ASSESSMENT OF KNOWLEDGE, ATTITUDE AND PRACTICE OF POSTEXPOSURE

PROPHYLAXIS FOR HIV/AIDS AMONG HEALTH CARE WORKERS IN JUSH , SOUTH

WEST ETHIOPIA, JIMMA ZONE,OROMIA,ETHIOPIA.

BY:

GIZACHEW ASSEFA

A RESEARCH PROPOSAL SUMITTED TO DEPARTMENT OF PHARMACY, COLLEGE

OF PUBLIC HEALTH AND MEDICAL SCIENCE, JIMMA UNIVERSITY IN PARTIAL
FULFILLMENT OF THE BACHELOR DEGRE IN PHARMACY (B.PHARM)

JAN, 2013

JIMMA, ETHIOPIA
 JIMMA UNIVERSITY

COLLEGE OF PUBLIC HEALTH AND MEDICAL SCIENCES

DEPARTMENT OF PHARMACY

ASSESSMENT OF KNOWLEDGE, ATTITUDE AND PRACTICE OF POSTEXPOSURE

PROPHYLAXIS FOR HIV/AIDS AMONG HEALTH CARE WORKERS IN JUSH, SOUTH
WEST ETHIOPIA, JIMMA ZONE,OROMIA,ETHIOPIA.

BY:

GIZACHEW ASSEFA

ADVISOR

Mr. DEREGE KEBE BE (B.PHARM, MSC, IN

JAN 2013

JIMMA, ETHIOPIA
PROPOSAL SUMMARY

Back ground:Although AIDS remains one of the world’s most serious health challenges; global
solidarity in the AIDS response during the past decade continues to generate extraordinary health
gains.Globally 34.0 million peoples were living with HIV/AIDS at the end of 2011, although the
burden of the epidemic continues to vary considerably between countries and regions.Sub-
Saharan Africans remains most severely affected,with nearly 1 in every 20 adults (4.9%) of
living with HIV/AIDS and accounting for 69% of the people living HIV/AIDS in worldwide,in
UNAIDS Report on the global AIDS epidemic (2012).In 2011, the prevalence of HIV/AIDS in
adults was estimated 1.5% and approximately 1.2 million Ethiopians were lived HIV/AIDS in
2010; even if the prevalence of HIV/AIDS infections is decreased the number of peoples living
HIV/AIDS are high, so this play the great in increasing the occupational exposure of HCWS to
HIV/AIDS. Infection with Human Immunodeficiency Virus is a serious public health problem
costing the lives of many people including health workers. Hence, Ethiopia has developed
guideline on the prevention of infection in health institutions in July 2004 and also employed the
use of post exposure prophylaxis since the implementation of free antiretroviral in January 2005.

Objective:To assess the knowledge, attitude and practice of health workers about PEP against
HIV/ AIDS in JUSH, south west Ethiopia, Jimma zone, oromia, Ethiopia.

Method: The study will be conducted on health workers in JUSH, which is located in south west
Jimma zone, oromia, Ethiopia, 345km away from Addis Ababa. Since it is the only referral
hospital in this area currently it is giving service to the people living in south west Ethiopia and
surrounding areas.

A cross sectional study,self-administered structured questionnaire will be filled by HCWs of

JUSH form as the collection data tool.

Result: The results will be presented after the data collection using self-administered
questionnaire filled by the health care workers.

I
AKNOWLDGEMENT

I would like to express my heart felt gratitude to my advisor Mr. Dereje.K for his indispensable
comment and suggestions in developing this proposal paper.

I would also like to thank the SRP office and pharmacy department for giving me this chance to
conduct the study. My thanks also extend to Miss Yemisirach E. and Esubalew A.; who
providing me computer service in searching literatures and typing this paper.

II
Table of Contents

PROPOSAL SUMMARY ............................................................................................................... I

AKNOWLDGEMENT ................................................................................................................... II
ACRONYMS ................................................................................................................................. V
LIST OF DUMMY TABELES ..................................................................................................... VI
OPERATIONAL DEFNITIONS ................................................................................................. VII
1. INTRODUCTION ................................................................................................................... 1
1.1. Background ...................................................................................................................... 1
1.2. Statement of the problem ................................................................................................. 6
1.3. Significance of the study .................................................................................................. 6
2. LITERATURE REVIEW ........................................................................................................ 8
3. OBJECTIVES ........................................................................................................................... 14
3.1. General objectives .............................................................................................................. 14
3.2. Specific objectives.............................................................................................................. 14
4. METHODOLOGY ................................................................................................................... 15
4.1. Study area and study period ............................................................................................... 15
4.2. Study design ....................................................................................................................... 15
4.3. Study population ................................................................................................................ 15
4.3.1. Source population ........................................................................................................ 15
4.3.2. Sample population ....................................................................................................... 15
4.4. Sample size and sampling technique .................................................................................. 15
4.5. Study variables ................................................................................................................... 15
4.5.1. Independent variables .................................................................................................. 15
4.5.2. Dependent variables .................................................................................................... 16
4.6. Method of data collection ................................................................................................... 16
4.7. Data processing and analysis.............................................................................................. 16
4.8. Ethical consideration .......................................................................................................... 16
5. WORK PLAN ........................................................................................................................... 17
6. BUDGET BREAKDOWN ....................................................................................................... 18
7. REFERANCES ......................................................................................................................... 19

III
8. ANNEX..................................................................................................................................... 21
8.1. Annex – I: Dummy Table .................................................................................................. 21
8.2. Annex-II: Data collection format ....................................................................................... 30

IV
ACRONYMS

AIDS: acquired immune deficiency syndrome.

ARV: Anti retro viral.

CSF: cerebrospinal fluid.

HCWs: Health care workers.

HIV: Human immune deficiency virus.

JUSH: JimmaUniversity

KAP: Knowledge, Attitude and Practice.

NNRTIs: Non-nucleoside reverse transcriptase inhibitors.

NRTIs:Nucleoside reverse transcriptase inhibitors

NSI:Needlesticks injury.

PEP: Post exposure prophylaxis.

PI: Protease inhibitors.

SRP: Student research project.

UP: Universal precaution.

WHO: World health organization.

ZDV: Zidovudine

3TC:Lamivudine.

IDV: Indinavir.ddI:Didanosine.

V
LIST OF DUMMY TABELES

Table 1: Socio demographic characteristics of respondent health care workers of JUSH. .......... 21
Table 2: Distribution of HCWs based on their knowledge about occupational risk for HIV /AIDS
and universal precaution, in JUSH................................................................................................ 22
Table 3: PEP of HIV - knowledge of respondent health workers of Jimma University specialized
hospital. ......................................................................................................................................... 23
Table 4: Distribution of HCWs based on their knowledge about the availability of PEP and
number of drugs used for PEP in JUSH........................................................................................ 24
Table 5: Respondent health workers knowledge about occupational risk conditions for
HIV/AIDS in JUSH. ..................................................................................................................... 25
Table 6: Respondent health workers’ perceived cause of exposure to HIV risk conditions and
reasons for not using PEP of HIV in JUSH. ................................................................................. 26
Table 7: HCWs by their knowledge about the time of initiation and duration of PEP for
HIV/AIDS in JUSH. ..................................................................................................................... 27
Table 8: Distribution of HCWs by their past occupational exposure to HIV /AIDS in JUSH. .... 28
Table 9: Attitude of HCW stewards the effectiveness of PEP for HIV/AIDS in JUSH. .............. 28
Table 10: Health care workers exposure to HIV risk conditions and practice of PEP after
exposure ........................................................................................................................................ 29

VI
OPERATIONAL DEFNITIONS

Adequate Knowledge: when respondents correctly answer > 75 % of the eleven knowledge
questions.

Exposure to HIV risk conditions: health workers’ exposure to HIV risk conditions.

Such as blood, patients /clients’ body fluids, needle prick/sharps injury at work place.

Heath care workers:persons working in health care setting who have potential for exposure for
exposure in infectious materials.

Inadequate knowledge: when the correct answer of respondents is < 75 % of the eleven
knowledge questions.

Occupational exposure:procedures that put the health care workers in to a risk of infection.

PEP use /practice: reporting as they have practiced using Post-exposure prophylaxis of HIV.

Post-exposure prophylaxis: is an emergency medical response that can be used to protect

individuals exposed to the human immuno-deficiency virus (HIV) and a short term anti retro
viral treatment to reduce the likely hood of HIV infection after potential exposure either
occupational or through sexual intercourse. PEP consists of counseling, laboratory tests and or
medication.

Percutaneous injury: a needle stick or sharp cut with an infected needle or sharp materials that
put the health care worker at risk.

Regimen: a course of treatment, possibly combining drugs, exercise, diet etc. designed to bring
about an improvement in health.

Universal precautions: universally adopted measures take before medical procedures to avoid
risk of exposure whole on work.

VII
1. INTRODUCTION

1.1. Background

Although AIDS remains one of the world’s most serious health challenges, global solidarity in
the AIDS response during the past decade continues to generate extraordinary health gains.
Historic success in bringing HIV programs to scale – combined with the emergence of powerful
new tools to prevent people from becoming infected and from dying from AIDS-related causes –
has enabled the foundation to be laid for the eventual end of AIDS. Although much of the news
on AIDS is encouraging, challenges remain. The number of people newly infected globally is
continuing to decline, but national epidemics continue to expand in many parts of the world.
Further, declines in the numbers of children dying from AIDS-related causes and acquiring HIV
infection, although substantial, need to be accelerated to achieve global AIDS target (1).

Populations such as healthcare workers (HCWs), injection drug users (IDUs), and people
engaging in unprotected sex are all at risk of being infected with the human immunodeficiency
virus (HIV). Animal models show that after initial exposure, HIV replicates within dendritic
cells of the skin and mucosa before spreading through lymphatic vessels and developing into a
systemic infection (CDC 2001). This delay in systemic spread leaves a "window of opportunity"
for post-exposure prophylaxis (PEP) usingantiretroviral drugs designed to block replication of
HIV (CDC 2001). PEP aims to inhibit the replication of the initial inoculum of virus and thereby
prevent establishment of chronic HIV infection (2).

Occupational exposure to blood and body fluids is a serious concern for healthcare workers, and
presents a major risk for the transmission of blood-borne infections such as HIV. The prevention
of exposures to blood and body fluids is the primary means of preventing occupationally
acquired human immunodeficiency virus (HIV) infection; however it has been found that the
appropriate use of post-exposure prophylaxis (PEP) is important in the prevention of HIV
infection in exposed healthcare workers. The aims of this study were to assess the level of
knowledge, attitudes and practices of healthcare workers at JUSH on occupational HIV post-
exposure prophylaxis (4).

1
Since the rapid spread of HIV infection in the 1980s and 1990s—primarily by commercial sex
workers, truck drivers, and soldiers along major transportation routes—children, adolescents, and
the general population have increasingly become infected. While the epidemic has spread rapidly
in the towns and more slowly in rural areas, surveillance activities remain underdeveloped. Thus,
the fragmentary data on the occurrence and impact of HIV/AIDS are speculative, and planning
and implementation of prevention and control programs have been hindered. Available data
show that knowledge levels about HIV/AIDS and use of condoms have increased in towns, and a
few populations with declining risk behavior have been identified in Addis Ababa, although a
high degree of denial, discrimination, and high-risk behavior persist.(6)

Little is known about the situation in rural Ethiopia. Poverty, war, gender inequities, traditional
practices, and political problems have all inhibited the effectiveness of prevention and patient
care/support programs. The socioeconomic impacts of HIV/AIDS are severe and increasing, and
a sharp decline in population growth is anticipated. The national HIV/AIDS prevention program
is briefly reviewed, and prospects for decentralized, multi sectoral, and community based
planning and implementation of prevention and patient support strategies are examined.(6)

Needle stick injuries (NSI) in healthcare settings are a global issue. Occupational exposures to
percutaneous injuries are a substantial source of infections with blood borne pathogens among
healthcare workers (HCWs). Reported risk associated with transmission of hepatitis B virus
(HBV) to a non-immune health care worker ranges from 2% if the source patient is Hepatitis B e
antigen negative, to 40% if the patient is positive(8).

Similarly, studies of HCWs exposed to hepatitis C virus (HCV) by a needle-stick or any other
percutaneous injury have found that the incidence of anti HCV seroconversion averages at 1.8%
(0-7%) per injury. The calculated rate from meta-analysis of worldwide studies for HCWs
exposed to HIV infected blood through percutaneous injuries is 0.3-0.4% per injury (8).

After initial reports in 1981, Sub-Saharan Africa now has the highest prevalence of Human
Immunodeficiency Virus (HIV) infection in the world with profound social economic impact.
This has led to a heightened concern in the surgical community in terms of its impact on the
practice of surgeryand safety of the practitioners. This concern arises from the significant risk of

2
infection through the parental route, lack of curative treatment, and the highest risk of exposure
of surgical staff to the body fluids of patients (9).

While most cases of infection in Africa are through heterosexual transmission, there is
inadequate documentation of the incidence of occupational HIV infection among health care
workers. It has been estimated that at least 1 in 500 surgeons is likely to be infected by HIV in
the next 35 years and that a surgeons cumulative life risk of HIV sero conversion ranges from
1% to 10%.This risk arises from the frequent and intimate exposure to the patient’s body fluids
through glove punctures, needles tick injuries, or ocular splashes and it is related to the
prevalence of HIV infection in the community (9).

In a study done in Nigeria, attitude and practices of Nigerian surgery trainees to HIV infected
person’s in1997; it was found that non-availability of relevant devices remains the most
important factor militating against the use of universal precautions. Studies from other parts of
the world have addressed these issues, but due to differences in sero-prevalence, among other
factors the results of studies conducted in one environment cannot be extrapolated to others.
Previous studies in this environment have either focused on health workers generally or on
categories of health. (9).

Health-care professionals are at a high risk of AIDS infection, among hospitalized HIV infected
patients. Proper training and knowledge accompanied by necessary preventive measures are by
all means, the most significant factors which ensure low accident rates and furthermore lower
contamination rates of the health-care personnel (5).

The Human Immunodeficiency Virus /Acquired Immuno Deficiency Syndrome (HIV/ AIDS)
epidemic has become one of the most important public health problems in recent times, and sub-
Saharan Africa has been disproportionately impacted by the disease. As the largest and most
populous country in Africa,Nigeria has a population approximately 130 million (7).

Nigeria has been experiencing a steady increase in annual Human Immunodeficiency Virus
(HIV) sero-prevalence rates (from 0% in 1986 to 3.7% in 1993, and 5.8% in 2003), with rates of
up to 23% being reported among commercial sex workers. Gwarzo; examined the HIV
prevalence rates in health care settings in Nigeria and found that the prevalence of HIV infection

3
ranges from 4.5% in antenatal clinic users, 15% in Sexually Transmitted Disease (STD) patients
to 34.5% among commercial sex workers (7).

The national prevalence is 5.4% and 2.9 million people are already infected with the HIV virus.
These statistics, it is noted parenthetically, come from sentinel surveys in the formal medical
sources, which are accessible to less than 50% of the population, suggesting that the prevalence
is much higher than is reported. The difference between HIV sero prevalence in urban and rural
areas is not large, indicating that the AIDS problem in Nigeria is not strictly an urban one. As the
prevalence of HIV/AIDS continues to rise, health care practitioners in all geographic regions of
Nigeria can expect greater clinical exposure to patients infected with HIV (7).

In 2000, after seven years of limited prevention measures, the Ethiopian government
implemented the comprehensive Multi sectorial HIV/AIDS Five-Year Strategic Plan (Ministry of
Health 1999a) and established a National AIDS Council responsible for its implementation.
Although the implementation, monitoring, and evaluation of this plan—including prevention,
control, and patient care and support interventions—require extensive and reliable baseline data
on the progression of the epidemic as well as its impacts on society, no such studies have been
carried out besides the epidemiological study by Kebede, Aklilu, and Sanders;2000 (14).

While epidemiological studies are necessary to answer questions about who, when, where, and
how people become infected and thus guide health policy and control programs, they cannot
fully explain the great disparities in the prevalence of HIV/AIDS among communities, regions,
and countries. It is well recognized that broader underlying socioeconomic, cultural, and political
factors, including poverty, women’s rights and other gender issues, must be considered as well
for effective interventions (14).

Antiretroviral post-exposure prophylaxis (PEP) is short-term antiretroviral therapy initiated soon

after known or suspected exposure to HIV, aims to prevent the establishment of HIV infection in
an exposed person. PEP has become the standard of care to prevent acquisition of HIV infection
after occupational exposure to blood or other bodily fluids of people infected with HIV. (13)

There is less of a consensus regarding the administration of PEP after no occupational exposure.
While PEP is part of the package of post-sexual assault care in most countries, the use of non-

4
occupational PEP, outside of rape or isolated incidents of exposure, is more controversial—
particularly when the HIV status of the source case is unknown. The World Health Organization
(WHO) and the U.S. Department of Health and Human Services offer guidelines for non-
occupational PEP (13).

In the paired case studies, the theoretical responses of participating health professionals showed
a greater preference for initiating self-directed treatment with antiviral or immunization rather
than complying with the hospital protocol, when the patient was known to be infected. The
differences in practice when exposed to a patient with suspected blood pathogens compared to
patient known to be infected was statistically significant (p < 0.001) in all 3 paired cases. Failure
to test an infected patient’s blood meant that an adequate risk assessment and appropriate
secondary prevention could not be performed, and reflected the unwillingness to report the
occupational exposure (12).

Regarding knowledge- the majority knew the very important issues related with laboratory safety
like Post Exposure Prophylaxis (96.55%) & discarding of blood samples (93.10%) etc. In regard
to attitude towards the scientific process, all are very much aware about importance of protective
devices (i.e. Wearing Gloves) and Biomedical waste management. In regard to the practice in
laboratory, the entire study subject group (100%) replied “YES” in each question that shows the
good quality work of the laboratory (11).

Health care workers (HCWs) are at a high risk of occupational blood-borne infections, which
may be increased in low and middle income countries by low adherence to Universal Precautions
(UP). A baseline survey of Knowledge, Attitudes and Perceived adherence (KAP) was executed
to design evidence-based tailor made interventions (18).

Infection with Human Immunodeficiency Virus is a serious public health problem costing the
lives of many people including health workers. Hence, Ethiopia has developed guideline on the
prevention of infection in health institutions in July 2004 and also employed the use of post
exposure prophylaxis since the implementation of free antiretroviral in January 2005. However
in the country, specifically in Jimma zone, published studies showing the clear picture about HIV
post exposure prophylaxis in the work place were non-existent. Therefore, this study was

5
conducted to assess the knowledge, practice and factors associated to HIV post-exposure
prophylaxis use among health workers of governmental health institutions in the Zone (3).

1.2. Statement of the problem

Globally 34.0 million peoples were living with HIV/AIDS at the end of 2011, although the
burden of the epidemic continues to vary considerably between countries and regions. Sub-
Saharan Africans remains most severely affected ,with nearly 1 in every 20 adults (4.9%) of
living with HIV/AIDS and accounting for 69% of the people living HIV/AIDS in worldwide ,in
UNAIDS Report on the global AIDS epidemic ; 2012.

In 2011,the prevalence of HIV/AIDS in adults was estimated 1.5% and approximately 1.2
million Ethiopians were lived HIV/AIDS in 2010;even if the prevalence of HIV/AIDS infections
is decreased the number of peoples living HIV/AIDS are high, so this play the great in increasing
the occupational exposure of HCWS to HIV/AIDS.

There is increasing evidence of exposure to HIV/AIDS at work despite this exposure increment,
availability of PEP reduces the risk of post exposure infections and ensures workplace
safety.PEP is recommended for exposed individuals who seek care before 72hrs after potential
exposures and it has been associated with 8-0% reduction in risk of HIV/AIDS infection. The use
of PEP after potential exposure depends on the knowledge and attitude of HCWs about it , but
some HCWs are not aware of the presence of PEP and proper utilization of it. In addition to this
there is no studies doe to assess the KAP of HCWs about PEP in JUSH.

1.3. Significance of the study

Due to an increased number of people living HIV/AIDS and non-adherence of HCWs to

universal precautions the risk of being infected by HIV from occupational exposure is increased
,so PEP is the means to reducing the occupational risk of infection in working setting , the use of
PEP depend upon the knowledge and attitude of the HCWs about it . The study will be carried
with an intension of assessing KAP of HCWs about PEP in JUSH .This will provide information
to concerned bodies and to take measures to improve the use of universal precautions by HCWs

6
while at work. it may also help to take measures to improve the awareness about PEP and its
utilization after occupational exposure of HCWs.

7
2. LITERATURE REVIEW

Although AIDS remains one of the world’s most serious health challenges, global solidarity in
the AIDS response during the past decade continues to generate extraordinary health gains.
Historic success in bringing HIV programs to scale – combined with the emergence of powerful
new tools to prevent people from becoming infected and from dying from AIDS-related causes –
has enabled the foundation to be laid for the eventual end of AIDS. Although much of the news
on AIDS is encouraging, challenges remain. The number of people newly infected globally is
continuing to decline, but national epidemics continue to expand in many parts of the world.
Further, declines in the numbers of children dying from AIDS-related causes and acquiring HIV
infection, although substantial, need to be accelerated to achieve global AIDS targets (1).

Globally, 34.0 million [31.4 million–35.9 million] people were living with HIV at the end of
2011. An estimated 0.8% of adults aged 15-49 years worldwide are living with\ HIV, although
the burden of the epidemic continues to vary considerably between countries and regions. Sub-
Saharan Africa remains most severely affected, with nearly 1 in every 20 adults (4.9%) living
with HIV and accounting for 69% of the people living with HIV worldwide. Although the
regional prevalence of HIV infection is nearly 25 times higher in sub-Saharan Africa than in
Asia, almost 5 million people are living with HIV in South, South-East and East Asia combined.
After sub-Saharan Africa, the region’s most heavily affected are the Caribbean and Eastern
Europe and Central Asia, where 1.0% of adults were living with HIV in 2011 (1).

Effect of PEP on HIV sero conversion No randomized controlled trials were identified. Only one
case-control study was included. HIV transmission was significantly associated with deep injury
(OR 15, 95% CI 6.0 to 41), visible blood on the device (OR 6.2, 95% CI 2.2 to 21), procedures
involving a needle placed in the source patient's blood vessel (OR 4.3, 95% CI 1.7 to 12), and
terminal illness in the source patient (OR 5.6, 95% CI 2.0 to 16). After controlling for these risk
factors, no differences were detected in the rates at which cases and controls were offered post-
exposure prophylaxis with zidovudine. However, cases had significantly lower odds of having
taken zidovudine after exposure compared to controls (OR 0.19, 95%CI 0.06 to 0.52). No studies
were found that evaluated the effect of two or more antiretroviral drugs for occupational

8
PEP.Eight reports from observational comparative studies confirmed findings that adverse events
were higher with a three-drug regimen, especially one containing indinavir. However,
discontinuation rates were not significantly different (2).

Among the total 254 participants, 213 (83.9%) had inadequate knowledge about post exposure
prophylaxis of HIV and 174 (68.5%) had ever been exposed to HIV risk conditions. Out of 174
health workers exposed to HIV risk, 105 (60.3%) sustained needle prick/cut by sharps, 77
(44.3%) to blood and 68 (39.1%) exposed to patients' body fluid. Perceived causes of exposure
were; high workload 77 (44.3%), lack of protective barriers 58 (33.3%) and lack of knowledge
on standard precautions 31 (17.8%). One hundred forty two (81.6%) of those exposed did not use
post-exposure prophylaxis. Lack of information about the existence of post-exposure prophylaxis
service 48 (33.8%), fear of stigma and discrimination 46 (32.4%), lack of understanding the
value of reporting 33 (23.2%) and lack of support and encouragement to report 29 (20.4%) were
the reasons for not using. Moreover, formal (separate) HIV post-exposure prophylaxis center
with proper guideline was non-existent in the study areas (3).

A total of 164 questionnaires were distributed and 131 were returned giving a response rate of
80%. The results of the study show that majority of the participants had poor knowledge of
occupational HIV PEP. 65% of the respondents scored less than 50% in the section on
knowledge, which was regarded as poor knowledge. Only 5% of the respondents scored above
75% which was regarded as good knowledge. Participants were found to have a positive attitude
towards HIV PEP. The majority (93%) of respondents expressed willingness to undergo PEP in
case of exposure. Out of the 49 respondents who reported a previous exposure to potentially
infectious body fluids, only 45% sought PEP (4).

25.5% (n=13) of the participants in this research have treated at least one patient for HIV
infection, 19% (n=10), of them would willingly specialize in intense care of HIV patients and
lastly 90.2 %(n=46) believe that we should preserve the medical confidential for HIV patients.
96.1% (n=49) of the participants doctors knew that AIDS disease is caused by Human
Immunodeficiency Virus (HIV), 88.2 %(n=45) is aware that HIV virus damages the immune
system and finally 92% (n=47) recognize HIV symptomatology. The vast majority of the doctors
(98%, n=50) is aware that HIV infection is spread through sexual intercourse, blood contact and

9
by sharing needle or syringes. Nevertheless, a percentage of 13.7% (n=7) believe that HIV
transmission is feasible through kissing and 7.8% (n=15) through insects’ bites. At last 85-98%
of the personnel refer that it’s familiar with the general preventive measures, which are usually
applied to all HIV positive in patients (5).

An estimated 2.2 to 3.0 million people in Ethiopia are infected with HIV, and 1.2 million
children are AIDS orphans (Ministry of Health 2002; UNAIDS 2000). The complexity of the
HIV/AIDS epidemic and the high demands successful programs make on planners,
administrators, and people at risk constitute a tremendous challenge. HIV/AIDS now poses the
foremost threat to Ethiopia’s development, and its future depends on responding to the epidemic
fast and forcefully (6).

The study done in tertiary care hospitalAhmedabad, Mean age of Health care workers was 33.5
years, majority (50%) in the age group of 20-30 years. 61% HCWs had less than 5 year of work
experience. 67% HCWs had received hepatitis B vaccination of which only 17.9% had carried
out Anti HBs antibody checkup. Knowledge about disease transmitted by NSIs was satisfactory.
Though 36% had suffered Needle stick injury (NSIs), only 8.3% reported the incident of NSIs.
81% HCWs know about universal precaution guidelines (15).

The commonest clinical activity to cause the NSI was blood withdrawal (55%), followed by
Suturing (20.3%) and vaccination (11.7%). The practice of recapping needles after use was still
prevalent among HCWs (66.3%). Some HCWs also revealed that they bent the needles before
discarding (11.4%). It was alarming to note that only 40 per cent of the HCWs knew about the
availability of PEP services in the hospital and 75 per cent of exposed nursing students did not
seek PEP (16).

A total of 300 questionnaires were administered and 186 were returned. Only 175 had adequate
information and were included in the analysis. There were 43 (24.6%) female respondents with
a mean age 38 ± 7 years but ranged from 27-64 years.Majority (97.7%) of the respondents was
aware of the concept of HIV PEP and 99.4% believed it was effective in preventing HIV
transmission. Over two third of our respondents had been exposed to NSI; however, less than
25% of those exposed received PEP. There was high level of knowledge of the various high-risk

10
body fluids as well as types of high-risk exposures. 93.9% of our respondents knew that HIV
PEP should commence within 1 h of exposure, 83.3% knew the correct duration of HIV PEP, but
only 57.0% knew the ideal PEP regimen for high-risk exposures. The total mean score for our
respondents was 17.8±2.9 with 79.4% having an adequate score. Being a junior doctor and male
sex were associated with adequate knowledge (17).

One hundred and seventy-one (97.7%) of the respondents were aware of the concept of HIV post
exposure prophylaxis. One hundred and forty two (82.1%) had existing protocols for HIV PEP at
their workplaces, 13 (7.5%) did not have HIV PEP protocols at their workplaces, and 18 (10.4%)
were not aware of the existence of HIV PEP protocols in their facilities, 158 (91.3%) indicated
that they were at risk of acquiring HIV from the workplace while 15 (8.7%) indicated otherwise.
94 (54.7%) respondents had daily contact with body fluids, 30 (17.4%) had weekly contact while
48 (27.9%) handled body fluids infrequently. One hundred and twenty (69.4%) of the
respondents reported history of needle stick injuries and majority (66.7%) of those reporting
needle stick injuries (NSI) had had multiple injuries. Only 26 (21.6%) of the 120 respondents
that had history of NSI had received antiretroviral prophylaxis following such NSI. (17)

A cross-sectional, descriptive study using self-administered questionnaires was conducted among

HCWs in the obstetrics and gynecology department of an Indonesian teaching hospital from
September-October 2007. The survey included 524 HCWs with a response rate of 72% (n=377).
The results indicated that the level of knowledge regarding hand washing, personal protective
equipment, medical waste disposal and post exposure prophylaxis was high, over mean score of
71.8. However, level of knowledge regarding instrument processing and medical sharps disposal
was low. Perceived adherence was low as reported by majority of respondents (95%). There was
significant association between knowledge and attitude (r=0.235; P<0.001); knowledge and
perceived adherence (r=0.314; P<0,001); attitude and perceived adherence (r=0.233; P<0.001).
This study suggest tailor made interventions were needed to improve adherence to UP (18).

In this study participants considered the following fluids, not blood stained, high risk for HIV
transmission: breast milk (79%), saliva (14%), urine (27%), pleural fluid (53%), CSF (55%),
synovial fluid (37%), faces (27%), peritoneal fluid (53%) and vomitus (21%). The respondents
estimated the risk of transmission of infection after a needle stick injury from a patient with:

11
HIV, mean 22.5%, HBV, 34% and HCV, 26%. Needles for drawing blood were identified as
having the highest risk for transmission of infections in 63%. The following precautions were
adhered to all the time: wearing gloves (38%), not reheating needles (22%), not passing needles
directly to others (70%), properly disposing of sharps (86%) and regarding patients' blood and
other high risk fluid as potentially infected (62%). Post exposure, 43% indicated
bleeding\squeezing the NSI site as the initial first-aid procedure, washing with soap and water
(29%) and irrigating the area with water (20%)(19).

In the paired case studies, the theoretical responses of participating health professionals showed a
greater preference for initiating self-directed treatment with antiviral or immunization rather than
complying with the hospital protocol, when the patient was known to be infected. The
differences in practice when exposed to a patient with suspected blood pathogens compared to
patient known to be infected was statistically significant (p < 0.001) in all 3 paired cases. Failure
to test an infected patient's blood meant that an adequate risk assessment and appropriate
secondary prevention could not be performed, and reflected the unwillingness to report the
occupational exposure (20).

A cross-sectional survey conducted on 230 health care providers in UATH. Majority (97.0%) of
the respondents have heard about PEP, but only a few (30.9%) of them could correctly identify
the drugs used and duration of PEP. A third of respondents have had one form of accidental
exposure or the other. HIV test was carried out in about two-thirds (64.8%) of the source
patients. Thirteen (28.3%) of the source patients were HIV-positive. Of the 13 respondents that
were exposed to HIV-positive patients, only 3 (23.1%) received PEP, and these three completed
PEP, while majority, 10/13 (76.9%) did not receive PEP in spite of their exposure to HIV-
positive source (21).

Overall correct knowledge about causative agent was observed among 90.13% HCP. Knowledge
regarding HIV/AIDS transmission was found to be significantly higher among medical
personnel. Overall 74.94% HCP had correct knowledge about the symptoms of the disease.
87.34% of care providers had correct knowledge about post-exposure prophylaxis (PEP) while
66.67 % of them could able to tell correct drugs used in PEP, while 90.89% stated correctly
about universal safety precautions. Correct knowledge about diagnosis of HIV/AIDS was known

12
to 96.96% of HCP. 89.11% HCP stated correctly that disease is not curable. 96.20% study
subjects had correct knowledge about prevention of HIV/AIDS. Awareness about NACP was
present in 93.67% of care providers. Fear of contagion was reported by 39.24% HCP. ‘AIDS
patient should be kept in isolation’ was the opinion of 25.57% of HCP (22).

Regarding knowledge- the majority knew the very important issues related with laboratory safety
like Post Exposure Prophylaxis (96.55%) & discarding of blood samples (93.10%) etc. In regard
to attitude towards the scientific process, all are very much aware about importance of protective
devices (i.e. Wearing Gloves) and Biomedical waste management. In regard to the practice in
laboratory, the entire study subject group (100%) replied “YES” in each question that shows the
good quality work of the laboratory (23).

13
3.OBJECTIVES

3.1. General objectives

 To assess the knowledge, attitude and practice of health workers about PEP against HIV/
AIDS in JUSH, south west Ethiopia, Jimma zone, oromia, Ethiopia.

3.2. Specific objectives

 To assess the knowledge of health workers about PEP and other measures taken following
occupational exposure.
 To assess the attitude of HCWs about PEP after occupational exposure.
 To assess the practice occupational risk that HCWs exposed and use of HCWs about PEP
after occupational exposure.
 To assess the previous occupational risk that HCWs exposed and use of PEP for
HIV/AIDS.
 To assess the predominant sample type which the HCWs exposed occupationally at
working time.
 To assess the knowledge of HCWs about occupational risk of HIV/AIDS

14
4. METHODOLOGY

4.1.Study area and study period

The study will be conducted on health workers in JUSH, which is located in south west Jimma
zone, oromia, Ethiopia, 345km away from Addis Ababa from Jan 28/2013 to Feb 8/2013. Since
it is the only referral hospital in this area currently it is giving service to the people living in
south west Ethiopia and surrounding areas.

4.2.Study design

A cross sectional study,self-administered structured questionnaire will be filled by HCWs of

JUSH form as the collection data tool.

4.3. Study population

4.3.1.Source population

All health care workers in JUSH

4.3.2.Sample population

All HCWS excluding sanitarians, pharmacy professionals and students that working in JUSH
during the study period will be included in the study.

4.4.Sample size and sampling technique

No sampling technique will be employed as the study is aimed to include all actively participated
HCWs in JUSH.

4.5.Study variables

4.5.1.Independent variables

Socio demographic variables, Professional type, Ward section, year service

15
4.5.2.Dependent variables

Knowledge about PEP, Attitude about effectiveness of PEP, Practice of PEP

4.6. Method of data collection

The data will be collected by using structure self-administered questionnaires.

4.7. Data processing and analysis

The data will be analyzed by using scientific calculators and it will presented by using figures
and tables.

4.8.Ethical consideration

The formal written consent for the conduct of the study obtained from Jimma university
department of pharmacy in collaboration with office of SRP will be done with the respective
medical director, to get permission for the study. in addition a brief explanation about the
purpose of the study will give to HCWs and to the consent of the confidentiality ; Name, identity
of the HCWs will convinced that the study mean academic purpose4 and the letter gets
acceptance and the data will be collected.

16
 5. WORK PLAN

S.No. Activities Responsible body

1 Topic selection PI &Adv.

2 Proposal preparation PI
First proposal draft
3 PI
submission
Final proposal draft
4 PI
submission
Collection of budget,
5 PI
material & other resource
6 Data collection PI
Data analysis &
7 PI
interpretation
8 Report writing PI
First research draft
9 PI
submission
Feedback & discussion
10 PI& Adv.
with advisor
Paper finalization
11 PI& Adv.
submission
12 Presentation PI
13 Monitoring PI& Adv.

PI= Principal investigator

Adv. = Advisor

17
 6. BUDGET BREAKDOWN

Description Item Unit price Quantity Total price (Br)

Personnel secretary 200.00 Br. 1x200.00 200.00

Stationary cost Duplicating paper 90.00 Br. 2x90.00 180.00

Pen 3.50 Br. 3x3.50 10.50

Pencil 1.50 Br. 1x1.50 1.50

Flash disk 150.00 Br. 1x150.00 150

Total 542.00

18
7. REFERANCES

1. UNAIDS Report on the global AIDS epidemic 2012.

2. Young TN, Arens FJ, KennedyGE,LaurieJW,RutherfordGw, Bosena T, BSc, MSc/RH1 and Chernet
H, BSc, MPH2. Ethiopian Journal of Health Sciences are provided here courtesy of College of Public
Health and Medical Sciences of Jimma University. Volume 20:No.1:55-64; march 2010.
3. T Monera, P Ncube. Journal of the International AIDS Society | eISSN 1758-2652 | Editors-in-Chief:
Mark Wainberg, Susan Kippax and Papa Salif Sow
4. International Journal of Caring Sciences; www.inernational journal of caring scienes.org Vol 3: Issue
2; 2010 May-August
5. Kloos, Helmut.M ,Damen H. An Overview HIV/AIDS in Ethiopia: Northeast African Studies,
Published by Michigan State University Press. Volume 7, No. 12000 (New Series): 13-40; 2004.
6. Chiamaka N.U , M.D., M.P.H1, E. James Essien, M.D., Dr.P.H1,2, Emmanuel N. E , M.D3, and
Michael W. R , Ph.D1 .1WHO Center for Health Promotion and Prevention Research, School of Public
Health, University
7. AfiaZafar (Department of Pathology and Microbiology. Aga Khan University, Karachi.)Naveen
Aslam,NosheenNasir,RiffatMeraj( Medical College. Karachi. ) VikramMehraj( Department of Pathology
and Microbiology. Khan University, Karachi.)
8. R.Alenyo, J.Fualal, J.J Jombwe. Department of Surgery, Mulago Hospital, Kampala – Uganda
9. World Bank 2000; Overview of HIV epidemic & impact of HIV/AIDS in Ethiopia, ADDIS ABABA;
July, 2006.
10. Hansa M1, Sumeeta T2, Sachin M3, Mitesh K4. National Journal of Community Medicine.Vol 2:
Issue 3 Oct-Dec 2011 .
11. Zaidi MA et al. Moazzam Ali ZAIDI 1, Robin GRIFFITHS 1, Salem A BESHYAH 2, Julie
MYERS 1 andMukarram A ZAIDI 3 .Safety and Health at Work . Vol. 3, No. 3, Sep. 30, 2012.
12. HIV Prevention Knowledge Base A Collection of Research and Tools to Help You Find What
Works in Prevention
13. (Caldwell 2000; Carael, Buve, and Awusabo-Asare 1997; Eshete et al. 1993; Farmer, Connors,
and Simmons 1996; Foreman 1999; Kloos 1993; Setel 1999).
14. Rakesh Shah 1, H.K. Mehta 2, Manish Fancy3, Sunil Nayak4, Bhavesh N. Donga5.Original
Article ,KNOWLEDGE AND AWARENESS REGARDING NEEDLE STICK INJURIES AMONG
HELATH CARE WORKERS IN TERTIARY CARE HOSPITAL IN AHMEDABAD, GUJARAT

19
1Assistant Professor, Community Medicine Department, Smt. N.H.L. Municipal Medical College,
Ahmedabad,
15. SumathiMuralidhar, Prashant Kumar Singh*, R.K. Jain, MeenakshiMalhotra&ManjuBala
Regional STD Teaching Training & Research Centre, Safdarjang Hospital, *VardhmanMahavir Medical
College &Safdarjang Hospital, New Delhi, India
16. Patricia A Agaba1, Emmanuel I Agaba2, Amaka N Ocheke3, Comfort A Daniyam2, Maxwell O
Akanbi2, Edith N Okeke2. ORIGINAL ARTICLE ,Awareness and knowledge of human
immunodeficiency virus post exposure prophylaxis among Nigerian Family Physicians Volume : 53
Issue : 3; Page : 155-160 ; 2012.
17. Department of Family Medicine, University of Jos, Jos; Department of Family Medicine, AIDS
Prevention Initiative Nigeria Plus, Jos University Teaching Hospital, Jos, Nigeri
18. Sari ,Int J Infect Control 2011, v7:i4 doi: 10.3396/ijic.V7i4.036.11 ,International Journal of
Infection Control Knowledge, attitude and perceived adherence with universal precautions among health
care workers in the obstetrics and gynecology department of an Indonesian teaching hospital
.www.ijic.info ISSN 1996-9783
19. West Indian Medical Journal Print version ISSN 0043-3144 West Indian med. j. vol.59 no.2
Mona Mar. 2010.surname
20. Moazzam Ali Zaidi,1 Robin Griffiths,1 Salem A Beshyah,2 Julie Myers,1 and Mukarram A
Zaidi3. Blood and Body Fluid Exposure Related Knowledge, Attitude and Practices of Hospital Based
Health Care Providers in United Arab Emirates, 1Occupational and Aviation Medicine, University of
Otago, Wellington, New Zealand.2Department of Medicine, Sheikh Khalifa Medical City, Abu Dhabi,
UAE.
21. Rotimi S Owolabi, Peter Alabi, Samuel Ajayi, Olusoji Daniel, AdeniyiOgundiran, Tanimola M
Akande: J IntAssoc Physicians AIDS Care (Chic). 2011 Apr 21: 21511981
22. S. S. Rajderkar1, Sanjivani. D. Langare 1*, J. D. Naik 1. International Journal of Health Sciences
& Research (www.ijhsr.org) 83 Vol.2; Issue: 1; April 2012.
23. Hansa M Goswami 1, Sumeeta T Soni 2, Sachin M Patel3, Mitesh K Patel 4. National Journal of
Community Medicine: Vol2;Issue 3 Oct-Dec 2011.

20
 8. ANNEX
8.1. Annex – I: Dummy Table
Table 1: Socio demographic characteristics of respondent health care workers of JUSH.

Socio Demographic
Descriptions Number Percent
Characteristics
15-24
25-34
Age of respondents
35-44
>44
Male
Sex
Female
Medical
Surgery
Ward section
Gynecology and obestric
Pediatrics
<5

Service in year: 5-10

>10
Senior doctors
Resident doctors
Medical interns
Laboratory technologists
Field of profession
Laboratory technicians
Nurse
Midwife
Anesthetics

21
 Table 2: Distribution of HCWs based on their knowledge about occupational risk for HIV /AIDS
and universal precaution, in JUSH.

Senior Resident Medical Laboratory Laboratory

Knowledge on Nurse Midwife Anesthetics
Dr. Dr. interns Technologist Technicians

Occupational
Risk

Universal
Precaution

22
 Table 3: PEP of HIV - knowledge of respondent health workers of Jimma University specialized hospital.

Senior Resident Medical Laboratory Laboratory

Variables Nurse Midwife Anesthetics
Dr. Dr. interns Technologist Technicians
N. (%) N. (%) N. (%) N. (%) N. (%) N. (%) N. (%) N. (%)
PEP of HIV Knowledge Level
Adequate knowledge
Inadequate knowledge
Response for selected knowledge
questions
PEP reduces the likelihood of HIV infection
after exposure
Correct response
Not correct response
Measures to be taken after someone
encounters needle stick injury at work place
Correct response
Not correct response
Procedures of PEP of HIV
Correct response
Not correct response
Measures to be taken when someone
exposed to patients’ blood
Correct response
Not correct response

23
 Table 4: Distribution of HCWs based on their knowledge about the availability of PEP and
number of drugs used for PEP in JUSH.

Senior Resident Medical Laboratory Laboratory

Response

Nurse Midwife Anesthetics

Knowledge Dr. Dr. interns Technologist Technicians
on
N. (%) N. (%) N. (%) N. (%) N. (%) N. (%) N. (%) N. (%)

Yes

Availability
of PEP
No

One

Number of Two
drug used

Three

24
 Table 5: Respondent health workers knowledge about occupational risk conditions for
HIV/AIDS in JUSH.

Variables Profession / occupational status

Anesthetics
Senior Resident Medical Laboratory Laboratory
Nurse Midwife
Occupational Dr. Dr interns Technologist Technicians
Risk

N. (%) N. (%) N. (%) N. (%) N. (%) N. (%) N. (%) N. (%)

Needle
stick/sharp
cut

Exposure to
blood

Exposure of
body flood

Others

25
Table 6: Respondent health workers’ perceived cause of exposure to HIV risk conditions and
reasons for not using PEP of HIV in JUSH.

Health care workers

Variables
Frequency Percent

Perceived cause of exposure to HIV risks:

Lack of protective barriers

Lack of Knowledge on standard precautions

Heavy work load

Others

Reasons for not using PEP:

Unaware of the existence of PEP service and protocol

Lack of understanding the value of reporting exposures

Fear of stigma and discrimination

Fear of judgment from colleagues

Uncertain about confidentiality

Lack of support and encouragement to report

Client tested negative

26
 Table 7: HCWs by their knowledge about the time of initiation and duration of PEP for
HIV/AIDS in JUSH.

Senior Resident Medical Laboratory Laboratory

Nurse Midwife Anesthetics
Occupation Dr. Dr. interns Technologist Technicians

N. (%) N. (%) N. (%) N. (%) N. (%) N. (%) N. (%) N. (%)

Optimal As
period soon
of as
initiation
of PEP 24hr

24-
72hr

>72hr

≤2wks
Duration
3wks
of PEP
4wks

>4wks

27
 Table 8: Distribution of HCWs by their past occupational exposure to HIV /AIDS in JUSH.

Variables Profession / occupational status

Senior Resident Medical Laboratory Laboratory

Nurse Midwife Anesthetics
Occupational dr. dr interns Technologist Technicians
risk
N. (%) N. (%) N. (%) N. (%) N. (%) N. (%) N. (%) N. (%)

Needle
stick/sharp
cut

Exposure to
blood

Exposure of
body flood

Others

Table 9: Attitude of HCW stewards the effectiveness of PEP for HIV/AIDS in JUSH.

Senior Resident Medical Laboratory Laboratory

Nurse Midwife Anesthetics
Dr. Dr. interns Technologist Technicians

Effectiven
ess N. (%) N. (%) N. (%) N. (%) N. (%) N. (%) N. (%) N. (%)

Strongly
agree

Agree

Undecided

Disagreed

Strongly
dis agree

28
 Table 10: Health care workers exposure to HIV risk conditions and practice of PEP after
exposure

Senior Resident Medical Laboratory Laboratory

Nurse Midwife Anesthetics
Dr. Dr. interns Technologist Technicians
Variables

N. (%) N. (%) N. (%) N. (%) N. (%) N. (%) N. (%) N. (%)

Ever been
exposed YES
to

HIV risk
conditions
NO

Practice
of PEP YES
after
exposure
NO

29
8.2. Annex-II: Data collection format

I. Demographic characteristics

1. Age _______

2. Sex M F

3. Occupational status:a. Senior Dr.

b. Resident Dr.f. Laboratory technologist

c. Medical intern g. Laboratory technician

d. Anesthetics h. Midwifee. Nurse

4. Service in year : a) <5 b) 5-10 c) > 10

5. Ward work at a time: a) medical ward c) Gynecology &obestrics

b) Surgery ward d) Pediatrics e) emergency ward

II. Knowledge

6. Do you know the risk of occupational exposure for HIV/AIDS?

A) Yes B) No

7. If yes to Q6what risk do you know?

a) Needle stick/sharp cut b) exposure to blood c) exposure to body fluid d) others

8. Do you know about universal safety precaution procedure for decreasing risk of exposure?

A) Yes b) No

9. If yes to Q8 what safety precaution do you know?

a) Hand washing before and after procedure. C) Careful handling of sharp materials

b) Washing gowns, gloves masks d) disinfect and sterilized reusable devices

e) Proper disposal of used needles

10. Do you know about PEP for HIV /AIDS after occupational exposure at work time?

A) Yes B) No

11. If yes to Q10 is it available in your hospital?

30
 A) Yes b) No

12. Which drug regimen do you know to use for PEP? (More than one answer is possible)

a) Two NRTIs (ZDV: 300 mg BID or 200 mg TID + 3TC: 300 mg QD or 150 mg BID)
b) Two NRTIs(ZDV: 300 mg BID or 200 mg TID + FTC: 200 mg QD)
c) Two NRTIs (TDF: 300 mg QD + 3TC: 300 mg QD or 150 mg BID)
d) Two NRTIs (TDF: 300 mg QD + FTC: 200 mg QD)
e) Two NRTIs (3TC: 300 mg QD or 150 mg BID + d4T:≤ 40 mg BID)
f) Two NRTIs(FTC: 200 mg QD + d4T: :≤ 40 mg BID)
g) Two NRTIs (3TC: 300 mg QD or 150 QD + ddI: ≤200mg BID or 400 mg QD).
h) Two NRTIs (FTC: 200 mg QD + ddI: ≤ 200 mg BID or 400 mg QD).
i) Two NRTIs +PI (Basic regimen +LPV/RTV: 400/100 mg QD )
j) Two NRTIs+PI (Basic regimen +ATV /RTV : ≤ 400 / 100 mg QD)
k) Two NRTIs+PI ( Basic regimen+ IDV/ RTV: 800 /100 mg BID)

13. What is the recommended time to initiation of HIV PEP after exposure when PEP is indicated?

A. As soon as possible (preferably within hours)

B. 24 hrs.
C. 24–72 hours.
D. >72hrs.

14. What is the recommended duration of HIV PEP for occupational exposures to HIV?

A. 7 days.B. 14 days.C. 21 days.D. 28 days.E. 2 months

III. Attitude

15. What is your attitude about the usage of PEP after occupational exposure?

a. Strongly agree. b. Agree c Undecided. d. Disagree e. strongly disagree

16. What is your idea about the efficacy of PEPS?

a. Strongly agree. b. Agree c Undecided. d. Disagree e. strongly disagree

IV. Practice

17. Have you ever had any exposure while at work?

a) Yes b) No

18. If yes to Q17 what risk of occupational exposure do you have while at work?

31
a) needle stick / sharp cut b) exposure to blood c) exposure to body fluids d) others

19. What was the sero-status of the source patent?

A) Positive b) negative

20. If for Q19 is positive or unknown have you tried to get PEP service?

A) Yesb) No

21. If for Q20 is yes have you completed according to the prescription?

A) Yes b) No

22. If for Q20 is No why you haven’t tried to get PEP service?

a) Unaware of the existence of PEP service and protocol

b) Lack of understanding the value of reporting exposures
c) Fear of stigma and discrimination
d) Fear of judgment from colleagues
e) Uncertain about confidentiality
f) Lack of support and encouragement to report
g) Client tested negative

32