Abstract
Objectives: Oral health care of patients with human immunodeficiency virus (HIV)/acquired immune-deficiency syndrome (AIDS) is a growing area of concern. Information on HIV- and AIDS-related knowledge among dental students provides a crucial foundation for efforts aimed at developing an appropriate dental curriculum on HIV and AIDS. The purpose of this study was to assess the knowledge and attitude of Indian clinical dental students towards the treatment of patients with HIV/AIDS and perceived sources of information regarding HIV-related issues. Materials and methods: Data were collected from clinical dental students (third year, fourth year and internship) from three dental institutions in Delhi National Capital Region (NCR). The questions assessed the knowledge and attitude towards treatment of patients with HIV and the perceived source of information related to HIV. Results: The willingness to treat HIV-positive patients among dental students was 67.0%, and 74.20% were confident of treating a patient with HIV/AIDS. The potential problems in rendering treatment to these patients were effect on the attitude of other patients (49.90%) and staff fears (52.50%). The correct knowledge regarding the infection-control practice (barrier technique) was found among only 15.50% of respondents. The respondents had sufficient knowledge regarding the oral manifestations of HIV/AIDS. Conclusions: There was no correlation between the knowledge and attitude score, demonstrating a gap between knowledge and attitude among dental students regarding treatment of HIV-infected patients. Appropriate knowledge has to be delivered through the dental education curriculum, which can instil confidence in students about their ability to manage HIV-positive patients.
Key words: Oral health, HIV/AIDS, infection control, education
INTRODUCTION
Human immunode?ciency virus (HIV) infection and acquired immune-de?ciency syndrome (AIDS) are globally emerging public health problems. In India alone, over 2.5 million people are living with HIV/AIDS [PLWHA (people living with HIV/AIDS)]1 and the estimated prevalence is 0.91%2. According to the joint UN Programme on HIV/AIDS (UNAIDS) and the World Health Organisation (WHO), more than 25 million people had died worldwide from AIDS by 2005. According to new estimates released by NACO (National Aids Control Organisation), supported by UNAIDS and the WHO, an estimated 2.5 million people were living with HIV in India by July 20073.
Dental therapeutic procedures frequently involve blood and saliva, which may contain a variety of blood-borne pathogens and microorganisms, such as HIV4., 5.. Dental professionals are at a high risk for cross-infection with HIV and may therefore avoid treating HIV-positive dental patients6. This has serious public health consequences. For instance, in 60–70% of HIV-positive individuals, oral symptoms of HIV infection are the first signs of the syndrome appearing and these can be used as appropriate diagnostic criteria in the detection of AIDS7.
Additionally, healthy asymptomatic HIV-positive dental patients may conceal their condition in order to receive appropriate treatment, which may have serious consequences, such as increased risk of cross-contamination8. Cross-infection can theoretically take place from patient to patient, from dentist to patient and vice versa. The estimated risk of HIV transmission from general practice dentists to their patients is recognised to be minimal if infection-control guidelines are strictly adhered to. About 90% of the HIV infections among health-care workers occur in developing countries where occupational safety is a neglected issue9.
It is of major importance that attitude and knowledge regarding HIV/AIDS, together with possible relationships, are studied to highlight their role in fulfilling the intentions of the authorities and expectations of the consumers concerning the risk-group patients. The dental students (dentists of the future) play an important role in health-care delivery to individuals with HIV/AIDS and are therefore of special interest and importance in this respect10.
All dental students should have complete knowledge about universal precautions, an administrative control measure that calls for the implementation of practices and equipment to protect the health-care workers whenever the potential exists for exposure to blood. Every patient is considered to be infected with a blood-borne pathogen, regardless of the known serostatus11.
Clinical dental students, in particular, may encounter a number of incidents in which infections, including AIDS, from patient’s body fluids may be present. In comparison with other infectious diseases, dental students were found to be more willing to treat patients infected with hepatitis B virus (HBV) and hepatitis C virus (HCV) than those infected with HIV4.
A number of studies published between 1988 and 1997, involving dental students10 and dental hygiene students12 documented that students exhibited bias towards individuals with AIDS as well as a more generalised homophobia13. Several studies have been conducted to assess the willingness of oral health professionals to treat HIV-positive individuals, either as a main survey or as part of a knowledge, attitudes and practice survey, in many parts of world, such as Brazil, Mexico, Jordan and Nigeria14.
To date, very little work has been carried out to assess the knowledge and attitude among Indian dental students. Therefore, the present study was carried out to assess the knowledge and attitude of Indian dental students regarding the treatment of patients with HIV/AIDS.
MATERIALS AND METHODS
A descriptive, cross-sectional survey was conducted to assess the HIV-related knowledge and attitude among clinical dental students studying in third and fourth (final) years and interns from three dental colleges in Delhi National capital region (NCR): Maulana Azad Institute of Dental Sciences, New Delhi; Sudha Rustagi College of Dental Sciences and Research, Faridabad; and SGT Dental College and Hospital, Gurgaon.
In India, the undergraduate dental course comprises undergraduate training of four years, followed by one year of internship training programme, which pertains to exclusive clinical practice. In the third and fourth years, apart from classes corresponding to courses in the core curriculum, students also complete rotations in various clinical departments. During internship, the students rotate through various dental specialties after the completion of the formal coursework to hone their clinical skills. Therefore, the present study was conducted among the students during their clinical years from third year to interns.
Ethical clearance
Permission to carry out the study was obtained from the principals of the respective colleges. Written informed consent was obtained from all participants. The permission to carry out the study was also obtained from the Institutional Committee of the Sudha Rustagi College of Dental Sciences and Research. The present research was conducted in full accordance with the World Medical Association Declaration of Helsinki.
Questionnaire
The questionnaire included information such as demographic factors, including gender, age, and year of study. The questions assessed the willingness, knowledge, and attitude regarding the treatment of HIV-positive patients and perceived source of information about HIV- and AIDS-related issues among dental students. A total of 610 students were delivered the survey questionnaire, of which 427 completed the whole questionnaire. The over-all response rate among the respondents was 70%.
Statistical analysis
The data were tabulated using Microsoft Excel, and statistical analysis was performed using SPSS version 17.0. Descriptive statistics were calculated and the statistical tests used were chi-square test for comparison of prevalence of knowledge and attitude scores among third- and fourth (final)-year students and interns, analysis of variance (ANOVA) for comparison of mean knowledge and attitude scores among third- and fourth (final)-year students and interns. Pearson’s correlation test was used for testing correlation between knowledge and attitude score among the study population. The P-value was significant when less than 0.05.
RESULTS
The present study assessed the attitude and knowledge regarding the treatment of patients with HIV/AIDS among Indian Clinical Dental students. The mean age of the study population was 21.24 ± 1.52 years. The study population consisted of 126 (29.5%) male students and 167 (70.5%) female students, which corresponded to the higher number of female students opting for dental education in India.
Willingness to treat patients with HIV was found to be 67% among the study population, with students in the third year (70.70%) showing a significantly (P <0.05) higher willingness to treat such patients compared with students in the other groups. The majority of the respondents (74.20%) considered treating HIV positive patients to be the moral and ethical responsibility of the dentist, with significantly (P <0.05) more fourth (final)-year students (86.50%) agreeing (Table 1).
Table 1.
Attitude among the study population
| Question | Response | Year of study |
Total (%) | P | ||
|---|---|---|---|---|---|---|
| Third year (%) | Fourth year (%) | Intern (%) | ||||
| Question 1: Will you willingly treat a patient if you know he/she is HIV positive? | Yes | 104 (70.70) | 88 (66.20) | 94 (63.90) | 286 (67.00) | 0.450 |
| No | 43 (29.30) | 45 (33.80) | 53 (36.10) | 141 (33.00) | ||
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | ||
| Question 2: Do you think treating an HIV-positive patient is a moral and ethical responsibility of the dentist? | Agree | 103 (70.10) | 115 (86.50) | 99 (67.30) | 317 (74.20) | 0.000*** |
| Not sure | 17 (11.60) | 16 (12.00) | 48 (32.70) | 81 (19.00) | ||
| Disagree | 27 (18.40) | 2 (1.50) | 0 (0.00) | 29 (6.80) | ||
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | ||
| Question 3: Treatment of an HIV-positive patient increases risk of HIV transmission to you? | Agree | 75 (51.00) | 85 (63.90) | 76 (51.70) | 236 (55.30) | 0.027* |
| Not sure | 16 (10.90) | 13 (9.80) | 8 (5.40) | 37 (8.70) | ||
| Disagree | 56 (38.10) | 35 (26.30) | 63 (42.90) | 154 (36.10) | ||
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | ||
| Question 4: If you treat an HIV patient, other patients would avoid rendering treatment from you? | Agree | 65 (44.20) | 64 (48.10) | 84 (57.10) | 213 (49.90) | 0.002** |
| Not sure | 51 (34.70) | 28 (21.10) | 23 (15.60) | 102 (23.90) | ||
| Disagree | 31 (21.10) | 41 (30.80) | 40 (27.20) | 112 (26.20) | ||
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | ||
| Question 5: Dealing with staff/assistant fears about HIV/AIDS could be a potential problem for treating a patient with HIV/AIDS? | Agree | 68 (46.30) | 65 (48.90) | 91 (61.90) | 224 (52.50) | 0.002** |
| Not sure | 11 (7.50) | 22 (16.50) | 16 (10.90) | 49 (11.50) | ||
| Disagree | 68 (46.30) | 46 (34.60) | 40 (27.20) | 154 (36.10) | ||
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | ||
| Question 6: Infection-control procedures for treatment of the patients with HIV/AIDS could raise cost for dental practice? | Agree | 51 (34.70) | 30 (22.60) | 44 (29.90) | 125 (29.30) | 0.036* |
| Not sure | 36 (24.50) | 30 (22.60) | 23 (15.60) | 89 (20.80) | ||
| Disagree | 60 (40.80) | 73 (54.90) | 80 (54.40) | 213 (49.90) | ||
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | ||
| Question 7: Are you confident of safely treating a person with HIV infection? | Agree | 84 (57.10) | 68 (51.10) | 39 (26.50) | 191 (44.70) | 0.000*** |
| Not sure | 33 (22.40) | 33 (24.80) | 30 (20.40) | 96 (22.50) | ||
| Disagree | 30 (20.40) | 32 (24.10) | 78 (53.10) | 140 (32.80) | ||
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | ||
| Question 8: Do you treat all your patients as potentially HIV infectious? | Agree | 58 (39.50) | 90 (67.70) | 67 (45.60) | 215 (50.40) | 0.000*** |
| Not sure | 21 (14.30) | 9 (6.80) | 40 (27.20) | 70 (16.40) | ||
| Disagree | 68 (46.30) | 34 (25.60) | 40 (27.20) | 142 (33.30) | ||
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | ||
AIDS, acquired immune-deficiency syndrome; HIV, human immunodeficiency virus.
P <0.05 (Significant), **P <0.01 (Highly Significant), ***P <0.001 (Very Highly Significant).
As per the study population, 236 (55.30%) respondents agreed that treating an HIV-positive patient can be a risky behaviour and might result in the transmission of HIV infection to the treating dentist, whereas 154 (36.10%) disagreed (Table 1).
The statement ‘Treatment of an HIV patient by you can make other patients uninterested in taking treatment from you’ was agreed upon by 213 (49.90%) respondents, whereas only 112 (26.20%) respondents disagreed. A significantly (P <0.05) higher proportion of the fourth (final)-year students (30.80%) also agreed. Also, one more obstacle perceived was dealing with the staff fears while treating HIV patients in the dental setting, which was agreed upon by 224 (52.50%) respondents, whereas 154 (36.10%) disagreed (Table 1).
Only 125 (29.30%) respondents agreed that dealing with HIV-positive patients would result in a financial burden to the dental practice, whereas 213 (49.90%) respondents disagreed. Only 191 (44.70%) respondents were confident of treating an HIV-positive patient, of whom third-year (57.10%) and fourth (final)-year (51.10%) students were significantly (P <0.05) more confident in comparison to interns (26.50%) (Table 1).
A large number (n = 215; 50.40%) of the respondents agreed that they treat their every patient as potentially an HIV-positive patient, with a significantly (P <0.05) higher number of fourth-year students (n = 90; 67.70%) agreeing with this statement (Table 1).
When asked about knowledge regarding the barrier technique for treating an HIV-positive patients, 66 (15.50%) respondents had correct knowledge about it. A significantly (P <0.05) better knowledge about the infection-control practices was found among interns (n = 32; 21.80%) in comparison to third-year (13.6%) and fourth (final)-year (10.5%) students (Table 2).
Table 2.
Knowledge regarding the infection control, modes of transmission of human immunodeficiency virus (HIV) and measures to be taken in the event of a needlestick injury among the study population
| Knowledge questions | Response | Year of study |
Total (%) | P | ||
|---|---|---|---|---|---|---|
| Third year (%) | Fourth year (%) | Intern (%) | ||||
| Question 9: The Barrier technique to be followed for treating patients with HIV/AIDS? | Correct (1) | 20 (13.60) | 14 (10.50) | 32 (21.80) | 66 (15.50) | 0.000*** |
| Not sure (2) | 2 (1.40) | 4 (3.00) | 22 (15.00) | 28 (6.60) | ||
| Incorrect (3) | 125 (85.00) | 115 (86.50) | 93 (63.30) | 333 (78.00) | ||
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | ||
| Question 10: According to you, is HBV more infectious than HIV? | Correct (1) | 65 (44.20) | 97 (72.90) | 101 (68.70) | 263 (61.60) | 0.000*** |
| Not sure (2) | 22 (15.00) | 19 (14.30) | 38 (25.90) | 79 (18.50) | ||
| Incorrect (3) | 60 (40.80) | 17 (12.80) | 8 (5.40) | 85 (19.90) | ||
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | ||
| Question 11: Infection-control practices for HBV are adequate for protection against HIV? | Correct (1) | 38 (25.90) | 38 (28.60) | 91 (61.90) | 167 (39.10) | 0.000*** |
| Not sure (2) | 43 (29.30) | 36 (27.10) | 0 (0.00) | 79 (18.50) | ||
| Incorrect (3) | 66 (44.90) | 59 (44.40) | 56 (38.10) | 181 (42.40) | ||
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | ||
| Question 12: The occupational exposure to saliva in the dental setting can readily transmit HIV to the dentist? | Correct (1) | 46 (31.30) | 60 (45.10) | 79 (53.70) | 185 (43.30) | 0.004** |
| Not sure (2) | 12 (8.20) | 9 (6.80) | 8 (5.40) | 29 (6.80) | ||
| Incorrect (3) | 89 (60.50) | 64 (48.10) | 60 (40.80) | 213 (49.90) | ||
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | ||
| Question 13: What measures would you take in case of needlestick injury from a diagnosed case of HIV-infected person? | Correct (1) | 40 (27.20) | 62 (46.60) | 84 (57.10) | 186 (43.60) | 0.000*** |
| Not sure (2) | 75 (51.00) | 48 (36.10) | 48 (32.70) | 171 (40.00) | ||
| Incorrect (3) | 32 (21.80) | 23 (17.30) | 15 (10.20) | 70 (16.40) | ||
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | ||
| Question 14: In your opinion, how much is the risk of contracting HIV infection from an HIV-contaminated needlestick injury? | Correct (1) | 3 (2.00) | 19 (14.30) | 29 (19.70) | 51 (11.90) | 0.000*** |
| Not sure (2) | 46 (31.30) | 61 (45.90) | 54 (36.70) | 161 (37.70) | ||
| Incorrect (3) | 98 (66.70) | 53 (39.80) | 64 (43.50) | 215 (50.40) | ||
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | ||
| Question 15: Which drugs are taken under ART therapy for the treatment of HIV/AIDS? | Correct (1) | 9 (6.10) | 14 (10.50) | 68 (46.30) | 91 (21.30) | 0.000*** |
| Not sure (2) | 82 (55.80) | 65 (48.90) | 40 (27.20) | 187 (43.80) | ||
| Incorrect (3) | 56 (38.10) | 54 (40.60) | 39 (26.50) | 149 (34.90) | ||
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | ||
AIDS, acquired immune-deficiency syndrome; ART, Anti-retroviral Therapy; HBV, hepatitis B virus.
implies significant difference.
The correct response to the question ‘Is HBV more infectious than HIV?’ was given by 263 (61.6%) respondents. A significantly (P <0.05) better correct response rate was shown by fourth (final)-year students (72.9%). Only 167 (39.10%) respondents gave a correct response that the ‘Infection control practices for HBV are adequate for protection against HIV’ with a significantly (P <0.05) better correct response rate given by interns (61.90%) (Table 2).
When asked about saliva as a source of HIV transmission in the dental setting, 43.30% respondents had the correct knowledge that saliva is not a potential source for HIV infection, with significantly (P <0.05) better knowledge among the interns (53.70%) (Table 2).
The correct knowledge regarding the measures to be taken in the event of needlestick injury from a diagnosed case of HIV-infected person was reported by 186 (43.60%) respondents, and interns (57.10%) had significantly (P <0.05) better knowledge. Very few (11.9%) respondents had the correct knowledge regarding the risk of contracting HIV infection after an HIV-contaminated needlestick injury. A significantly (P <0.05) higher correct response rate was seen among the interns (19.70%) and fourth (final)-year students (14.30%) with the lowest among the third-year students (2.00%) (Table 2).
The correct knowledge regarding the drugs taken under therapy for HIV/AIDS was found among 91 (21.3%) respondents, with significantly (P <0.05) better knowledge among the interns (46.3%) (Table 2).
The majority of the respondents correctly identified the oral lesions that can be associated with HIV/AIDS, such as oral candidiasis (n = 348; 81.50%), oral hairy leukoplakia (n = 339; 79.40%), oral Kaposi’s sarcoma (n = 303; 71.00%) and salivary gland enlargement (n = 260; 60.90%). The knowledge regarding the oral lesions was significantly (P <0.05) better among the fourth (final)-year dental students (Table 3).
Table 3.
Knowledge regarding the lesions/conditions associated with human immunodeficiency virus (HIV)/ acquired immune-deficiency syndrome (AIDS)
| Question 16: Lesions/conditions are associated with AIDS/HIV? | Response | Year of study |
Total (%) | P | ||
|---|---|---|---|---|---|---|
| Third year (%) | Fourth year (%) | Intern (%) | ||||
| Oral candidiasis | Correct (1) | 91 (61.90) | 125 (94.00) | 132 (89.80) | 348 (81.50) | 0.000*** |
| Not sure (2) | 51 (34.70) | 6 (4.50) | 8 (5.40) | 65 (15.20) | ||
| Incorrect (3) | 5 (3.40) | 2 (1.50) | 7 (4.80) | 14 (3.30) | ||
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | ||
| Oral hairy leukoplakia | Correct (1) | 88 (59.90) | 122 (91.70) | 129 (87.80) | 339 (79.40) | 0.000*** |
| Not sure (2) | 48 (32.70) | 9 (6.80) | 10 (6.80) | 67 (15.70) | ||
| Incorrect (3) | 11 (7.50) | 2 (1.50) | 8 (5.40) | 21 (4.90) | ||
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | ||
| Oral Kaposi’s sarcoma | Correct (1) | 84 (57.10) | 107 (80.50) | 112 (76.20) | 303 (71.00) | 0.000*** |
| Not sure (2) | 52 (35.40) | 14 (10.50) | 17 (11.60) | 83 (19.40) | ||
| Incorrect (3) | 11 (7.50) | 12 (9.00) | 18 (12.20) | 41 (9.60) | ||
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | ||
| Salivary gland enlargement | Correct (1) | 70 (47.60) | 96 (72.20) | 94 (63.90) | 260 (60.90) | 0.000*** |
| Not sure (2) | 55 (37.40) | 19 (14.30) | 25 (17.00) | 99 (23.20) | ||
| Incorrect (3) | 22 (15.00) | 18 (13.50) | 28 (19.00) | 68 (15.90) | ||
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | ||
For assessment of perceived sources of information, the response categories very much and much were combined. Lectures (62.7%) and Internet (50.8%) were the most frequently reported sources for respondents regarding information related to HIV/AIDS, followed by Friends/Relatives (41.3%), Radio/TV (39.30%) and Reading materials (32.10%) (Table 4).
Table 4.
Perceived sources of information regarding human immunodeficiency virus (HIV)/ acquired immune-deficiency syndrome (AIDS)
| Question 17: How much information about HIV- and AIDS-related issues have you received from: | Year of study |
Total (%) | P | ||
|---|---|---|---|---|---|
| Third year (%) | Fourth year (%) | Intern (%) | |||
| Lectures | |||||
| Very much (1) | 44 (29.90) | 52 (39.10) | 57 (38.80) | 153 (35.80) | 0.000*** |
| Much (2) | 21 (14.30) | 43 (32.30) | 51 (34.70) | 115 (26.90) | |
| Little (3) | 20 (13.60) | 10 (7.50) | 4 (2.70) | 34 (8.00) | |
| None (4) | 62 (42.20) | 28 (21.10) | 35 (23.80) | 125 (29.30) | |
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | |
| Internet | |||||
| Very much (1) | 27 (18.40) | 46 (34.60) | 55 (37.40) | 128 (30.00) | 0.000*** |
| Much (2) | 20 (13.60) | 24 (18.00) | 45 (30.60) | 89 (20.80) | |
| Little (3) | 24 (16.30) | 19 (14.30) | 10 (6.80) | 53 (12.40) | |
| None (4) | 76 (51.70) | 44 (33.10) | 37 (25.20) | 157 (36.80) | |
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | |
| Radio/TV | |||||
| Very much (1) | 15 (10.20) | 31 (23.30) | 46 (31.30) | 92 (21.50) | 0.000*** |
| Much (2) | 16 (10.90) | 25 (18.80) | 35 (23.80) | 76 (17.80) | |
| Little (3) | 30 (20.40) | 17 (12.80) | 8 (5.40) | 55 (12.90) | |
| None (4) | 86 (58.50) | 60 (45.10) | 58 (39.50) | 204 (47.80) | |
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | |
| Reading materials | |||||
| Very much (1) | 12 (8.20) | 27 (20.30) | 42 (28.60) | 81 (19.00) | 0.000*** |
| Much (2) | 10 (6.80) | 16 (12.00) | 30 (20.40) | 56 (13.10) | |
| Little (3) | 33 (22.40) | 22 (16.50) | 12 (8.20) | 67 (15.70) | |
| None (4) | 92 (62.60) | 68 (51.10) | 63 (42.90) | 223 (52.20) | |
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | |
| Friends/relatives | |||||
| Very much (1) | 20 (13.60) | 39 (29.30) | 48 (32.70) | 107 (25.10) | 0.000*** |
| Much (2) | 15 (10.20) | 18 (13.50) | 36 (24.50) | 69 (16.20) | |
| Little (3) | 29 (19.70) | 25 (18.80) | 17 (11.60) | 71 (16.60) | |
| None (4) | 83 (56.50) | 51 (38.30) | 46 (31.30) | 180 (42.20) | |
| Total | 147 (100.00) | 133 (100.00) | 147 (100.00) | 427 (100.00) | |
The mean knowledge score among the respondents was 2.11 ± 0.37 and mean attitude score was 1.75 ± 0.35. The mean knowledge score was significantly better among interns (1.98 ± 0.37) whereas mean attitude score was significantly better among the fourth (final)-year students (1.68 ± 0.34) (Table 5).
Table 5.
Comparison of the mean knowledge and attitude score among the third-year students, fourth (final)-year students and interns
| Group | Attitude score(mean ± SD) | Knowledge score(mean ± SD) |
|---|---|---|
| 1. Third year | 1.77 ± 0.26 | 2.28 ± 0.37 |
| 2. Fourth (final) year | 1.68 ± 0.34 | 2.06 ± 0.30 |
| 3. Intern | 1.78 ± 0.41 | 1.98 ± 0.37 |
| Total | 1.75 ± 0.35 | 2.11 ± 0.37 |
| ANOVA | 3.930 | 29.188 |
| P | 0.020* | 0.000* |
| Post-hoc comparisons | 3 > 2 | 1 > 2, 3 |
ANOVA, analysis of variance.
P-value <0.05 (Significant).
These results indicate that there was a significant gap between the knowledge and attitude among the study population, with no correlation between knowledge and attitude score but a significant correlation was found between knowledge and attitude scores among third-year students (0.179) and interns (−0.217) (Table 6).
Table 6.
Correlation between knowledge and attitude score among the study population
| Group | Mean attitude score |
|---|---|
| Mean knowledge score | |
| Overall | |
| Pearson correlation coefficient | −0.024 |
| P-value | 0.617 |
| Third year | |
| Pearson correlation coefficient | 0.179 |
| P-value | 0.030* |
| Fourth year | |
| Pearson correlation coefficient | 0.042 |
| P-value | 0.634 |
| Intern | |
| Pearson correlation coefficient | −0.217 |
| P-value | 0.008* |
The P-value is significant at the 5% level.
DISCUSSION
The present study assessed knowledge regarding the modes of transmission of HIV infection, related aspects of infection control, sources of HIV transmission and perceived need for further education regarding HIV and AIDS among Indian clinical dental students. The provision of dental care for people who are HIV positive is essential for their overall health and the well-being of this population14.
The intention to treat HIV patients was found among 67.0% of the students in the present study, which was exactly the same as reported by Bennett et al.15 (67%), but higher than reported by Mostafa and Hakimi (51%)16, Hu et al.4 (49%), Azodo et al.17 (in which 58.8% expressed willingness to treat HIV positive individuals) and Solomon et al.18 (62%) among dental school seniors in the USA, but lower in comparison with the studies conducted by Utomi et al.19 (78.4%) among Nigerian dentists, and by McCarthy et al. (81.0% among Canadian dentists and 83% among dental students in the USA)20. This factor among dental students is disconcerting for dental educators because of increasing rates of HIV infection in the world.
The majority (74.20%) of the students in the present study considered treatment of a patient with HIV to be the moral and ethical responsibility of the dentist, showing concern towards these patients, which was higher than in the study by Mostafa and Hakimi16, in which 49.7% of dental students agreed that ‘I am not obligated to treat HIV/AIDS patients’.
Current guidelines are that dentists must not refuse to treat a patient solely on the grounds of HIV infection19 and they cannot legally refer these patients to specialty clinics for routine dental care20. Some of the reasons that dentists are afraid of treating these patients and refer them to other dentists are as follows: lack of ethical responsibility; fear among staff members in the dental operatory; concerns related to uncertainty regarding safety regulations; cost of infection-control procedures; lack of knowledge regarding oral lesions associated with HIV; and loss of patients uninfected with HIV as a result of treating HIV-positive patients5., 13., 19..
Just over half (55.30%) of students agreed that treating an HIV-positive patient is a risky behaviour and might transmit HIV infection to the treating dentist, which was higher than the study by Crossley21 (36%) among dental practitioners in a group of dental surgeons in the UK but was lower than reported by McCarthy et al.20 (63%), among dental surgeons in Canada, and Azodo et al.17 (74.2%). A low occupational risk of HIV exposure exists among dental professionals because of the frequent accidental puncturing of the skin with sharp instruments.
That treatment of HIV-positive patients can make other patients avoid seeking treatment was agreed upon by 49.90% of the students, which was higher than the study conducted by Crossley (34%)21 but was much lower than the study conducted by McCarthy et al.20 (68%). The majority (52.50%) of the students agreed that it would be difficult to deal with the staff fears, which was in agreement with the studies by McCarthy et al.20 (59%) and Crossley (67%)21.
The statement ‘treatment of HIV-positive patients would be a financial burden to the dental practice as a result of the infection-control practices’ was agreed by 29.30% of the students, which was lower when compared to the studies of Crossley (32%)21 and McCarthy et al.20 (45%) among dental practitioners. The infection-control protocols needed for patients with AIDS raise the cost of treatment, which, for some clinicians, might create a disincentive to treat them. Dentists should be taught that universal precautions should be used for all patients because dentists and patients themselves will not always be aware of who is HIV positive.
Proportionally, fewer (44.70%) students were confident of treating an HIV-positive patient when encountered, whereas in the study by Mostafa and Hakimi16, only 14.2% of students reported that they could safely treat patients with HIV/AIDS.
Overestimation of the transmission risk of HIV seemed to be the most important reason for fear in providing dental care to patients with HIV/AIDS4. Dental students’ fear may overpower their intellectual and practical abilities to cope with the treatment and management of such patients.
A large number (50.40%) of the students agreed that they treat every patient as a potentially HIV-positive patient. However, this was lower than the study conducted by Mostafa and Hakimi16, in which 65.7% thought that each patient should be considered as potentially infectious, and in the study of Seacat et al.6 in which nearly every student (99.5%) thought that each patient should be considered as potentially infectious. This is a very important issue because some patients with HIV/AIDS abstain from declaring their illness out of fear of being denied dental care. Based on these considerations, infection-control precautions must be strictly followed with every patient.
Dental personnel may be exposed to a wide variety of microorganisms in the blood and saliva of patients in the dental operatory. A very high number of students (15.5%) reported having correct knowledge about the barrier technique (use of mouth masks, gloves and eye glasses). Protective barriers, such as masks, gloves and safety glasses, form the first line of defence in reduction of infectious materials, such as aerosols, in the dental practice.
That ‘HBV is more infectious and a greater hazard to nonvaccinated persons than is HIV’ was reported correctly by 61.6% students, whereas 75.9% of students in the study of Seacat et al.6 gave a correct response. However, a better correct response rate was shown in the study by Mostafa and Hakimi (91.6%)16. Few (39.10%) students correctly reported that the ‘Infection control practices for HBV were adequate for protection against HIV’, whereas a higher (73.7%) number of students had correct knowledge in the study of Seacat et al.6 and Mostafa and Hakimi (75.5%)16.
In the present study, 213 (49.9%) students correctly replied that exposure to saliva cannot be a transmission route for HIV/AIDS to a dental health worker, whereas in the study conducted by Mostafa and Hakimi16, 24.5% of respondents agreed that saliva can be a vehicle for the transmission of AIDS. Transmission through saliva in the dental clinic has not yet been reported, and this has been explained by the ability of the glandular saliva to inhibit the infectivity of HIV22.
The knowledge regarding postexposure prophylaxis (PEP) to be taken in case of needlestick injury from a diagnosed case of HIV-infected person was reported by 43.6% students. However, in the study of Singh et al.22 29.8% students were in favour of taking anti-HIV drugs.
Only 11.9% of students had correct knowledge regarding the risk of contracting HIV infection after an HIV-contaminated needlestick injury. This level of knowledge about the transmission of HIV was very poor among the dental students in the present study, although in the study of Singh et al.22, a better response (37.1%) was seen among the Indian dental students. Immunisation and dental infection control and safety (IC&S) should be an integral part of dental education.
Providing proper dental care to patients with HIV/AIDS necessitates good knowledge in the recognition of the oral lesions associated with the disease. The students in this study showed adequate knowledge about the lesions strongly associated with HIV/AIDS, such as Kaposi’s sarcoma, hairy leukoplakia, oral candidiasis and salivary gland enlargements. Kaposi’s sarcoma, hairy leukoplakia and oral candidiasis may also be seen in patients without HIV infection or AIDS. This was similar to the findings of the research in an earlier study in India carried out by Aggarwal and Panat23 and that of Sadeghi and Hakimi16.
Lectures (62.7%) and the Internet (50.8%) were the most frequently reported sources for students regarding information related to HIV/AIDS in our study, which was similar to the study of Nasir et al.24 in which lectures (61%), media (44%) and health-care workers (39%) were the most frequently reported sources of HIV information among both public and private dental students in Sudan. The sources of AIDS related information reported in this study were different from those identified previously among dental health-care workers from Europe, the USA, Japan and Iran, as well as in students of medical subjects from Iran and Pakistan25. The present results are in contrast to a study of Japanese dental health-care workers, in which TV and newspapers were cited as the most common source of AIDS-related knowledge25.
In contrast to a study carried out by Kitaura et al. in Japan,25 a majority of the students in the present study had good knowledge, but did not relate well to their attitude. Although the interns had better knowledge, they had a poor attitude towards the treatment of these patients.
In a country, such as India, there is a shortage of health-care resources because of its vast population and the majority of the population being located in rural areas. The burden of infectious diseases is high in this country, and the prevalence of HIV is rising, further increasing the burden on health-care services, which are already under much strain. Furthermore, this condition is hampered by the increased number of HIV patients requiring oral health-care services. One of the important resources in such a scenario will be the large number of dental colleges in this country. The provision of appropriate training to dental students in these colleges can help in increasing the knowledge, and subsequently pertaining to the management, of these patients.
CONCLUSION
To carry out effective clinical management, dental students need to be aware of, and understand, the significance of HIV/AIDS and its effect on the oral cavity6., 25.. Willingness to treat patients with HIV/AIDS appears to be related to knowledge of the disease process, recognition of oral manifestations and understanding the modes of transmission5., 25..
In dental students, the overall recognition that HIV-related fear may be irrational is a positive sign, and it points to possible intervention strategies for combating the ill effects of such fear. Appropriate emphasis on ethics training at undergraduate and postgraduate levels, and on continuing education, may improve ethical responsibility and lead to a greater willingness to treat patients with blood-borne pathogens.
Also, rigorous infection-control training for students before graduation is also highly recommended. The findings should alert dental educators about the importance of educating their students clearly and comprehensively about infection-control measures.
Although the sample was homogenous, one of the limitations of the present study was the method for assessing the knowledge and attitude. We could not supervise the responders’ practice and therefore had to rely on self-assessment reports. Future studies are encouraged to study the influence of other factors, which were not studied here, such as the social class, the income, education of parents and the area of residence, on the student’s attitude towards HIV patients, as these are limitations of the present study.
Acknowledgements
No external source of funding or grant was received for the current research work from any agency or person.
Conflict of Interest
There is no conflict of interest among the authors.
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