A Study on Knowledge, Attitude, and Practice of Standard Precautions andPost-Exposure Prophylaxis for HIV/Aids Among Healthcare Professionals inTertiary Care Hospital, Shivamogga

Introduction

Healthcare is committed to compassion, empathy, patience, and dedication. Healthcare professionals (HCPs) are at risk of occupational exposure to HIV, hepatitis B, hepatitis C, and additional blood-borne infections, often through needle stick injuries or splashes of blood and body fluids, especially when standard precautions are not followed.¹ To protect themselves, HCPs must adhere to standard precautions, pre-exposure prophylaxis (PEP), and proven measures to prevent occupational exposure to infectious agents.^2,3

Standard precautions are the minimum infection prevention practices for all patient care, regardless of the patient's infection status, and include hand hygiene, use of personal protective equipment, respiratory hygiene, safe handling of sharps, safe injection practices, and maintenance of sterile instruments and clean environments.² PEP involves taking medicine within 72 hours of possible exposure to HIV to prevent infection.³

The risk of acquiring infections from needle stick injuries is as follows: 0.3% for HIV, 6-30% for HBV, and 1.8% for HCV. For blood and body fluid splashes, the probability of HIV infection is 0.09%.⁴ Although there is no comprehensive data on occupational exposure among HCPs in India, it is known that 39 million people lived with HIV globally at the end of 2022, including 2.5 million cases in India. In the same year, HIV claimed about 630,000 lives worldwide and 12,422 in India.^5,6 India represents approximately 5% of the global HIV incidence, with Karnataka showing a higher prevalence (0.46%) than the national average (0.21%).⁷

The large number of infected individuals seeking treatment burdens healthcare facilities and increases the risk of occupational exposure for HCPs if they are not well-informed about standard precautions and PEP protocols. Medical interns, who are early in their clinical exposure and training, are particularly vulnerable to these risks due to limited experience.^8,9 They face a high risk of accidental occupational exposure during their compulsory one-year internship for an MBBS degree.

The study intends to evaluate medical interns' knowledge, attitudes, and practices regarding standard precautions and PEP for HIV who are at high risk of occupationally acquired infections. If awareness is low, the findings could inform necessary interventions, such as training, monitoring, and supportive supervision.

Objectives: To evaluate the knowledge and practice of standard precautions among medical interns, identify any gaps in their knowledge and adherence to basic HIV prevention measures, and assess their knowledge, attitudes, and practices regarding PEP guidelines for preventing HIV infection.

Materials and Methods

This institutional-based cross-sectional study was conducted for the duration of 6 months [3 months for data collection (January-March)] on medical interns working in a tertiary care hospital, Shivamogga district of Karnataka, India.

Sample size-

The minimum sample size required was calculated by using the following formula,

Considering the following values:

(p) Proportion = 50% of interns reported always practicing hand hygiene correctly.10

(q) = (100-p) = 100-50 = 50

(d) allowable error = 5%

The sample size comes to 384.

There were 150 interns/batch, so the sample size was adjusted to the population size of 150.

The adjusted sample size comes to 108.

A 10% non-response rate was added to the adjusted sample size to get the final sample size of 119.

 Methods

Approval from the Institutional Ethics Committee, the principal of the college, and the HOD of the Department of Community Medicine was obtained before starting this study. The questionnaire was developed based on the WHO Standard Precautions guidelines, CDC guidelines on PEP for HIV, and a review of relevant literature, as well as the authors' working experience.^11,12 Experts in the field did content validation, and necessary modifications were made. A pilot study involving ten interns assessed the reliability and acceptability of the questionnaire, with Cronbach's alpha used to measure reliability and completion time evaluated for acceptability. Modifications were made based on pilot results, and those interns were excluded from the main study.

The final questionnaire included demographic details (gender and age), understanding and implementing standard precautions questions on PEP duration, timing, availability, and notification. It also assessed interns’ attitudes towards PEP for HIV prevention.

Medical interns were assigned to various departments in tertiary care hospitals according to a one-year compulsory rotatory internship from March to February. Data was collected from January to March, coinciding with the end of the internship, to capture interns' collective occupational exposure and overall awareness and practice of standard precautions and PEP.

Participants were selected using simple random sampling through Open Epi’s random number generator and contacted face-to-face during their free time. The study's objectives, procedures, purpose, and voluntary nature were explained to the interns, ensuring the anonymity and confidentiality of their responses. Interns who provided written informed consent were included until the sample size was met. Participants who were not willing to participate were excluded from the study. Pretested, self-administered, and semi-structured questionnaires were distributed, and interns were asked to submit the completed forms in the department chamber to ensure anonymity and reduce the risk of biased responses. After data collection, all interns were educated on standard precautions and PEP for HIV and other occupational exposures.

Data Analysis: All data were entered and analyzed using MS Excel, with results expressed as proportions and percentages, presented in tables and flow charts. The questionnaire included eight knowledge and six practice questions on standard precautions, in addition to ten knowledge, five attitude, and nine practice questions related to PEP for HIV.

Knowledge responses were categorized as correct or incorrect and represented as proportions and percentages. A score below 100% on knowledge questions was considered inadequate, as these are essential guidelines. The correct practice of standard precautions was defined as consistent adherence to guidelines. In contrast, incorrect practice was defined as inconsistent or incorrect adherence, labelled as ‘always practised’ or ‘not always practised’ and presented in percentages. Deviations from standard guidelines were considered poor or incorrect practice.

Differences in the percentages of correct knowledge versus correct practice identified gaps knowledge and practice of standard safeguards. Attitude responses towards PEP were shown as proportions of agreement, disagreement, or neutrality, with PEP practice statistics also presented in proportions and percentages.

 Results

Out of 119 interns who participated in this study, 60 (50.42%) were female, and 59 (49.58%) were male. The median age of study participants was 24 (23,25).

Table 1 shows the knowledge of interns regarding standard precautions. It was found that almost all of them (99.16%) knew about the necessity of hepatitis B vaccination for HCPs, and only 63.03% knew that needles should not be recapped/bent/removed by hand.

Table 2 shows the interns' practice or adherence to standard precaution guidelines. All of them (100%) took the hepatitis B vaccination before the internship, but only 61.34% used goggles, 62.18% never recapped/bent needles, and 91.60% disposed of needles in puncture-proof containers.

Table 2 shows the interns' practice or adherence to standard precaution guidelines. All of them (100%) took the hepatitis B vaccination before the internship, but only 61.34% used goggles, 62.18% never recapped/bent needles, and 91.60% disposed of needles in puncture-proof containers.

Table 3 shows the gap between knowledge and practice of standard precautions. Not all those who knew the guidelines were practicing them, as the difference between correct knowledge and practice is more than 0%.

Table 4 shows the knowledge of interns about PEP for HIV. Among 119 interns, 104 (87.39%) knew the full form of PEP, 99 (83.19%) reported that they had heard about PEP, and only 68 (57.14%) knew about indications for PEP for HIV.

Table 5 shows the attitude of interns towards PEP for HIV. Only 107(89.92%) interns believe that PEP is important for HIV prevention following possible exposure at work. Also, it was found that 31(26.05%) thought that reporting NSI was unimportant.

Figure 1 shows the practice of PEP guidelines for HIV. Among 33 who had occupational exposure, only 29 (87.88%) reported the issue; 11 reported that occupational exposure was via exposure to blood and other potentially infectious body fluids, four from Needle Stick Injury (NSI), and the remaining 18 reported being exposed via both modes. 24 out of 29 who reported the exposure reported that the staff were supportive and felt satisfied with their way of treatment.

Discussion

This study assessed 119 interns at a tertiary care hospital in Shivamogga were assessed on their knowledge and application of standard precautions (SP) and post-exposure prophylaxis (PEP) for HIV. Over 90% of interns knew key SP guidelines, including that SP applies to all body fluids (99.16%), handwashing (96.64%), using PPE like gloves (94.96%), gowns/ aprons (96.64%), and goggles/face shields (89%), and proper needle disposal (93.28%). However, less than 75% knew needles should not be recapped, bent, or removed from syringes after use.

Compared to previous studies, such as one by Sudheera Sulgante et al., at Raichur, where knowledge of SP was lower (handwashing 31.8%, use of gloves 75%, gowns and goggles 48.9%), the current study shows reasonable but still inadequate knowledge, as complete adherence to SP is crucial for healthcare providers' safety.¹⁰

A significant finding is the gap between knowledge and practice: not all interns who knew the guidelines adhered to them consistently at work. This aligns with findings by Mukherjee et al. and Sulgante et al., who noted that time constraints, workload, and lack of PPEs hinder adherence.^10,13 However, the lack of proper training and supervision is believed to be a primary factor leading to non-adherence.

Needlestick injuries (NSI) are common, preventable routes of occupational exposure.¹⁴ Most interns knew not to recap needles, but a quarter still practiced recapping. Sulgante et al., reported that only 4.5% knew not to recap needles, while in Kerala, 73.8% of interns continued this unsafe practice.^10,15 Insufficient training and supervision in medical colleges are likely contributors.

While 99.16% knew the modes of HIV transmission, only around 90% were aware of first aid after exposure. Concerningly, only about 30% knew the correct PEP drugs, and about 50% knew the optimal timing and maximum delay for initiating PEP. Around 60% knew the PEP duration. Similar knowledge gaps were reported by Chacko et al., at the Punjab Institute, where only 31.6% knew the correct time to start PEP, and Sulgante et al., found that less than half knew critical details about PEP.^10,16

Although over 90% had a positive attitude toward PEP’s importance in preventing infections and reporting exposure, sensitization training could improve full compliance.

Among the 33 interns (27.7%) with occupational exposure, 4 (12.12%) experienced NSI, 11 (33.33%) had exposure to potentially infectious fluids, and 18 (54.55%) reported both. In a Punjab study, the percutaneous injury rate among interns was 157.89 per 100 person-years, reflecting gaps in knowledge and adherence, particularly around needle disposal.¹⁶ Of the 29 interns who reported exposure, PEP was started for 24 (82.76%), but only 16 (66.67%) completed the course, higher than the 25% PEP initiation rate reported by Sulgante et al.¹⁰ Yet, there was no data on full PEP completion for 28 days. In Kerala, Anitha Madhavan et al., found that 68% of interns did not report NSI.¹⁵

 Studies outside India also highlight inadequate knowledge and practice.17-19 In 2019, 136 out of 175 interns in South Africa reported occupational exposure, with only 63% completing PEP, and two interns reported HIV seroconversion due to occupational exposure.18 Failure to train interns adequately increases their risk during further medical training and beyond.20 Similar studies have shown inadequate knowledge and poor practices among resident doctors, emphasizing the need for consistent training and monitoring of SP and PEP guidelines.

Measures to ensure response anonymity likely reduced false reporting, however, self-reporting bias suggests that adherence might be even lower than reported. Blinded participant observational studies could provide more accurate SP and PEP adherence data. The sample size met estimates, and appropriate statistical methods were used, suggesting that these findings may reflect interns' knowledge, attitudes, and practices in similar settings. However, multi-institutional studies offer a more comprehensive understanding than this single-institution study.

Conclusion

The study revealed participants lacked knowledge of conventional precautions and practiced them inconsistently. Knowledge of PEP guidelines was also poor, and although many interns had a favourable attitude towards PEP, initiation and completion rates were below 100%, which is concerning.

Compulsory training on standard precautions, PEP, and infection prevention protocols, with post-training evaluations and regular monitoring, is recommended. Supportive supervision and continuous adherence checks are crucial. Assigning a dedicated infection control supervisor can help enforce training and retraining. Emphasizing the consequences of non-adherence can further ensure adequate understanding and applying standard precautions.

Acknowledgement

The authors thank all interns who participated in this study.

Conflict of interest

None