7 prageeth ho intervention study

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 venereologyNational 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.

2

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

5

Knowledge and

practice of HIV testing

Base line assessment

• Poster• Guide

Intervention(2 months)

Knowledge and


Post intervention assessment

Methods ctd:Sample size & selection: 182 intern medical officers attached to 8 teaching hospitals in Sri Lanka.

6

1- T.H Karapitiya2- T.H Colombo south3- Castle street4- T.H Sri Jayawardanapura

Control group (N=91)

1- NHSL2-T.H Colombo north3- DMH4- T.H Kandy

Intervention group (N=91)

33

33

2533

33

25

Medicine

Surgery

Gyn/Obs

• 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

8

Knowledge and



• Poster• Guide


Knowledge and



• 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 guideOn requesting an HIV test in the ward

setting (consent, specimen collection, lab info;).

9

Methodology• Intervention

10

Knowledge and



• Poster• Guide


Knowledge and practice

of HIV testing


11

Poster was displayed in the clerking area

12

13

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 5ml of venous blood collected to a plain tube Labeling Name, age, sex, ward number, BHT number and HIV Ab test

Storage 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.

Transport Separate tightly closed container Request form

Normal blood request form. ( Do not put it inside the container )

4. Further information: Please refer back for the contact details of STD clinics in Sri Lanka.

Clinic Address Telephone

National STD/AIDS Control Programme (central STD clinic)

No 29, De Saram Place, Colombo 10

011-2-667163 011-2-696433

Ragama Teaching Hospital, Ragama 011-2-960224 Kalubowila Teaching Hospital, Kalubowila. 011-4-891055 Mahamodara Teaching Hospital, Mahamodara 091-2-245998 Ampara Hospital Road, Ampara 063-3-636301 Anuradhapura Teaching Hospital,Anuradhapura 025-2-236461 Badulla Provincial General Hospital, Badulla 055-2-222578 Balapitiya Base Hospital, Balapitiya 091-3-094667 Batticaloa Teaching Hospital, Batticaloa 065-2-222261 Chilaw District General Hospital, Chilaw 032-2-220750 Gampaha Base Hospital, Gampaha 033-2-234383 Wathupitiwala Base Hospital, Wathupitiwala 033-2-280261 Hambantota Base Hospital, Hambantota 047-2-222247 Jaffna Teaching Hospital, Jaffna 021-2-222261 Kalutara District General Hospital, Kalutara 034-2-236937 Kalmunai Base Hospital A, Kalmunai 067-2-223660 Kandy P.O. Box 207, Kandy 081-2-203622 Kegalle District General Hospital, Kegalle 035-2-231222 Kurunegala Teaching Hospital, Kurunegala 037-2-224339 Mannar District General Hospital, Mannar 023-2-250573 Matale District General Hospital, Matale 066-2-222261 Matara District General Hospital, Matara 041-2-232302 Monaragala District General Hospital, Monaragala 055-2-276261 Negambo Base Hospital, Negambo 031-2-224156 Nuwaraeliya District General Hospital, Nuwaraeliya 052-2-223210 Polonnaruwa District General Hospital, Polonnaruwa 027-2-225787 Ratnapura Provincial General Hospital, Ratnapura 045-2-226561 Trincomalee District General Hospital, Trincomalee 026-2-222261 Vavuniya District General Hospital, Vavuniya 024-2-224575

Methodology• Post intervention data collection done

14

Knowledge and



• Poster• Guide


Knowledge and



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

0% 20% 40% 60% 80% 100%

Progressive multifocal leucoencephalopathyPrimary CNS lymphoma

Vaginal intraepithelial neoplasiaPulmonary tuberculosis

Severe or recalcitrant (uncontrolled or refractory) …Cerebral abscess

Cervical intraepithelial neoplasiaSevere or recalcitrant (uncontrolled or refractory) …Salmonella , shigella or campylobacter infections

DementiaNon Hodgkins lymphoma

AspergilosisCerebral toxoplasmosis

Anal cancer or anal intraepithelial neoplasiaUnexplained thrombocytopenia

Space occupying lesion of unknown originRecurrent oral ulcers

Unexplained neutropeniaCervical cancer

Guillain-Barre syndromeTransverse myelitis

Cryptococcal meningitisPeripheral neuropathy

Unexplained retinopathyLeucoencephalopathy

Recurrent Bacterial pneumonia

35%

25%

21%

26%

36%

27%

32%

18%

7%

24%

27%

49%

63%

32%

47%

34%

52%

67%

42%

10%

24%

70%

32%

32%

35%

55%

76%

64%

56%

59%

69%

60%

63%

47%

35%

53%

55%

77%

88%

57%

73%

58%

76%

90%

65%

33%

47%

92%

53%

53%

56%

75%

The correct response rate of the participantsCl

inic

al co

nditi

onControl group

Intervention group

Results - knowledge on clinical indications > 20% improvement

17

Pulmonary tuberculosis

DementiaNon Hodgkin's lymphoma

Unexplained thrombocytopenia

Cervical cancerGuillain Barre syndrome

Transverse myelitis

Peripheral neuropathy

Results (improvement following intervention) knowledge on WHO stage 1 clinical condition

18

79%

90%

72% 74% 76% 78% 80% 82% 84% 86% 88% 90% 92%

Unexplained persistent generalized lymphadenopathy

Percentage who correctly identified the condition as an indication for HIV testing

The

clin

ical

cond

ition

Intervention groupControl group

19

36%

52%

18%

74%

84%

69%

76%

32%

86%

84%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100%

Severe or recalcitrant (uncontrolled or refractory) seborrhoeic dermatitis

Recurrent oral ulcers

Angular chelitis

Weight loss of unknown cause

Multidermatomal or recurrent herpes zoster

Percentage who correctly identified the condition as an indication for HIV testing

Clin

ical

cond

ition

s

Intervention group

Control group

Results (improvement after intervention) knowledge on WHO stage 2 clinical conditions

Weight loss of unknown cause

Angular chelitis

Recurrent oral ulcers

Severe or refractory seborrhoeic dermatitis

20

59%

73%

90%

56%

79%

91%

91%

26%

47%

67%

46%

70%

88%

89%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%



Unexplained neutropenia

Oral candidiasis

Oral hairy leukoplakia

Chronic diarrhea of unknown cause

Pyrexia of unknown origin

Percentage who correctly identified the clinical condition as an indication for HIV testing

The

clin

ical

cond

ition

s

Intervention group

Control group




Unexplained neutropenia

Oral candidiasis

21

35%

25%

27%

63%

55%

53%

41%

70%

86%

87%

90%

76%

64%

55%

88%

75%

71%

58%

86%

92%

93%

95%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Progressive multifocal leucoencephalopathy

Primary CNS lymphoma

Non Hodgkins lymphoma

Cerebral toxoplasmosis

Recurrent Bacterial pneumonia

Cytomegaloviral retinitis

Aseptic meningitis/encephalitis

Extra pulmonary tuberculosis

Kaposis sarcoma

Oesophageal candidiasis

Pneumocystis jirovecii pneumonia

Percentage who correctly identified the clinical condition as an indication for HIV testing

The

clin

ical

cond

ition

s

Control group

Intervention group


Progressive multifocal leucoencephalopathy

Primary CNS lymphoma

Non Hodgkins lymphoma

Cerebral toxoplasmosis

Recurrent bacterial pneumonia

Cytomegaloviral retinitis

Aseptic meningitis/encephalitis

Extra pulmonary tuberculosis

47

15

29

33

49

9

0 10 20 30 40 50 60

average

good

poor

Number of participants

Know

ledg

e gr

adin

g

Improvement of the knowledge on clinical indications

Control group

Intervention group

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

22

Improvement of the mean knowledge following the intervention(Independent sample t test)

23

48.5750.81

48.24

70.22

0

10

20

30

40

50

60

70

80

Control group Intervention group

Before the intervention

After the intervention

N=91p<0.00195% CI : 15.42 - 28.53

Mea

n kn

owle

dge

scor

e

Knowledge on HIV testing procedure

24

Improvement of knowledge on testing procedure following the intervention

(Independent sample t test)

25

54%

66%

20%

93%

89%

41%

0 10 20 30 40 50 60 70 80 90 100

specimen needed

Tube/Container

volume required

Percentage who responded correctly

Intervention groupControl group

26

60

12

27

40

55

5

0 10 20 30 40 50 60 70

average

good

poor

Number of participants

Know

ledg

e on

test

ing

proc

edur

e

Intervention group

Control group

Improvement of knowledge on testing procedure following the intervention

(Independent sample t test)

Practice of HIV testing

• Base line number of HIV tests requested by the IMOs in both intervention and control groups were not comparable.

• 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).

27

Mean number of tests requested by one participant in the intervention group

(t test-paired two sample for means)

28

2.07

4.594.96

6.347.02

10.93

0.00

2.00

4.00

6.00

8.00

10.00

12.00

Decided on own

After senior opinion

Total

Before the intervention After the interventionMea

n nu

mbe

r of

HIV

test

s req

uest

ed d

urin

g th

e pa

st 2

mon

ths

df -89 , p= 0.46

df -89 , p= 0.20

df -89 , p= 0.08

Clinical conditions considered in requesting HIV tests in the intervention group

29

23

2

9

3

31

8

14

4

6

2

5

0 5 10 15 20 25 30 35

Pyrexia of unknown origin

Chronic diarrhoea


Oral candidiasis

Patients with foriegn travels

Prisoners

Hepatitis B or C

Number of participants requested HIV testing

Before the intervention

After the intervention

How many noticed the poster?

30

82, 90%

9, 10%

82, 90%

Number of IMOs who have noticed the poster - 82

Number of IMOs who have not noticed the poster - 9

N=91N=91N=75

75 (91.4%)

N=82

66 (88 %)

Referred the

poster

Referred the

protocol

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

• Data cannot be generalized as it only represents eight teaching hospitals in Sri Lanka.

• Number of HIV tests carried out by the IMOs was assessed asking the respondents to recall (recall bias).

32

Recommendations

Reducing the high number of late diagnoses and improving early case detection is a public health priority;

• Displaying of the poster and the guide island wide in ward settings as well as in clinic settings in both government and private sectors.

33

References• Evan Hunter,Meghan Perry, Clifford Leen, Nikhil Premchand 2011,A survey of

knowledge , attitudes and practice among non HIV specialist physicians, PostgradMed 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

http://www.aidscontrol.gov.lk/web/index.php?option=com_content&view=article&id=154&Itemid=123&lang=en

http://www.aidscontrol.gov.lk/web/index.php?option=com_content&view=article&id=154&Itemid=123&lang=en

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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Documents

7 prageeth ho intervention study