AUGUST 2001------------ THE SOUTHERN AfRICAN JOURNAL OF HIV MEDICINE

STUDENT TRAINING

HIV EDUCATION AND HEALTH CARE
STUDENTS - WHERE ARE WE GOING?

EVER-CHANGING PERCEPTIONS OF HEALTH CARE
STUDENTS

successful post-exposure prophylaxis (PEP) and the
commonplace occurrence of occupational HIV exposure
incidents recently seems to have diminished the extent of

the often expected horrified reaction to occupational

exposure. Worrying as that statement may be, health care

students' everyday and repetitive encounter with the

tragedy of HIV!AIDS may well evoke a dangerous and

complacent attitude and a possible non-caring ethos akin

to 'HIV fatigue:' Health educators and all members of this

profession need to rise to this challenge and ensure health
care quality in the age of a changing infectious disease

status. Although this argument may not be a new concept

and problem for health care students and practising

professionals, the overwhelming nature and high

prevalence rate of this epidemic, and its ramifications that

involve individual, family and community suffering and the

socio-economic and human rights aspects, place the

approach to this infection in a unique light.

There can be no doubt that students will work with HIV-

infected individuals, and each one will be affected by this

disease and long-term illness. Initially and in the recent

past, students expressed a variety of feelings and attitudes

in their approach to infected patients' Dread of acquiring

the infection as a result of workplace exposure, fear of

potential exposure to concomitant and opportunistic

infections in immunosuppressed patients, and the lack of

skills and emotional burden of dealing with terminally

IMPACT OF HIV

As the 20th anniversary of the first report of an AIDS case
in 1981 approaches, HIV poses one of the greatest pUblic

health challenges of this era.' Whether or not it is or will

be the greatest health challenge for mankind remains to be

seen or debated; nonetheless the HIV pandemic is of

herculean proportion. It has been estimated that more than

40 million people globally were infected with this virus by

the end of the year 2000.' In addition, 70% of those

infected live in sub-Saharan Africa.' Analysis of the data

from the unlinked anonymous 1999 South African HIV

seroprevalence survey of women attending pUblicly funded
antenatal clinics has submitted the following conclusions:

• HIV in South Africa is one of the fastest growing
epidemics worldwide

• the highest prevalence rates are in women aged 20 - 30
years, and

• the HIV prevalence differs for each province, with
KwaZulu-Natal exhibiting a rate of 32.5%.'

The current status of HIV/AIDS statistics for southern Africa highlights and elevates the plight of health care students,
already burdened by the specific nature of their training under the peculiar circumstances now prevailing in South African
hospitals and training centres. The everyday and repetitive encounter with the tragedy of HIV/AIDS may well evoke a
dongeraus and complacent attitude on the part of health care students and a possible non-coring ethos akin to 'HIV

fatigue: Health educators and all members of this profession need to rise to this challenge and ensure health core quality
in the age of a changing infectious disease status.

It is not unreasonable to expect that 60 - 70% of beds in

publicly funded and tertiary hospitals may be occupied by

HIV-infected patients. South African health care workers

remain at high risk of occupational HIV exposure,

illustrated partly by this high HIV prevalence rate. This high

risk elevates the plight of health care students, already

burdened by the specific nature of their training under the

peculiar circumstances now prevailing in South African

hospitals and training centres. Although there still exists a

dread of acquiring this bloodbarne virus, the availability of

lynne M Webber, MB ehB, MMedPath (Viro!), DTH

Department of Medical Virology, University of Pretoria

Penelope A Richards, PhD

Depart11lellt of Anatomy, University of Pretoria

Somarie V Grey, DSc

Deputy Dean, Faculty of Medicine, University of Pretorm



THE SOUTHERN AfRICAN JOURNAL Of HIV MEDICINE ----------- AUGUST 2001

diseased young people appeared to be the most dominant
emotions.' This HIV epidemic is continuing to evolve in

South Africa; it has not yet peaked and students will
continue to see its ravages for a considerable period. In

turn, the epicentre of the AIDS epidemic is still awaited and
health care students will have to be prepared to handle a

large and growing number of terminally ill young patients
and children as a natural part of their training and future
direction.

The recent media attention during and after the XlIlth

International AIDS Conference in Durban focused attention

firmly on the fact that little has been done to awaken the
South African government from its torpor.' In addition, a

recent comment in a renowned international journal,
Noture Medicine, entitled 'South African government

continues policy of inactivity', alluded strongly to issues

that were not scientifically addressed, such as reduction of
mother-to-child transmission' Reading about such

worrying approaches to matters that form critical

components of their training and future attitudes, points to
the fact that students need constructive support in order to

shape their caring and professional ethos. Real issues have
to be tackled by students wherein they deal regularly with

HIV-infected patients denied access to treatment and

inteNention strategies proven to be successful but

financially beyond the reach of most infected individuals.

Most health care curricula expect the student to know
about the latest developments in HIV management, therapy

and inteNention, yet little may be in place to teach them

how to apply this knowledge and the facilities to patients.'

These attitudes, together with the possible ethos of HIV
fatigue creeping insidiously into the South African health

care profession, will impact significantly on student

perceptions. In addition, perceptions of a killer disease that

is crippling the infrastructure within South Africa will

change from the junior to the senior student. These

problem areas and others, such as the following, have

already been identified by health care educators and

students.'.'

SHOULD HIV-POSITIVE HEALTH CARE STUDENTS BE
ALLOWED TO CONTINUE THEIR TRAINING?

This question tends to assess the rights of both the student

and patient Can health care training institutions turn

down or stop the training of an individual in a given health

care field should they contract HIV/AIDS? Should such

institutions, in recognising the potential risk HIV/AIOS

poses, be insisting on compulsory HIV testing on a regular

basis, despite the individual's constitutional rights) Do

patients have the right to refuse treatment or contact with

an HIV-infected student? Do only those patients who can

afford private care have the right to choose who will care

for them? Although most of the questions have clear-cut

answers or directions according to the constitutional rights
of each South African, they still pose dilemmas that require

thought, debate and action.

Who should be responsible for insuring the student against
HIV?

The question begs to be asked - should such insurance be

compulsory? Considering the economic devastation of this
infection coupled with individual expense, it is not

unreasonable to expect the training institution to provide
such insurance for all individuals in training. Ideally, this

cost should be borne by the training institution as part of
the safe environment for students. In turn, in the absence

of the provision of a safe environment, through no fault of

the student, the institution should be prepared to find
alternative safeguards.'

BY WHOM AND WHEN SHOULD A NATIONAL POUC
BE DEVISED TO ADDRESS THESE EMOTIVE ISSUES?

Any national policy should be inclusive, therefore it is

mandatory that all stakeholders be involved in this process.

As students are at the forefront of this issue, strong
student leadership is essential. In addition, health care

educators, administrators and health care professionals

must be consulted. A top-down policy is doomed to failure

should bottom-up buy-in not be sought. When one

considers all the currently available HIV/AIOS statistics in

South Africa, such a policy appears to be long overdue.
How can educational values be reinforced)

A major paradigm shift is required among health care

educators in order to alter attitudes of students working in

surgical and internal medicine environments where

HIV/AIDS may feature commonly. Truly integrated curricula,

with an emphasis on community and evidence-based

health care, go a long way towards encouraging an

educationally sound basis to attitude transformation.

However, how do health care educators identify solutions

to these problems and still keep such education healthy?

THE ROLE FORWARD FOR HEALTH CARE EDUCATORS

The Faculty of Medicine at the University of Pretoria has

recently devised various action plans to address pertinent

issues such as the provision and cost bearing of

chemoprophylaxis following occupational exposure to HIV,

and voluntary membership for all students and staff of a

specifically designed HIV insurance scheme (this was

cancelled at the last moment because of technicalities that

arose after the promulgation of the new Medical Schemes

Act, which caused the underwriters of the scheme to

withdraw their support), and it has drawn up a policy



REFERENCES

AUGUST 200 I ------------ THE SOUTHERN AfR.ICAN JoUR.NAL OF HIV MEDICINE

1 L~vl J The public health challenges of the HIV epidemic (Editorial). Am J Public
Health 2000; 90: 1023-1024.

2. Alien OM, Simelela NP, Makuabalo L Epidemiology of HIV/AIDS in Soum Africa
The Southern African Journal ofHIVMroicine 2000; 1: 9-11.

3. Kramer S. AIDS - still more mmp!ace.(\~? Health and Hygiene 2CKlO; 11: 26.
4. Pantanowitz L, Connel! L Attitudes and perceptions of medical and allied

m~ical students towards HIV/AIDS. South Afr J Epidemio/lnfect 1996; 11; 99-
103.

5. Missed opportunities in Durban [Editorial). Nature Medicim: 2000; 6: 839.
6. Birmingham K. South African government continues policy of inactivi[)'. Nature

Medicine 2000; 6: 843.
7. Webber W, Richards PA, Grey W. HIV prophylaxis: afe South African health-

care students bl"ing negll"ctl"d7 SAfrJ Sei 2000; 96: 295-296.
8. Dl"partment of Education. Annual Report. 1999. Pretoria: DOE, 2000: 157 - 161.

CONCLUSION

The correct and caring altitudes of health care students

and professionals must be cherished and should be deemed

an urgent and necessary goal for all involved in health care

education in South Africa.

considering the health care of infected students and

professionals.' Yet this is only the beginning, and

monitoring of these actions and new directives is required.

Relevant data must be compiled, rationally analysed and

the knowledge gained fed through to all students and

professionals using a continuous reporting system. Quality

of health care education can be maintained and improved

even in times of change, but this will require a detailed

research agenda: Partnerships must also be nurtured and

involve input and output from other faculties and

universities. A system must exist for the support of all

levels of students and all ranks of professional staff

members, incorporating the continuous feedback reporting

service that is kept open for discussion (C Coombes,

'HIV/AIDS and the Education Sector Strategic Plan:

Education sector planning - learning to live with AIDS' -

paper prepared for the Educator Sector Strategic Plan First

Annual Rev·,ew Meeting, Maputo, May 1999). Finally, a

support structure should also be in place to support and

guide HIV-infected students and professionals as well as

those burdened and crippled by the impact of HIV on their

families, communities and peers.

An annual report from the Department of Education has

cited that there are 300 000 university students, 190000

technikon students and close to 73 000 other and support

personnel within the education system' In turn, there are

just over 12 million pupils at school (50.5Ofa female),

supported by about 375 000 teachers' Not only are many

of these destined to become health care students or

participants within the health care system, but many will

become victims of this system. Accordingly the impact of

HIV/AIDS as a whole on education in South Africa needs to

be addressed. Recently, the Youth AIDS Project was

launched and has been described as a non-profit project

with a board of directors consisting of the deans of the

medical schools. Or Atholl Kent, national director of the

Project, has .cited the aims in the executive summary,

namely to reduce the spread of HIV!AIDS among young

South Africans, and to provide them with tools to be

compassionate and effective in dealing with HIV/AIDS in

their lives and communities. As another part of the Project,
medical students will be afforded the opportunity of

informing other young South Africans about HIV/AIDS. This

Project, and many other initiatives in South Africa and

Africa, offer hope, optimism and encouragement. However,

attitudes of complacency and hopelessness must be

guarded against and again, feedback and data analysis

must be readily and frequently available.

EDUCATION IN SOUTH AFRICA