*Officer Commanding, Station Health Organisation, Ambala Cantt,  +Associate Professor, Department of Preventive and Social Medicine,
Armed Forces Medical College, Pune.
Received : 09.08.2003; Accepted : 29.02.2004
Original Article
Introduction
AIDS is a disease long associated with fear. Coupled
to contain the virus, HIV elicits a strong emotional
response in most HCWs. The moral panic about HIV/
AIDS and the theories of deviance that go with it are
not a new phenomenon. People expect HCWs to know
all about the disease, but most of them experience the
same fear, ignorance and prejudice as the general public
[1]. Knowledge and attitude of HCWs regarding HIV/
AIDS still leaves much to be desired and even after
almost two decades of sustained effort, most HCWs
still harbour a morbid fear of the disease [2].
Armed Forces personnel have always been
considered as a high-risk group for HIV, given their
unique work setting and prolonged separation from
family. The prevalence of HIV infection has also
increased in the services along with the rising trend in
the country. In such a scenario, HCWs of the Armed
Forces are often faced with a situation where they may
have to care for a large number of sexually transmitted
disease and HIV-reactive patients.
The specific needs of health care providers in the
era of HIV infection include the spectrum of an evolving
incurable infectious disease epidemic with new concepts
in patho-physiology and treatment, specific phobias
generated by the epidemic, including the fear of
occupational transmission of HIV, phobia of death and
fear of helplessness. The wide spectrum of issues
related to HIV/AIDS include the traditional role of
HCWs as health information resource in the face of
newly generated clinical and biopsychosocial information,
often skewed by media presentation. Occupational stress
associated HIV patient-care is a real thing and there is
definite potential for ‘burnout’ among the HCWs [3].
The present study was planned to assess the knowledge
and attitude of paramedical workers in the Armed Forces
regarding HIV/AIDs.
Material and Methods
The present study was a cross-sectional population based
analytical epidemiological design in the setting of a medical
college and tertiary care hospital of the Armed Forces Medical
Services between May 1999 and December 2000. Armed
Forces paramedical workers of Army, Navy and Air Force
undergoing training courses in various departments, formed
the study population. The subjects were classified into 3
groups i.e. Public Health Assistants (HA) (health assistants
from PSM Department), Laboratory workers (Lab) and Clinical
paramedical workers (Nursing assistants). Minimum sample
The Curse of HIV : How Well Prepared is our
Paramedical Force?
Maj Anuj Bhatnagar*, Col Rajvir Bhalwar+
Abstract
Background: HIV patient-care is determined by the knowledge and attitudes of the health care workers (HCWs) towards the
disease and towards HIV-positive individuals. With increasing incidence of HIV, a need was felt to assess the preparedness of the
health care providers in the Armed Forces.
Methods: A population based, cross-sectional, questionnaire based analytical study was undertaken among para medical workers
in the setting of a medical college and tertiary care service hospital to assess the knowledge and attitudes of HCWs towards HIV.
Results: The study indicated that contrary to the expectations and general belief, important knowledge gaps regarding modes of
transmission, clinical course, diagnosis and management of HIV infection still exist among the paramedical workers of the
Armed Forces.
Conclusions: The present study has highlighted the urgent need to review the training curriculum of our paramedical workers
at all levels and undertake intensive on the job training. The study recommends that medical officers should take full responsibility
for imparting correct knowledge and ensuring correct attitude among the paramedical workers.
MJAFI 2005; 61 : 230-233
Key Words: Health care workers (HCWs); HIV/AIDS; Knowledge and attitude; Armed Forces
MJAFI, Vol. 61, No. 3, 2005
Curse of HIV 231
size, keeping the expected parameter (proportion of HCWs
with satisfactory knowledge) at 0.5 and with an acceptable
deviation of 0.1 on each side at an alpha error of 0.05 (two-
tailed) (i.e. acceptable 95% confidence limit 0.4 to 0.6), worked
out to 100. Actually a much larger sample of 204 was studied.
This included 44 Health Assistants, 66 Lab Assistants and 94
Clinical HCWs. A total of 441 HCWs were listed, out of which
33 came under the defined exclusion criteria (i.e. any HCW
who was specifically trained in HIV management / himself
suffering from HIV / had a close relative suffering from HIV or
formed part of the pilot study). The detailed list of 408 HCWs
formed the sampling frame. Simple Random Sampling
procedure was followed keeping the sampling ratio 1 in 2, so
as to obtain the final sample of 204. In the absence of any pre-
existing valid questionnaire, a questionnaire  was developed
by the workers based on extensive reading, discussion with
experts and peer group analysis. The draft questionnaire so
developed was further standardized by a pilot study on a
representative sample of 25 HCWs. The results of pilot study
were not included in the final analysis. The questionnaire
was administered personally by the principal worker (using
the personal interview technique) who in turn was trained in
administration of the questionnaire by a senior faculty member.
Interviews were conducted in a quiet room and in privacy.
Respondents were informed of the scope of the study and
assured of full confidentiality. After initial rapport building,
questions were asked by personal, face to face method of
interview.
Results
(a) General awareness about HIV/AIDS:
The findings revealed that all HCWs studied had heard of
AIDS and correctly knew that AIDS stood for ‘Acquired
Immunodeficiency Syndrome’. Similarly all HAs knew that
AIDS is caused by HIV whereas 98.5% and 96.8% of Lab
workers and clinical HCWs respectively knew this. Only
23.5% of HCWs overall correctly knew that ‘HIV’ stood for
‘Human Immunodeficiency Virus’. The knowledge was least
among clinical HCWs with only 8.5% responding correctly.
Majority of the HCWs said that ‘HIV’ stood for ‘Human
Immuno Virus’.
(b) Knowledge about modes of transmission:
The findings are presented in Table 1. It was seen that the
majority of HCWs have correct knowledge about modes of
transmission of HIV and could discriminate between the
correct and incorrect modes. In general, the level of knowledge
was higher among lab assistants but they were also found to
have important misconceptions, especially regarding HIV
transmission through coughing (4.5%), by bite of an infected
mosquito (3.0%), by using public toilets (1.5%), by eating
contaminated food (1.5%), by working next to an infected
person (3%) and by eating in a place where the cook is infected
(3%). Significant knowledge gap was found for transmission
through breast milk with only 43.2% of Health Assistants,
42.4% of Lab workers and 48.9% of clinical workers exhibiting
the correct knowledge. Knowledge regarding vertical
transmission from infected mother to unborn child was also
found to be significantly low among all groups.
(c) Knowledge about clinical course and diagnosis of HIV
infection:
The findings have been presented in Table 2 and the details
observed are as follows:
(i) Knowledge about asymptomatic HIV infection: It was
interesting that HAs (who have the least clinical
exposure) exhibited correct knowledge with 88.6% giving
the correct answer. On the other hand, clinical HCWs
(who have the maximum clinical exposure) had the least
knowledge with only 74.5% giving the correct answer.
Overall, 21.1% of the HCWs did not know that HIV can
exist in an asymptomatic form in a patient. However,
difference in proportion was not significant.
(ii) Knowledge about pathogenesis of HIV: The findings of
the study reveal that a significant number of clinical
HCWs (44.7%) were not aware that lymphocytes are
attacked by HIV in the host. Expectedly, lab workers were
found to have the highest knowledge (84.8%) but clinical
HCWs had significantly low knowledge at only 55.3%.
Overall more than 30% of HCWs did not have correct
knowledge of pathogenesis of HIV, which is quite a bit
for HCWs. The difference in the level of knowledge
between the three groups was found to be very highly
significant.
(iii) Knowledge about status of an individual tested positive
by Western Blot: It was observed that overall a large
number of HCWs (42.2%) did not know that an individual
Table 1
Knowledge about the modes of transmission of HIV
Mode of transmission HA Lab Clinical
By coughing 0 3 (4.5%) 0
By sexual intercourse with an infected person 40 (90.9%) 62 (93.9%) 90 (95.7%)
By taking injections from infected needles 40 (90.9%) 63 (95.5%) 90 (95.7%)
By bite of infected mosquito 0 2 (3.0%) 2 (2.1%)
By using public toilets 0 1 (1.5%) 0
By homosexual intercourse with an infected male 41 (93.5%) 64 (97.0%) 87 (92.6%)
By transfusion of infected blood 42 (95.5%) 65 (98.5%) 72 (76.6%)
From infected mother to unborn child 37 (84.1%) 60 (90.9%) 72 (76.6%)
By working next to an infected person 0 2 (3.0%) 2 (2.1%)
Eating in a place where the cook is infected 0 2 (3.0%) 3 (3.2%)
Breast feeding by an infected mother 19 (43.2%) 28 (42.4%) 46 (48.9%)
MJAFI, Vol. 61, No. 3, 2005
232 Bhatnagar and Bhalwar
All HCWs need to be aware that the transmission
potential of HIV increases many fold in the presence of
concurrent STDs, because of microscopic breaks in the
genital mucosa and exudates from the lesions, which is a
rich source of HIV.
(ii) Knowledge about the most efficient route of HIV
transmission: It is evident from the findings that a
significant number of HCWs studied were not aware that
blood is the most efficient route for HIV transmission.
Lowest knowledge was found among HAs with only
56.8% correctly identifying blood as the most efficient
route for HIV transmission. Even Lab workers, expected
to have a much higher level of knowledge, exhibited quite
low knowledge levels with only 75.8% correctly
identifying blood as the most efficient route. The
difference among the 3 groups was found to be
significant (P<0.05). This could possibly be because of
the basic training curriculum for Lab HCWs and clinical
HCWs.
(iii) Attitude towards hospital admission of a HIV positive
individual: It is evident that a large number of the subjects
did not have the correct atitude towards hospital
admission of a HIV positive individual. These HCWs
felt that a person should be admitted to a hospital as
soon as he is diagnosed as HIV seropositive irrespective
of his clinical condition. However, the difference in the
level of knowledge among the different groups was not
found to be significant. The attitude displayed by the
HCWs is in contravention to the ruling that a HIV sero-
Table 2
Knowledge regarding clinical course and diagnosis of HIV infection
HA Lab Clinical
Corr (%) Incorr (%) Corr (%) Incorr (%) Corr (%) Incorr (%) chi2
Knowledge of asymptomatic 39 (88.6) 5 (11.4) 52 (78.8) 14 (21.2) 70 (74.5) 24 (25.5) p>0.05
HIV infection
Knowledge of pathogenesis 34 (77.3) 10 (22.7) 56 (84.8) 10 (15.2) 52 (55.3) 42 (44.7) p<0.001
of HIV
Knowledge about status of 34 (77.3) 10 (22.7) 34 (51.5) 32 (48.5) 50 (53.1) 44 (46.9) p  <0.05
Western blot positive individual
Knowledge about availability 0 44(100) 27 (40.9) 39 (59.1) 6 (6.4) 88 (93.6) p<0.001
of confirmatory test in Armed Forces
Corr=Correct knowledge, Incorr=Incorrect/No knowledge
who had tested positive by Western Blot test can be
labelled as HIV positive. Interestingly, the correct
knowledge of Western Blot as a confirmatory test for
HIV was found to be lowest amongst lab workers, i.e.
only 51.5% of them knew that an individual tested
positive by Western Blot test is to be diagnosed as HIV
positive. The difference in the level of knowledge between
the various groups was found to be significant.
(iv) Knowledge regarding availability of confirmatory test
in Armed Forces:  It is seen that a large majority of HCWs
were not aware that the confirmatory test is not availabile
in the Armed Forces and samples are sent to National
Reference Labs at Pune, Delhi and Kolkata. Knowledge
was particularly low among HAs and clinical HCWs, and
the difference in the level of knowledge among the groups
was found to be very highly significant. This is likely to
have an adverse impact on the advice they render to the
patients.
(d) Knowledge about transmission and hospital
management of HIV infection:
The findings are presented in Table 3 and are discussed in
detail as under:
(i) Knowledge of the association between HIV/STDs: From
the findings it is evident that the knowledge regarding
the close association between STDs and risk of
acquiring HIV infection is quite low, especially among
clinical HCWs (59.6%). HAs exhibited the maximum
knowledge (81.8%) and the difference in the level of
knowledge among the various groups was significant.
Table 3
Knowledge about transmission and management of HIV infection
HA Lab Clinical
Corr (%) Incorr (%) Corr (%) Incorr (%) Corr (%) Incorr (%) chi2
Knowledge of association 36 (81.8) 8 (18.2) 48 (72.7) 18 (27.3) 56 (59.6) 38 (40.4) p<0.05
between HIV & STDs
Knowledge about most 25 (56.8) 19 (43.2) 50 (75.8) 6 (24.2 73 (77.7) 21 (22.3) p<0.05
efficient route of HIV transmission
Attitude towards hospital 24 (54.5) 20 (45.5) 26 (39.4) 40 (60.6) 43 (45.7) 51 (54.3) p>0.05
admission of a HIV positive individual
Not afraid Afraid Not  afraid Afraid Not afraid Afraid
Fear of contagion 39 (88.6) 5 (11.4) 25 (37.9) 41 (62.1) 56 (59.6) 38 (40.4) p<0.001
Corr=Correct knowledge, Incorr=Incorrect/No knowledge