Knowledge of HIV/AIDS Among General Practitioners in Health Facilities in Brazzaville in Republic of Congo

Background: Despite the growing HIV burden, the disease continues to receive a relatively high public health priority in the Republic of Congo.

Objective: To establish the knowledge, attitude and practice on HIV/AIDS among general practitioners working in Brazzaville and to register their actual behaviour in the prevention of HIV/AIDS.

Methodology: Incidence of AIDS and AIDS related conditions in Masvingo Province has been rising. The lowest Incidence was in 2007. The burden of HIV/AIDS was higher in females than males. The most affected age group was the 30-49 years. Pneumonia was the leading opportunistic infection followed by TB and Kaposi sarcoma. The proportion of TB patients who were co infected with HIV was 81% in 2008.

Results: The study was conducted on 35 general practitioners, 87.5% of whom had prescribed at least one HIV test in the month preceding the survey. Tuberculosis and pneumonia were among the clinical manifestations observed in AIDS/HIV patients in 27.42% of GPs. Only 71.05% of GPs responded that if an individual with HIV antibodies was defined as HIV-positive. Results revealed that 6.36% of GPs feel concerned about HIV because working with AIDS patients can put their health at risk.

Discussion: Relatively large number of general practitioners do not know how to detect the symptoms associated with HIV/AIDS, which is alarming in public health. Awareness of PEP and its availability for individuals are crucial to ensure that PEP is used to its full potential in any HIV prevention strategy. The low level of knowledge of our general practitioners is quickly to be filled in order to provide quality care to people living with HIV. Most general practitioners showed a negative attitude towards PLWHIV, usually associated with little HIV knowledge.

Conclusion: The survey found some flaws in HIV attitudes and knowledge among general practitioners. Improved knowledge and strategy of targeted continuing medical education programs and special training sessions could be put in place to encourage GPs to apply more to public health.

Keywords: HIV/AIDS; Prevention; General Practionners; Republic of Congo

List of abbreviations: Gps: General Practitioners; STD: Sexually Transmitted Diseases; PNDS: Programme National De Developpement Social; CERSSA: Comité D’éthique De La Recherche En Sciences De La Santé; IRSSA: Institut National De Recherche En Sciences De La Santé; PLWH: People Who Living With HIV/AIDS; PEP: Post-Exposure Prophylaxis; NRTI: Nucleoside And Nucleotide Reverse Transcriptase Inhibitors; NNRTI: Non-Nucleoside Reverse Transcriptase Inhibitors; PI: Protease Inhibitors

In 2017, according to UNAIDS: new infections among adults decreased by 11% between 2010 and 2016, about 34.5 million people in the world are living with HIV / AIDS, of which 64% in Africa [1]. In the Republic of Congo, the HIV epidemic is developing due to insufficient knowledge about HIV and its transmission pathways. In 2016, the incidence of HIV per 1000 population was 1.65 [1.17-2.18], there were 3 800 AIDS-related deaths and 91 000 people living with HIV in 2016 [1].

In the Republic of Congo, 75-80% of people go to the integrated health center to see a general practitioner, a state-certified nurse or a health assistant, in case of illness. Integrated health center are a first point of contact for non-emergency and preventative medical care during centers hours and especially the cost of consultation is relatively low ranging from 1.82 to 3.64 USD. The average cost of drugs, sold in these health centers, at the expense of people for care are also very low. These health professionals are the main educators for the prevention of infections or diseases, including HIV/AIDS. In addition to integrated health centers, non-governmental organizations or associations are working to raise awareness of HIV/AIDS. Brazzaville is the largest city in the Republic of Congo with about 1,800,000 inhabitants [2]. In 2016, the Brazzaville basic hospitals had 17 general practitioners, in the 39 Integrated State Health Centers in the city of Brazzaville, none had general practitioners. In addition to the State Integrated Health Centers, there are 46 Integrated Health Centers run by religious denominations and the private sector, which had more than 80 GPs.

Brazzaville has an insignificant number of general practitioners (GPs), illustrating the poor policy of recruitment and training of health personnel for years. The need for health human resources in terms of ration per population is obvious. GPs play a major role in the primary health care service. A previous study in Pakistan found that general practitioners treated the majority of sexually transmitted diseases (STD) cases [3]. As key players in the health care system, GPs are involved in the prevention of communicable diseases such as HIV, particularly with respect to HIV awareness and testing [4]. Screening is the only effective way to find out if you are infected with a STD or HIV. In addition, early detection of HIV improves the long-term response to treatment and increases the expectation and quality of life of PLWH, and reduces the transmission of the virus through antiretrovirals [3,4].

Providing HIV counseling and testing is a pathway to prevention, antiretroviral treatment, care and psychological support services. Two important points to note in HIV prevention: firstly, early knowledge of HIV-positive status optimizes for people living with HIV (PWLH) the possibilities of accessing treatment and thereby greatly reduces the morbidity and mortality associated with HIV/AIDS [5,6]. And for couples wanting to have a child, to prevent mother-to-child transmission; secondly, people who are HIV-negative are warned and can guard against prevention methods to limit the risk of infection.

Several studies have shown that adherence to the HIV test depends significantly on the attitude of their doctors [7]. A previous study revealed that a national HIV testing policy requires a strong mobilization of general practitioners [4]. Their level of knowledge, attitudes and practices in HIV and testing is important for them to be effective actors in any HIV/AIDS prevention and control program [8,9].

In the Republic of Congo, the Programme National de Developpement Social (PNDS) focuses on health care at three levels. The third-level care provided by specialist doctors at the general hospitals; and the University Hospital Center which concentrates almost all specialists and the teachers at the Faculty of Health Sciences [10]. The second-level care provided by general practitioners in referral hospitals. There is the primary-level care for common pathologies, community care and maternal health, these are State Integrated Health Centers, religious denominations and the private sector. The primary-level care is sometimes under the supervision by general practitioners, but very often by paramedical and social workers in integrated health centers. Among the charges charged to integrated health centers and their minimum activity package, there is preventive care, curative consultations and management of sexually transmitted diseases [11].

The purpose of this survey was to assess knowledge about HIV/AIDS among Congolese general practitioners in Brazzaville.

The study was conducted among Congolese general practitioners. The data was collected between 01 and 31 August 2017. The study was conducted in Brazzaville. The survey was based on a random sample of households in an underserved and understudied general practitioners population. General practitioners who accepted, for almost an hour, to participate in the survey were included in the survey. A questionnaire was self-administered anonymously. This survey included 6 questions about the socio-demographic and occupational characteristics of general practitioners and 15 questions about their experience with HIV.

GPs who agreed to participate in the survey answered all the questions and signed their survey form. At the end of the survey, the investigator retrieved the investigation form. The 35 general practitioners who responded to the questionnaire constitute the material in this article.

The study to assess GPs knowledge, attitudes, practices on HIV among general practioners recruited cross sectional study design.

Data entry researchers were trained in coding, typing and error checking. The collected data were captured and analyzed using the statistical software EPI info 2010. The categorical variables were analyzed using the frequencies and the percentage (IC is 95%).

The approval of this study was obtained from the Comité d’Éthique de la Recherche en Science de la Santé (CERSSA) of the Institut National de Recherche en Sciences de la Santé of Brazzaville. Managers at the Institut National de Recherche en Sciences de la Santé (IRSSA) agreed to the survey and if GPs agreed, they should be included in the study and completed the survey.

All GPs had at least one HIV-infected patient in the past 12 months, and of these, 87.5% had prescribed at least one HIV test in the month prior to the survey. Only 62% of general practitioners said that repeated fever, weight loss and persistent diarrhea were common symptoms of HIV/AIDS. Tuberculosis and pneumonia were among the clinical manifestations observed in HIV/AIDS patients in 27.42% of GPs (Table 1).

Health workers reported having the right to know the HIV status of patients (43.14%). Some GPs would warn all medical staff about the HIV status of a patient, even if the patient disagrees (13.73%). Due to confidentiality and anonymity, only 9.8% of doctors said that they would inform a sex partner of an HIV-positive person even if they strongly disagree. The survey revealed that only 33.3% of general practitioners said they should be tested for HIV (Table 2).

The correct responses of general practitioners to the most commonly reported HIV-associated oral lesions were 23.48% oral candidiasis and 11.36% oral Kaposi’s sarcoma, respectively. In contrast, less than 10% of GPs responded that oral leukoplakia, oral melanoma hyperpigmentation, shingles, herpes simplex, necrotizing gingivitis, and condyloma were HIV-associated oral lesions in patients. Less than 5% of GPs thought that Crohn’s disease, salivary gland hypertrophy, xerostomia, idiopathic thrombocytopenic purpura (ITP), non-Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, histoplasmosis, and papilloma were oral lesions associated with HIV (Table 3). To the question, if an individual with HIV antibodies was defined as HIV-positive, 71.05% of general practitioners said yes. On the contrary, a percentage of 18.42% of general practitioners said it was immunity to infection. The response on mean time between contraction of HIV and antibody production was 6 to 12 weeks for 51.52% of general practitioners, while 21.21% responded that the average time between contraction of HIV and antibody production was less than 6 weeks.

Responses showing a negative attitude were recorded: a percentage of 6.36% of general practitioners felt concerned by HIV. For them to work with AIDS patients, could put their health at risk. Only 4.05% of GPs would be ready to perform a mouth-to-mouth resuscitation of an AIDS patient in the event of respiratory arrest, while 2.89% of general practitioners would report to a sexual partner the serology of an HIV-positive patient. Finally, 5.78% of general practitioners were not concerned about being infected with HIV by their patients.

Only 11.56% of general practitioners reported treating patients with HIV/AIDS (Table 4). A total of 25 GPs out of 35 knew that people living with HIV/AIDS were treated at the same time by INRT, INNRT and IP. On the other hand, 4 doctors indicated that the treatment followed by people infected with HIV was only the INRT. TCD4 cells were cited by 34 general practitioners as defective cells affected by HIV/AIDS. GPs (30) responded that host defense cells affected by HIV/AIDS are predominantly T cells (Figure 1,Figure 2 and Figure 3).

Positive attitudes can be cited: a small percentage of 15.03% of general practitioners considered, respectively, that people infected with HIV should not be isolated in a specialized center or that people infected with HIV should have the right to whether my patients are infected with HIV or even that people infected with HIV should have the right to refuse to treat a patient with HIV/AIDS (Table 5).

To our knowledge, this is the first study of HIV beliefs and knowledge among Congolese GPs. Most GPs have not been trained for HIV infection. The training on HIV would have improved their knowledge of HIV, but also good care for people living with HIV. Several studies in developed and developing countries have shown that general practitioners seem to have little or no knowledge about HIV. This poor knowledge leads to poor quality of care for infected patients [12].

In our study, repeated fever, weight loss and persistent diarrhea were cited by 62% of general practitioners as being the common symptoms of HIV/AIDS. A relatively large number of general practitioners do not know how to detect the symptoms associated with HIV/AIDS, which is alarming in public health. In the literature, some common HIV symptoms are cited, these symtoms include dry cough and shortness of breath [13], memory loss, depression and neurological disorders [14], unexplained tiredness, rapid weight loss, profuse night sweats, swollen lymph glands [15], severe headaches. The most common clinical manifestations among HIV/AIDS patients observed by general practitioners were tuberculosis (27.42%) and pneumonia (27.42%). These two pathologies are the most common opportunistic diseases found in Africa among PLWH [16,17]. For blood exposure, 28.75% of general practitioners recommended an early onset, two hours after exposure, and 20% responded that a 4-week treatment would be required based on zidovudine + lamivudine or lamivudine + stavudine, as a protocol to be used for post-exposure prophylaxis (PEP). For a better awareness of PEP, it is imperative to make post-exposure prophylaxis available. This treatment is essential to ensure that PEP is applied in any HIV prevention strategy. In the literature, it is clear that the HIV/AIDS-related medical protocol is related to the anonymity and confidentiality of information about individuals [18,19], to avoid stigma and discrimination. The protection of the rights of people living with HIV can thus be guaranteed [20].

With respect to oral lesions associated with HIV, 23.48% of general practitioners responded to oral candidiasis, 11.36% said it was oral Kaposi’s sarcoma; Oral leukoplakia, herpes simplex and necrotizing gingivitis were cited in each case by 9.85% of GPs. Oral lesions have been shown to be early clinical features of HIV infection [21]. Oral lesions contribute to the morbidity of patients, affecting the psychological functioning of the individual [22]. Some of the oral lesions have a fatal outcome, such as Kaposi’s sarcoma, the most common intra-oral lesion in people with HIV infection. In a South Africa study, the prevalence of Kaposi’s sarcoma ranged from 15% to over 80% in HIV-positive adults [23]. All this information amply demonstrates the importance for general practitioners of knowing the clinical manifestations and oral lesions associated with HIV. The low level of knowledge of our GPs needs to be briskly addressed to provide quality care to people living with HIV.

There were 71.05% of general practitioners who answered that the HIV carrier was an individual with anti-HIV antibodies. In addition, 51.52% thought that the mean time interval between contraction of HIV and antibody production was 6 to 12 weeks. The level of knowledge, while satisfactory, should be strengthened given the extent of HIV infection in our country.

Although there are not enough GPs in Brazzaville, a significant number refused to participate in our survey. In our study, some physicians treated PLWH, which is of major importance in public health. In key players in the health system, general practitioners are the facilitators in primary health care. Several studies in Africa have confirmed the role of general practitioners in the health of the population and among PLWHs [24-26].

In our study, GPs’ responses to symptoms and clinical manifestations of HIV/AIDS patients are not encouraging. There is a significant lack of knowledge about HIV among GPs, which is unacceptable given the role that general practitioners play in the lifestyle of the population. Low knowledge of HIV among general practitioners has also been observed in Pakistan [27].

Our study also found that a small percentage of general practitioners had a positive attitude toward PLWH. This positive attitude would be linked to their training profile. A previous study found that health professionals who had knowledge of the disease had a positive attitude towards patients [28]. In contrast, insufficient knowledge about disease was associated with a negative attitude of practitioners [29]. Training and knowledge about the disease have an important role in changing attitudes towards patients. Kwasnicka et al. (2016) explained that behavior change interventions are effective in helping individuals achieve temporary behavioral change [30]. The behavior change interventions in our study are the acquisition of knowledge about HIV and the management of PLWH. GPs should play a central role in HIV prevention. Studies have observed another intervention such as the support of a facilitator to help general practitioners develop the skills needed to prevent HIV infection.

The size of the sample makes the results difficult to generalize to all general practitioners in the country. It is also likely that GPs who responded are those who are most interested in HIV/AIDS and, therefore, those who are most likely to take into account any changes in HIV testing policy. The response rate of general practitioners was not optimal; only 35 of the 60 who were contacted answered the questionnaires. The refusal to participate in the investigation was an obstacle to the completion of the investigation. Another limitation to the study was that most health centers do not have general practitioners, these health centers are run by state-approved nurses or health assistants. General practitioners are in private facilities such as clinics, their staff is not listed by the competent authority.

The results of this survey suggest that general practitioners in Brazzaville should improve their knowledge of HIV/AIDS and the care of people living with HIV.

It emerges from our study that doctors are inadequately trained. Counseling-type seminars can enable physicians to perceive the meaning of a screening test without notifying the patient, providing positive results and conveying prevention messages. Public health strategies are crucial to promote health to enable physicians to be more ready to become involved in this condition in order to increase their level of knowledge. Initiatives should be taken to strengthen the role of general practitioners in AIDS prevention, through targeted continuing medical education programs and special training sessions.

Conceived, designed, Performed, Analyzed data and wrote the paper: GHOMA LINGUISSI Laure Stella. Participated to investigate, collecte and analyze data : Robin Noé ONGAGNA YOMBI, Gérald Launay Evrard MISSAMOU and Suzanne LOUVOUANDOU. All authors read and approved the final manuscript.

For the first time, a nationwide KAP study on HIV was conducted among the general practioners of Brazzaville. Author would like to acknowledge all the study participants. This study was financially supported by the Institut National de Recherche en Sciences de la Santé (IRSSA).