HIV/AIDS (Human Immunodeficiency Virus/

Transcription

1 Knowledge, Attitude, and Behavior in Managing Patients with HIV/AIDS Among a Group of Indian Dental Students Ashish Aggarwal, M.D.S.; Sunil R. Panat, M.D.S. Abstract: With increasing numbers of people with HIV/AIDS receiving oral dental care, dentists should have sufficient knowledge of the disease, and their attitude should meet professional expectations. HIV and AIDS-related knowledge among dental students provides a crucial foundation for efforts aimed at developing appropriate education on these topics. Accordingly, the aim of this study was to assess the HIV/AIDS-related knowledge and attitudes amongst the 460 dental students of the Institute of Dental Sciences, Bareilly (UP), India. A self-administered survey consisting of fifty-three structured questions was conducted with the students. Overall, the response rate was 79.7 percent. The total mean knowledge and attitudes scores were 78.8 percent (excellent) and 77.7 percent (positive). There was no statistically significant difference between the knowledge and attitude scores of males and females. Regarding oral manifestations, Kaposi s sarcoma and candidiasis were the most identified. The results indicated that the students knowledge on HIV/AIDS generally increased as they progressed through the curriculum, but their utilization of all barrier techniques for infection control and clinical protocol lacked consistency and compliance. Hence, there is a need to address, more clearly, the students misconceptions and attitudes towards the disease. Dr. Aggarwal is Senior Lecturer, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India; and Dr. Panat is Professor and Head, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India. Direct correspondence and requests for reprints to Dr. Ashish Aggarwal, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Pilibhit Bypass Road, Bareilly, Uttar Pradesh, India ; drashishagg@rediffmail.com. Keywords: dental education, clinical education, dental students, HIV/AIDS, India Submitted for publication 10/5/11; accepted 9/21/12 HIV/AIDS (Human Immunodeficiency Virus/ Acquired Immunodeficiency Syndrome) has profoundly affected every aspect of health care. The first case of HIV was recognized in the United States in 1981 and has since been diagnosed in populations around the world. 1 Statistics from the Joint United Nations Program on HIV/AIDS and the World Health Organization published in December 2009 estimated that the number of people living with HIV in the world totaled 33.4 million. An estimated 2.7 million people were said to be newly infected with HIV, and an estimated two million had lost their lives to AIDS. It has been estimated that more than 40 million people between the ages of fifteen and twenty-four will have contracted HIV by the year In 2009, it was estimated that 2.4 million people were living with HIV in India, which equates to a prevalence of 0.3 percent. 3 While this percentage may seem low, because India s population is so large, it represents the third greatest number of people living with HIV in the world. 4 However, the estimated number of people diagnosed with new HIV infections in India has declined drastically in recent years from 5.5 million in 2005 to below 2.5 million in According to the United Nations 2011 AIDS report, there has been a 50 percent decline in the number of new HIV infections in the last ten years in India. 3 As people are diagnosed with HIV and live longer lives due to the success of antiretroviral therapies, these patients will require increasingly competent and compassionate health care services, including oral health care. 6 Since 1988, the World Health Organization has stated that all dentists should treat HIV-positive patients. 7 Despite these recommendations, ignorance of the risk of HIV transmission during dental procedures has led many dentists around the world to refuse and/or become reluctant to treat patients with HIV/AIDS As recently as 2007, researchers in countries like South Africa, Brazil, Japan, and Sudan have found that dental students had insufficient knowledge about HIV/AIDS-related information and management of patients with HIV/AIDS, particularly in relation to transmission. 7,11-13 Despite the importance of oral health care for people living with HIV/AIDS, many of these individuals fail to receive adequate oral health care treatment. This is particularly important in developing countries like India where patients with HIV/ September 2013 Journal of Dental Education 1209

2 AIDS do not receive adequate professional oral care due to financial barriers as many such patients live at or below the poverty level. In India, as elsewhere, people living with HIV face stigma and discrimination in a variety of contexts. Research in India has shown that stigma and discrimination against HIVpositive people and those perceived to be infected are common in hospitals and act as barriers to their seeking and receiving critical treatment and care services. 14 Considerations concerning the safety of oral health care providers treating patients with HIV and other infectious communicable diseases make it imperative to educate students optimally about these patients and all aspects of their treatment, including infection control. 9 Data on oral health care needs of people with HIV should alert dental educators regarding the importance of including these issues in dental and dental hygiene curricula. 15,16 It is not surprising that the Institute of Medicine report on the future of dental education also stressed the significance of preparing future oral health care providers to effectively deliver care for diverse and underserved patient populations. 17 The Institute of Dental Sciences at Bareilly, India, provides a five-year training program for about 500 students (100 students per year), in which students are taught basic biomedical science subjects in the first two years and clinical subjects in years three and four. In the second year, students acquire knowledge regarding HIV in the subjects of General Pathology and Microbiology. In the third year, the subject of Oral Pathology gives them a greater insight regarding the oral manifestations of HIV. In the fourth year, these students are taught regarding dental considerations and precautions to be taken with patients with HIV/AIDS in the subjects of Oral Medicine and Oral Surgery. The fifth year consists of clinical rotations in dental specialty departments. Thus, the students are given a solid theoretical background about the manifestations, modes of transmission, diagnosing, and treatment of infectious diseases such as HIV and Hepatitis. Willingness, however, to treat patients with HIV/AIDS among dental students appears to be related to their knowledge of the disease, recognition of oral manifestations, and understanding the modes of transmission. 18 Appropriate knowledge may also instill confidence in students about their own ability to manage patients with HIV. 19 Thus, gaining insight into students knowledge about HIV/AIDS and their attitudes regarding how to effectively manage pa- tients with HIV/AIDS is essential in assessing the adequacy of HIV/AIDS education in curricula. 6 Studies have been published on the knowledge and attitude of Indian dental students towards HIV/ AIDS. Jain et al. 20 reported that the overall knowledge and attitude among dental students in their study was found to be satisfactory, with percent having a positive attitude regarding HIV/AIDS education. Shan et al. 21 also concluded that a group of students knowledge and attitude perspectives were both moderately adequate. There was still a need for higher levels of knowledge as only three-quarters of those students were knowledgeable, and the remaining one-quarter needed additional education and practice with patients who are HIV-positive. Also, certain items like transmission through saliva were not well understood by students in the previous studies. Our study was designed to assess whether the dental students at our institute have sufficient knowledge of HIV/AIDS and its transmission. Also, we planned to evaluate the attitudes of the students about related issues such as infection control regulations, their perception of their ethical obligations, and their willingness to treat HIV-positive patients. Methods The cross-sectional survey was carried out from January to March 2011 at the Institute of Dental Sciences, Bareilly, Uttar Pradesh, India. The study s population consisted of undergraduate students from all four years of study plus the fifth-year internship. All the 460 students (first year=60, second year=100, third year=100, fourth year=100, and internship=100) who were enrolled at the dental school in 2011 were invited to participate in the study. The surveys were distributed to the students at the end of regularly scheduled classes, which meant that students not present on a given day due to illness, external rotations, or other reasons did not receive the survey. Interns (residents) completed the questionnaire during their clinical postings in their respective departments. The differences in the response rates were, therefore, primarily a function of class attendance rates. All students were informed that participation was voluntary and that the refusal to participate would not affect their grades. No identifying information was gathered. The students returned their completed surveys to the researchers in sealed envelopes. The study was approved by the Ethical Committee, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India Journal of Dental Education Volume 77, Number 9

3 The survey instrument was a self-administered anonymous questionnaire in English, containing questions regarding HIV and AIDS-related knowledge, oral manifestations of HIV, students attitude towards patients with HIV, and student interest in a need for further education about HIV-positive patient care. This instrument had been employed previously among dental students in Iran. 22 This survey instrument had a moderate degree of internal consistency as indicated by Cronbach s alpha correlation coefficient (α=0.6). The survey was made up of four major categories. First were demographic factors, including gender and academic year. Second were eighteen closed-ended questions about knowledge of HIV and modes of transmission of HIV/AIDS. The knowledge questions were answered using the options of correct and incorrect. A total knowledge score was obtained by adding the points given for each true/ false question with each correct response receiving two points and each incorrect answer getting zero points. Hence, a student s total score could range from 0 to 36. A higher score indicated a greater level of knowledge. Scores less than 25 percent were deemed a weak level of knowledge, between 25 percent and 50 percent a moderate knowledge level, between 50 percent and 75 percent a good knowledge level, and more than 75 percent an excellent knowledge level. Third were fifteen questions about oral manifestations of HIV/AIDS, with answer options yes and no. Fourth were seventeen questions about attitudes regarding treating HIV-positive patients, right of HIV-positive health personnel to practice, and willingness to treat. The answer to each question about attitudes was rated on a five-point Likert scale from strongly agree to strongly disagree with a maximum score of 85. The professional attitudes scores were computed from five to one and negative attitudes, conversely. Scores of more than 75 percent were considered positive, between 50 percent and 75 percent considered passive, and less than 50 percent were considered negative. The positive attitudes (higher scores) were considered as professional attitudes. A pilot test to check the applicability of questions was conducted at the Institute of Dental Sciences at Bareilly with fifty dental students, and the data collected from these students were included in the main study. The data were analyzed using Statistical Package for Social Sciences (SPSS) version A one way ANOVA (Analysis of Variance) was used to compare students means for knowledge levels and attitudes towards HIV/AIDS between genders, years of study, and age groups. For multiple intergroup comparisons, a post hoc analysis was done. Pearson correlation coefficient was conducted for the correlation of age and class with knowledge and attitude score. A p-value of <0.05 was considered statistically significant. Results The overall response rate to the survey was 79.7 percent (N=367), with 80 percent participation for first-year students (N=48), 84 percent for second-year students (N=84), 72 percent for third-year students (N=72), 88 percent for fourth-year students (N=88) and 75 percent for students doing internships (N=75) (Table 1). Out of the total students, 70.1 percent (N=257) were females, and 29.9 percent (N=110) were males (Table 2); in India, the vast majority of dental students are females. The total scores (based on correct responses) ranged from 24 to 32. The total mean knowledge score was 28.4 out of the maximum score of 36 (a total mean percentage of 78.8 percent, an excellent knowledge score), with a total mean of 28.5 for females and 28.3 for males. There was no statistically significant difference between knowledge scores for males and females. The maximum correct response (97.5 percent) was obtained for the question HIV/ AIDS patients can contaminate dental workers, Table 1. Sample selection and response rate Total Number Number of of Students Respondents Response Year of Study (N=460) (N=367) Rate First % Second % Third % Fourth % Internship % Table 2. Distribution of study population by gender Year of Study Males Females Total First Second Third Fourth Internship Total September 2013 Journal of Dental Education 1211

4 Table 3. Students who gave correct responses to knowledge statements about HIV/AIDS Knowledge Statement Correct Response HIV/AIDS patients can contaminate dental workers. 97.5% HIV/AIDS patients can be diagnosed with oral manifestations. 96.2% ELISA is a screening test for HIV infection. 94.3% The specificity of the HIV tests is 100%. 92.8% Western blot is a definite test for HIV/AIDS diagnosis. 89.5% Dental workers can act as an intermediary for transmission of HIV. 87.9% Saliva can be a vehicle for the transmission of AIDS. 86.5% All sterilization methods have cidal effects against HIV. 86.1% Needlestick injury can transmit HIV. 85.3% The negative HIV tests surely indicate that the persons are free of viruses. 84.6% Hepatitis B is more communicable than HIV/AIDS. 83.2% Infection control methods for Hep B provide adequate protection against HIV transmission. 78.6% Medical staff are more prone for cross-contamination. 75.3% There is a lot of HIV in the saliva of HIV/AIDS patients. 71.4% HIV can be transmitted through aerosols by handpieces. 70.2% There are special dental clinics for treatment of HIV/AIDS patients in India. 68.2% Now, AIDS is the most important health problem in the world. 64.8% CPR for patients with AIDS can transmit HIV infection. 60.4% and the least correct response was for CPR in patients with AIDS can transmit HIV infection (60.4 percent) (Table 3). Regarding oral manifestations, 95.2 percent of the students correctly identified oral candidiasis, 94.5 percent Kaposi s sarcoma, and 93.8 percent ANUG. There was no statistically significant difference between male and female knowledge regarding oral manifestations (Table 4). The total mean attitude score was 66.1 out of total possible 85 (a total mean percentage of 77.7 percent, a positive attitude score), with a mean of 66.2 for females and 66.0 for males. The attitude Table 4. Students knowledge about oral manifestations of AIDS Oral Manifestation Yes (%) Oral candidiasis 95.2% Kaposi s sarcoma 94.5% ANUG 93.8% Major aphthous 92.6% Cytomegalovirus 90.4% Hairy leukoplakia 88.2% Severe periodontitis 85.7% Xerostomia 82.5% Salivary gland infection 80.6% Gingivitis 75.8% Herpes zoster 74.3% Herpes simplex 72.9% Condiloma 57.3% Papiloma 50.5% scores ranged from 56 to 79. There was no statistically significant difference in attitude scores between males and females. Most students (84.9 percent) disagreed or strongly disagreed with the statement that treatment of HIV/AIDS patients means wasting national resources ; this statement obtained the highest positive attitude score. Also, the majority of students (87.2 percent) agreed or strongly agreed with the statement I have a right to know if my patients are HIV-positive ; this statement obtained the highest negative attitude score (Table 5). Post hoc analysis showed that students of each class had significantly different knowledge and attitude score from other classes. In other words, the longer a student had been in dental school, the higher the knowledge and attitude scores (Tables 6 and 7). Also, as each class became more educated, its knowledge level increased (r=0.958; p<0.001). Similarly, the attitude scores showed a significant increase with the increase in the student s class (r=0.964; p<0.001), showing that as members of a class became more educated, their attitude became more positive (Tables 8 and 9). Also, correlation between age and knowledge score was highly significant (r=0.901; p<0.001) and attitude was highly significant (r=0.909; p<0.001), showing that as the age of the student increased, both the knowledge and attitude scores increased significantly. It was also noted that students with high knowledge had positive attitudes in treating patients with HIV (r=0.979; p<0.001) (Tables 8 and 9) Journal of Dental Education Volume 77, Number 9

5 Table 5. Students responses to questions about their attitudes towards patients with HIV/AIDS Strongly Strongly Attitude Statement Agree Agree Neutral Disagree Disagree Treatment of HIV/AIDS patients means wasting national resources. 3.7% 5.1% 6.3% 58.2% 26.7% All dental patients should be considered potentially infectious. 5.3% 60.2% 30.4% 1.9% 2.2% If I know that my friend has HIV, I end the friendship. 4.7% 17.5% 9.9% 55.2% 12.7% Supporting HIV/AIDS patients improves community health. 10.5% 46.6% 31.5% 5.1% 6.3% Dentists with HIV/AIDS should not be allowed to treat patients. 8.2% 10.5% 20.4% 50.3% 10.6% HIV/AIDS patients should be treated at a separate ward. 2.5% 37.2% 52.4% 3.5% 4.4% A blood test should be taken for diagnosis of HIV in all dental patients. 12.3% 25.4% 38.7% 11.1% 12.5% I am morally responsible to treat HIV/AIDS patients. 7.3% 13.3% 60.5% 10.2% 8.7% HIV/AIDS patients can live with others in the same place. 5.4% 18.2% 62.1% 9.5% 4.8% I am not obligated to treat HIV/AIDS patients. 9.5% 40.2% 22.3% 25.6% 2.4% HIV/AIDS patients can lead a normal life. 8.5% 22.1% 52.2% 10.4% 6.8% I can safely treat HIV/AIDS patients. 10.1% 53.8% 22.5% 13.6% I will treat HIV/AIDS patients. 15.8% 50.6% 23.4% 10.2% My knowledge about infection control is enough to treat HIV/AIDS patients. 8.6% 41.7% 20.1% 29.6% I worry about being infected with HIV by my patients. 28.5% 53.1% 7.3% 11.1% I will do CPR if HIV/AIDS patients need it. 1.4% 15.7% 50.5% 32.4% It is my right to know if my patients are infected by HIV. 52.5% 34.7% 8.4% 3.8% 0.6% Table 6. Year-wise differences in knowledge and attitude Year of Study Number Mean Knowledge Score Percentage Mean Attitude Score Percentage First % % Second % % Third % % Fourth % % Internship % % Total % % Table 7. Multiple comparison using post hoc Tukey HSD Knowledge Score Attitude Score Comparison of Year of Study Mean Difference p-value Mean Difference p-value First vs. second year (0.122) < (0.231) <0.001 First vs. third year (0.126) < (0.238) <0.001 First vs. fourth year (0.122) < (0.229) <0.001 First year vs. internship (0.125) < (0.236) <0.001 Second vs. third year (0.109) < (0.205) <0.001 Second vs. fourth year (0.103) < (0.194) <0.001 Second year vs. internship (0.108) < (0.202) <0.001 Third vs. fourth year (0.108) < (0.203) <0.001 Third year vs. internship (0.112) < (0.210) <0.001 Fourth year vs. internship (0.107) < (0.200) <0.001 Discussion In our study, the mean of students knowledge about patients with HIV/AIDS was excellent (78.8 percent), and this knowledge was significantly associated with the willingness to treat these patients. The overall mean knowledge score was comparable to the results obtained by Sadeghi and Hakimi, who September 2013 Journal of Dental Education 1213

6 Table 8. Age-wise differences in knowledge and attitude Age Number Knowledge Score Percentage Attitude Score Percentage % % % % % % % % % % % % % % % % Total % % Table 9. Correlation analysis Age Knowledge Score Attitude Score Class r-value 0.831* 0.958* 0.964* p-value <0.001 <0.001 <0.001 Age r-value 0.901* 0.909* p-value <0.001 <0.001 Knowledge score r-value 0.979* p-value <0.001 *Correlation is significant at the 0.01 level. reported an overall knowledge score of 82.1 percent for Iranian dental students. 22 Also, the results of our study show that these dental students attitudes towards treating patients with HIV/AIDS were positive (77.7 percent). The overall attitude score was comparable to the results of Seacat and Inglehart (81.1 percent) 9 ; however, our results were higher than the findings of Hu et al. (51 percent). 8 In 1993, Rankin et al. reported that less than half of the dental students from three dental schools in Texas were willing to treat patients who were HIV-positive. 23 In our study, 15.8 percent of the students were willing to treat patients with HIV/AIDS. Although there is evidence that dentists willingness to treat patients with AIDS has improved in recent years, among our group of respondents, evidence of negativity remains. A previous study reported that factors associated with refusal to treat patients with HIV/ AIDS include, primarily, a lack of ethical responsibility, fears related to cross-infection, loss of other patients if dental care is provided to patients with HIV/ AIDS, cost of infection control procedures, etc. 27 In our study, 49.7 percent of the dental students agreed that I am not obligated to treat HIV/AIDS patients. In a 2002 study, 83 percent of Kuwaiti family physicians chose to opt out of treating patients with HIV in family practice. 28 Dentists are ethically obligated to provide care for patients with infectious diseases. 29 Overestimation of the transmission risk of HIV was the most important reason for fear among dental students in providing dental care to HIV/AIDS patients in the study done by Erasmus et al. 11 Students fear may overpower their intellectual and practical ability to cope with the treatment and management of such patients. 11 Most students (65.5 percent) in our study thought that each patient should be considered potentially infectious. This feeling may be warranted since some patients with HIV/AIDS abstain from declaring their illness out of fear of being denied dental care. 30 Based on these considerations, the concept of universal precautions (all patients treated as potentially infectious) continues to be the most important method in treating all patients, and patients must be treated with the same infection control procedures that should be routinely applied in every dental treatment (sterilized instruments, non-contaminated operative field, and professionals wearing gloves, masks, caps, glasses). At the Institute of Dental Sciences, Bareilly, students are taught the significance and the various methods of sterilization in the second academic year in their course on microbiology and in all the 1214 Journal of Dental Education Volume 77, Number 9

7 specialty dental departments in the third and fourth academic years. Special attention is paid so that the students learn each and every aspect of sterilization. Also, it is important to note that 34.5 percent of the students in our study did not consider all patients to be potentially infectious. This could be because of the lack of knowledge of dental students regarding infectious diseases and their transmission in the dental settings. Hence, there is need to modify our curriculum to increase awareness of potentially infectious diseases among the students. In our study, most of the students were aware of the major oral manifestations of AIDS. Kaposi s sarcoma and candidiasis, two of the most common oral lesions in HIV-positive patients, were the most identified in our study. This was similar to the findings of the research by Samaranayake et al. 31 and Sadeghi and Hakimi. 22 From our study, it can be concluded that these Indian dental students knowledge level regarding oral manifestations is comparable with that of students from developed countries such as Scotland and the United States. In their study, Angelilo et al. 32 concluded that early diagnosis of HIV was important to prevent the spread of the disease. Although the possibility of HIV transmission in the oral health care setting is very rare (no cases reported in the United States), the dental clinic has become a helpful setting for early diagnosis of HIV/AIDS with at-risk populations, as most lesions of HIV infection present orally during the first stages of the disease. 33 Eighty-seven percent of the students in our study agreed that dental professionals can act as intermediaries for transmission of HIV, which suggested that most students are aware of disease transmission. These findings clearly highlight the importance of teaching dental educators about HIV disease transmission. It is vital that universal precautions should also be adopted through faculty policy and reinforced at an early level of study, so that all barrier techniques become protocol and the norm in the daily practice of clinicians. This will eventuate in a truly professional and patient-centered oral health care provider. 9 On the question of whether HIV could be transmitted through aerosols produced by a handpiece, 29.8 percent of the students in our study responded negatively. This may be because of the fact that reports of HIV transmission through this route are very rare; however, the theoretical possibility exists. 34 A patient s oral fluids and blood can be aspirated into a handpiece or dental unit waterline, and unless water quality is controlled, a practitioner or new patient could be exposed to the microbes of previous patients. In addition, a practitioner s skin and eyes are often not completely protected, thereby increasing the possibly of spatter and aerosol contact. 35 Regarding the possible risk of transmission through saliva, 13.5 percent of the students in our study did not know that contact with saliva contaminated with the blood of a patient with HIV/AIDS is a possible route of transmission of the virus. Contact with saliva has never been shown to transmit HIV because of the ability of the glandular saliva to inhibit its infectivity. 9,36 However, the Centers for Disease Control and Prevention recommends the application of universal precautions to saliva in a dental setting. 37 It is notable that 85.3 percent of the students knew that needlestick injury can transmit HIV. Needlestick injuries can be a potential risk factor for dental professionals; therefore, it is imperative that more emphasis be placed on the prevention protocol. Although the risk of HIV infection after percutaneous exposure is very low (0.3 percent), needlestick injuries can be quite alarming to the practitioner, creating extreme psychological stress. Therefore, students need to be made aware of the proper protocols for prompt management. 11 In our study, only 1.4 percent of the students were willing to perform cardiopulmonary resuscitation (CPR) if patients with HIV/AIDS needed it. The less positive response in this aspect might be the fear of transmission of HIV while doing CPR. The risk of HIV transmission through mouth-to-mouth resuscitation is extremely slim because of low infectious virus titers and properties of saliva that inhibit HIV. In the absence of blood, mouth-to-mouth resuscitation cannot result in HIV infection. 28 In such circumstances, the potential benefit to the patient who goes into cardiac arrest during dental procedures greatly outweighs the small risk of transmission. Although universal precautions are helpful in building positive treatment attitudes among dental students, they ultimately may not impact personal sensitivity to people with HIV/AIDS. The results of our study are in agreement with that of Seacat and Inglehart 9 and Erasmus et al., 11 which found that students knowledge of the HIV/AIDS disease process and oral manifestations increased as the level of study increased throughout the curriculum. This finding is consistent with the students perceptions of the degree to which the program prepared them well for treating patients with HIV. India is a developing country with many economic and social problems. Access to health care September 2013 Journal of Dental Education 1215

8 providers is limited for most people, and the level of knowledge among the majority of the population is insufficient to prevent infectious diseases that have already been controlled in developed countries. HIV has had a significant impact on oral health delivery services in India, mainly because of public and professional perceptions about its contagion. India is one of the countries that still have a conservative society, and adult education in India is still in its early stages. Emotional reactions also play a significant role in one s willingness to treat patients with HIV. In our study, the reasons for certain lack of knowledge may be due to students being more examination-oriented and not interested in acquiring sufficient knowledge about the disease for future clinical practice. Insufficient knowledge may also be due to deficiencies in the curriculum and inconsistencies in the way information about the disease is presented to the students. Our study shows that there are still inconsistencies and deficiencies in our dental curriculum that need re-evaluation and correction. Limitations and Conclusion A potential limitation of our study is that the data were collected from students of one single dental program. Care should be taken in interpreting the results as the study is solely based upon self-reported information and was solicited from individuals volunteering to complete the survey. Though other published studies on this topic have been limited to single-school recruitment, this recruitment strategy may limit the generalizability of the findings. Therefore, the data from this study should not be considered to reflect the nature and beliefs of all dental students in dental programs in India. The Institute of Dental Sciences at Bareilly is a relatively new dental school established in Hence, the results obtained from this study would be an assessment of the needs in a newly emerging Indian dental curriculum. Furthermore, the results may also help to reinforce the existing knowledge of the dental students towards patients with HIV and improve on the curricular shortcomings. Although students knowledge about the disease was found to be relatively high, it was still inadequate in preparing them to clinically manage patients with HIV/AIDS. On the basis of our study, we would make the following recommendations. The dental curriculum should include experiential opportunities for structured interaction between the students and patients with HIV, both in the classroom and in clinical settings. The use of an objective structured clinical examination (OSCE) with actual persons with HIV/ AIDS near the end of the preclinical years holds good potential. The students should also be involved in discussion groups regarding the dental management of patients with HIV, guided by experienced clinicians who analyze real cases. It is important to ensure that future dentists attitude towards these patients is not a barrier to their receiving the best possible oral health care. For this reason, we believe that, in addition to lectures increasing the level of knowledge in education, there is a need to also bring about positive changes in the students attitudes and behaviors towards patients with HIV/AIDS by making this portion of the curriculum more clinically oriented and removing misconceptions regarding transmission of the infection. REFERENCES 1. Centers for Disease Control and Prevention. Pneumocystis pneumonia, Los Angeles. MMWR 1981;30: UNAIDS. AIDS epidemic update, Geneva, Switzerland: Joint United Nations Program on HIV/AIDS (UNAIDS) and World Health Organization, December UNAIDS report on the global AIDS epidemic, At: GlobalReport_full_en.pdf. Accessed: October 5, UNICEF India. HIV/AIDS. At: hiv_aids_156.htm. Accessed: October 5, World Health Organization. 2.5 million people in India living with HIV, according to new estimates. At: www. who.int/mediacentre/news/releases/2007/pr37/en/index. html. Accessed: October 5, Seacat JD, Litt MD. Dental students treating patients living with HIV/AIDS: the influence of attitudes and HIV knowledge. J Dent Educ 2009;73(4): Oliveira ER, Narendran S, Falcao A. Brazilian dental students knowledge and attitudes towards HIV infection. AIDS Care 2002;14(4): Hu SW, Lai HR, Liao PH. Comparing dental students knowledge of and attitudes toward hepatitis B virus, hepatitis C virus, and HIV-infected patients in Taiwan. AIDS Patient Care STDS 2004;18(10): Seacat JP, Inglehart MR. Education about treating patients with HIV infections/aids: the student perspective. J Dent Educ 2003;67(6): Bennett ME, Weyant RJ, Wallisch JM, Green G. Dentists attitudes toward the treatment of HIV-positive patients. J Am Dent Assoc 1995;126(4): Erasmus S, Luiters S, Brijlal P. Oral hygiene and dental students knowledge, attitude, and behavior in managing HIV/AIDS patients. Int J Dent Hyg 2005;3(4): Kitaura H, Adachi N, Kobayashi K, Yamada T. Knowledge and attitudes of Japanese dental health care workers towards HIV-related disease. J Dent 1997;25(3-4): Journal of Dental Education Volume 77, Number 9

9 13. Nasir EF, Astrøm AN, David J, Ali RW. HIV and AIDS related knowledge, sources of information, and reported need for further education among dental students in Sudan: a cross-sectional study. BMC Public Health 2008;14(8): Horizons Program. Measuring stigma: an example developing a stigma index in India. At: org/horizons/ortoolkit/toolkit/stigmadevindex1.htm. Accessed: October 5, Oral health in America: a report of the surgeon general executive summary. Washington, DC: Department of Health and Human Services, U.S. Public Health Service, Evans CA, Kleinman DV. The surgeon general s report on America s oral health: opportunities for the dental profession. J Am Dent Assoc 2000;131(12): Dental education at the crossroads: a summary. J Dent Educ 1995;59(1): Azodo CC, Ehigiator O, Oboro HO, Ehizele AO, Umoh A, et al. Nigerian dental students willingness to treat HIV-positive patients. J Dent Educ 2010;74(4): Gillbert AD, Nuttall NM. Knowledge of the human immunodeficiency virus among final-year dental students. J Dent 1994;22: Jain M, Mathur A, Kumar S, Dagli RJ, Prabu D, Kulkarni S. Knowledge and attitude among dental students of Udaipur, India towards HIV/AIDS. J Oral Health Community Dent 2008;2(2): Shan V, Shethwala ND, Bala DV. Knowledge, attitude, and health behavior of dental students towards HIV patients. Health Line 2011;2(1): Sadeghi M, Hakimi H. Iranian dental students knowledge of and attitudes towards HIV/AIDS patients. J Dent Educ 2009;73(6): Rankin KV, Jones DL, Reeds TD. Attitudes of dental practitioners and dental students towards AIDS patients and infection control. Am J Dent 1993;6: McCarthy GM, Koval JJ. Changes in dentists infection control practices, knowledge, and attitudes about HIV over 2-year period. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;81: Godin G, Naccache H, Brodeur JM, Alary M. Understanding the intention of dentists to provide dental care to HIV+ and AIDS patients. Community Dent Oral Epidemiol 1999;27: Daniel SJ. Compliance with infection-control procedures and attitudes of oral health care providers toward patients with HIV/AIDS: a synthesis of the literature. J Dent Hyg 1998;72: McCarthy GM, Koval JJ, Macdonald JK. Factors associated with refusal to treat HIV-infected patients: the results of a national survey of dentists in Canada. Am J Public Health 1999;89: Fido A, Al Kazemi R. Survey of HIV/AIDS knowledge and attitudes of Kuwaiti family physicians. Fam Pract 2002;19: Jessri M, Fatemitabar SA. Implication of ethical principles in chair-side dentistry. Iran J Allergy Asthma Immunol 2007;6: Fallahi H, Fotohi A, Farzadi F, Yunesian M, Almasi F. HIV-positive patients and utilization of dental health services. J Iran Health Sci Res 2008;1(7): Samaranayake LP, Figueiredo HM, Rowland CA, et al. Comparison of the attitudes of hospital dentists and dental students in Glasgow, UK and Los Angeles, USA towards treatment of AIDS and hepatitis B patients. Am J Dent 1990;3: Angelilo G, Villari P, D Erricco MM, Grasso GM, Riccardi G, Pavia M. Dentists and AIDS: a survey of knowledge, attitudes, and behavior in Italy. J Dent Public Health 1994;53: Ogunbodede EO, Rudolf MJ. Policies and protocol for preventing transmission of HIV infection in oral health care in South Africa. S Afr Dent J 2002;57: Blignaut E. The role of the dental profession in the AIDS epidemic: practitioners corner. J Dent Assoc S Afr 1994;49: Palenik CJ, Burke FJ, Miller CH. Strategies for dental clinic infection control. Dent Update 2000;27: Borsum KM, Gjermo PE. Relationship between knowledge and attitudes regarding HIV/AIDS among dental school employees and students. Eur J Dent Educ 2004;8(3): Centers for Disease Control and Prevention. Guidelines for infection control in dental health care settings. MMWR 2003;52(RR-17):1-61. September 2013 Journal of Dental Education 1217