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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 32  |  Issue : 3  |  Page : 178-184

Human immunodeficiency virus infection: Vulnerability of doctors in surgical subspecialties of a tertiary health-care setting in Nigeria


1 Department of Surgery, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria
2 Department of Community Medicine, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria
3 Department of Oral and Maxillofacial Surgery, College of Medicine, University of Lagos, Lagos, Nigeria
4 Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
5 Department of Dental and Maxillofacial Surgery, University of Ilorin Teaching Hospital, Ilorin, Nigeria
6 Department of Oral and Maxillofacial Surgery, Lagos University Teaching Hospital, Lagos, Nigeria

Date of Web Publication11-Feb-2019

Correspondence Address:
Dr. Abdulrazaq Olanrewaju Taiwo
Department of Surgery, College of Health Sciences, Usmanu Danfodiyo University, Sokoto
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_77_17

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  Abstract 

Introduction: Anxieties about the transmission of human immunodeficiency virus (HIV) infection in Nigeria are present both in general public and the surgical communities. Research on its effect on occupational health and safety is still evolving in Sub-Saharan Africa.
Materials and Methods: This was a cross-sectional study conducted in a tertiary referral hospital from October to December 2016. Doctors working in all surgical subspecialties area were included in the study. Data were stored and analyzed using Analyze-it version 2.25 Excel 12+ (2013). Multivariate analysis to determine predictors of vulnerability toward HIV infection was carried out. P = 0.05 or less was considered statistically significant.
Results: Of the 95 questionnaires returned, 74 were fully completed making a response rate of 77.9%. Males preponderance was observed (66 [89.2%)]), while there were only 8 (10.8%) females (male:female = 8.3:1). The age ranged from 24 to 53 years (mean age = 36.9 years ± 8.2 standard deviation). More than half of the doctors, i.e. 49 (66.2%) had operated on a known HIV/AIDS-infected patient. There was no correlation between perception of HIV occupational hazard with age, gender, specialty, practice years, and cadre (χ2 = 15.73, df = 17, P = 0.543). Twenty-three surgeons (31.1%) sustained needlestick injuries in the past 1 year and 19 (82.6%) confirmed having at least two episodes. Four (17.4%) had received free postexposure prophylaxis.
Conclusion: The findings from this series suggested that the hospital adherence to universal cross infection control measures is suboptimal. It is necessary for hospital to promote minimal invasive surgery.

Keywords: Hazard, human immunodeficiency virus, infection, postexposure prophylaxis, surgeons


How to cite this article:
Taiwo AO, Raji MO, Adeyemi M, Braimah RO, Ibikunle AA, Adeyemi MF, Kaoje AU, Amoo TA. Human immunodeficiency virus infection: Vulnerability of doctors in surgical subspecialties of a tertiary health-care setting in Nigeria. J Med Soc 2018;32:178-84

How to cite this URL:
Taiwo AO, Raji MO, Adeyemi M, Braimah RO, Ibikunle AA, Adeyemi MF, Kaoje AU, Amoo TA. Human immunodeficiency virus infection: Vulnerability of doctors in surgical subspecialties of a tertiary health-care setting in Nigeria. J Med Soc [serial online] 2018 [cited 2019 Aug 19];32:178-84. Available from: http://www.jmedsoc.org/text.asp?2018/32/3/178/252004


  Introduction Top


Anxieties about the transmission of human immunodeficiency virus (HIV) infection in Nigeria are not only confined to the general public at large but also extend to the health and surgical communities.[1],[2] A recent review showed that the risk of HIV occupational transmission among surgeons in Sub-Saharan Africa is 15 times compared to that of their counterparts practicing in western countries.[3] Parenteral transmission of HIV could arise from unintentional cuts and sharp injuries from needles, scalpels, burs, and exposed bone fragments contaminated with blood and other infectious body fluids.[4] Others include intimate contact of these infectious agents with nonintact skin and accidental splashing of blood into exposed mucous membrane of the eyes.[5],[6] Conversely, patients could also be at risk of iatrogenic exposure to HIV during surgical or dental procedures by surgeons.[7] Research on its effect on occupational health and safety is still evolving particularly in the remote part of tropical Africa and Nigeria.[3],[8] Lack of its timely resolution placed formidable obstacles in the delivery of effective life-saving surgical services to our vulnerable population.[3],[8]

Therefore, the aim of this study is to examine the concern and occupational vulnerability of HIV infection among doctors in surgical subspecialties at a tertiary referral hospital in North West Nigeria.


  Materials and Methods Top


This was a cross-sectional study conducted at a tertiary referral hospital, Sokoto, from October to December 2016. The study population comprised doctors working in all surgical subspecialties (cardiothoracic surgery, oral and maxillofacial surgery, general surgery, neurosurgery, obstetrics and gynecology (O and G), ophthalmology, orthopedic surgery, and otorhinolaryngology) in the study area.

A 23-item structured questionnaire containing open- and close-ended questions [Appendix 1] was self-administered to consenting participants. The questionnaire contained three parts that sought to assess the sociodemographic and professional characteristics of study participants and HIV screening and status as well as their vulnerability to HIV infection.



The questionnaires after retrieval were entered into Excel, and data analysis after cleaning was performed using Analyze-it version 2.25 Excel 12+ (2013). Descriptive statistics of mean and standard deviation (quantitative data) and counts and percentages (qualitative data) were made. Subsequently, inferential statistics were carried out to determine factors associated with vulnerability toward HIV infections. Multivariate analysis was conducted to determine predictors of vulnerability toward HIV infection. Statistical significance was drawn when P = 0.05 or less.

Ethical approval to conduct this study was obtained from the ethics committee of the institution. Informed verbal consent was also obtained from individual study participants.


  Results Top


This was a cross-sectional study conducted in 2016. Of the 95 questionnaires returned, only 74 were fully completed making a response rate of 77.9%. Most of the respondents were males 66 (89.2%) while 8 (10.8%) were females (male:female = 8.3:1). The age of the respondents ranged from 24 to 53 years (mean age = 36.9 years ± 8.2 standard deviation) [Table 1]. The modal age group was 31–40 years (n = 26, 35.1%).
Table 1: Distribution of gender by age group of respondents

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General surgery had the largest number of doctors, i.e. 22 (29.7%), followed by obstetrics and gynecology with 19 doctors (25.7%), oral and maxillofacial surgery had 8 doctors (10.8%), orthopedic surgery had 4 (5.4%), 7 otorhinolaryngology (9.5%), 4 neurosurgery (5.4%), urology 4, plastic surgery 3 (4.1%), 1 pediatric surgery (1.4%), and 1 cardiothoracic surgery (1.4%).

There were 26 (35.1%) consultants, 13 (17.6%) senior registrars, 13 (17.6%) registrars, 13 medical officers (17.6%), and 9 (12.2%) house officers. Most respondents, i.e. 27 (37.0%) had 5 years or less of practice and only 3 (4.1%) had practiced for over 20 years. Majority, i.e. 22 (29.7%) were in general surgery unit trailed by O and G 19 (25.7%) and only 1 (1.4%) each in cardiothoracic, orthopedic, and pediatric surgery.

More than half of the doctors, i.e. 49 (66.2%) had operated on a known HIV/AIDS-infected patient. Sixty-seven (90.5%) respondents had HIV screening in the past with over half 39 (58.2%) doing so voluntarily. Sixty-four (90.1%) concurred with routine preoperative HIV testing of patients, while 62 (83.8%) advocated HIV screening for surgeons if requested by patients or their caregivers.

Sixty-nine (93.2%) expressed their fears about occupational risk of HIV infection with half of the respondents (n = 37) having the perception that the risk of being infected with HIV in their surgical practice as very high. There was no correlation between perception of HIV occupational hazard with age, gender, specialty, practice years, and cadre (χ2 = 15.73, df = 17, P = 0.543).

Twenty-three surgeons (31.1%) sustained needlestick injuries in the past 1 year. Needlestick injuries were most common among O and G (n = 8, 34.8%), general surgeons (n = 6, 26.1%), Oral and Maxillofacial Surgeons (OMFS) (n = 3, 13.0%), and others (n = 6, 26.1%). One needlestick injury episode 4 (17.4%) was reported and 19 (82.6%) confirmed having at least 2 episodes. Four (17.4%) of the victims indicated that they had received free postexposure prophylaxis (PEP). Only 19 (26.4%) of the participants agreed that the hospital had a well-advertised postexposure [Table 2].
Table 2: Ratings of the hospital adherence to universal precautions measures by surgeons

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Only 2 (2.7%) respondents rated the hospital infection control measures as excellent. Fifty-nine (79.7%) of the respondents agreed that the hospital routinely employed adequate sterilization and disinfection of equipment/instruments [Table 2].

There was a high compliance with universal precautions such as use of facemasks (70, 94.6%), change of gloves in between patients (70, 94.6%), presurgical hand scrubbing with disinfectants (69, 93.2%), double gloving during surgery (67, 90.5%), and availability of dedicated containers for sharps and medical waste (62, 83.8%) [Table 2].

There was least observance of universal safety measures such as the use of staplers instead of sutures (7, 9.5%), disposable gown (15, 20.3%), impervious gown (28, 37.8%), and indirectly passing of instruments during surgeries (28, 37.8%) [Table 2].


  Discussion Top


HIV prevalence in Nigeria jumped from 1.8% to 4.6% in <2 decades with recent estimate of 3.6 million Nigerians living with HIV/AIDS.[1],[9] In Nigeria like several African states, the level of HIV among the population is abysmal with many surgical patients oblivious of their HIV status.[1],[3],[10] It has been demonstrated that surgeons in Africa have approximately 4-fold risk of exposure to occupational HIV than other HCWs.[3],[11] Moreover, some stakeholders have considered it prudent to prevent HIV-positive surgeons from operating and performing invasive procedures.[2]

The approximately 80% response rate recorded in this study is within the reported range of 75%–100% from preceding Nigerian studies.[5],[12],[13]

Consultants formed the bulk of respondents (35.1%) in this research in harmony with previous findings from Owotade et al.[8] (35.4%), Obalum et al.[12] (100%), and Sowande et al.[5] (100%). However, it diverged from earlier works by Adebamowo et al.[2] (100%) and Obi et al.[13] (69%) were resident doctors formed the bulk of the respondents.

A large part of our respondents (37%) were within 5 years of clinical practice suggesting that their attitude toward HIV and surgery can still be modified to the benefit of health service delivery improvement.

The result of this series demonstrated that more than half of the respondents (66.2%) had in the past operated on known HIV-positive patients in conformity with Owotade et al.[8] (41.5%) from South West Nigeria. Most trainee surgeons (65%) in a prior study expressed inadequate training in management of patients with HIV.[2] Dearth of education, training, and availability of basic universal safety/protection materials were identified as barriers to proper treatment of People Living With HIV/ AIDS (PLWHA).[2],[8],[9],[13] Targeted HIV/AIDS training backed by availability of needed items would boost the number of surgeons attending to patients with HIV/AIDS infection.[2]

This study demonstrated that nearly all (90.5%) of the surgeons were conscious about their HIV status. The current figure is higher than 57.9%, 53.3%, and 36.9% reported among pediatric surgeons, orthopedic surgeons, and other surgical specialties, respectively.[5],[8],[12] Perhaps more than other categories of health workers, surgeons are routinely at risk of parenteral HIV transmission from contaminated sharp medical devices and hard tissues such as bone and prolonged contact with infective human agents.[2],[8],[12],[13] Some authors have noted that the high interest among surgeon could be related to the society stigma, apprehension of losing their career, reputation, and professional standing if infected by HIV/AIDS.[2],[3],[4] The dilemma on mandatory HIV testing as a precondition for surgery persists in the face of strident call for its abolishment by some, either risk transgressing patients' autonomy or satisfy the surgeons' need for guarantee on occupational exposure to HIV.[14] Reports of multiple instances of testing without consent in public and private hospitals are widespread in Nigeria, India, and some developing countries.[9] This practice is considered discriminatory, and the costs of these tests are often borne by the patients or their family.[9],[15] This invariably could impede early hospital presentation, sow fear and distrust for the health system, and aggravate the population's surgical burden.[2] The finding of this research demonstrated 90.1% unanimous approval for this practice which mirrors earlier observations among doctors and other health workers.[2],[8],[9],[12],[13]

The current work observed that many surgeons feel highly vulnerable to HIV infection in their workplace which transcends age, gender, specialty, cadre, and years of practice. The concern about occupational HIV transmission among health care workers (HCW's) has been highlighted by numerous workers across Nigeria.[2],[5],[8],[12],[13] Surgeons regularly undertake invasive procedures which render them susceptible to HIV infection.[3],[10],[16],[17] The most crucial strategy to minimize the risk of occupational HIV exposure is to make available safety devices and barriers that will guarantee protection from contact with potentially infectious body fluids and blood.[6],[8]

Adegboye et al.[18] observed high incidence of needlestick injuries among Nigerian HCW's. Dentists and surgeons (2.3 per person-year) had about 4- and 6-fold occurrence than nonsurgical physicians (0.6 per person-year) and nursing staff (0.4 per person-year), respectively.[18] Immediate and continuous PEP treatment with 4 weeks, 2 antiretroviral drug regimens are obligatory to mitigate the risk of HIV infection.[6],[8],[18] Delay in receiving these chemoprophylactic agents could increase the chance of HIV transmission as every hour counts.[3] The result of this study highlighted that various surgeons (31.1%) had multiple needlestick injury in the past 1 year with poor uptake of PEP (17.4%). Findings of low reporting rate of exposure coupled with low uptake of PEP following occupational exposure to HIV have been observed in Nigeria and Tanzania.[6],[18] These have been blamed on ignorance about PEP, lack of discernible guidelines on exposure to bloodborne pathogens, and absence of continuous training for the HCWs.[16],[18]

The findings from this series suggested that surgical practices are suboptimal and at variance with global accepted practices of universal cross infection control measures.[5],[6],[8],[10],[12],[13] In the current study, appreciable performances in vital areas such as sterilization, hand scrubbing, availability of facemasks, face shield, double gloving, change of glove between patients' prophylactic antibiotics, and dedicated waste containers for sharps was observed. However, there was abysmal observance of measures such as use of staplers instead of sutures (9.5%), disposable gown (20.3%), impervious gown (37.8%), and indirectly passing of instruments during surgeries (37.8%). Some past studies demonstrated that most accidental needlestick injury occurred during suturing, intramuscular, or dental injections and disposal of used consumables, especially syringes and needles.[2],[16],[18] Isah et al.[6] observed that lack of stringent institutional framework on adherence to universal safety measures in Nigerian public health facilities, persistent shortage of essential supplies, and poor organizational climates contributed to this scenario, thereby endangering the safety of the patients and health personnel likewise.


  Conclusion Top


Our findings demonstrated that to limit exposure to bloodborne pathogens, it is necessary for surgeons to rigorously embrace universal safety precautions, advocate minimal invasive surgeries, and adopt careful surgical techniques. Moreover, the hospital should invest more in technologies that will support minimal invasive techniques such as harmonic knives, endoscopes, ultrasound, robotic surgery, and others. In addition, they should proactively setup a dedicated occupational health and safety department that would facilitate regular implementation, monitoring and evaluation of these measures, and documentation of occupational percutaneous injuries coupled with PEP uptake. Finally, regulatory bodies entrusted with these responsibilities, especially at state level should bring to book erring health facilities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Awosan KJ, Ibrahim MT, Arisegi SA, Erhiano EE. Knowledge of HIV/AIDS, risk perception, sexual lifestyle and condom use among drivers in Sokoto, Nigeria. J Infect Dis Immun 2014;6:19-25.  Back to cited text no. 1
    
2.
Adebamowo CA, Ezeome ER, Ajuwon JA, Ogundiran TO. Survey of the knowledge, attitude and practice of Nigerian surgery trainees to HIV-infected persons and AIDS patients. BMC Surg 2002;2:7.  Back to cited text no. 2
    
3.
Bowa K, Kawimbe B, Mugala D, Musowoya D, Makupe A, Njobvu M, et al. Areview of HIV and surgery in Africa. Open AIDS J 2016;10:16-23.  Back to cited text no. 3
    
4.
Labib M. Scalpel-free surgery could reduce surgeons' risk of HIV and hepatitis. Med J Zambia 2010;37:99-103.  Back to cited text no. 4
    
5.
Sowande OA, Talabi A, Olowookere S, Adejuyigbe, Owotade F. HIV/AIDS pandemic and current practice among paediatric surgeons in Nigeria. Afr J Med Med Sci 2015;44:297-302.  Back to cited text no. 5
    
6.
Isah HO, Sabitu K, Ibrahim MT. Profile of institutional infrastructure for implementing universal precautions in primary health care facilities in Sokoto state, Nigeria: Implication for occupational safety. Afr J Cln Exper Microbiol 2009;10:164-74.  Back to cited text no. 6
    
7.
Tanner J, Parkinson H. Double gloving to reduce surgical cross-infection. Cochrane Database Syst Rev 2002;3:CD003087.  Back to cited text no. 7
    
8.
Owotade FJ, Ogunbodede EO, Sowande OA. HIV/AIDS pandemic and surgical practice in a Nigerian teaching hospital. Trop Doct 2003;33:228-31.  Back to cited text no. 8
    
9.
Umar AS, Oche MO, Adeoso AA. Discriminatory practices of health workers towards people living with HIV/AIDS in Sokoto, Nigeria. J AIDS HIV Res 2012;4:223-8.  Back to cited text no. 9
    
10.
Consten EC, van Lanschot JJ, Henny PC, Tinnemans JG, van der Meer JT. A prospective study on the risk of exposure to HIV during surgery in Zambia. AIDS 1995;9:585-8.  Back to cited text no. 10
    
11.
Gumodoka B, Favot I, Berege ZA, Dolmans WM. Occupational exposure to the risk of HIV infection among health care workers in Mwanza region, united republic of Tanzania. Bull World Health Organ 1997;75:133-40.  Back to cited text no. 11
    
12.
Obalum DC, Eyesan SU, Ogo CN, Enweani UN, Ajoku JO. Concerns, attitudes, and practices of orthopaedic surgeons towards management of patients with HIV/AIDS in Nigeria. Int Orthop 2009;33:851-4.  Back to cited text no. 12
    
13.
Obi SN, Waboso P, Ozumba BC. HIV/AIDS: Occupational risk, attitude and behaviour of surgeons in Southeast Nigeria. Int J STD AIDS 2005;16:370-3.  Back to cited text no. 13
    
14.
Sheikh K, Porter JD. “It's 100% for me”: Hospital practitioners' perspectives on mandatory HIV testing. Indian J Med Ethics 2009;6:132-7.  Back to cited text no. 14
    
15.
Orji EO, Ogunniyi SO. The case against mandatory preoperative HIV screening in Africa. Niger J Med 2001;10:162-4.  Back to cited text no. 15
    
16.
Mponela MJ, Oleribe OO, Abade A, Kwesigabo G. Post exposure prophylaxis following occupational exposure to HIV: A survey of health care workers in Mbeya, Tanzania, 2009-2010. Pan Afr Med J 2015;21:32.  Back to cited text no. 16
    
17.
Gabriel J. Reducing needlestick and sharps injuries among healthcare workers. Nurs Stand 2009;23:41-4.  Back to cited text no. 17
    
18.
Adegboye AA, Moss GB, Soyinka F, Kreiss JK. The epidemiology of needlestick and sharp instrument accidents in a Nigerian hospital. Infect Control Hosp Epidemiol 1994;15:27-31.  Back to cited text no. 18
    



 
 
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