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Dentistry &Medical Research

ISSN 1305-7456January-June 2015

Dentistry and Medical Research| Jan-Jun 2015 | Vol 3 | Issue 1 8

Knowledge and attitudes of libyan dental students about HIV/AIDS infection and HIV‑positive patients

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DOI: 10.4103/2348-1471.149566

Syed Wali Peeran, P. G. Naveen Kumar1, Karthikeyan Ramalingam2, Syed Ali Peeran3 , Nureldeen Abdel Jawad N. Elhammali4, Ahmed Elhassan5, Fatma Mojtaba Alsaid6

Departments of Periodontology and Oral Implantology and 2Oral Pathology and Microbiology, Faculty of Dentistry, Sebha University, 6Faculty of Dentistry, Sebha University, Sebha, 4Department of Oral Surgery, Faculty of Dentistry, Sirte University, Sirte, 5Department of Periodontology, Faculty of Dentistry, Benghazi University, Benghazi, Libya, 1Department of Community and Preventive Dentistry, College of Dental Sciences, Davengere, Karnataka, India, 3Department of Oral and Maxillofacial Prosthodontics, Faculty of Dentistry, Jazan University, Jazan, Saudi Arabia

Address for correspondence: Dr. Karthikeyan Ramalingam, Department of Oral Pathology and Microbiology, Faculty of Dentistry, Sebha University, Sebha, Libya. E‑mail: drrkn79@gmail.com

Orig ina l Ar t icl e

AbstractIntroduction: Though the possibility of contracting infection from human immuno‑deficiency virus (HIV) infected patient is very slim, dental professionals show high reluctance to treat such patients. Their attitude and behavior is a reflection of their understanding about the disease. Aim: The aim of the survey was to evaluate the knowledge and attitude of dental students toward HIV/acquired immuno‑deficiency syndrome (AIDS), oral indicators, ethical aspects of its treatment, and their inclination to treat HIV/AIDS patients. This is the first attempt of such evaluation among Libyan students to the best of our knowledge. Materials and Methods: The study was conducted as a cross‑sectional survey using a questionnaire among 101 dental students comprising 3rd year, the final year and BDS interns in Faculty of Dentistry, Sebha University, Sebha, Libya. The results were analyzed for statistical significance using SPSS version 17.0 (SPSS Inc., Chicago, IL, USA). Results and Discussion: The response rate to the questionnaire was 100%. Statistical significant correlations were observed in attitudes toward the curriculum, modes of transmission, treatment of HIV‑infected patient, information of HIV status to patients, rights to reject treatment of infected patients, stress on treating and resuscitation of such patients. Conclusion: Our study reflects the knowledge status and positive attitude of Libyan students toward management of HIV. Sincere efforts should be made to improve the modes of educating the students about the HIV infection and its dental implications.

Key words: Acquired immuno‑deficiency syndrome, aerosol, attitude, disease transmission, human Immuno‑deficiency virus infection, libyan students

INTRODUCTION

Human immuno‑deficiency virus (HIV) infection has profoundly affected every aspect of health care.[1] Acquired immuno‑deficiency syndrome (AIDS) endemic is continuing to grow.[2] HIV continues to be a major public health issue, having claimed >36 million lives so far. There were approximately 35 million people living with HIV in 2012. Sub‑Saharan Africa

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is more affected region, with nearly 1 in every 20 adults living with HIV.[3] WHO recommends the assessment of knowledge about the disease in different cultures, so as to ascertain requirements for overcoming ignorance and spreading awareness.[4]

Health care practitioners are being called upon to counsel and educate patients regarding HIV.[5] Access to affordable and complete cure for HIV or an effective vaccine to prevent HIV may not be available in the near future. Hence, primary prevention to control HIV is through health education program and creating awareness.[6]

Dentists have a professional and ethical duties to treat HIV patients since many oral lesions are common in such patients.[7,8] Dental treatment usually has direct contact with patient’s blood and saliva and hence dental professionals are prone for exposure to HIV, but the risk of infection is only less.[9‑11] Since 1988, WHO has stated all dental professionals must treat HIV patients. It is unethical and unlawful for dental professionals’ to refuse to treat HIV positive patients.[12] Research in countries such as South Africa, Brazil, Japan and Sudan have found dental students had insufficient knowledge about HIV, particularly in relation with transmission.[11‑14]

Oral care for HIV patients is very important as it improves the nutritional intake, medication tolerance and quality of life.[15] With improved survival rates in the future, there may be numerous HIV‑positive patients seeking dental treatment without their knowledge of serologic status.[16] It is necessary for dental professionals to have adequate knowledge to recognize these oral lesions are very important in early diagnosis and treatment of HIV infection. Dentists, therefore, play an important role in detection and referral of suspicious or infected patients to physicians for an early management.

Libya is a country in North Africa having large areas covered by Sahara desert and a scanty population of around 6 million. Data regarding HIV status is minimal, and the recent study shows only 0.13% are infected.[16] The present study was conducted among dental students of the Faculty of Dentistry, Sebha University, Sebha, Libya, that is the only dental school for entire South Libya. To the best of our knowledge, it is the first study on the knowledge and attitude of dental students toward HIV in Libya till date. Hence, a cross‑sectional survey was conducted to assess knowledge and attitude of Sebha university dental students toward HIV/AIDS.

The aim of the survey was to assess the knowledge and attitude of Sebha university dental students towards HIV/AIDS, its treatment, oral manifestations, ethical considerations, and willingness to treat HIV/AIDS patients.

MATERIALS AND METHODS

This cross‑sectional survey was conducted among all third and 4th year dental students and interns of Faculty of Dentistry, Sebha University, Sebha, Libya between January and February 2014. The permission and ethical clearance were obtained from institutional review board and ethical clearance committee of Faculty of Dentistry, Sebha University, Libya.

The student participation was voluntary after verbal communication of the study purpose, and there were no incentives for involving in this study. The demographic status of students such as gender, age and year of study was recorded. The survey instrument consisted of a structured questionnaire of 18 questions to assess knowledge and 24 questions toward attitude regarding HIV/AIDS. The questions on knowledge consisted about modes and routes of transmission, precautions of AIDS and most of the questions had options as Yes/No only. All the questions were close‑ended.

The data collected was entered in Microsoft excel sheet and analyzed statistically using SPSS 17.0 version (SPSS Inc., Chicago, IL, USA). Frequency distributions were obtained, and Chi‑square test was used to compare differences between groups. Statistical significance was set at P < 0.05 for all tests.

RESULTS

After data analysis [Table], we concluded the questionnaire had a high degree of internal consistency as shown by Cronbach’s alpha (0.73).

A total of 101 dental students including interns were distributed the questionnaire and all of them participated and answered the survey actively. Forty‑one students were from 3rd year, 31 students from 4th year and 29 were interns. Of 101, 24 (23.9%) were males, and 77 (76.1%) were females.

Most of the 3rd year (61%) and 4th year (54.8%) students answered they were not having adequate knowledge on HIV infection respectively, whereas (55.6%) of interns said that they had adequate knowledge regarding HIV. However, there was no statistically significant difference (P = 0.4).

When asked about whether the present curriculum was significant enough for managing HIV patient, 3rd year (61%) and 4th year (54.8%) answered no, but (66.7%) of interns said it was OK, but there was a statistically significant difference (P = 0.02).

Interns, 3rd year and 4th year students had a similar opinion when asked about ways to improve their knowledge on HIV,

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maximum subjects answered as books, followed by visual media, meetings and least by journals.

Almost all the participants agreed that blood was the main mode of transmission (P = 0.24). When asked about saliva, 80.5% of the subjects said that it was not the mode of transmission (P = 0.99). 65.9% of the 3rd year and 70.4% of interns said HIV was not transmitted through breast milk, but 61.3% of 4th year said that HIV is transmitted through breast milk. However, the difference was statistically not significant (P = 0.24).

90.3% of 4th year and 77.8% of interns said HIV is transmitted through vaginal secretions, but only 41.5% of 3rd year said it was transmitted through vaginal secretion. The difference was statistically highly significant (P = 0.00).

Only 51.2% of 3rd year agreed that HIV is transmitted through semen, whereas 87.9% of 4th year and 70.4% of interns answered yes. The difference was statistically highly significant (P = 0.005). Most of the participants (85.4% of 3rd year, 87.1% of 4th year and 81.5% of interns) said that HIV was not transmitted through mucus (P = 0.83).

About 97.6% of 3rd year, 87.1% of 4th year and all the interns said that HIV is not transmitted through tears (P = 0.05).

When the subjects were asked about the major routes of transmission, only 9.8% of 3rd year, 29% of 4th year and 18.5% of interns agreed injection drug as main route of transmission (P = 0.11).

When asked whether blood transfusion is also a route of transmission, only 19.5% of 3rd year, and 18.5% of interns said yes, but 48.5% of 4th year agreed to this route. The difference was statistically significant (P = 0.01).

Most of the participants (97.6% of 3rd year, 87.1% of 4th year and 92.6% of interns) answered that HIV is not main route of transmission through hemodialysis (P = 0.22).

82.9% of 3rd year, 58.1% of 4th year and 81.5% of interns said sexual intercourse is not the main mode of transmission of HIV. The difference is statistically significant (P = 0.036).

68.3% of 3rd year, 96.8% of 4th year and 88.9% of interns agreed that a dentist can contact HIV from patients if they do not use proper barrier technique. The difference was statistically significant (P = 0.004).

When asked whether the patient can contact HIV from dentist, if proper barrier technique is not used 92.7% of 3rd year, 87.1% of 4th year and 89% of interns answered yes (P = 0.72). 87.1% of 4th year, 90.2% of 3rd year and 70.4% of interns said that HIV is not transmitted through handshake (P = 0.078).

The subjects when asked about transmission of HIV with kissing, 29.3% of 3rd year, 16.1% of 4th year and 14.8% of interns said yes, the HIV is transmitted through kissing (P = 0.255).

73.2% of 3rd year, 74.2% of 4th year and 77.8% interns said that HIV is not transmitted by the use of public toilets (P = 0.909).

Most of the subjects 82.9% of 3rd year, 93.5% of 4th year and 92.6% of interns said, yes the contaminated needle stick injury can transmit HIV (P = 0.28). Similar results were obtained when asked about does share a shaving razor spread HIV.

39.0% of 3rd year, 35.5% of 4th year and 48.1% of interns thought that the human bite transmits HIV (P = 0.60).

When the subjects were asked about whether the aerosols produced by hand piece can transmit HIV. Only 22.0% of 3rd year, 32% of 4th year and interns answered yes (P = 0.49).

51.2% of 3rd year, 58.1% of 4th year and 55.65% of interns said that they would carry out ultrasonic scaling procedures for HIV‑infected people (P = 0.84).

When asked whether Kaposi Sarcoma was an oral manifestation associated with HIV/AIDS, 31.7% of 3rd year, 36.7% of 4th year and 37% of interns said yes (P = 0.80). 51.2% of 3rd year, 51.6% of 4th year and 40.7% of interns thought that Oral Candidiasis was an oral manifestation of HIV/AIDS (P = 0.64).

Similarly, when the same group was asked about Acute Necrotizing Ulcerative Gingivitis, 43.9% of 3rd year, 41.9% of 4th year and 66.7% of Interns agreed that it is an oral manifestation of HIV/AIDS (P = 0.67).

When asked whether Hairy Leukoplakia was an oral manifestation associated with HIV/AIDS 22% of 3rd year, 38.7% of 4th year and 29.6% interns said yes (P = 0.30). About Herpetic Infections as an oral manifestation of HIV/AIDS, 31.7% of 3rd year, 38.7% of 4th year and 29.6% of interns said yes (P = 0.73).

However, when Aphthous Ulcerations were considered as an oral manifestation of HIV/AIDS, 17.1 of 3rd year, 35.5% of 4th year and 29.6% of Interns agreed upon it (P = 0.19). When asked whether Lichen Planus/Lichenoid reaction was an oral manifestation associated with HIV/AIDS, 4.9% of 3rd year, 19.4% of 4th year and 3.7% of Interns said yes (P = 0.056).

When the same group was asked about Linear Gingival Erythema, 5% of 3rd year, 6% of 4th year and 11.1% Interns agreed that it is an oral manifestation of HIV/AIDS (P = 0.59). 31.7% of 3rd year, 35.5% of 4th year and 33.3% of Interns think that Necrotizing Ulcerative Periodontitis was an oral manifestation of HIV/AIDS (P = 0.94). However, when Atypical Periodontitis were considered as an oral

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manifestation of HIV/AIDS 36.6% of 3rd year, 22.6% of 4th year and 25.9% of Interns agreed upon it (P = 0.39).

78% of 3rd year feel that an HIV affected person cannot be treated in a dental setting whereas majority of 4th year (58.1%) and interns (51.9%) felt that the patient can be treated. There was a statistically highly significant difference in attitude between the three groups (P = 0.004).

Majority of the 4th year (83.9%), Interns (74.1%) and 3rd year (65.9%) students would allow HIV affected patient to study with them. 40.7% of Interns and only 19.5% of 3rd year, 6.5% of 4th year students knowingly treated an HIV patient. There was a statistically highly significant difference in attitudes between the three groups (P = 0.006).

A majority of interns (70.4%) were willing to treat HIV patients, but (65.9%) of 3rd year and (64.5%) of 4th year were not willing to do so. This had shown a statistically highly significant difference in attitudes (P = 0.006).

Most of the participants, 85.2% of Interns, 77.4% of 4th year and 51.2% of 3rd year students would feel stressed to treat a known case of HIV infection. It was highly significant (P = 0.006).

A high number of the dental students, 92.6% of Interns, 74.2% of 4th year and 63.4% of 3rd year think that the patient should inform his HIV‑positive status correctly to them. There was statistically significant difference in attitudes (P = 0.025) among the dental students.

Majority of the participants, 55.6% of Interns, 54.8% of 4th year and 53.7% of 3rd year feel ethically responsible for treating HIV‑positive patient. 82.9% of 3rd year, 80.6% of 4th year and 63.0% of Interns are of the opinion that an HIV positive dentist/health care provider should inform his patients about his status. A high number of 4th year (71.0%) and 3rd year (65.9%) students felt that all the patients be tested for their HIV status. 63.4% of 3rd year, 59.3% of Interns and 58.1% of 4th year feel that treating an HIV positive patient will increase the risk for the dentist. Most of the participants, 96.8% of 4th year, 88.9% of Interns and 82.9% of 3rd year students said that HIV‑positive people should be supported, helped and treated.

70.4% of Interns and 67.7% of 4th year students said that the dentist/health care provider has no right to reject treating a HIV positive patient, whereas 56.1% of 3rd year students felt that they can do so. This difference in attitudes was statistically significant (P = 0.04).

About 81.5% of Interns were ready to perform mouth to mouth resuscitation in an HIV positive patient in case of emergency whereas only 61.3% of 4th year, and 48.8% of 3rd year were willing to do so. A statistically significant difference was observed (P = 0.025).

93.5% of 4th year, 88.9% of Interns and 78.0% of 3rd year think that they can pray with a hepatitis HIV positive patient in mosque. 80.6% of 4th year, 70.4% of Interns and 58.5% of 3rd year students think that they have to uphold the confidentiality of a patient’s HIV positive status.

85.2% of Interns, 80.6% of 4th year and 73.2% of 3rd year BDS think that they should inform the HIV‑positive status of the patient to his wife/close family members.

DISCUSSION

As the number of HIV patient’s increases, the need of these patients for dental care will also increase in the future.[12,16] Hence, the dentists should have sufficient knowledge and good attitude about HIV patients. The present study was focused on assessing the knowledge and attitude of 3rd year and 4th year dental students and interns, who will be future dentists working in various health care delivery systems. Hence, it is vital for dental students to have adequate knowledge about HIV, as it increases their confidence in approaching and handling HIV patients.[17]

In the present study, more than half of the dental students considered themselves of not having adequate knowledge about HIV, whereas the majority of respondents considered their knowledge to be more than average in survey among Japanese dental students[13] and Iranian dental students said that they had excellent knowledge.[18]

Only around one‑third of students and two‑third of interns in present study thought that their curriculum was fit enough to handle HIV patients, but Jordanian dental students had answered that the teaching received was adequate or more than adequate.[17]

Most of the students and interns had the right knowledge regarding blood transmission. Very few students knew that breast milk also was one of the possible route of transmission. Similar results were found in Kuwait university dental students.[19] Breast milk transmission is one the most common means by which a child will get HIV from his mother.[20]

Only two‑third of students said that they knew HIV is also transmitted through semen and vaginal secretions. Almost all the subjects knew that HIV is not transmitted through tears. It was alarming to note that less than one‑third knew that HIV is transmitted by drug injections, blood transfusion and sexual intercourse.

Around 85% of the students knew that a dentist can get AIDS from patient and vice versa if proper barrier techniques are not used. In the present study most of the students, >85%

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thought HIV is transmitted through needle stick injury and when skin contacted with saliva, of HIV positive patients which reveals the inadequate knowledge the students. Similar finding were obtained in Jordan study[17] and also in Kuwait study.[19] Evidence indicated that there was low occupational risk for HIV infection among health care professionals.[21] The highest risk seen among various procedures was needle stick injury which was <0.5%.[22] There was no evidence of HIV transmission following exposure of unbroken skin of the health care professionals to body fluids of HIV positive patients.[21]

In the present study, only few students, 22% of 3rd year, 32.5% of 4th year and interns knew that HIV is transmitted through aerosols. The other reported ratios among dental students were 5.5% in Kuwait,[19] 75% in Jordan[17] and 51.5% in Iran.[18] This route even though rare, students should know that the possibility of transmission is there.[23]

In the present study, 2% of the subjects thought the saliva can transmit HIV whereas 67.3% of Kuwait students thought that saliva contaminated with blood can transmit HIV.[19]

To provide proper care to HIV‑positive patients, one need to have a good knowledge and also know to diagnose HIV patients with their oral manifestations. There are around forty oral manifestations to HIV patients.[24] In the present study only around47.5% of subjects said candidiasis was associated with HIV, whereas 98.1% of Iranian students[18] and >90% of Jordanian students[17] said it was associated with HIV. Only 34.6% said Kaposi’s sarcoma was associated with HIV but 93.8% of Iranian students[18] and 94.5% of Jordanian students[17] knew it was associated with HIV.39.6% of the subjects said ANUG was associated with HIV whereas 91.3% of Iranian students[18] knew it was associated.

Only 28.7% of our students said that oral hairy leukoplakia was associated with HIV but it was 82.2% in Iranian students[18] and 90.7% in Jordanian students[17] Similarly very less percentage of students knew the associations of herpetic injections (32.6%), xerostomia (19.7%), aphthous ulcers (25.9), lichen planus (8.9%) and NUP (32.5%), with HIV‑positive patients when compared with that of Iranian[18] and Jordanian[17] dental students who had good knowledge about oral manifestations of AIDS.

The Libyan students felt they had inadequate knowledge or their results are comparatively low. This could be attributed to the present scenario in Libya, which is also quite volatile and students are not able to concentrate hard on studies or attend classes regularly, due to the current lack of security and tribal issues.

In the present study around 34.8% of students and 70.4% of interns agreed to treat high risk patients, whereas only

11.6% Iranian students[3] agreed for this and 45.7% remained neutral, but in the study conducted by Hu et al.[25] and Seacat and Inglehart,[26] 51% and 81.1% students told that they would treat HIV patients.

22% of 3rd year, 58.1% of 4th year and 51.9% of interns in the present study said that a HIV positive patient can be treated in a normal setting, whereas only 40% of Kuwait[19] students and 14.4% of Iranian students[18] thought that they can be treated in a normal setting. This shows that in spite of the inadequate knowledge the Libyan students had a positive attitude towards handling HIV patients.

In the present study, 72.3% of the subjects agreed that HIV positive students can study with them in the same dental school, similar results were also obtained in Kuwait.[19]

When asked they have ever treated an HIV positive patient, only 20.6% had agreed. It could be an indicator of low HIV prevalence in Libya.

67.6% of the subjects said they would be stressed while treating HIV positive patients, whereas 85.5% of the Kuwaiti[19] students said they would be concerned. This could be attributed to higher awareness about the disease and its complications.

53.8% of our students said they were ethically responsible for treating HIV positive patients, but only 2.6% of Iranian[18] students thought it was their moral responsibility to treat. Thus, Libyan students were more concerned about the welfare of HIV patients.

82.9% of 3rd year, 80.65% of 4th year students thought that the dentist or health care provider should inform his or her status to the patients but only 63% of interns agreed for the same. This difference may be due to the variations in the knowledge between interns and students, the interns might take proper protection and precaution to prevent the transmission of HIV from them to the patients. Only 51.6% of Iranian dental students[18] thought that HIV positive dentists can treat the patients.

In the present study, 59.7% of the respondents thought all patients should be screened for HIV before treatment, but only 28.1% of Iranians[18] said the blood test should be mandatory. The reason for this difference may be that screening of every patient for HIV is feasible in their country and would allow dentists to take special precautions required to treat them.

Around 59.6% of the students in the present study thought that treating HIV‑positive patients increases risk of them getting the disease, similar results were found in Kuwaiti[19]

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dental students and 84.2% of Iranian students[18] were worried about getting infected. This figure is really worrisome, as these future dentists will be carrying out treatment for such patients in the near future.

Surprisingly 56.1% of 3rd year, 32.3% of 4th year and 29.6% of interns thought that they have right to reject to treat HIV patient, which shows the limited knowledge of the 3rd year students for their negative attitude. But 4th year and interns would learn more about the disease in their course and that could be the reason for their positive attitude.

Surprisingly 63.6% of Kuwaiti[19] dental students thought that they should have right to reject, which is not ethical. Even 49.7% of Iranian[18] students also thought they should not be obligated to treat the HIV positive patients.[27] Current guidelines are that the dentist should not reject to treat the HIV positive patients, and they cannot legally refer them to special clinics.[28] This response shows the positive attitude of Libyan students than others.

Around 90% of the subjects in the present study thought that HIV positive patients should be helped, supported and treated which was similar to the Kuwaiti study.[19]

In the present study, only 37.7% of the subjects were ready to give mouth to mouth resuscitation in HIV positive patients whereas only 16.4% of Kuwaiti students[19] were ready for this act. Only 0.2% of Iranian students[18] were ready to give cardiopulmonary resuscitation. In the absence of blood in the mouth, the mouth to mouth resuscitation cannot result in the spread of HIV infection.[29]

Around 89% of the subjects in the present study said they would pray with the HIV positive people in the mosque, which is a very positive and good attitude of the Libyan students. This is a specific question and first of its kind to be asked in assessing the attitude regarding HIV positive patients.

In the present study, 77.7% of the subjects said that they would inform the patients close relative about the status of HIV positive patient, whereas only 60% of Kuwaiti students[19] would do so. This shows the concern of the Libyan students about the family members of the HIV‑positive patients. Overestimation of the transmission risk is thought to be the most important reason for the fear in treating HIV‑positive patients[1,3] This fear in the students may overcome their clinical skills.

CONCLUSION

Our results conclude that Libyan students have a positive attitude towards management of HIV‑positive patients. Their awareness is low which could be attributed to the unstable

conditions prevailing in the country. Hence, modification of existing modes of teaching, continuing dental learning with current trends and updates is a vital necessity to motivate the current generation of budding dentists to become a valuable service provider in the near future.

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How to cite this article: Peeran SW, Naveen Kumar P G, Ramalingam K, Peeran SA, Elhammali NN, Elhassan A, et al. Knowledge and attitudes of libyan dental students about HIV/AIDS infection and HIV‑positive patients. Dent Med Res 2015;3:8‑14.Source of Support: Nil, Conflict of Interest: Nil.

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iPhone App

A free application to browse and search the journal’s content is now available for iPhone/iPad. The application provides “Table of Contents” of the latest issues, which are stored on the device for future offline browsing. Internet connection is required to access the back issues and search facility. The application is Compatible with iPhone, iPod touch, and iPad and Requires iOS 3.1 or later. The application can be downloaded from http://itunes.apple.com/us/app/medknow-journals/id458064375?ls=1&mt=8. For suggestions and comments do write back to us.