasis

30

Cerebral abscess Cerebral abscess

30

Pulmonary tuberculosis

31

31

Pulmonary tuberculosis 0

10

20

30

40

50

60

70

80

90

100

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Results - knowledge on indications Identification of WHO stage 2 clinical conditions as indications for HIV testing (N = 100) Multidermatomal or recurrent herpes zoster

80

Weight loss of unknown cause

76

Recurrent oral ulcers

67

Severe or recalcitrant (uncontrolled or refractory) seborrhoeic dermatitis

37

Angular chelitis

10 0

10

20

30

40

50

60

70

80

15 90


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

Unexplained persistent generalized lymphadenopathy

79

0

10

20

30

40

50

60

70

80

90

16


stage 2

Poor knowledge on WHO clinical conditions (N= 100) Severe or recalcitrant seborrhoeic dermatitis

37

stage 3

Angular chelitis

10

Cerebral abscess

30

Pulmonary tuberculosis

31

stage 4

Cervical cancer

39

Primary CNS lymphoma

30

Non Hodgkins lymphoma

18 0

5

10

15

20

25

30

35

40

45

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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

51%

45%

average good poor

4% 18


Results - knowledge on procedure Knowledge on the specimen required for HIV testing (N = 100) 8%

9%

Serum Anticoagulated blood

83%

bone marrow aspirate

19


Results - knowledge on procedure knowledge on specimen collection (N= 100)

9%

2% 1%

Plain tube 88%

EDTA bottle

Heparin tube Don't know

20


Knowledge on the required volume of the specimen (N = 100) 10%

24%

1.6ml 66%

2ml 5ml

21


knowledge on the venue in which HIV testing is carried out (N=100) 1%

6%

NHSL

3% 2%

7%

31 % 3% 9%

Infection control unit Hospital main lab MRI STD clinic Blood bank Don't know microbiology lab

69%

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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

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Results- Practice of HIV testing Reason for requesting HIV testing (N = 285) 6%

5%

Clinical indications

17%

Percieved or real high risk behaviours Prior to the invasive procedures/surgeries 72%

Needle prick injury

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Common clinical conditions where HIV tests were requested (N = 100) Pyrexia ofPyrexia unknown origin origin of unknown

39 (21.8%) 39

Pulmonary tuberculosis Pulmonary tuberculosis

1919 (10.6%)

Recurrent Patients withpneumonia recurrent pneumonia

19 (10.6%) 19

Extra pulmonary tuberculosis

15

Immunodeficiency screening

14

Oral Oralcandidiasis candidiasis

7

weight loss

7

Thrombocytopenia

5

Generalized lymphadenopathy

5

Unresolving or poorly resolving pneumonia

4

Multidermatomal herpes zoster

4

Genital ulcers

4

Oesophageal Oesophagealcandidiasis candidiasis

7(3.9%)

4 4 (2.2%)

others ( =<3)

23 0

5

10

15

20

25

30

35

40

25

45


Results- Knowledge vs practice Association of mean number of testing with the level of knowledge 12.00

10.00

9.84

8.00

5.67

6.00

4.00

2.25 2.00

0.00

average

good

poor

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Results- obstacles encountered Obstacles encountered during HIV testing (N = 100) 12 (26.6%)

Reports delayed Reports delayed

12 (26.6%)

10 (22.2%)

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

10 (22.2%)

Non consenting patients

7 (15.6%)

Getting the consent is time consuming

7 (15.6%)

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

6 (13.3%)

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

3 (6.6%)

0

2

4

6

8

10

12

14

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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 â&#x20AC;˘ Data cannot be generalized as it only represents four tertiary care hospitals in Colombo. â&#x20AC;˘ Number of HIV testing assessed asking the respondents to recall (recall bias).

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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


Acknowledgement â&#x20AC;˘ Dr C D Wickramasuriya, consultant venereologist, National STD/AIDS control programme. â&#x20AC;˘ All the intern medical officers attached to NHSL, CSHW, DMH & LRH.

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