Perceptions and knowledge of medical students about HIV and AIDS

Background and Objectives: The degree of information is not restricted to informative and opportunity issues of knowledge, but also to the development of a conscious individual perception for the adoption of preventive practices. This study aimed to assess the perception and knowledge of medical students about HIV and AIDS. Methods: This is a cross-sectional, observational, and unicentric study, through the application of a structured questionnaire and two referring to the attitude towards HIV and the individual risk perception and knowledge on modes of transmission. Student’s and Pearson’s Chi-Square Tests were applied, with p <0.05. Two hundred twenty-three medical students from the first to eighth semesters participated. Results: Most university students reported having compassion (90.58%) and no blame (97.31%) for HIV. However, 69.06% did not feel prepared to treat these patients. Moreover, 76.68% reported not having a risk of contracting HIV, a fact of concern for the inherent risk of the profession. Of the 20 questions on knowledge on modes of transmission, the degree of accuracy ranged from 18.2 and 19.4 points. Prevalence (85.2%), prejudice (75.78%), and condom (72.65%) were the main symbolic values associated with HIV. Conclusion: Students presented ethical and humanistic attitudes towards patients with HIV and a high degree of knowledge about the modes of transmission of HIV. Regarding risk perception, there is need for a more focused approach in the Public Health, Infectology, and Immunology disciplines.


INTRODUCTION
The Acquired Immunodeficiency Syndrome (AIDS) is a challenge for the health and socio-political sectors. It has deep implications in biopsychosocial aspects, being intrinsically related to economic and cultural factors. It is characterized as a destabilizing phenomenon and a great misfortune for human history, presenting itself as a serious worldwide public health problem and in a continuous expansion. [1][2][3] In 1981, the U.S. Center for Disease Control officially recognized AIDS as a new disease, not yet classified, with a likely infectious and transmissible etiology. In 1984, this infectious agent and its consequences were accepted by the entire scientific community. In the following year, the first HIV detection tests were commercialized. [4][5][6] Nationally, in 1982, the first confirmed cases of AIDS emerged in the state of São Paulo, and from the free and universal Antiretroviral Therapy (AVT) access policy of the Brazilian Health System (Sistema Único de Saúde, abbreviated SUS), nearly the 90s, morbidity and mortality rates decreased concomitantly with the increase in life expectancy of these patients. 7 However, looking at the national trend of evolution of cases, it was found that, according to the Department of STD/HIV and Viral Hepatitis of the Ministry of Health of Brazil, the Northern and Northeast regions have an indication of recurrent increase in mortality, while the Southeast has decreasing indicators. 8 Therefore, socioeconomic aspects, especially related to the issue of perception and attitudes towards HIV, stand out as influencers, although isolated knowledge is not enough to adopt a behavior protector. 1,9 In view of this reality, it is clear that the degree of information is not restricted to informational issues and the opportunity for knowledge, but also to the development of an individual perception for the adoption of preventive practices in view of the various transmission routes of the virus. 9,10 This fact can be hindered by the difficulty of accessing systematic and clear information in health centers, as well as by the proximity to infected people, drug use and exposure to violence. 11 In the meantime, there is an affective dimension associated with AIDS, favoring the development of symbolic values, such as fear, suffering, prejudice, and death. Faced with this, it is clear that the notion of "risk group" can become distorted -even among health professionals -leading to stigmatization of patients and avoidance of preventive measures, given that many of them think they are not at risk of HIV. 3 Therefore, individual, cognitive, behavioral and social vulnerabilities are installed. 9.12 Still in the health sphere, there is a lack of professional preparation in the face of patients with this condition. 3 This fact indicates the need for constant professional training to adapt knowledge to the different faces of the epidemic, as well as the formation of a doctor-patient bond with their own health care system. Based on this, the inexistence of a curriculum based on the biopsychosocial aspects of HIV, in addition to the predominance of hostile mentalities, negative perceptions and stigmatization of this condition, generates obstacles to comprehensive, dignified and respectful care for these patients -who face the physical consequences of the disease and social prejudice. 12,13 Analyzing the relevance of professional training to deal with HIV-positive patients, as well as the vulnerability to which they are exposed, the present research aimed to determine the perception of medical students about the care of patients with HIV / AIDS. Perception of care will directly influence the doctor's attitude towards patients, addressing ethical and moral aspects inherent to medical practice and humanized health care.
In view of the complexity of the topic, as well as the need for medical training based on ethical and moral precepts, greater academic and professional attention is needed with regard to the development of studies on how medical students understand this condition, as well as the forms of approach, attitude and perception towards HIV-positive patients. Therefore, based on the expansion of knowledge and the effectiveness of this study, interest in the topic is justified, as results may contribute to the improvement of academic training, doctor-patient relationship and patient care. This study aimed to assess the perception and knowledge of medical students about HIV and AIDS.

METHODS
This is a cross-sectional, observational and unicentric study, involving 223 medical students enrolled from the 1 st to 8 th semester of the course. The research protocol corresponded to a structured and self-administered questionnaire, containing 9 multiple-choice questions. It presents sociodemographic variables of sample description, such as age, sex, color/race, religion, and semester. Furthermore, school education site, guidance on HIV transmission and prevention methods, feeling of preparedness to care for a patient with HIV and the main symbolic values attributed to this condition (prevention, prejudice, condoms, fear, suffering, carelessness, sadness, irresponsibility, and death) were verified.
In addition, two questionnaires were applied regarding the attitude towards AIDS and the individual/risk perception and knowledge on the modes of transmission of HIV, which are adapted and validated. 9 The statistical analysis methodology was used to describe and synthesize the collected data, enabling its presentation in different forms, which favors the quality of the interpretations.
Data were organized in contingency tables "l x c", based on absolute and relative frequencies and using Pearson's Non-Parametric Chi-Square Test for independence and trend among nominal variables. Pearson's Chi-Square Test for association was calculated to verify the relationship among the epidemiological profile variables, with a significance level below 0.05.
In addition, T-Student Test was used for the correlation and comparison of data.
Consequently, the collected data were tabulated, interpreted, processed and analyzed by using descriptive and inferential statistics, adopting a confidence level of p <0.05 to verify the
As for the mode of contagion of HIV, of the 20 questions related to the knowledge on the modes of transmission of HIV, the average of correct answers ranged from 18 to 20 points.
There was no significant difference among the groups studied (p <0.05).
It was also found that 220 respondents (98.65%) answered that attending the same  (Table 3).
However, the two questions, which presented the highest level of error among students, were related to public toilet use (82.06%) and kissing on the lips of patients (88.34%) ( Table   3). It is evident that the only question where the results were not statistically significant, addressed blood donation as a means of contagion, where 98 (43.95%) said it was likely, while 125 (56.05%) said it was unlikely (Table 3).  When analyzing issues related to school education and receiving guidance on methods of preventing HIV contagion, it was found that 203 students (91.03%) answered "yes", regardless of whether the school is public (22.87%) or private (60.54%), referring to a level of significance lower than 0.001 (Table 4). In contrast, 126 students (56.5%) were not instructed on the theme by their parents or guardians (  H1: There is a significant dependency relationship between the variables and the observed frequency (p <0.05).

DISCUSSION
In view of the results obtained regarding attitudes towards people with AIDS, it was found that most students reported a respectful and accepting behavior. 15 In this context, the low number of university students with feelings of aversion or detachment in relation to their seropositive colleagues it may be related to the biological knowledge of the human condition itself, through the understanding and proximity to the intrinsic biopsychosocial aspects, mainly with regard to the rights to education and work of people with HIV and AIDS. 15,16 Furthermore, most students considered that patients "do not deserve to be sick" and that they feel "compassion for people with AIDS", expressing empathy and respect. These questions infer non-blame for the referred situation, as well as the negation of the individual subjective affective dimension, replacing it with the consideration of the individual's social, cultural and economic factors -contrary to what was highlighted in another research. 16 Regarding symbolic values, prevention, prejudice and condoms were found to be the main ones highlighted by undergraduates. Given this, there is still a great divergence in the current scientific literature on the knowledge and prejudice associated with HIV and AIDS, emphasizing that most of the participants did not present prejudiced behaviors, but referred to prejudice as an expressive symbolic value related to such condition. 15,17 Thus, its influence in the current socio-cultural context is notorious, increasing stigmatization and the chances of prevention for a large part of the population. 3 In fact, the psychic and emotional factors have a strong relationship with the health-disease, so that stigma and prejudice become as harmful as the action of HIV on the human body. 16 There is a need to expand researches on the risk of HIV contagion and the vulnerability of the population in general, in order to expose the "risk groups" and the misconceptions regarding perception and attitudes before this reality. These actions would prevent the spread of erroneous information by health professionals. Most patients seek knowledge among doctors, nurses, social workers, and could guarantee the development of prevention and health promotion strategies more geared to the needs of the target group target studied, besides of follow-up and clarification of doubts. 11 Collaborating with this argument, the Ministry of Health (MoH), through Ordinance 151/09, considered "the need to create alternatives for expanding access to the diagnosis of HIV infection, in compliance with the principles of equity and integrality of assistance, as well as the universality of access to health services of SUS". For this purpose, correct information and preventive measures must be propagated to citizens. 14,20 For questions regarding the modes of transmission of the virus, it was found that medical students had a level of correctness ranging from 18.2 to 19.4 points, that is, an excellent level of knowledge. This situation can be justified by the fact that most of them have received guidance on care, means of contagion and treatment since school life, which made it possibleafter entering university -to combine past information and new medical notions. Such results corroborate with the researches developed, where the media, the internet and the information provided by family members were the first sources of understanding on the subject by medical students before entering college. 19 Furthermore, advertising campaigns can be highlighted, and media influence as a tool for the dissemination of truthful information, and health services can take advantage of this medium to help raise public awareness. 15,21 Vaginal and anal sex and with multiple partners without using a condom, receiving contaminated blood transfusions, sharing needles with injecting drug users are highly likely means of contagion, recognized by approximately 96.41% of the interviewees. However, a high number of incorrect answers was identified regarding transmission through blood donation and "being born to a mother who has HIV", a fact similar to that found in other studies. 3,15,22 The high rate (96.41%) of students reporting that being the child of a mother with HIV is likely to be transmitted should be analyzed carefully. 3,15,21 In Brazil, about 80% of infections in children are due to vertical transmission (VT), whether in the intrauterine period, in the intrapartum (at birth) or postpartum (in breastfeeding). In these cases, most mothers are unaware of positive serology, have not been subjected to HIV research tests, have not undergone adequate prenatal care or have no access to therapeutic prophylaxis. This reality is seen in developing countries, mainly. If the pregnant woman and her child have access to ARV -developed since the 1990s -the chances of HIV transmission are less than 1%. Therefore, VT is likely in cases of non-performance of therapy, while it is unlikely with adherence to ARV drugs, a situation that guarantees the right to maternity. 2,23 Blood donation still generates great doubts about the chances of contamination of several diseases, mainly in relation to HIV. This fact is extremely concerning, since it can generate resistance to donations in blood centers and in campaigns to raise awareness of their importance in saving lives. In addition, the strict protocol followed by blood collection centers should be considered, aiming at nullifying the chances of contamination, such as the recruitment of voluntary donors and with low risk of infection; conducting HIV tests (such as the ELISA test) and other blood-borne infections; training health professionals and regular supply of the necessary equipment for collection. There is also an anti-HIV test, which is extremely important to identify this condition early and avoid situations of risk to patients as donors. Therefore, it is a highly praised method, with efficiency and without negative stigmas. 3,15,22 Despite the students having a high degree of knowledge about HIV and AIDS, most of them (69.06%; p <0.001) declared that they were not prepared to attend a HIV-positive patient, which can be justified by the high need for biopsychosocial skills for its performance. Thus, the importance of a curriculum that is more focused on the psychic and emotional aspects of HIV is emphasized, in order to ensure professional practice and skills based on trust, security, respect and empathy at the time of service. 12 It should be emphasized that the chronic aspect of HIV demands a great responsibility for health professionals, needing mastery in communication to guarantee adherence to treatment, to allow the continuity of the exercise of citizenship and a great doctor-patient relationship. 12,18,19,24 Therefore, it was observed that the subjective dimension of attitudes and risk perception must always be related to technical and scientific knowledge, in order to train professionals to assist, guide, and care for all patients who seek care in health care units. 18 Therefore, unethical and non-humanized situations can be avoided and real medicine can be carried out.