Knowledge of HIV post exposure prophylaxis among public healthcare providers in Ilala District, Dar es Salaam CURRENT STATUS:

Background Post-exposure prophylaxis (PEP) using highly active antiretroviral therapy (HAART) significantly reduces the risk of HIV infection to the victims. Evidence based practice has brought dynamicity in HAART regimens necessitating continual updates on knowledge of health care providers (HCPs) regarding PEP. Therefore, this study aimed to assess contemporary knowledge of HCPs on PEP three years after the introduction of Tenofovir based HAART regimens as a default for PEP in Tanzania. Methods A health care facilities based cross-sectional study was conducted between April and June 2018 in Ilala municipal Dar es Salaam, Tanzania. A consecutive sampling method was deployed and 233 HCPs were enrolled. Data were collected using a self-administered questionnaire with closed-ended questions. The level of knowledge was graded using Bloom’s cut off point. Chi-square and multinomial logistic regression tests were used to check for association at significance level of p<0.05. Results A total of 13 health facilities were visited and 233 HCPs were interviewed among them 30.9%, 5.6%, 58.4%, and 5.2% were medical doctors, pharmaceutical personnel, nurses and laboratory technician respectively. The majority 72.1% (168) of the participants were female and the majority 47.2% (110) of the HCPs were aged ≥55 years. Diploma (43.8% (102)) education level constituted the largest proportion of the participants and the majority 50.2% (117) were nurses. About 70% of the respondents had low to moderate knowledge. The majority 87.6%(204) of the study participants were knowledgeable on dosage duration for PEP. However, only 41.2% (96) knew the recommended ARV regimen for PEP in Tanzania and 48.9% (114) knew how soon PEP should be initiated to prevent HIV acquisition. Certificate holders were more likely to have low knowledge on PEP compared to diploma and degree holders aOR (95% CI) 14(3.9 – 50.8), p=<0.01. The main source of PEP information to study participants was HIV treatment guideline (29%) followed by seminars (22%). Conclusion The majority of the assessed HCPs had low to moderate knowledge on PEP. The level of knowledge


Introduction
Human immunodeficiency virus (HIV) infection is one among the diseases of public concern worldwide. The infection is high in developing countries compared to developed countries. It is transmitted by different models such as unsafe sex, transfusion of infected blood, sharing of sharp objects with HIV infected person and unintentional exposure to infected blood/body fluids at work place (occupational exposure) [1,2]. Occupational exposure plays a significant role in HIV transmission. Healthcare providers (HCPs) are among the group of people named by World Health Organization (WHO) to be at risk of being infected by HIV as a result of exposure to infectious materials through injuries/accidents from sharp objects such as needle stick, scissors, and knives or contact with blood or other infectious body fluids [3][4][5][6][7]. The severity of exposure increases the odds of occupational transmission. For example, percutaneous exposure to HIV infected blood results to 0.3% increased risk of HIV and 0.09% when exposed to mucosal membrane. WHO, reports 3 million HCPs are exposed to HIV percutaneously; these results to 200-5000 HIV infections worldwide. About 90% of occupational exposures to HIV occur in low-resource countries [8,9]. The HIV transmission can be reduced by 81% following the timely administration of antiretroviral medications (ARVs) [10,11].
ARVs have been used in preventing the acquisition of HIV since 1990 as post-exposure prophylaxis (PEP). PEP is the immediate administration of ARVs following exposure to potentially infected blood or other bodily fluids to minimize the risk of acquiring HIV infection [12,13]. Usually, PEP is initiated within 2 hours but it can go up to 72 hours following exposure to potentially infected blood or other body fluids and the dose continues for 28 days [12][13][14].
Despite being at the highest risk, HCPs are also responsible for counseling and initiation of PEP to other individuals when exposure occurs [12,13]. The studies conducted in Africa on knowledge of PEP among HCPs demonstrated inconsistent level of knowledge across the region [9,10,11,15,16]. In Tanzania, studies were conducted in 2007, 2012 and 2013 reported the majority of HCPs to have unsatisfactory knowledge on PEP [4,11,17]. Previously reported determinants of PEP knowledge among HCPs to include qualifications, level of education, experience, and type of health facility [11,18].
Since 2015 in Tanzania there have been implementations of new policies and guidelines on PEP with many campaigns and seminars on prevention and treatment of HIV among HCPs [13]. There has also been a huge increase in the number of qualified HCPs and health care facilities all over the country.
However, recent data on the HCPs level of knowledge on PEP are lacking. Therefore, this study aimed to provide an update on the level of knowledge on PEP against HIV infection among HCPs in public health facilities in Ilala district, Dar es Salaam.

Sample Size and Sampling Technique
A consecutive sampling method was deployed to recruit participants and a total of 233 HCPs were enrolled after being informed and agreed to sign a consent form.
Data collection procedure and Scoring of knowledge Data were collected using a self-administered questionnaire with closed-ended questions. The questionnaires were in English and had three sections; socio-demographic characteristics, knowledge assessing part and the last part for assessing the source of the knowledge regarding PEP. A total of 5 questions were developed by using published articles/guidelines [10,11,12,14] and were used to assess the level of knowledge with a total of 7 points. The questions were pre-tested and validated using 20 HCPs. Bloom's cut off point was generated by calculating the median and inter quarterly range (IQR) of the scores point as follows; 0-25% percentile was equivalent to 0-3 points and considered as low knowledge, ≥ 75% percentile equivalent to 6-7points and was considered as high knowledge and between (26-74) % percentile equivalent to 4-5 points was considered as moderate knowledge.

Data analysis
Microsoft Excel sheet was used for data entry. Data cleaning and analysis was performed using statistical package for social sciences (SPSS) version 23.0. Frequencies and percentages were used to summarize social-demographic characteristics and level of knowledge. Association between independent variables and level of knowledge was done by Chi-square and multinomial logistic regression. The result was of statistical significance when p<0.05.

Results
Socio-demographic characteristics of the study participants. Association between independent variables and the level of knowledge among HCPs.
Sex, age, working experience and level of health facilities were not determinants of the level of knowledge among HCPs (p>0.05). On the chi-square test, the level of knowledge was significantly affected by the level of education whereby those with a degree seemed to have high knowledge 38.9% (21) compared to those with a low level of education at p-value < 0.001, Table 2. On logistic regression analysis those with certificate were more likely to have low knowledge compared to diploma and degree holders (aOR(95% CI) 14(3.9-50.8), p = <0.01) analysis, Table 3.

Sources of information regarding PEP among HCPs
The main source of PEP information to study participants was HIV treatment guideline (29%) followed by seminars (22%) and classroom lectures (15%). Other mentioned sources of information include social media, friends, posters, broadcasting, textbooks and ward rounds, figure 3.

Discussion
This study was designed to assess the knowledge of HCPs on PEP 3 years following the introduction of Tenofovir based HAART regimens for PEP and managements of people living with HIV(PLHIV). Majority of respondents had low (32.2%) to moderate (39.9%) knowledge. This finding is consistent with previous reports in Tanzania [11,17], Uganda [10], Nigeria [19] and Cameroon [20] whereby the majority of HCPs had inadequate knowledge on PEP. More than 75% of our study participants had a certificate or a diploma which could be a contributing factor to the observed low knowledge among study participants. The inadequate level of knowledge among HCPs with certificate level could due the fact that the topic on pre and post-exposure prophylaxis of HIV infection is not weakly engaged in their training course. Therefore, findings from this study necessitate a need for health college/university to consider PEP and make it conspicuous topic in their curriculum.
Post exposure prophylaxis should be provided as soon as possible following exposure as its efficacy in preventing transmission is time dependent [21]. Low knowledge was demonstrated by HCPs on how soon should PEP be initiated. Only 41.2% were able to mention the regimen that are currently recommended for PEP in Tanzania. Majority of the HCPs were knowledgeable on the duration of taking PEP, whereby 87.6% answered that PEP should be taken for 28 days. These results are similar to what was reported in Ethiopia [22] and Botswana [23], whereby the majority of HCPs (> 90%) were aware of the duration of taking PEP but about 50% failed to respond on how soon should PEP be initiated. This can be explained by the previous experience gathered by HCPs on PEP management as it is now more than 15 years since the care and treatment clinics (CTCs) were established in 2004 in Tanzania.
The results are similar between these countries probably because they are all located in Sub-Sahara Africa and share some similarities in their Health policy regarding to PEP.
Most of the respondents obtained knowledge regarding PEP from HIV treatment guidelines (29%) followed by seminars (22%) and only 15% from class lectures. Although the current study didn't focus on availability of HIV/AIDS guidelines but it has revealed the role of reference materials and seminars in fostering HCPs knowledge on PEP. The findings are further supported by similar studies conducted in Ethiopia and Botswana, where the majority of the HCPs obtained information regarding PEP after attending training (seminars) [22,23].
All other factors such as; age, sex, years of experience, profession and level of health facilities failed to predict the level of knowledge of PEP among HCPs on both levels of analysis. Different in education level attained by the HCPs appeared to be a determinant of the level of knowledge. Those with a certificate level of education appeared to have low knowledge of PEP compared to those with a degree. This could be due to differences in program duration attended; certificate programs are short (maximum of 2 years) compared to degree courses (maximum of 5 years) and content of the curriculums. Therefore, those who are taking degrees are more exposed to different disease management approaches, are more exposed to the health system of the country through field    Sources of information regarding PEP among HCPs