Getting the testing message across: Effectiveness of a poster and a guide in improving
the knowledge and practice of HIV testing among intern medical officers : A quasi experimental study. Premadasa PS*, Azraan A*, Widanage WN*, Perera TMAS* *Registrars in venereology National STD/AIDS control Programme, Ministry of Health, Sri Lanka. 1
Introduction
• Sri Lanka is a low HIV prevalence country. • Reducing the existing gap between the estimated and the reported number scaling up of HIV testing is essential. • Promotion of provider initiated HIV testing is recognized as one of the effective strategies in achieving the above goal. • Adults detected at ward setting were significantly immunocompromised at the time of diagnosis. • It is evident for many HIV patients, testing has been offered late despite repeated hospital admissions with HIV related illnesses.
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Introduction ctd; • Late diagnosis is associated with increased mortality, morbidity and impaired response to ART . • It was observed that the practice of HIV testing and knowledge on certain clinical indications among intern medical officers were not satisfactory. • Therefore methods of improving the knowledge and practice of HIV testing should be explored.
3
Objectives • The aim of the study was to investigate the effectiveness of – a poster & – a guide ( on requesting an HIV test in ward setting)
in improving the knowledge and practice of HIV testing among intern medical officers attached to eight teaching hospitals in Sri Lanka. 4
Methodology • Study design : A Quasi experimental study
Base line assessment
Knowledge and practice of HIV testing
Intervention (2 months)
• Poster • Guide
Post intervention assessment
Knowledge and practice of HIV testing
5
Methods ctd:
Sample size & selection:
182 intern medical officers attached to 8 teaching hospitals in Sri Lanka. Control group (N=91)
Intervention group (N=91)
1- T.H Karapitiya 2- T.H Colombo south 3- Castle street 4- T.H Sri Jayawardanapura
1- NHSL 2-T.H Colombo north 3- DMH 4- T.H Kandy
33
Medicine
33
33
Surgery
33
25
Gyn/Obs
25
6
• Study instrument : A pre tested structured self administered questionnaire used to assess; – The knowledge on clinical indications for HIV testing . – The knowledge on HIV testing procedure. – The current practice of HIV testing in the ward setting 7
Methodology • Baseline data collection
Base line assessment
Knowledge and practice of HIV testing
Intervention (2 months)
• Poster • Guide
Post intervention assessment
Knowledge and practice of HIV testing
8
• Interventions: 1.
A poster Displayed in the clerking area on indications for HIV testing developed using the UK national guideline for HIV testing in adults (2008) and with the inputs of local expertise.
2. A guide On requesting an HIV test in the ward setting (consent, specimen collection, lab info;). 9
Methodology • Intervention
Base line assessment
Knowledge and practice of HIV testing
Intervention (2 months)
• Poster • Guide
Post intervention assessment
Knowledge and practice of HIV testing
10
11
Poster was displayed in the clerking area
12
Provider initiated HIV testing protocol for wards
1. When to offer HIV screening in ward? • All the patients with clinical indications should offer screening for HIV. • All patients without clinical features but with background and behavioral risk factors for HIV should offer HIV testing (eg: Drug addicts, migrant workers). 2. Inform consent • • • • • •
May not need detailed pre test counseling Minimum information to be given including reason for testing and benefit (clinical and prevention) of testing. Patients should be informed that he/she has the right to decline and the fact that declining will not affect the services and care provided to the patient. Confidentiality should be ensured to the patient during the testing procedure and in delivering reports. If patient declines an HIV test, it should be clearly documented on medical records In critically ill or unconscious patients consent should be obtained from guardian or caregiver.
3. How to send the sample? Specimen
Whole blood
Collection Labeling
5ml of venous blood collected to a plain tube Name, age, sex, ward number, BHT number and HIV Ab test Keep on the room temperature for ½ - 1 hour until clot is formed. Then refrigerate at 4-8 0C and send to lab within 2-3 days. Separate tightly closed container Normal blood request form. ( Do not put it inside the container )
Storage Transport Request form
4. Further information: Please refer back for the contact details of STD clinics in Sri Lanka.
Clinic National STD/AIDS Control Programme (central STD clinic) Ragama Kalubowila Mahamodara Ampara Anuradhapura Badulla Balapitiya Batticaloa Chilaw Gampaha Wathupitiwala Hambantota Jaffna Kalutara Kalmunai Kandy Kegalle Kurunegala Mannar Matale Matara Monaragala Negambo Nuwaraeliya Polonnaruwa Ratnapura Trincomalee Vavuniya
Address
Telephone
No 29, De Saram Place, Colombo 10 Teaching Hospital, Ragama Teaching Hospital, Kalubowila. Teaching Hospital, Mahamodara Hospital Road, Ampara Teaching Hospital,Anuradhapura Provincial General Hospital, Badulla Base Hospital, Balapitiya Teaching Hospital, Batticaloa District General Hospital, Chilaw Base Hospital, Gampaha Base Hospital, Wathupitiwala Base Hospital, Hambantota Teaching Hospital, Jaffna District General Hospital, Kalutara Base Hospital A, Kalmunai P.O. Box 207, Kandy District General Hospital, Kegalle Teaching Hospital, Kurunegala District General Hospital, Mannar District General Hospital, Matale District General Hospital, Matara District General Hospital, Monaragala Base Hospital, Negambo District General Hospital, Nuwaraeliya District General Hospital, Polonnaruwa Provincial General Hospital, Ratnapura District General Hospital, Trincomalee District General Hospital, Vavuniya
011-2-667163 011-2-696433 011-2-960224 011-4-891055 091-2-245998 063-3-636301 025-2-236461 055-2-222578 091-3-094667 065-2-222261 032-2-220750 033-2-234383 033-2-280261 047-2-222247 021-2-222261 034-2-236937 067-2-223660 081-2-203622 035-2-231222 037-2-224339 023-2-250573 066-2-222261 041-2-232302 055-2-276261 031-2-224156 052-2-223210 027-2-225787 045-2-226561 026-2-222261 024-2-224575
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Methodology • Post intervention data collection done
Base line assessment
Knowledge and practice of HIV testing
Intervention (2 months)
• Poster • Guide
Post intervention assessment
Knowledge and practice of HIV testing
14
Results • Base line knowledge on clinical indications and on testing procedure in both intervention and control groups were comparable. • Therefore the improvement was assessed comparing the intervention and control groups following the intervention (independent sample t test).
15
Knowledge on clinical indications for HIV testing
16
Results - knowledge on clinical indications > 20% improvement Control group
Clinical condition
Intervention group Progressive multifocal leucoencephalopathy Primary CNS lymphoma Vaginal intraepithelial neoplasia Pulmonary tuberculosis Pulmonary tuberculosis Severe or recalcitrant (uncontrolled or refractory)‌ Cerebral abscess Cervical intraepithelial neoplasia Severe or recalcitrant (uncontrolled or refractory)‌ Salmonella , shigella or campylobacter infections Dementia Dementia Non Hodgkins lymphoma Non Hodgkin's lymphoma Aspergilosis Cerebral toxoplasmosis Anal cancer or anal intraepithelial neoplasia Unexplained thrombocytopenia Unexplained thrombocytopenia Space occupying lesion of unknown origin Recurrent oral ulcers Unexplained neutropenia Cervical cancer Cervical cancer Guillain-Barre syndrome Guillain Barre syndrome Transverse myelitis Transverse myelitis Cryptococcal meningitis Peripheral neuropathy Peripheral neuropathy Unexplained retinopathy Leucoencephalopathy Recurrent Bacterial pneumonia
The correct response rate of the participants 0%
20%
40%
60%
80%
35%
100%
76%
25%
64%
21%
56%
26%
59%
36%
69%
27%
60%
32%
63%
18%
47%
7%
35%
24%
53%
27%
49%
55% 77%
63% 32%
88%
57%
47%
73%
34% 52%
58% 76%
67% 42% 10% 24%
90%
65%
33% 47% 32% 32% 35%
70%
92%
53% 53% 56% 55%
75%
17
The clinical condition
Results (improvement following intervention) knowledge on WHO stage 1 clinical condition
90%
Unexplained persistent generalized lymphadenopathy
Intervention group 79%
Control group
72% 74% 76% 78% 80% 82% 84% 86% 88% 90% 92%
Percentage who correctly identified the condition as an indication for HIV testing 18
Results (improvement after intervention) knowledge on WHO stage 2 clinical conditions 84%
Multidermatomal or recurrent herpes zoster
84%
86%
Clinical conditions
Weight of unknowncause cause Weight loss loss of unknown
Angular chelitis Angular chelitis
74%
32% 18%
Intervention group Control group 76%
Recurrent oralulcers ulcers Recurrent oral
Severe or recalcitrant or Severe(uncontrolled or refractory refractory) seborrhoeicdermatitis dermatitis seborrhoeic
52%
69% 36% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100%
Percentage who correctly identified the condition as an indication for HIV testing 19
Results (improvement after intervention) knowledge on WHO stage 3 clinical conditions Percentage who correctly identified the clinical condition as an indication for HIV testing 0%
Pulmonary Pulmonarytuberculosis tuberculosis
The clinical conditions
Unexplained Unexplainedthrombocytopenia thrombocytopenia
10%
20%
30%
40%
50%
60%
Oral hairy leukoplakia
80%
90% 100%
59% 26% 73% 47%
Unexplained Unexplainedneutropenia neutropenia Oral Oralcandidiasis candidiasis
70%
90% 67%
Intervention group Control group
56% 46% 79% 70%
Chronic diarrhea of unknown cause
91% 88%
Pyrexia of unknown origin
91% 89%
20
Results (improvement after intervention) knowledge on WHO stage 4 clinical conditions Percentage who correctly identified the clinical condition as an indication for HIV testing 0%
10%
20%
30%
Progressive multifocal leucoencephalopathy Progressive multifocal leucoencephalopathy Primary Primary CNS CNS lymphoma lymphoma
The clinical conditions
Non NonHodgkins Hodgkins lymphoma lymphoma
40%
50%
60%
35% 25% 27%
55% 63% 55% 53%
Cytomegaloviral retinitis retinitis Cytomegaloviral
Kaposis sarcoma Oesophageal candidiasis Pneumocystis jirovecii pneumonia
90% 100%
64%
Recurrent Bacterial bacterial pneumonia pneumonia
Extra Extrapulmonary pulmonary tuberculosis tuberculosis
80%
76%
Cerebral Cerebraltoxoplasmosis toxoplasmosis
Aseptic Asepticmeningitis/encephalitis meningitis/encephalitis
70%
41%
88%
Control group
75%
Intervention group 71%
58% 70%
86% 86%
92%
87%
93%
90% 95%
21
Knowledge on clinical indications for HIV testing • 48 clinical indications : 2 marks for each correct answer. • Good knowledge : >70 % marks • Average knowledge : 41 – 69 % marks • Poor knowledge : < 40 % marks Improvement of the knowledge on clinical indications Number of participants
Knowledge grading
0
10
20
30
40
50
60
47
average
33
Control group
poor
Intervention group
15
good
49
29 9
22
Improvement of the mean knowledge following the intervention (Independent sample t test) 80 70.22
Mean knowledge score
70 60 50 40
N=91 p<0.001 95% CI : 15.42 - 28.53
48.24 50.81 48.57
Before the intervention
30
After the intervention
20 10 0
Control group
Intervention group
23
Knowledge on HIV testing procedure
24
Improvement of knowledge on testing procedure following the intervention (Independent sample t test) 41%
volume required
20%
89%
Tube/Container
Intervention group
66%
Control group 93%
specimen needed
54% 0
10
20
30
40
50
60
70
80
90
100
Percentage who responded correctly 25
Knowledge on testing procedure
Improvement of knowledge on testing procedure following the intervention (Independent sample t test) 5
poor
27
55
good
Intervention group
12
Control group 40
average
60
0
10
20
30
40
50
60
70
Number of participants 26
Practice of HIV testing â&#x20AC;˘ Base line number of HIV tests requested by the IMOs in both intervention and control groups were not comparable. â&#x20AC;˘ Therefore the improvement was assessed comparing the practice of the intervention group before and after the introduction of the poster (t test- paired two sample for means).
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Mean number of HIV tests requested during the past 2 months
Mean number of tests requested by one participant in the intervention group (t test-paired two sample for means) 12.00
10.93
df -89 , p= 0.20
10.00
8.00
6.00
4.00
7.02
6.34
df -89 , p= 0.46
4.96
4.59
df -89 , p= 0.08 Decided on own
2.00
After senior opinion
2.07
Total 0.00
Before the intervention
After the intervention
28
Clinical conditions considered in requesting HIV tests in the intervention group Number of participants requested HIV testing 0
5
10
15
35
2 8 9 14
Before the intervention After the intervention
3
Oral candidiasis
4
Patients with foriegn travels
Hepatitis B or C
30
31
Pulmonary tuberculosis
Prisoners
25
23
Pyrexia of unknown origin Chronic diarrhoea
20
6 2 5 29
How many noticed the poster?
N=91
N=91
9, 10% 82, 90%
82, 90%
N=82
N=75
75 (91.4%)
66 (88 %)
Referred the poster
Referred the protocol
Number of IMOs who have noticed the poster - 82 Number of IMOs who have not noticed the poster - 9
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Conclusion • The knowledge on clinical indications for HIV testing and testing procedure has significantly increased following the introduction of the poster and the guide to the ward setting. • The practice of ordering HIV testing by the intern medical officers has also improved following the intervention. • Poster and the testing guide are shown to be an effective way to improve HIV testing in ward setting. 31
Limitations â&#x20AC;˘ Data cannot be generalized as it only represents eight teaching hospitals in Sri Lanka. â&#x20AC;˘ Number of HIV tests carried out by the IMOs was assessed asking the respondents to recall (recall bias).
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Recommendations ď&#x192;&#x2DC;Reducing the high number of late diagnoses and improving early case detection is a public health priority; â&#x20AC;˘ Displaying of the poster and the guide island wide in ward settings as well as in clinic settings in both government and private sectors.
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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. 34
Acknowledgement • Dr C D Wickramasuriya, consultant venereologist, National STD/AIDS control programme. • All the intern medical officers included in the study. • All the colleagues assisted in data collection.
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