Knowledge, Attitude and Practice of Healthcare Workers Towards Availability of Antiretroviral Pre-Exposure Prohylaxis in Nigeria

Worldwide, almost 1.8 million people became infected with HIV in 2016¹. According to the Centres for Disease Control and Prevention ^CDC in 2015 about 1.1 million persons had indications for pre-exposure prophylaxis (PrEP) in the US but less than one in ten of them had PrEP. Also, the uptake of PrEP has been highly skewed, with some people who needed PrEP the most being less likely to have it ². While regulatory agencies in some countries have approved PrEP for use by populations at high risk of HIV, the W.H.O, in 2015, also recommended PrEP as an additional prevention option for HIV negative people at significant risk of HIV. The uptake and scope of PrEP activities is increasing globally, In June 2016 an estimated 60 000 people were enrolled on PrEP, the majority of whom were in the United States. The rapid establishment of government-regulated programmes across many nations is needed to improve the monitoring and evaluation of PrEP use and its impact on the epidemic to attain the global target of reaching three million people at substantial risk of HIV infection with PrEP by 2020. ³.

The approved drug is a fixed dose combination of emtricitabine(FTC] 200 mg and tenofovir disoproxil fumarate (TDF] 300 mg, taken as a daily pill for preventing HIV infection. However, the number of new HIV cases globally does not appear to reduce especially among certain key populations such as young women, sex workers, people who inject drugs (PWID) and men who have sex with men (MSM) since regulators approved its use for that purpose in 2012[⁴, ⁵, ⁶].This is partly because in eastern and southern Africa, for instance, young women in serodiscordant sexual relationship who account for 26% of the region’s new infections rarely have access to the PrEP. Researches are therefore needed to assess the availability of PrEP services, the awareness and practice of health workers about PrEP especially in Nigeria, where Healthcare workers are expected to promote the use of PrEP services.

Civil societies have joined medical authorities and agencies in demanding from and partnering with governments to provide PrEP, highlighting provision of PrEP as a human right. However, while some countries like the USA have already included PrEP in their national HIV prevention programmes, others such as Nigeria are in different stages of various PrEP demonstration projects .At whatever stage of PrEP programme implementation, countries must ensure access equity to PrEP, so that the very people who need it most, and are often the hardest to engage because of the same conditions that make them most vulnerable to HIV, are not disenfranchised. PrEP can be defined as the ongoing use of antiretroviral drugs by HIV-negative persons in a bid to reduce their risk of acquiring the HIV infection. It is a very potent HIV prevention strategy deployed during periods when the risk of HIV infection is high. People at high risk of HIV infection include those living in communities and sexual networks with HIV incidence of at least 3% higher than the general populations and this include men who have sex with men (MSM),female sex workers, women in heterosexual relationships, adolescent girls, people who inject drugs

PrEP service entails the daily intake of oral antiretroviral pill starting before a potential exposure to HIV and continuing afterwards. Apart from the approved combination ARV (TDF+FTC) for PrEP, standalone Tenofovir (TDF) has also been found to be effective in two PrEP clinical trials. Before prescribing ARV for PrEP, an HIV test and a risk assessment must be done to determine if a person’s level of risk makes him eligible for the service. An important aspect of the PrEP service is the commitment to regular medical follow-up appointments every three months. During such visit the client is monitored for side effects and toxicity, and retested for HIV (if a person tests HIV positive, their PrEP use must be discontinued) and sexually transmitted infections (STIs). PrEP cannot protect against other STIs, such as gonorrhea, chlamydia, herpes and syphilis, and their presence may reduce the ability of PrEP to prevent HIV infection.

There is also the need for an ongoing adherence support and additional HIV prevention services, such as risk-reduction counselling and provision of condoms. Continuous risk assessments are essential to determine if a PrEP user is still at "high risk" and eligible for PrEP.

There is substantive evidence to show PrEP efficacy at reducing the risk of HIV infection across various categories of sexual exposure and sexes – male, female, transgenders, cisgenders. Many randomized placebo-controlled trials have proved the effectiveness of daily TDF+FTC as PrEP. These trials confirmed that PrEP can reduce the risk of HIV acquisition when used by several different populations, including men who have sex with men (MSM), transgender women who have sex with men, people who use injection drugs, and heterosexual men and women. The overall effectiveness of PrEP in those trials ranged widely from 0 to 75 %(7-12).But, reports from some other studies suggested that the consistent use of PrEP may reduce the risk of HIV infection by over 90 %^{7, 8, 12}.

The wide range in the effectiveness of PrEP in all these studies is due to different levels of adherence to the prescribed ARV among the study participants, as some participants only took their pills occasionally while others failed to take their pills at all¹³.

Literature Review: the iPrEx study ⁷ proved the efficacy of pre-exposure prophylaxis (PrEP) with daily oral TDF +FTC combination to prevent HIV acquisition in men who have sex with men (MSM) and transgender women. The Lancet HIV journal also reported a demonstration trial of PrEP among MSM and transgender women vulnerable to HIV under real-world conditions in the Brazilian public health system,⁸. The results showed that PrEP was effective, drug adherence was good, and sexual risk compensation was not observed; which was a surprise to a few in the HIV prevention field. Several other studies have shown that MSM and transgender women were willing to use PrEP, had good drug adherence, and did not start having riskier sex ^{8, 9} so why the delay in PrEP implementation? The usual reasons for the slow implementation of PrEP programme include poor knowledge among policy makers, fear of increased expenditures associated with PrEP, criminalization of sexual behaviours, and the stigma and discrimination that MSM and transgender women face in many parts of the world ¹⁰ leading to denial of PrEP to these vulnerable populations. The Brazilian PrEP study demonstrated the effectiveness and feasibility of PrEP in a real-world setting and that PrEP can be offered at public health-care clinics in a middle-income country with majority of the enrolees retained in care and having high levels of adherence without risk compensation in the investigated populations ¹¹.

Previous works that have demonstrated adherence as a critical factor in the success of PrEP intervention include the ^{14, 15} nested sub-study of the Partners trial In 2013 which concluded that high (> 80%) PrEP adherence was associated with 100% PrEP efficacy (95% CI 83.7 to 100%) ¹⁶ and the VOICE trial in 2015 which failed to demonstrate PrEP clinical effectiveness in young African women ¹⁷, where only 30% of quarterly plasma samples contained a detectable level of TDF.

Common causes of poor adherence to PrEP that have been documented in studies ^{18, 19} include individuals low risk perception, ARV side-effects, perceived stigma and dosing regimen incompatibility.

Three different oral dosing regimen options for PrEP which have been investigated are the Daily dosing, Event-driven dosing, where individuals take two tablets prior to intercourse, followed by single doses 24 and 48 h after the first ²⁰ and the Time driven dosing where individuals take pills twice weekly with a post-intercourse boost ^{21, 22, 23}.In all these routes, adherence was consistently associated with effectiveness. Recently long-acting PrEP formulations with controlled release have been suggested to lead to improved adherence and acceptability ²⁴, implying high efficacy.

The fear of emergence of ARV resistance with PrEP has been debunked by several studies that showed that the only few cases of ARV resistance was associated with individuals who were infected between enrolment and randomisation ^{25, 26, 27}, or had missed diagnoses of pre-existing HIV infection ¹⁹, andwere later randomised to receive PrEP.

This was a cross sectional questionnaire-based study conducted in southern Nigerian states of Ondo and Ekiti over a 6 months period. Data were collected from 250 healthcare workers using interviewer-administered questionnaires. Quantitative data were collected during the interview using a questionnaire comprising of 35 close ended questions. The questions were to determine participant’s demography, awareness on PrEP including knowledge, concerns, and attitudes towards the use of a PrEP by the healthcare workers and where PrEP services can be located within the surroundings of the health workers. Respondents had the option to comment and give additional information not captured by the available options. The data analysis was done using statistical package for the social sciences (SPSS) for windows version 20.0 software (SPSS Inc; Chicago, IL, USA). Frequency counts were generated for all variables and statistical test of significance was performed with chi-square test. Significance was fixed at P < 0.05 and highly significance if P < 0.01.

Even though over 60% of the respondents were highly educated health workers(majorly Nurses and medical doctors) with more than half having at least 10yrs working experience in the health sector and most especially on the HIV program(>90%), majority (94%) of the health workers had heard about ARV pre-exposure prophylaxis but very few ( 6% )could give the standard definition for PrEP as the use of ARV drugs by HIV negative persons to prevent the acquisition of HIV.Most of them gave wrong definition for PrEP and worse still about one fifth had no idea what PrEP was all about. Most (70%) could not correctly identify all the approved ARV drugs in a standard PrEP regimen while about 35% had no idea at all of the approved ARVs used for PrEP. Though PrEP services was not available at any of the facilities where the respondents were working ,the approved drugs(TDF+FTC) for PrEP were available at about 40% of the health facilities(public and private) and 15% community pharmacies in the vicinity of the respondents. This is a reflection of the current reality in Nigeria, where PrEP is only available on the ongoing national demonstration project being conducted by the National Agency for the Control of AIDS (NACA) which aim to evaluate the effectiveness of models for delivery of PrEP and TasP as combination prevention strategy for 1,200 heterosexual, serodiscordant couples. Study findings will be used to inform scale-up of PrEP and TasP as part of comprehensive national HIV-prevention package. In terms of willingness to use PrEP if indicated, more than half of the respondents were willing to use PrEP if prescribed and for those who were not willing, commonest reason for this was the concern for the side effects or adverse reactions. According to the manufacturer some common side effects of taking TDF+FTC include mild nausea, diarrhea, headaches, and/or weight loss, which mostly disappear after a few weeks of taking PrEP. However, reductions in bone-mineral density and kidney health have been observed in some HIV-positive people taking TDF+FTC as part of their long-term treatment for HIV. Similar toxicities were also seen in a very small proportion of PrEP users but the kidney damage resolved after stopping PrEP. Another concern is the potential for the development of drug resistance. If an HIV-negative person becomes HIV positive while using PrEP, their virus could develop resistance to TDF+FTC. According to Idoko et ²⁸ the poor attitude of health care workers towards PrEP users, including breaching confidentiality and stigma expressed by health care workers could also be one of the concerns about PrEP use by serodiscordant couples in Nigeria .None of the respondents had prescribed PrEP for any patient, and none had seen any client that was placed on PrEP. This is in contrast with findings from other studies in the developed settings such as the survey conducted among Canadian healthcare providers relatively knowledgeable about HIV, in which 13% said they had prescribed PrEP²⁹. In a separate survey of Canadian AIDS Service Organization (ASO) workers, 11% knew of one or more people using PrEP³⁰.Awareness and knowledge of PrEP among healthcare workers can be improved by engaging them through update courses, outreach, educational resources, campaigns/seminars and counselling/workshops. These efforts need to ensure that they know what PrEP is and who it is for and that any decisions related to starting or stopping PrEP are well informed. Efforts also need to engage those at "high risk" and address their lack of PrEP knowledge and awareness. All healthcare service providers need to be prepared to talk about HIV risk perception with clients so as to differentiate someone who requests PrEP but is actually at low risk and does not need PrEP from someone who may perceive himself to be at low risk when in reality his behaviour puts him at high risk for HIV infection. In a study presented at the PrEP education press conference titled, "Emergency Medicine Physicians Overlooked in PrEP Education Efforts," Tortelli and coauthors found that in a survey of 67 emergency medicine physicians, although the majority of respondents were aware of PrEP, only 24% were knowledgeable about its guidelines ³¹. Furthermore, 57% of ED physicians sampled were uncomfortable discussing PrEP with patients, 54% had concerns about whether PrEP was effective, 90% were concerned about adverse effects of PrEP, and 70% feared it would promote HIV resistance.

In addition, according to Tortelli and colleagues, emergency medicine physicians are unlikely to prescribe PrEP because it requires follow-up and continued care. Nevertheless, ED physicians can serve a crucial role in identifying patients at high risk for HIV—who would otherwise go unnoticed—and referring these patient to appropriate care.

Although PrEP is not meant to replace other effective HIV prevention strategies (such as condoms and needles replacement), it may provide an important prevention option during periods where a client is struggling to manage their HIV risk in other ways. Since PrEP carries risks and is expensive, it is not a strategy that a client would necessarily need or want to take for a long period of time. Healthcare service workers at primary and secondary levels need to be aware of and develop partnerships with other higher health facilities with capacity to offer PrEP. This can ensure that clients who may benefit from PrEP, and are interested in using it, are linked to a location where it is available. To further improve knowledge and awareness on PrEP, electronic, paper and social media can be recruited into the publicity of information on PrEP. This coupled with development of job aids on PrEP for clinicians would increase the awareness and knowledge. While PrEP service can be made available free of cost if the cost is covered by organizations providing funding for HIV care and treatment in the country.

PrEP has been shown to be highly effective yet numerous barriers impede the wider adoption of PrEP prescription and use. Some of these barriers lie with healthcare workers who have limited knowledge of the product and are unaware that it's safe, effective, and available. In this study, the level of awareness of PrEP among healthcare workers was very high at about 90% yet many(60%) could not give correct standard definitions of the ARV regimen, dosages and level of efficacy of PrEP. Also none of the respondent had PrEP services available either at their center or any known referral centers. This is unacceptable in a country with second highest HIV burden in the world and has adopted PrEP in her national HIV guideline though still conducting demonstration studies. Healthcare workers who were aware of PrEP appeared to be better equipped with all necessary information to prescribe and counsel their clients appropriately on the use of PrEP.

Awareness and knowledge of PrEP among healthcare workers especially those in poor resource settings need to be improved by engaging them through update courses outreach, educational resources, campaigns/seminars and workshops and various job aids. All healthcare service providers should be very comfortable to carry out HIV risk assessment of their clients and provide PrEP to those indicated directly or indirectly through referral. Also engagement of PrEP champions and PrEP users who are powerful advocates that can get correct information about PrEP to all the nooks and crannies where potential clients can be found would go a long way to promote its use . This will also be a powerful way to influence community by being a visible example.

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