Abstract

Thousands of healthcare workers around the world suffer accidental occupational exposure to blood borne pathogens each day. Adequate knowledge and practices on post exposure prophylaxis (PEP) for HIV among health care providers are crucial for HIV prevention. However, there is limited data on PEP knowledge and practice in Cameroon as well as other developing countries where the burden of HIV infection continues to increase.

It is of utmost importance that health care providers utilize HIV post exposure prophylaxis (PEP) to protect, as occupational exposure to HIV has been a problem in health care delivery. This study was conducted to determine the prevalence of occupational injury and explore factors that influence the use of HIV post-exposure prophylaxis among health workers in the Biyem-Assi, Buea and Limbe health districts.

This was a cross-sectional study conducted from May to October 2019, involving the administration of questionnaires to health care workers in Biyem-assi, Buea and Limbe health districts. Data collected was analysed with SPSS version 21 and results presented as percentages and tables. Chi-square and multivariate logistic regression analyses were used to determine statistically significant relationship between different factors in association to risks of occupational exposure and compliance to HIV PEP use. Out of a total of 312, a high proportion of participants, (198) 63.5% had experienced occupational injury, with (81/198) 40.9% suffering from needle stick injuries, and (42/198) 21.2% splashing of blood /bodily fluids unto mucosal surfaces.

One hundred and fifty-nine (52%) had adequate knowledge and (241) 86.7% had a good attitude towards HIV PEP. Sixty (35.0%) of the participants who had at least one occupational exposure made use of HIV Post Exposure Prophylaxis. Of the 198 participants who experienced occupational injuries, 137 (65.0%) adopted good practice. Of the 137 respondents who observed good practice, 60 (43.8%) of the respondents elected to use HIV PEP.

Majority of the respondents who elected to use HIV PEP, 37 (61.7%) had been exposed via needle stick injuries. Following a multiple logistic regression analysis, age (p-value = 0.005), place of work (tertiary health facility (p-value=0.007) and inadequate knowledge (p-value=0.050) were shown to be risks factors to occupational exposure.

Being a medical doctor (p- value=0.002) and health care workers who were aware of the HIV PEP guidelines (p- value=0.024) were likely more to comply with the HIV PEP usage than the male health workers (p-value=0.039).

CHAPTER ONE

INTRODUCTION

1.1 Introduction

HIV/AIDs is a serious public health problem costing the lives of many people including health care workers (Julia & Maggy, 2005). According to the 2002 World Health Report it was estimated that 2.5% of HIV cases among health care workers worldwide were as a result of occupational exposure. Thousands of healthcare workers around the world suffer accidental occupational exposures to blood borne pathogens each day (Julia & Maggy, 2005).

The World Health Organization (WHO) recommended the use of HIV Post-exposure prophylaxis (PEP) in preventing the occurrence of HIV infection resulting from such accidental injuries at work place (WHO, 2005). The HIV/AIDS pandemic marks a severe developmental crisis in Africa which remains by far the most affected region in the world.

With the very high prevalence of sharps injuries, low rate of reporting and use of Post exposure prophylaxis (PEP), the expected national incidence may be seriously underestimated. The World Health Organization (WHO) has reported that about 90 % of occupational exposures to HIV occur in Sub-Saharan Africa (SSA) (WHO Guidelines, 2013).

HIV infection, one of the main communicable diseases in Sub-Saharan African has been a global challenge over the last 30 years (Baytner-Zamir et al., 2014). Cameroon, according to the 2013 WHO report had the highest HIV prevalence rate (5.1%) in West and Central Africa among adults aged 15–49 years, whereas in 2009, the HIV prevalence was 4.9 % (DHS, 2011).

The advent of antiretroviral therapy (ART) has turned HIV infection into a chronic disease, and as such healthcare practitioners are increasingly expected to provide care to people living with HIV infection (PLWHIV) including unrelated medical conditions (Baytner-Zamir et al., 2014) which makes them prone to acquiring the disease. Post exposure prophylaxis (PEP) refers to the use of short-term antiretroviral drugs to reduce the risk of HIV acquisition (Sultan et al., 2014).

Following exposure, it may require 3 days for the virus to be detected in lymph nodes, and up to 5 days in blood (Pinto et al., 1997). When administered shortly following exposure, post exposure prophylaxis (PEP) treatment has been shown to reduce the risk of HIV infection by 81% (Karen et al., 2004).

This offers a short window of opportunity during which, HIV acquisition following exposure can be prevented through prophylaxis as it inhibits viral replication and halts the irreversible establishment of the infection.

Health care workers are at an increased risk of contracting HIV after an occupational injury or exposure to infectious materials, such as blood, body tissue, body fluids, and contaminated environmental surfaces (Agaba et al. 2012; Mathewos et al. 2013) with 3/1000 injuries resulting in HIV transmission after percutaneous exposure from an HIV infected patient in health settings (Kuhar et al., 2013). It is vital to ensure the health and safety of health care workers in a hospital setting. Percutaneous injury, usually inflicted by a hollow-bore needle, is the most common mechanism of occupational HIV transmission.

The CDC estimates that more than 380,000 needle stick injuries occur in hospitals each year; approximately 61% of these injuries are caused by hollow bore devices (CDC, 1996). The World Health Report 2002 estimates that 2.5% of HIV cases among health care workers worldwide are the result of occupational exposure (WHO, 2002).

Most people at risk of occupational exposures are in developing countries where there is a paucity of standard reporting protocols (WHO, 2002). The distribution of exposures to blood borne pathogens among different cadre of health care workers (HCWs) is an important variable in implementing preventive measure.

Some studies have indicated that exposures to blood-borne infections in healthcare settings are most frequent with nurses than other HCWs. In a study carried out among health care workers in England, Wales and Northern Ireland between July 1997 and June 2000, it was discovered that midwives were the most common group exposed to blood borne viruses followed by doctors (Tokars et al., 1992). A similar study in Brazil found the same distributions of exposures (Apparini et al., 2007) In most studies percutaneous exposure is the most common route of exposure.

Providing relevant information on post-exposure prophylaxis for the health care professionals would help to prevent the transmission of HIV, provide epidemiological data, identify unsafe practices, and reduce anxiety, and/or increase staff retention and productivity (Sarah et al., 2014). However, studies have shown that there is an information gap in the health care setups. For instance, a study done in Governmental Health Institutions in Jimma zone and Jimma City in Ethopia in 2008 indicated 81.6% of health care workers exposed did not use post-exposure prophylaxis (Bosena and Chernet., 2010).

A national study in Kenya also showed that among those who were knowledgeable, only 45% sought HIV post-exposure prophylaxis. The main reasons for not seeking post-exposure prophylaxis among this group was lack of sufficient information (35%) followed by fear of the process and what could follow (28%) (Kiragu et al., 2014).

A study carried out in Cameroon by Leopold Ndemnge and colleagues in 2015, showed a poor level of knowledge of HIV PEP among nurses (73.7%) in the Tubah health district in the Northwest Region of Cameroon (Leopold et al., 2015).

This was due to the fact that a good number of the nurses had not received proper training regarding HIV post exposure prophylaxis. Several studies have explored knowledge on post exposure prophylaxis (PEP) for HIV among healthcare providers as a whole (Ajibola et al., 2014), nurses (Aminde et al., 2015), medical doctors (Agaba et al., 2012), surgical residents (Nwanko et al., 2011), midwifery students (Sendo 2014), medical interns (Chacko & Isaac, 2007), and dental students (Kasat et al., 2014).

However, there is very little data on the factors that influence the use of HIV prophylaxis among health care workers after an occupational exposure in Cameroon. It is of utmost importance that health care providers utilize HIV post exposure prophylaxis to protect, as occupational exposure to HIV has been a problem in the health care delivery.

Therefore, the objectives of this study were to determine prevalence of occupational exposure to HIV infection and identify the factors that impede the use of HIV post-exposure prophylaxis among health workers in the Biyem-Assi, Buea and Limbe health districts.

1.2 Statement of the problem

HIV/AIDS is a serious public health problem costing the lives of many people including health care workers. Each day thousands of health care workers around the world suffer accidental occupational exposures to blood – borne pathogens (Che et al., 2018).

Cameroon is no doubt among Sub-Saharan African countries hard-hit by HIV/AIDS. According to the World Health Organization (WHO, 2012) report, 2.5%of HIV cases among Health Care Workers worldwide are as a result of occupational exposure.

Despite the availability of HIV post exposure prophylaxis (PEP) in health institutions, health workers still acquire HIV through occupational exposure. Over 90% of these infections are occurring in low-income countries, and most are preventable (Aarti et al, 2012; Ajibola et al., 2014). The World Health Organization in 2015 recommended that post exposure prophylaxis (PEP) should be offered as an additional prevention option for people at substantial risk of HIV infection (WHO, 2015).

Post-exposure prophylaxis (PEP) is a short-term antiretroviral treatment to reduce the likelihood of HIV infection after potential exposure (WHO, 2014). Occupational exposure to blood and body fluid is a serious public health problem (Varghese et al., 2003) with health care workers at high risk of infection as a result of the high prevalence of infections among patients and increased occupational risk among health care workers due to unsafe practices like careless handling of contaminated needles, unnecessary injections on demand, reuse of inadequately sterilized needles, improper disposal of hazardous waste and overcrowding of hospitals. In addition to taking post exposure prophylaxis by health care workers after an exposure, the World Health Organization recommends the surveillance of occupational accidents, infections due to occupational accidents and uptake of post exposure prophylaxis among exposed health care workers. There exist little or no data on the prevalence of occupational accidents, the reporting of occupational exposures and the uptake of post exposure prophylaxis in the South West and Centre Regions, which makes it quite difficult to evaluate compliance of the health care workers to HIV post-exposure prophylaxis.

Consequently, the effectiveness of the post-exposure prophylaxis cannot be assessed as there are no records of already administered HIV PEP, hence a gap in the implementation of the WHO guidelines. Differences in annual exposure rate has been observed between health professionals of different categories and working experience. In a study conducted to estimate the global burden of disease attributable to contaminated sharp injuries, 1000 new human immunodeficiency virus infections occurred in the year 2000 worldwide among health care workers due to their occupational exposure to percutaneous injury (Pruss-Ustun et al., 2005).

 

Although percutaneous occupational exposure us still occurring worldwide, it is greatly under reported.

A report published by World Health Organization also estimated that 0.5% of health care workers are exposed to human immunodeficiency virus annually, corresponding to 1000 new human immunodeficiency virus infection from occupational exposure (Uslan and Virk, 2005). These all poses a high risk of occupational exposure and transmission to health care workers in hospitals attending to these patients.

Therefore, this study will determine the magnitude of occupational exposure among healthcare workers and associated factors in relation to the occupational hazards to human immunodeficiency virus infection. The risk of acquiring blood borne pathogens is high in Africa, most probably reflecting the high prevalence of those conditions in the African setting.

1.3 Rationale

Although human immunodeficiency virus infection is an epidemic condition all over the world, this study focuses on health care workers who are more vulnerable to human immunodeficiency virus exposure due to their occupation. Currently in Cameroon there is inadequate data about occupational exposure in relation to transmission of blood-borne pathogens among healthcare providers.

Healthcare workers in Cameroon have inadequate knowledge of risky occupational activities. Information or data generated from this study may be exploited by policy makers in the Ministry of Public Health in developing policies that will improve on the use of PEP by healthcare workers and minimize transmission of HIV in this vulnerable group.

The purpose of this study was to investigate the prevalence, knowledge, attitude and practices of health workers regarding use of PEP and to identify the factors that influence its use. The study will be conducted in Limbe, Buea and Biyem- Assi health districts.

1.4 Research questions

1. What is the prevalence of occupational injury among health care workers of the Biyem- assi, Buea and Limbe health districts?
2. What is the knowledge, attitude and practices of health workers regarding the existing precautionary policy on HIV post exposure prophylaxis (PEP)?
3. What are the factors that influence the risks of occupational exposure and compliance to HIV post exposure prophylaxis (PEP)?

1.5 Objectives:

1.5.1 General objective;

To determine the prevalence of occupational exposure and assess knowledge, attitude and practices as factors that influence the compliance of HIV PEP among health care workers of the Biyem-assi, Buea and Limbe health districts in Cameroon.

1.5.2 Specific objectives;

1. To estimate the prevalence of occupational injury among health workers of the Biyem-assi, Buea and Limbe health districts.
2. To assess participant’s knowledge, attitude and practices of health workers on HIV post exposure prophylaxis (PEP).
3. To determine the relationship between factors that may influence the risk of occupational exposure to HIV and compliance to HIV PEP among health care workers.