Survey of the effect of knowledge obtained by family doctors after the thematic improvement cycle «management of hiv2patients for family doctor»

Survey`s results of the impact of knowledge obtained by 111 family doctors through the thematic improvement cycle «Management of HIV)patients for family doctor» are presented in the article. The main achievements of this pro) gram are: raising awareness on the subject of HIV)infec) tion / AIDS; formation of safe behavior of family doctors during their work with HIV)positive patients; establishing communication with patients; increase patient referrals for testing; awareness of the network of institutions and organizations servicing people living with HIV.

U kraine remains a country with high prevalence of HIV infection, especially among group at high risk (GHR). According to the data of SI «Ukrainian Centre for socially dangerous diseases control of the Ministry of Health of Ukraine», on 01.01.2016 in Ukraine the number of people liv ing with HIV (PLWH) was 220 000, the number of new HIV infection -16 000. The number of identified HIV posi tive patients among the GHR was 13,9%. According to the results of seroepidemiological monitoring the spreading of HIV among the GHR was 1,7% among injecting drug users (IDUs), 0,2% of persons engaged in commercial sex services, and 1,1% -men who have sex with men (MSM) [1].
People who live with HIV/AIDS, often face stigma and discrimination and this remains a major problem in provid ing them assistance from qualified medical staff. According to a survey in 2013, 11% of PLWH in the last 12 months at least once faced with limitation in access to health services for reasons related with HIV status. Although this index has decreased by almost half compared to the survey in 2010, PLWH, who identified themselves with the HPR, faced with the manifestations of stigma and discrimination when using health services more often (14%). The survey of health care workers from Kyiv and Kyiv region confirmed that more than 25% of staff has a high commitment to stig ma and discrimination of PLWH. The main reasons for this are lack of knowledge about HIV infection among physi cians [2].
Family doctors (FD) are health professionals of the pri mary contact who first must be aware of HIV infection and have the skills to support HIV positive patients. However, the education of FD does not include HIV infection topics at all or very limited. The knowledge and skills of FD often depends on timely diagnosis of opportunistic diseases, adher ence to follow up, initiation and adherence to antiretroviral therapy (ART). Thus, there is an urgent need for training of FD in support of HIV positive patients, and popularization of such training programs within the country.
For this purpose in 2015 the NGO «Kyiv Association of family doctors» took part in the project «Improving the qual ity of medical care for HIV infected patients by family doc tors», which was funded by the ACO «All Ukrainian Network of PLWH» implements project RESPECT: «Reducing HIV related stigma and discrimination for most at risk populations in health care facilities in Ukraine» by the US Agency for International Development (USAID)/ There were five 5 day cycles of thematic improvement (TI) «Management of patients with HIV infection/AIDS for fam ily doctor» for FD from Zhytomyr, Kyiv, Cherkasy, Chernihiv, Kyiv regions and Kyiv.
So, it was important to assess the impact of knowledge obtained by FD during cycle of TI, on the involvement of PLWH and representatives of GHR to programs to voluntary counseling and testing (VCT) and treatment of HIV infection.
The objective: to assess the impact of knowledge of FD obtained during cycle of TI, «Management of patients with HIV infection/AIDS for family doctor» the involvement of PLWH and representatives of GHR to programs to VCT and treatment of HIV infection.

PATIENTS AND METHODS
• clarify the level of stigma and stigmatization of PLWHA on the HIV status among FD, before and after par ticipating in training; • identify manifestations of discrimination on basis of HIV status among FD before and after participating in training; • compare the contents of work of FD with HIV infect ed patients before and after participating in the training, including the involvement of VCT and treatment of HIV infection.
Methods and research tools. A mixed design was used for the study that involved the collection of information by the survey FD using standardized and in depth interviews.
The procedure and criteria for selecting respondents. In the survey took part all 111 FD who attended cycle of TI «Management of patients with HIV infection/AIDS for family doctor». 17 respondents were selected (4 5 in each region) from FD, which took part in standardized survey, to participate in in depth interviews.
The procedure for processing and analysis. Statistical analysis of data was performed by program SPSS. It was also carried out traditional analysis and comparison answers of respondents before and after participating in the training.

Socio demographic characteristics of respondents.
The absolute majority of respondents were female (80,2%) and only about five parts -male (19,8%). The aver age age of respondents was 50 years; the average duration of practice -9 years.

RESULTS AND DISCUSSION
Participation in the study and assessment of the results All respondents highly appreciated the relevance of con tent of the TI for their professional activities. The highest score was 10 points and it was given by the majority of respondents -72,1%. Most of respondents (29,7%) got completely new information about ART, 9,9% of respondents -normative and legal laws, 8,1% -the treatment of HIV infected persons, 7,2% significantly enhanced their knowledge on the ways of trans mission of HIV infection. Results of in depth interviews are fully confirmed by the data obtained by standardized survey. It is important that doctors learned that mothers with HIV pos itive status, taking ART, can give birth to healthy children.

P10: «HIV infected woman can give birth to a healthy baby. This is a significant progress in the treatment of HIV infection».
Most respondents (23,4%) stressed that after participat ing in the training they have fear to patients HIV positive status, 13,5% indicated that they had improved attitudes to these patients (tolerance, loyalty, understanding), 11,7% pro pose more actively testing, 10,8% of respondents consider each patient as potentially HIV infected, 9,9% feel more con fident in working with HIV infected [ Fig. 1]. The same results were confirmed by the data of in depth interviews.
The in depth interviews also revealed that FD more often in their practice was recommended to patients to be tested for HIV. Also, doctors have more knowledge about cooperation with HIV positive patients. P10: «How to deal with infected patients as to provide him medical care, where he was to refer to testing, how to behave with his relatives».
Interviewed physicians are most interested in the subject «Rights and duties of health professionals related to the safe ty of medical services to patients infected» (45,9%). Another three important topics: «Algorithm of actions for health workers due contact with a potential source of HIV infection when performing professional duties» (42,3%), «Ukraine's legislation in the field of health and counteraction of HIV in Ukraine» (41,4%) and «Procedures for the prescription of post exposure prophylaxis of HIV infection» (39,6%).

The practice of medical services after participating in training and compare them with the previous experience
After completing the training doctors have changed parameters to assess the risk of getting infected by HIV infection. Thus, the number of persons who consider it «very real» decreased twice to 1,8% and 5,4% [ Fig. 3]. More than twice declined the part of doctors who assess their risk as «fifty fifty» (14,4% versus 36,9%). In this case, more respon dents chose the «unlikely» (42,3% versus 35,1%) and almost in three times -«not in danger» (32,4% versus 11,7%).
After completing the training the percentage of respon dents who assessed the risk as «absolutely realistic» remained the same -5,4%, and they did not influence participation in education. As a result of training significantly increased the proportion of physicians who are not afraid to be infected while working with HIV positive patients without latex gloves or    Figure 3. Assessment of risk of getting infected in the performance professional duties in the workplace before and after a cycle of thematic improvement Î Ð Ã À Í È Ç À Ö È ß Ç Ä Ð À Â Î Î Õ Ð À Í Å Í È ß other facilities of protection (84,7% versus 56,8%). Total num ber of respondents who indicated they are afraid of infection when interacting with HIV positive person has decreased from 48 to 17 people. In the survey the majority of FD (94,6%) consider that the attitude to HIV positive patients and other patients should be equal. However, the respondents agreed with the statement that HIV positive people deserve this disease through their behavior: MSM (9,9%); people who are HIV infected sexually (9%); IDU (7,2%). The same number (8,1%) believes that «HIV infected persons should be treated separately from others to protect the general population from infection» and «if the health worker is afraid of HIV infected patient, he may refuse to accept such patients». Only 3,6% of respondents did not agree with any of these allegations.
The proportion of answers in the category to whom is rec ommended to get tested for HIV infection -option «all patients» increased to 54,1% compared to the same period of study (27%). During the survey respondents said that the main reason for recommendations on testing -the presence of the patient opportunistic infections (69,4%), the history anamnesis (58,6%), the presence of family members with HIV positive status (51,4%), which is also confirmed by the results of in depth interviews. Also, FD the referred to test ing of patients at risk (IDU; persons who have been in prison; CWs) [ Fig. 4]. Significant numbers of doctors recommend testing young people or people under 60 years old.
The main indicator of the effectiveness of training is that after going through training doctors refer for testing on HIV in 2 3 times more patients than before. The average number of persons recommended to be tested has increased from 10 to 45 people.
Almost all doctors performed pre test counseling and dis cussed the following issues: the need for delivery of analyzes in connection with the various possible ways of transmission in the case of HIV positive status, early prescription of ART, which will allow the patient to significantly improve their health and live a full life. To report HIV status, it should be noted that compared to last year grew most percentage of those who said they «do not need to know the HIV status of patient during providing medical care» -from 22,5% to 47,7%.
The main source of information about HIV status of patients are themselves (50,5%). Most significantly decreased the proportion of those who know about the HIV status of patients by staff of the medical institution where the patient is tested (from 4,5% to 1,8%). Considerably rare doctors were informed of their HIV status by colleagues (from 8,1% to 5,4%) and family members of patients (from 11,7% to 8,1%). From 18,9% to 16,2% decreased the proportion of those who receive the information from the medical record of the patient.
Over the past year increased the number of doctors who referred HIV patients to non governmental organizationsfrom 6 to 29. Also significantly increased the proportion of those who refer such patients to other health facilities (from 22,5% to 38,7%) and prescribe clinical and laboratory exami nation (from 31,5% to 53,2%) [ Fig. 5]. Also increased the part of doctors who refer patients to another doctor (from 15,3% to 23,4%) and discuss with the patient the importance of cer tain safe behavior (from 40,5% to 60,4%).
After the cycle of TI, the proportion of respondents whose behavior does not depend on the status of HIV patients increased from 65,8% to 89,2%, while the share of those whose behavior depends on the patient's HIV status was reduced from 27,9% to 10, 8% and completely disappeared in the responses category of «difficult to say».

CONCLUSIONS
So, the cycle of TI «Management of patients with HIV infection/AIDS for family doctor» significantly influenced the involvement of PLWH and GHR to testing and treatment of HIV infection.
The main results and advances of the program should con sider the following: • greatly increased awareness of HIV infection / AIDS, legal basis on HIV / AIDS, ethical principles of working with such group of patients; • ART and its role in improving the health of patients with HIV positive status; • almost all the doctors confirmed they use obtained knowledge in practice; • knowledge obtained during the training helped create safe behaviors of FD in their professional activity; • FD now better understand how to behave yourself at work and to deal with HIV positive patients, overcoming barriers and misunderstandings in communication between FD and HIV positive patients; • after participating in training FD in 2 3 times more often refer their patients to the testing. The main causes of suspected HIV positive status were clinical symptoms; • FD increased their awareness about the network of institutions and organizations that work with PLWH, which significantly improve the algorithm of actions after receiving test results.   Figure 5. Actions doctor after detecting HIV positive status of the patient before and after a cycle of thematic improvement Î Ð Ã À Í È Ç À Ö È ß Ç Ä Ð À Â Î Î Õ Ð À Í Å Í È ß