Introduction

India has the third largest number of people living with HIV in the world, and according to 2008-2009 estimates, there are an estimated 2.39 million people with HIV in the country (1). The issues related to HIV/ADS are complex involving biological, psychosocial and ethical perspectives. HIV-positive clients are sensitive to the behaviour of health care providers which may signal stigma. Avoiding these potentially problematic behaviours is important for health care personnel, who regularly interact with HIV-positive clients (2). Having good access to care is imperative for maintaining the health, well being, and quality of life of HIV-positive clients (3). Additionally, ethical and legal issues pose challenges to health care providers in their practice and these issues have a direct bearing on patients’ care. Hence, a clear understanding of issues related to HIV/AIDS among health care providers has the potential to augment the overall patient experience, as well as reduce the likelihood of medical error and subsequent legal / administrative issues. Studies conducted among physicians report that one-quarter of physicians are not up-to-date on state codes relating to HIV (4). Among rural physicians in the US, legal and ethical issues serve as primary barriers to providing service (5). Adherence to appropriate standards of care is associated with more stable physician-patient relationships and a more positive response on the part of patients; and also depends on the level of knowledge possessed by the physician (6). A study conducted at an American university found that just above 50% of the physicians had complete knowledge of state laws, institutional policies and procedures on issues of confidentiality related to HIV or AIDS (7). The information related to these issues among health care providers in India is limited. The objective of this study was to assess the perceptions of doctors and nurses about training and knowledge in ethical issues related to HIV/AIDS in three hospitals associated with a medical college. We also included nurses in our study as they play an important role in providing care to HIV – positive clients.

Methods

A facility-based crosssectional study was carried out in three hospitals associated with Kasturba Medical College, Mangalore. The study population included doctors and nurses employed in the above mentioned institutions during the month of March 2011. A total of 262 doctors and 290 nurses are currently employed at the institution’s three hospitals. The sample sizewas calculated assuming that 50% of the health care professionals at these hospitals were aware of ethical issues related to HIV, and with a relative precision of 25% and confidence interval of 95%, the sample size was calculated to be 125. Assuming a non-response rate of 15%, the total sample size was 144. After obtaining written informed consent from the participants, data collection was done using a pre-tested, semi-structured self-administered questionnaireThe responses of the participants regarding legal and ethical issues were collected on a five point Likert scale, ranging from 1-5 viz. 1-strongly disagree, 2-disagree, 3-not sure, 4-agree and 5-strongly agree. The data were entered and analysed using SPSS version 11.5. The data are presented using descriptive statistics and the results are expressed as proportions in the tables. The responses “strongly disagree” and “disagree” and “strongly agree” and “agree” were combined as “disagreed” and ” agreed” Representation of doctors in the study was high when compared to nurses. This was because initially equal numbers of doctors and nurses were approached to participate in the study. Since the response rate among nurses was low because of frequent changing of shifts it was difficult to trace the nurses even after two visits. Hence, more doctors were approached to attain the sample size. Ethical clearance for this study was obtained from the institutional ethics committee of Kasturba Medical College, Mangalore, prior to the commencement of the study.

Results

A total of 144 health care providers participated in the study, of which 73.6% were doctors and 26.4% were nurses. Table 1 gives the baseline characteristics of the study participants. It can be observed from the table that a majority of the doctors (91.5%) and nurses (84.2%) were in the age group of 20-39 years .The mean age of the study population was 30.8(±8) years. Most (68.9%) of the doctors in the study were males, whereas a majority (94.7) of the nurses were females. Among the doctors, 77.3% had work experience of less than 5 years as compared to 47.4% nurses.

Table 2 represents the responses to questions on training in policies and procedures regarding HIV/AIDS. Only 52.8% of the doctors agreed that they received sufficient information about HIV data confidentiality and policies and procedures, compared to 94.7% nurses. Regarding receiving sufficient information with respect to policies and procedures related to HIV during their training, 56.6% of the doctors agreed that they got sufficient training compared to 86.8% of the nurses. The majority of doctors (85.8%) and nurses (84.2%) believed that they needed additional education/training in policies and procedures related to HIV. 92.5% of the doctors and 76.3% of the nurses also agreed that they need to be trained on the rights of HIV- positive patients. The main sources of information among the doctors were experience at work for 40 respondents (37.7%), post graduate training and undergraduate training for 36(34%) and lectures/seminars/CMEs/conferences for 18 (17%) of the respondents. The main sources of information among the nurses were: experience at work for 24 (63%) respondents, and under graduate training 9 (23.6%) respondents.

Table 3, shows responses to questions related to knowledge and practices regarding confidentiality in HIV/AIDS. 69% of doctors and 52.6% of the nurses agreed that information about HIV-positive clients could be released to any person or legal entity as a result of subpoena, court order or other judicial process. A majority (86.8%) of the study population agreed that clients’ HIV/AIDS status could be disclosed to the spouse or sexual partner after notifying the client. Most of the doctors (85.8%) agreed that confidential information could not be shared with anyone who is not legally authorised. In the case of nurses, only 68.4% agreed with this.

Table 4, shows that a majority of the doctors (80.25%) and nurses (92.1%) agreed that it was a legal necessity to refer clients for pre-test and post-test counselling in all situations. Also, 92.5% doctors and 86.8% nurses agreed that it is a legal necessity to disclose HIV test results to clients. Only 30.2% of doctors and 28.9% of nurses agreed that consent was required for testing patients HIV status in case of accidental exposure to a patient’s body fluids.

Discussion

This study explored the perceptions regarding HIV-related ethics among doctors and nurses and was successful in the identified areas of HIV ethics which need attention for better health care delivery. A majority of the study participants were in the age group of 20-40 years with mean age of 30.8(±8) which is similar to the Academic Medical Center (AMC) study (7).

In our study only 57% of doctors felt that they received adequate information and training related to aspects such as HIV data confidentiality, policies and procedures of the hospital. On the contrary most of the nurses felt that they received sufficient information with respect to the above aspects.In case of the AMC study, only 18% of the physicians reported receiving sufficient information during initial orientation (7). The reason for these findings among the physicians in our study could be due to the fact that the curriculum of medical training in India does not have any module addressing these issues. Hence, it is not surprising that a majority (85%) of the study subjects also felt the need for additional education/training in HIV policies and procedures which is similar to the findings of another study (7).

The study also found that 69% of the doctors and 53% of the nurses were aware that a client’s confidential information could be released to a legal entity. A similar (65%) finding was seen in the case of the AMC physicians. Most of the doctors (85%) and about 68% of the nurses agreed that it is an offence to intentionally, or knowingly disclose the patient’s confidential information to anyone who is not legally authorised; but less than half of the AMC physicians responded correctly to this issue (7). Though initially a majority of the nurses agreed that they received sufficient information with respect to HIV data confidentiality and policies and procedures, the findings of the study reflect an inadequate knowledge, which could be due to ineffective training and lack of experience among the respondents. The finding suggests an urgent need for training of nurses with respect to these issues. Surprisingly, a majority of the doctors and nurses were of the opinion that in case of accidental exposure to a patient’s body fluids it is mandatory to obtain patient consent to test the patient’s blood for HIV/AIDS.

The two chief limitations of our study are: that most (77%) of the doctors in our study were relatively inexperienced; and that the representation of nurses was low as compared to doctors, which could have led to selection bias. Hence, caution should be exercised while interpreting the study findings. Nevertheless, further research with a larger sample size with equal representation of doctors and nurses could be considered.

Following this study the authors suggest some steps that could be taken to address these issues. As HIV/AIDS involves several ethical and legal issues concerning confidentiality and disclosure, the medical training curriculum should include a module addressing these issues, with comprehensive training for doctors and nurses addressing issues such as confidentiality, policies, and procedures related to HIV. Hospital administrations should organise regular programmes to update knowledge among the employees with respect to the hospitals’ policies and procedures. The authors also feel there is a need for a uniform code on HIV/AIDS to guide health care providers on how to deal with complex issues related to HIV more effectively.

Conclusion

There appears to be moderate to poor perception about ethical and legal issues among the healthcare professionals in our study. Further sensitisation in the form of periodical/refresher training as mentioned by a majority of the participants’ could go a long way towards better management of HIV-positive patients.

Conflict of interest: Nil. Funding: Nil.

Table 1: Baseline characteristics of study participants (n=144)

Table 2: Training related to policies and procedures of HIV/AIDS (n=144)

Table 3: Perceptions related to confidentiality among study participants (n=144)

Table 4: Perceptions related to legal issues of HIV/AIDS among study participants (n=144)