Awareness and low uptake of post exposure prophylaxis for HIV among clinical medical students in a high endemicity setting

Our study revealed that the majority of medical students had poor-to-moderate knowledge on PEP. However, adequate knowledge on PEP generally increased with increasing level of studies. Poor practices on PEP for HIV were also observed.

In this study, 89 % of study participants had heard about PEP for HIV. This was lower than reported among health care workers in Gondar, Ethiopia (92.8 %) and in Nigeria (97 %) [11, 12]; although this was higher than the 83.8 % previously reported among nurses in the North West region of Cameroon [17] and the 67.1 % reported among nursing and midwifery students in Hawassa, Ethiopia [21] and the much lower awareness noted among pharmacy students in Malaysia [27]. The main source of knowledge on PEP among medical students in this study was the ward rounds. This is in contrast to findings of Jharn et al. [16] which revealed ‘self-learning’ to be the main source of knowledge.

In most instances, less than a quarter of medical students in this study could identify high risk bodily fluids for HIV transmission. Whilst this was relatively low, it was largely in contrast with other studies among dental students [28] and surgical and anaesthetic residents [29] who incorrectly reported saliva to be a high risk bodily fluid. Over 50 % of students correctly stated that washing site with soap and water was the initial first aid measure to be started following needle prick. This was similar to findings from studies among nurses [16, 17]. Regarding anti-retroviral drugs which could be used for PEP, a few identified Zidovudine which is acceptable especially in regions with limited ARV formulary. However, current recommendations from the updated WHO guidelines of December 2014 on PEP released after the conduct of this study do not suggest Zidovudine again as first line PEP drug [1]. Less than half of the students were aware of the appropriate time for initiating PEP. But the proportion was higher than the 33 % reported among junior doctors [24], 31.6 % among medical interns [22] and far below the 93.7 % reported among family physicians in Nigeria [19]. Significant efficacy of PEP could be obtained if received within 24 h of exposure, albeit can go as long as 48–72 h, after which, it is presumed to have a lower efficacy [5]. Most of these conclusions are however drawn from studies on animal models as evidenced from a recent meta-analysis [30] and not from humans due to ethical implications [5].

About a quarter of medical students knew that the ideal PEP regimen was the three-drug regimen. This is in line with the local adapted country guidelines for HIV PEP in Cameroon [25]. However, the two drugs regimen is likewise efficacious according to recent WHO guidelines [1]. With respect to the duration of PEP, only 35.1 % of medical students knew the duration was 28 days. This was somewhat similar to findings in Nepal [16] though higher than the 15 % recorded by Bairy et al. [31]. Variations in knowledge levels and patterns across these studies could be due to differences in sources of knowledge on PEP, predominantly informal in our study as opposed to formal training in other studies [12], and differences across study populations and settings as well as continued evolution in PEP guidelines during the time-period of conducting these studies.

Regarding students’ practices, almost all students (96.1 %) declared that they were at risk of acquiring HIV in hospital settings, with half admitting to have been exposed in the past. This was in sharp contrast with reports from Ethiopia, Nigeria and Italy [11, 12, 32] though similar to reports from India [33]. The main circumstances of exposure were during surgical procedures, while conducting deliveries, recapping needles and administering injections. Several studies have reported similar circumstances [12, 17, 26,]. In fact, in a study among medical students in Nepal, most exposures/injuries occurred while manipulating needle [34].

Notwithstanding the high exposure rate, only few participants received PEP. This was in line with reports from Nigeria [12], but at variance with reports from Gondar, Ethiopia where three-quarters of exposed participants received PEP, almost all within 24 h of exposure [11]. On the other hand, similar to a study among medical students in Nepal, despite the high rate of exposure to needle prick and sharps, only 11 % received PEP and 19 % did a post exposure serology test [34].

In our study, among reasons for not taking PEP after exposure by students were: “not to be aware of need to take PEP”, “not to be aware of hospital procedures on PEP” and ‘not believing that they could be infected with HIV”. It is possible that stigma, fear, absence of social support, concerns about side effects of ARV as potential barriers for low uptake of PEP for HIV discussed in other studies [35, 36], might in part have accounted for low uptake of PEP in our study. However, most of the reasons in our study were linked to limited knowledge as participants had average-to-poor knowledge on PEP for HIV, which also in part explains the low uptake of PEP in this study. It is noteworthy that studies elsewhere in different populations have suggested that repeated health education and promotion on PEP to improve awareness positively influences uptake of PEP [37]. Secondly, there is no existing university policy or induction program for students on work place safety prior to hospital placements. This in part might account for the non-optimal knowledge and low uptake of PEP. With the growing healthcare demands in Cameroon and increasing numbers of medical schools and/or health training institutions, more students would be faced with this risk and the absence of such policies/programs on work place safety prior to their placements may lead to catastrophic consequences, not only for HIV infection but other and even highly infectious agents like viral hepatitis from exposure to bodily fluids. Currently there exist no published reports on HIV infection rates following occupational exposure in Cameroon and central Africa at large. This would however be interesting to investigate in future studies. Moreover, Pre-exposure prophylaxis (PrEP) for HIV programs have not yet been introduced in Cameroon as opposed to other high income countries [38], which of course together with PEP will constitute a more comprehensive HIV prevention coverage.

The current study is retrospective by nature and therefore carries a high risk of recall bias, which constitutes the main limitation. The study was also conducted in a single medical institution and based on a convenient sample. It may therefore not reflect the full picture of PEP knowledge and uptake among medical students in the country. However, being a pioneer study in the region and owing to the current low ART coverage in Cameroon, the attention our study deserves from health policy makers cannot be overemphasised, with consequent urgent need to improve awareness, training and provision of PEP to curb the growing burden of HIV.