Int J Clin Pharm DOI 10.1007/s11096-013-9902-9
Knowledge of HIV and its treatment among health care providers in South Africa Karine Wabø Ruud • Sunitha C. Srinivas Else-Lydia Toverud
Received: 3 June 2013 / Accepted: 30 November 2013 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2013
Abstract Background In South Africa, availability of antiretroviral (ARV) drugs has increased largely in the public sector since it became available in 2004. Follow-up of stabilized patients on ARV drugs are done in primary health care (PHC) facilities run by nurses, often without specialized training. This has deep impact on the patients’ drug adherence. Objective To investigate health care providers’ (HCPs) knowledge about human immunodeficiency virus (HIV) and antiretroviral therapy (ART) in the Eastern Cape Province, South Africa. The aim was also to investigate nurses’ knowledge and experience regarding adverse drug reaction (ADR) reporting. Setting Public PHC clinics in one district of the Eastern Cape Province. Method Personal interviews, using a structured questionnaire, were conducted with 102 HCPs (nurses and auxiliary staff) working at six PHC facilities, one community health centre and one health post. Main outcome measure Knowledge about HIV and ART among nurses and auxiliary staff. Results Both nurses and auxiliary staff had some basic knowledge about symptoms of HIV and modes of transmission, but great uncertainty was seen regarding specific topics including ARV drugs, ADRs and HIV complications. The PHC staff were uncertain about how to administer ARV drugs—with or without food—and some of them would advice their patients not to take ARV drugs at times when food was lacking. Both nurses and auxiliary staff knew that HIV was treated with ARV drugs. Only 60 % of
the HCPs claimed that ART was the only effective treatment for HIV, whereas 39 % claimed that nutritious food also could treat HIV. Nurses showed lacking ability to manage ADRs. They also had very little knowledge about ADR reporting, and very few had ever submitted a report at all. Conclusion The study shows that both nurses and auxiliary staff are unable to provide the patients with adequate advice about administration of the ARV drugs and management of ADRs. Serious lack of knowledge among HCPs regarding the treatment of HIV presents structural barriers to the patients’ adherence. Keywords ADRs HIV/AIDS Nurses Primary health care South Africa Training
Impact of findings on practice •
Lacking knowledge among health care providers (HCPs) in South Africa present structural barriers to adequate treatment of HIV patients. Training of HCPs needs to be prioritized in order to improve management of adverse drug reactions among patients on antiretroviral drugs.
Introduction K. W. Ruud E.-L. Toverud (&) Department of Social Pharmacy, School of Pharmacy, University of Oslo, Pb 1068 Blindern, 0316 Oslo, Norway e-mail: [email protected]
S. C. Srinivas Faculty of Pharmacy, Pharmacy Administration and Practice, Rhodes University, Grahamstown 6140, South Africa
With 5.6 million HIV infected people, South Africa has the largest number of HIV infections in the world . The national HIV prevalence has stabilized at a high rate of approximately 17 % for the whole adult population. In the Eastern Cape Province the estimated prevalence is approximately the same [2–4].
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Until 2004 deaths due to HIV/AIDS were increasing, but has since then stabilized. This is believed to be due to increased availability of antiretroviral therapy (ART)  (estimated 36 % ART coverage in 2010) . Challenges still remain to provide ART to all those who need it. Such challenges include that many people are unaware of their HIV positive status, people being afraid of ARV drugs, and constraints in financial and human resources in the public health sector in the country [6–8]. In South Africa, diagnosing of HIV patients and followup of stabilized patients on ARV drugs are done in primary health care (PHC) facilities run by nurses. The PHC facilities are located in the communities, often within walking distance for the majority of the population. At the PHC clinics patients can be seen by nurses without making appointments, hence these clinics provide a low threshold option for patients to contact HCPs. These HCPs have a great responsibility to provide patients with appropriate health care and advice regarding use of medicines, including being able to distinguish between patients they can help in the PHC clinic and those who need referral to a hospital. Task shifting from doctors to nurses and from nurses to auxiliary staff has been essential in the scale-up of ART in resource-constrained settings [9, 10]. In South Africa, the public health sector which serves approximately 80 % of the population has only 2.7 doctors and 7.2 pharmacists per 10,000 population . According to a WHO report from 2006, the total health workforce in the African region is 23 workers per 10,000 population, whereas Europe and America has 189 and 248 per 10,000 population respectively . Nurses have the highest responsibility in the PHC clinics regarding HIV testing, preparation for ART, advising patients how to take their ART regimen, managing potential adverse drug reactions (ADRs), and referring patients with complications to the hospital [12, 13]. Previous research from South Africa has found that HIV patients on ARV drugs are at an increased risk of ADRs and complications which require hospital administration . The public health sector in resource-constrained countries often have a limited range of ARV drugs and, the chances to change the treatment in case of ADRs or drug resistance are limited. In South Africa, the counsellors at the PHC clinics play a major role in promoting adherence to ART. According to the South African ART guidelines, patients should have a psychosocial assessment at their first scheduled visit to the PHC clinic after a positive HIV test, to document social issues and their psychological state. During this visit, it is required to discuss adherence and strategies for overcoming any barriers to adherence. Patients will be scheduled for return to the PHC clinic for clinical assessments and
adherence counselling. Antibiotic prophylaxis is started according to clinical indications as part of the ART preparation. This provides a chance to prepare the patient of lifelong adherence, and to uncover problems related to adherence, before ART is initiated . Fixed drug combinations are recommended when it is possible to facilitate adherence. Despite the important role of nurses and auxiliary staff in all the above-mentioned parts of HIV care (from HIV diagnosis to adherence preparation and treatment followup), the level of training for these HCPs has often not been sufficient according to their new HIV related responsibilities [16–19]. This may put patient safety at risk . Provision of ART represents an additional challenge for HCPs who are coping with stressful working environment in the South African public sector [21–23]. Identifying knowledge gaps and training HCPs at PHC level to efficiently manage their work tasks is of utmost importance for a successful ART program in the public health sector .
Aim The aim of this study was to investigate HCPs knowledge about HIV and ART in the Eastern Cape Province, South Africa. The aim was also to investigate the nurses’ knowledge and experience regarding adverse drug reaction reporting.
Method Study setting The study was conducted in a resource-constrained public health care setting (approximately 130,000 inhabitants) in the Eastern Cape Province, South Africa. One public hospital is responsible for ART initiation of all the patients in the study area. In addition there are six PHC clinics and one community health centre which are all visited by HIV positive patients daily. These clinics provide follow-up and care when patients are considered stabilized on ART. In the rural outskirts of the study area there are primitive health posts with auxiliary care givers. These are only open a few hours weekly. At the time of the study approximately 1,500 patients received ART through the public health sector in the study area. Participants The study population consisted of 102 HCPs (39 nurses and 63 auxiliary staff) working in the six PHC facilities, the community health centre, and one health post in the study
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area (response rate 91 %). Only seven participants were males (see Table 1). All the participants were working with HIV patients. Auxiliary staff includes various categories of staff assisting nurses at first level of care. Their involvement in patient care varies for the different types of assistants; counsellors (e.g. counselling before and after an HIV test), community care workers and home base carers (making home visits and caring for the sick in their homes), community health workers and health educators (providing health education), directly observed treatment (DOT) supporters (observing patients who come daily to the clinic for TB treatment), clinic assistants (doing administrative work and providing health education). Previous level of schooling for auxiliary staff varies (primary/secondary/ matriculation), and they have generally not received formal training in health care. For auxiliary staff training for the work is primarily provided on site, with supplement training about topics e.g. counselling, nutrition, tuberculosis, data capturing (in general one day courses) offered according to their job description. Previous research in the area has shown that no standardized training program is available . Hence HIV-related training for nurses vary largely since their participation in training depended on them being able to take leave from the clinic on the days when training was offered. Courses which have previously been offered to some nurses in the area include among other subjects: management, ART, post exposure prophylaxis, tuberculosis, counselling and testing, and HIV paediatrics. These courses lasted from one to ten days .
Table 1 Demographics Nurse (N = 39)
Auxiliary staff (N = 63)
36 (92 %)
59 (94 %)
3 (8 %)
4 (6 %)
9 (23 %)
18 (29 %)
11 (28 %)
24 (38 %)
9 (23 %) 10 (26 %)
16 (25 %) 5 (8 %)
Highest level of education
31 (79 %)
1 or 2 year nursing college
7 (18 %)
32 (51 %)
29 (46 %)
1 (2 %)
1 (3 %)
1 (2 %)
Different from nursing diploma/college
The clinics experience a high turn-over of staff. Hence the clinic staff consists of personnel with various level of experience, and knowledge may be lost from the clinic when experienced and specially trained personnel are offered new positions. Due to the magnitude of the HIV epidemic, all HCPs at the clinics meet HIV patients on a daily basis. To get a broad picture of the level of knowledge among the HCPs who are influencing patient behavior, it was important to invite all HCPs involved with patient care for the study. Ethical approval Each participant signed a statement of informed consent prior to participation. This study was approved by Rhodes University’s Faculty of Pharmacy’s Ethics Committee, the Eastern Cape Department of Health, and the local authorities.
Method A questionnaire to study the HCPs’ level of knowledge was developed in cooperation with the district PHC supervisor, the district pharmacist, and one of the two HIV doctors at the local hospital. At each PHC clinic, the nurse in charge was approached to assist the researchers in identifying HCPs who were involved with HIV related work and hence were eligible to participate in the study. Personal interviews were conducted in March 2009 using a structured questionnaire with the same 29 questions for both nurses and auxiliary staff. Ten questions were added for nurses. A pilot study with four HCPs was conducted. Since no changes were made to the questionnaire the four participants of the pilot study were included in the total sample. Nurses and auxiliary health workers were asked questions about ARV treatment, ADRs and HIV complications. They were also asked questions regarding transmission and symptoms of HIV. Nurses also had to answer questions regarding reporting of ADRs. Data analysis All data were de-identified. Quantitative data from the questionnaire were coded for statistical analysis with SPSS version 16. Basic statistics of frequencies and percentages were calculated to describe and compare results of nurses and auxiliary staff. N-1 Chi square test was used to measure if differences between the groups were significant (P = 0.05). When there were no significant differences between nurses and auxiliary staff, a common percentage for all the HCPs as one group was used.
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Table 2 Frequencies of nurses and auxiliary staff who identified various medicines/vitamins as ARV drugs
General HIV knowledge
Name of medicine/vitamin
Nurse (N = 39) (%)
Auxiliary staff (N = 63) (%)
All the HCPs except three auxiliary staff knew that HIV could not be cured. Only a few (8 %) HCPs claimed that one could normally know if someone was HIV-positive just by looking at them. Almost a fifth (18 %) claimed that HIV-positive people always look thin and weak. Even fewer (13 %) claimed that HIV-positive people always cough a lot. Almost all the participants agreed that some HIV patients get various symptoms such as fungal infection in the mouth, a distributed rash or swollen glands, or herpes zoster due to HIV. All the HCPs were aware of unprotected sex as a mode of transmission, and almost all knew that it was possible to get HIV from blood transfusions, that an HIV-infected person could pass on the virus to others even if he/she felt healthy, and that the risk of HIV transmission was increased if the woman had a sore inside her vagina. There was a significant difference between nurses (90 %) and auxiliary staff (73 %) regarding awareness about risk of transmission from mother to child through breast milk. Using a condom was mentioned by all HPCs as a method of preventing HIV transmission.
Knowledge about antiretroviral treatment All the participants, except one auxiliary staff member, knew that ARV drugs are used to treat HIV. Sixty per cent of the HCPs were aware of that ARV drugs is the only effective way, whereas 39 % claimed that nutritious food is another possibility to treat HIV. There was great uncertainty regarding how to administer ARV drugs in relation to food. Less than half the respondents were aware of that most of the ARV drugs used in the public ART program could be taken independently of food, whereas 14 % (4/39 nurses, 10/63 auxiliary staff) would sometimes encourage non-adherence by advising patients to not take ARV drugs on days when food is lacking. Regarding specific knowledge about ARV drugs, Nevirapine and Efavirenz were the two ARV drugs most frequently identified by both nurses and auxiliary staff (see Table 2). Non-ARV drugs were incorrectly identified as ARV drugs by some of the HCPs, particularly by auxiliary staff. Co-trimoxazole (Trimethoprim/sulfamethoxazole) was identified by one third (32 %) of the auxiliary staff, and Amitriptyline by one fifth (22 %) of the auxiliary staff as ARV drugs. When asked to match full names of ARV drugs with their acronyms, Efavirenz and Nevirapine were the ARV drugs which were also most frequently matched with correct acronyms (EFV and NVP respectively). Details of these results are given in Table 3.
Co-trimoxazole Vitamin B6 (pyridoxine)
All correctly selected true ? false All true options correctly selected (? one or more false option selected)
In addition to questions regarding how to use ARV drugs, the HCPs were asked about their awareness of various ADRs that might result from ARV drugs. The ADRs that most HCPs claimed to have heard about were liver disease/hepatotoxicity, followed by peripheral neuropathy (Table 4). The best identified symptom was: ‘‘burning feet, weakness and diminished sensations in feet’’, identified as peripheral neuropathy by 84 % of the nurses and 29 % of the auxiliary staff. Further details regarding identification of various other symptoms as potential ADRs are given in Table 5. The HCPs were also asked what they would do if patients suffered from various clinical symptoms. Table 6 shows that almost all the HCPs would refer to higher qualified personnel, regardless of the symptoms presented. It was further found that for various symptoms which did not specifically include pain, between 17 and 32 % of the HCPs thought pain relief was appropriate.
ADR reporting Only nurses were asked questions regarding ADR reporting. When asked if both nurses and doctors in South Africa can send an ADR report, three out of four (76 %) knew that both professions are allowed to do that. When they were shown the ADR reporting form, not more than half of the nurses (49 %) thought they would be able to fill in the
Int J Clin Pharm Table 3 Frequencies of nurses and auxiliary staff who matched ARV drugs’ full names and acronyms
Table 4 Frequencies of nurses and auxiliary staff who had ever heard about the various ADRs
Full name and accronym
Nurse (N = 39) Correct (%)
Auxiliary staff (N = 63) False/no answer
Adverse drug reaction
Nurse (N = 39) (%)
Auxiliary staff (N = 63) (%)
Peripheral neuropathy Lactic acidosis
30 (77) 29 (74)
26 (41) 12 (19)
whole form independently. One in four (23 %) said they would be able to fill in the form with some assistance. The remaining participants claimed that they would either only be able to fill in parts of the form or not be able to fill it in at all. Only one third (32 %) had seen an ADR reporting form before, and not more than two (5 %) said that they had filled in and sent such a form.
Discussion Knowledge about the drugs used in ART Misconceptions and knowledge gaps among HCPs, which are factors that can lead to poor drug adherence, were identified for both basic and more specific topics regarding HIV and ART. This is in line with both the lack of confidence previously expressed by HCPs in the same area regarding work with HIV-infected patients [12, 24, 25] and the lack of training for HCPs in the current study area and in several other South African health care settings [16–19]. When the HCPs were asked to identify ARV drugs from a list of medications/vitamins that are frequently administered to HIV patients, particularly auxiliary staff had difficulty in distinguishing between ARV drugs and non-ARV drugs. Examples were Co-trimoxazole and Amitriptyline which were incorrectly identified as ARV drugs. Amitriptyline is often administered to HIV positive patients for
chronic pain in case of peripheral neuropathy, which was the one ADR most HCPs had heard of, and also the one ADR most frequently correctly matched with clinical symptoms. The ability to match full names of ARV drugs with correct acronyms varied to a great extent, with best results for Efavirenz and Nevirapine, and best for nurses. The single most well-known ARV was Nevirapine. Particular awareness of Nevirapine was in line with previous research from South Africa , and reflects that this drug has been widely used in the public sector for quite a few years (introduced for prevention of mother to child transmission in 2002) [26, 27]. In the area abbreviations and full names of ARV drugs are often used interchangeably, particularly by HCPs with higher responsibility. Since the abbreviations for the various ARV drugs are often used alone it is imperative to know the meaning of these to avoid misunderstandings among the HCPs with almost no education. As ART continues, an increasing number of HIV patients on first-line therapy will experience a need for second-line therapy due to factors such as non-adherence, resistance, and ADRs [28, 29]. Hence, adequate treatment and counselling will require that the HCPs’ knowledge goes beyond a few well known first-line ARV drugs. Administration of ART in relation to food A finding of great concern regarding treatment of HIV is that as much as four out of ten (39 %) believe that
Int J Clin Pharm Table 5 Percentages of nurses (N = 38) and auxiliary staff (N = 63) who identified possible causes to various clinical symptoms Symptoms
Liver disease (%)
‘‘Burning feet’’, weakness and diminished sensation in feet Nurse
Nausea, abdominal pain, vomit Nursea
Chestpain, shortness of breath, abnormal heartbeat Nursea 8% 27 % Auxiliary
Diarrhoea, loss of appetite, very tired/weak Nurse
Changed bodyshape. Fat accummulation or loosing fat Nurse
Excessive thirst, increased urination, weightloss Nurse
Bold correct answers. Bold italic significant differences (P = 0.05) between nurses and auxiliary staff P calculated by ‘N – 1’ Chi squared test a
Nurses (N = 37)
Table 6 HCPs’ responses to what they would do if patients on ARV drugs presented with various symptoms
Pain relief (%)
Lab test (%)
Nausea, abdominal pain, vomit
Chestpain, shortness of breath, abnormal heartbeat
Diarrhoea, loss of appetite, very tired/weak
N: 43 Aux: 13
Burning feet, weakness and diminished sensation in feet
Changed bodyshape. Fat accummulation or loosing fat Excessive thirst, increased urination, weightloss
N nurses. Aux auxiliary staff
nutritious food can treat HIV. This has serious consequences for drug adherence since patients will think that ART is not necessary. Previous research has found beliefs among South Africans that ‘vitamins, fruits and vegetables can cure AIDS’ (19 %) and that ‘ARVs are poisonous and make people sicker’ (7 %) . The trust in nutritious food can be understood in light of the history of ART policy in South Africa, with an initial distrust in ARV drugs by the government, emphasizing the potentially toxic effects of ARV drugs, and focusing on nutritious food to prevent AIDS [31, 32]. Focusing on nutritious food can have
negative consequences, as shown in a study from Tanzania were HIV-patients who were encouraged to eat a probiotic yoghurt perceived this as a medicine, and not only as a nutritional supplement. Some patients even said that they stopped taking their ARV drugs due to the positive effect of the probiotic yoghurt on their health . It was found that the HCPs were uncertain and confused if they should administer the ARV drugs together with food or not. There was a tendency among HCPs towards thinking that ARV drugs had to be taken with food. Previous research with South African HCPs has found a strong
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emphasis on the need for food together with ARV drugs . This is in line with a known fear of ADRs, particularly when these drugs are taken without food. Fear of ADRs is understandable, not only due to the nature of the ARV drugs but also since our study showed that the HCPs’ management of potential ADRs could be limited to administration of tablets for pain-relief, whether pain was part of the symptoms or not. Previous research has found that such fear of ADRs is an important barrier to ARV adherence in Sub-Saharan Africa , and several studies have also demonstrated a great impact of food-shortage on non-adherence [34–37]. Considering the food poverty rate in the country , it is of concern that 14 % of the participants in the current study would instruct their patients not to take ARV drugs at times when food is lacking. It is also worthwhile to pay attention to the result that some HCPs claim that HIV positive people always look thin and weak, since this can lead to stigmatizing of thin people in general by suspecting that they are HIV positive . In addition, overweight is often looked upon as attractive . In South Africa, as in many other countries, there is an emerging epidemic of non-communicable diseases associated with obesity , which according to what is said above can be reinforced by a stigmatizing perception of thinness.
patients enrolled to hospital care is supervised mainly by doctors, nurses are in charge of HIV care at the PHC clinics where most patients appear. Hence both the formal education and the roles of HCPs in charge of treatment differ according to point of care. Further research would be necessary to study the differences in knowledge between HCPs at PHC level and hospital.
Conclusion This study shows that although nurses in general are more knowledgeable than auxiliary staff, neither of these groups have sufficient knowledge regarding treatment of HIV patients. One serious barrier is that HCPs believe that nutritious food can treat HIV. On the other hand there is also the perception among some HCPs that patients who are lacking food should not take their ARV tablets. Additionally the HCPs have insufficient knowledge regarding management of ADRs which are known adherence barriers. It was found that spontaneous reporting of ADRs was hardly ever done by nurses at PHC level. It is obvious that more training about HIV treatment is needed with special focus on management of ART. Acknowledgments The authors are grateful to all the participants from the PHC clinics involved in the study.
Pharmacovigilance gaps Funding
In 2007, ADR monitoring and reporting was given increased focus in the study area, and the first pharmacovigilance plan for ART was introduced by the Eastern Cape Regional Training centre. The purpose of the plan was to increase knowledge regarding identification and spontaneous reporting of ARV ADRs among HCPs at both hospital and PHC level . Despite the recent focus on ADR reporting which implied that ADR forms should be available to PHC nurses, only one in three of the nurses at these clinics had ever seen such a form in the clinic, and only 2 of the 39 nurses had ever filled out this form. This is in accordance with previous finding from the same geographical area, where nurses at PHC level referred patients with potential ADRs to the hospital, without making a formal ADR report . Limitations and strengths A limitation of the present study is that it was conducted in one sub-district of the Eastern Cape of South Africa. Though a high response rate (91 %) of the identified staff in the PHC facilities at the time of the study provides a comprehensive report, more studies are needed in order to generalize for the country. Whereas HIV care for those few
Norwegian Pharmaceutical Society.
Conflicts of interest
The authors declare no conflicts of interest.
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