Attitudes towards the risk of HIV transmission in sport

A survey conducted by the South African Sports Commission in 2002 showed the number of participants in all sports to be 14.7 million. This translates to approximately 10 million adults participating in sport. Many adults participate in more than 1 sport. The average estimate is 1.5 sports per person. The sporting fraternity has to take cognizance of AIDS and its transmission and impact on sport because the probability of encountering an AIDS-infected person during sport is high. About 375 670 South Africans were expected to die from HIV/AIDS in 2003, an increase of more than 30% of the estimated 219 660 AIDS-related deaths in 2000, according to projections by the Human Sciences Research Council.


Introduction
A survey conducted by the South African Sports Commission in 2002 41 showed the number of participants in all sports to be 14.7 million.This translates to approximately 10 million adults participating in sport.Many adults participate in more than 1 sport.The average estimate is 1.5 sports per person.The sporting fraternity has to take cognizance of AIDS and its transmission and impact on sport because the probability of encountering an AIDS-infected person during sport is high.About 375 670 South Africans were expected to die from HIV/AIDS in 2003, an increase of more than 30% of the estimated 219 660 AIDS-related deaths in 2000, according to projections by the Human Sciences Research Council. 31e attitude of health care professionals has added to the confusion regarding the spread of the HIV virus.These professionals wear gloves while treating patients, yet maintain at the same time that the risk of transmission is very low. 10 In America a large number of leading sports personalities have made their HIV status public.These popular sports heroes have contributed towards demystifying the disease and have created greater public awareness by educating the public on the disease.This has not occurred in South Africa.Those most affected by HIV transmission are 18 -25 year old.This age group has the highest number of individuals participating in sports. 11,22,29These young adults play a central role in social, economic and political activities.Any epidemic that threatens to deplete this cohort, undermines the social, economic and demographic stability of society. 19e HIV/AIDS barometer on estimated HIV infections worldwide stood at 58 580 614 at 05h00 on Wednesday 11 August 2004. 32The sports environment is a social, recreational, economic and competitive arena providing opportunities for interaction and a venue for transmission.Competitive athletes are usually drawn from an economically active sector of the population. 5These athletes form part of an elite group which one would presume to be knowledgeable about HIV/AIDS.Therefore the focus of this study was to ascertain the attitudes of sportspersons involved in contact and non-contact sports, towards HIV-positive individuals in a competitive sport environment and the risk of HIV transmission through sport.
Calabrese 10 concluded that the HIV transmission risk in a sporting environment is very low.Brown et al. 8 calculated the risk of HIV transmission through sport to be less than 1 infection per 85 647 821 game contacts.The Centers for Disease Control and Prevention 13 placed the odds of contracting HIV during a sporting event to be greater than a million to 1.
No studies have documented athlete-to-athlete transmission from blood exposure on the playing field, except for 1 anecdotal report of an Italian soccer player. 16,48In this incident both players clashed, sustaining open, bleeding wounds resulting in possible mixing of blood.This was the first documented case, published in 1990, of HIV transmission that occurred directly as a result of sports participation.At present, accurate data on HIV transmission during sports participation is only available for American football players and professional boxers in South Africa.In American football the risk of HIV transmission has been calculated to occur at a rate of approximately 1 player per 100 000 000 games.In a boxing match of 12 rounds, the risk of an open bleeding wound has recently been calculated at 47%.In a study 42 of 952 boxers in South Africa HIV disease was determined at 9% and the risk of contact between boxers during a fight at 100%.The risk of infection among professional South African boxers has been calculated at 1 infection in 4 760 fights. 42cording to Gatheram 19 there is a need for an inter-sectoral response to HIV/AIDS.It is fundamental that HIV is not seen as merely a health issue, for it is indeed much more than that.It is a welfare issue, a legal issue, an educational issue, a human rights issue, and a sports issue.For these reasons alone it is of paramount importance that the role of sport and HIV/AIDS be utilised to unite our diverse country around this human issue. 19

Methods
The study design was that of a questionnaire survey consisting of 22 questions.The questionnaire was designed to assess variables that influence athletes attitudes towards the risk of HIV transmission of through sport.The research questionnaire was influenced by a similar study conducted by Calabrese 10 in 1993, which was confined only to college students and did not differentiate between risk categories.In the present study the questionnaire was amended to include variables that might have an influence on the formation of attitude to HIV.These variables included demographics, knowledge and fear of transmission, knowledge or lack of knowledge on the benefits of exercise in HIV-infected individuals, and the influence of health care workers, sports personnel and the media in HIV/AIDS education.Questions were divided into 4 major categories namely: (i) demographic data that could influence attitude formation; (ii) analysing responses to gauge attitude, knowledge and fears about HIV transmission in sport; (iii) assessing athletes knowledge of the benefits of exercise in HIV-infected individuals; and (iv) the influence of health care workers, sports personnel and the media in promoting education and awareness of HIV/AIDS in sport Questionnaires were administered to 22 sports clubs, comprising 11 sport codes.Participants were categorised into the following risk categories: (i) high-risk (173 respondents) comprising boxing (N = 14), karate (N = 44), wrestling (N = 52), and rugby (N = 63); (ii) medium-risk (201 respondents) comprising field hockey (N = 45), basketball (N = 46), volleyball (N = 50), and soccer (N = 60); and (iii) low-risk (201 respondents) comprising tennis (N = 34), athletics (N = 60), and swimming (N = 61).Sport science students (N = 46) were included in the lowrisk category as this was a mixed group of athletes participating at a high level of sport.
During the period between January 2001 and August 2001, 900 questionnaires were handed out to athletes competing at provincial or national level, or in a first-division club.These athletes were selected randomly.Five hundred and seventy-five questionnaires were completed.This resulted in a response rate of 64%.The gender balance for returned questionnaires was 378 males to 193 females, with 4 respondents not disclosing their gender.
The researchers administered most of the questionnaires.The balance were administered by colleagues from the Sport Science Department, and administrators of various sports institutions and clubs.
The majority of the questions required that the athletes place a tick in the relevant block.There were 11 yes or no questions.Open-ended questions formed part of the questionnaire, countering the restrictive nature of responses confined only to the alternatives provided.
The researchers and a team of colleagues visited approximately 22 clubs during administration of the questionnaires.
Further data were collected at tertiary institutions and selected competitive tournaments and matches.
The instructions for answering the questionnaire were clear.The athletes co-operation was sought in this study; it was explained that participation was completely voluntary and that all responses would be kept strictly confidential.Athletes signed informed consent to participate in the study.Ethical clearance was obtained from the University of KwaZulu-Natal (Westville campus).No names were written on the questionnaires, thus maintaining the anonymity of the responses.

Analysis
The completed questionnaires were entered into a database, checked for inconsistencies, and spoilt forms were removed from the analysis.Statistics were compiled by the Department of Statistics at the University of Kwa-Zulu-Natal.The SPSS version 9, library of statistical packages was used to compute the descriptive statistics reported in this study (Microsoft SPSS (version 9) standard version, Windows 2001).Since there is no comparative study of this nature in South Africa, no inferential statistics comparing results with different provinces could be analysed.

Results
The results reported refer to the attitudes of athletes towards the risk of HIV transmission in a sporting environment.The study assumed that the athletes answered the questions truthfully and sincerely.However this is an inherent limitation of questionnaire studies.Table I shows the demographic data of the sample.
Sixty-six per cent of athletes in the study were male, and 33% female respectively (Table I).A study by the South African Sports Commission 41 concluded that more males participated in sport than females, at 46% versus 27%.The majority of athletes (46%) surveyed in this sample fell into the 19 -25-year age group.This is also the most sexually active group, therefore most at risk of HIV infection. 1,42Research in the USA has repeatedly found that approximately 21% of AIDS cases involve people aged 20 -29 years. 24higher percentage of respondents were in the over-31 age group (18%) than in the 26 -31 age group (12%).More than half (52%) of the respondents indicated that they had a tertiary level of education.Generally this is the age group (18 -25 years) from which most elite athletes are drawn, and many of them are students. 29rty-one per cent of respondents were in the high-income group, which correlates with data obtained on educational background.

General knowledge of HIV transmission was assessed in
Table II.The majority of the athletes surveyed (64%) indicated that touching infected blood posed a risk of transmission.A transmission risk exists only if the skin is broken and infected blood enters through this route. 17,44Ninety-two per cent of respondents indicated that sharing needles was a means of transmission, especially among wrestlers and bodybuilders, who share needles used to inject steroids.Two cases have been reported among bodybuilders. 21,40ble III investigated athletes knowledge of whether HIV could/could not be transmitted through sport participation.
A large number (N = 355, 62%) of the athletes stated that HIV could be transmitted through sport participation.Twentyfive per cent of respondents in the high-risk category, 18% in the medium and 19% in the low-risk category believed that sport involves a risk of HIV transmission.There was a significant difference (p < 0.05l) in attitudes among the various sport codes and risk categories with regard to HIV being transmitted through sport participation.
Various questions were posed to athletes to determine their knowledge of HIV transmission through sport (Table IV).In assessing attitudes towards HIV-positive athletes being allowed to participate in sport (question 1, Table IV), the following was established.An equal percentage (14%) in the highrisk category responded both positively and negatively towards HIV-positive athletes being allowed to participate in sport.A larger proportion (30%) in the low-risk category and 27% in the medium-risk category were willing to participate with HIV-positive individuals.A total of 71% indicated that HIV-positive athletes should be allowed to participate, as opposed to 25%.
Fear of contracting the HIV virus (question 2, Table IV) was indicated by 59% of the respondents, while 37% indicated that they were not afraid.The largest percentage of respondents (24%), who indicated such fear were in the high-risk category, as these sports posed the most risk of infection. 18This correlates with a large number of bleeding injuries encountered in high-risk sports.In the low-risk category, 15% indicated that they were afraid of contracting the HIV virus.

No response
The response to participating with HIV-positive athletes was as follows (question 3, Table IV).In the high-risk category, 12% of the respondents did not want to participate with athletes known to be HIV-positive, whereas in the low-risk category 20% and in the medium-risk category 19% of the respondents agreed to participate against HIV-positive individuals.A majority of the respondents (46%) were willing to participate with HIV-positive, while 18% were unwilling, 34% were not sure how they felt and 2% did not respond at all.Most athletes (66%) indicated that they would continue to participate in sport if diagnosed HIV-positive, against 30% who indicated that they would not participate (question 4, Table IV).This correlates with a knowledge of the benefits of exercise for HIV-positive individuals.More respondents in the medium (24%) and low-risk (30%) categories indicated that they would continue to participate in sport compared with those in the highrisk category (12%).
Sixty-two per cent of respondents indicated that all athletes should be screened for HIV compared with 35% who indicated that athletes should not be screened (question 5, Table IV).
Fifty-eight per cent of the sample saw a need for testing in order to make HIV a notifiable disease in sport (question 6, Table IV).The majority (23%) of the yes responses came from the high-risk category.This correlates with the high incidence of bleeding injuries in high-risk sport and the greatest fear of contracting the HIV virus. 34e majority of respondents (52%) indicated that knowing their opponent was HIV-positive would influence their game strategy, while 44% indicated that it would not influence their game strategy (question 7, Table IV).
Only 32% of the respondents indicated that they were informed of the risk of HIV transmission through sport by doctors and coaches, while 67% indicated that they were not (question 8, Table IV).
Respondents were asked whether medical professionals used gloves when treating bleeding injuries; 90% indicated that they did, while only 8% indicated that they did not (question 9, Table IV).
A large majority of respondents (87%) indicated that more education on HIV transmission through sport was essential (question 10, Table IV).

Sources of information on the promotion of HIV awareness
show that television (84%) was the most effective medium (Table V).The least effective were managers and coaches.This again indicates the need for sport and health professionals to become more proactive on the HIV/AIDS issue.
Respondents displayed a good knowledge of the benefits of exercise for the HIV-positive individual, except with regard to maintaining weight and assistance in sleeping.A majority of the respondents (81%) were aware of the psychological benefit of exercise in terms of making a person feel good (Table VI).

Discussion
A number of athletes left questions unanswered.The rea-sons for this could be that some of the questions might have been too sensitive or intrusive.A total of 900 questionnaires were handed out to athletes.Only 575 questionnaires were completed.
Table I shows that the majority of the athletes were male.These findings are similar to those of a study by the South African Sports Commission, which concluded that more males participated in sport than females (46% versus 27%). 41The larger number of athletes in the over-31 age group could be attributed to older athletes who participate in athletics (long distance).Road running is currently increasing at a rate of 7% per annum. 41though there has been speculation on the possible transmission of HIV through saliva and sweat, it has been proved that such transmission is not possible. 9,26,51Even though sweat is the most common body fluid exchanged between athletes, it is not considered a risk factor for HIV transmission among athletes.McGrew et al. 34 stated that HIV transmission risk exists if the skin is broken and infected blood enters through this route.Table II indicates that this sample of athletes were knowledgeable about HIV transmission methods generally.
Theoretically a risk exists, but most experts agree that the risk of infection during competition is extremely low, and that the principal risks faced by athletes are related to off-the-field activities. 9,10,14,23,50No studies have been documented on athlete-to-athlete transmission from blood exposure on the playing field, except for 1 anecdotal report of an Italian soccer player. 48owever, the document rendered insufficient evidence to call the incident a conclusive case. 10Respondents in all 3 risk categories felt that HIV may be transmitted through sport participation.The data reveals that although the sportspersons were knowledgeable about the transmission modes of HIV, they still feared playing with or against infected players.This fear seems unjustified as their knowledge on modes of transmission was excellent.
There were a few concerns by sportspersons pertaining to other situations that could involve risk of transmission.These situations were blood from the eyes or mouth especially in contact sport, possible cross-infection from first aiders, openwound contact, and playing contact sport.
Most athletes (85%) knew that contact sport posed more of a transmission risk than non-contact sport.Sports considered to involve the most potential risk are boxing, wrestling and the martial arts 18 because of close contact and risk of blood exposure from broken skin and/or membranes.Other semi-contact sports such as basketball and soccer provide opportunities for open bleeding wounds to occur, providing a theoretical possibility of HIV transmission. 40,49The media exposure given to boxers and the compulsory HIV testing required could have convinced athletes that contact sport poses the greatest threat of HIV transmission.The South African Boxing Commission, like others worldwide, does not publish statistics on the number of HIV-infected boxers because of a serious controversy in 1995 after such disclosure. 30quiry into the number of bleeding injuries sustained in the total sample during competition revealed that 37% encountered no bleeding injuries.One incident of a bleeding injury per match was reported by 30% of the sample.The highest number of bleeding injuries was reported in rugby in the high-risk category (5 or more bleeding injuries in a match).The high incidence of bleeding in contact sport necessitates that all sport personnel be educated on how to treat and control bleeding so that it does not pose a transmission risk. 3,24Only 1 case of hepatitis B transmission has occurred in sport, when 5 of 10 young Japanese sumo wrestlers were infected from a teammate who bled on them during matches. 26Researchers, sport and medical organisations have developed policies regarding HIV transmission in the sports world emphasising the need for universal precautions. 4,14,23,25,40,45orts that showed most acceptances were in the individual and low-risk category.This finding is alarming due to the low incidence of bleeding injuries encountered in these sports.Low-risk individual sports like tennis afford few opportunities for physical contact.However, athletes displayed a fear of HIV transmission, which is not justified given the nature of the sport.One can only surmise that sensationalised reports of escalating infection rates have greatly contributed to fear of infection.Jackson 25 sought to construct a framework for ethical deliberation concerning HIV and sport to combat the isolation experi-enced by HIV-infected individuals participating in sport.
Athletes in the Calabrese 10 study questioned why it was acceptable to require testing for drugs but not for HIV.It seemed to them that society cares more about a player s drug status than his/her HIV status.HIV is the only infectious disease for which anonymous testing is publicly funded, an exception that has been controversial. 6 South Africa it is mandatory for all boxers to undergo an annual HIV-antibody test, to complete a medical examination, and to receive medical clearance before being allowed into the arena.The general exception to this is when boxers travel to the USA or to Britain where they must present results from tests conducted within the last 3 months. 47Matseka 36 stated that about 9% of South African boxers have tested positive for HIV and are therefore banned from boxing.Matseka 36 calculated that with the 9% incidence, boxers would have to fight 50 000 bouts before transmitting the virus.The American Academy of Pediatrics Committee on Sports Medicine and Fitness, 2 the World Health Organization Consensus Statement Consultation on AIDS and Sports, 50,51 the Canadian Academy of Sports Medicine Task Force on Infectious Diseases in Sports 12 and the National Collegiate Athletic Association 37 have all concluded that the risk of infection from one athlete to another (even in contact sports such as football, boxing and wrestling) is not sufficient to warrant a policy of mandatory testing.Since the risk of HIV transmission in sport is not zero, many voices have advocated mandatory testing.However, several problems are associated with mandatory HIV testing.These include the high probability of false-negative and false-positive test results as well as issues regarding the right to privacy. 39ucation remains the key in the effort to prevent bloodborne pathogen transmission.Sports medicine personnel play an important role in educating athletes, their families, athletic trainers, health care providers, coaches, and officials involved in sport. 39During 2002/2003 awareness was advanced mainly through the Khomanani Campaign and the lifeskills and HIV/ AIDS Education Programme in schools. 43st research studies recommend that HIV-positive individuals exercise as most participants show improvements after commencing on an exercise programme. 7,27,28,30,33,35The study by Rigsby et al. 39 on HIV-positive individuals in stages II, III and IV, indicated that bicycle exercise training for 12 weeks significantly increased neuromuscular strength and cardiorespiratory fitness.Pedersen 38 and Dudgeon et al. 15 maintain that the amount of data available does not allow any strong conclusion to be drawn regarding possible beneficial or detrimental effects of training, regardless of intensity and duration, on the immune system of HIV-positive subjects.This uncertainty is caused by conflicting results found among studies.The studies by Stringer 46,47 on HIV and aerobic exercise revealed that 6 -12 weeks of moderate exercise sessions (3 times per week for 1 hour), significantly improved aerobic capacity.Other benefits included improved functional status, improved immune function indices, maintenance of/improvements in lean body mass/weight, improved mood (reduced depressive symptoms) and improvement in the quality of the patient s life.Recent studies by Dudgeon et al. 15 concluded that the use of both aerobic and resistance exercise improves physiological parameters such as strength, endurance, time to fatigue and body composition in the HIV-infected population.Exercise has also been used successfully to treat psychological conditions such as depression and anxiety that are common in HIV-infected individuals. 20Thus, advice to HIV-positive patients to perform physical exercise relies on the positive effects of muscle strengthening and oxygen uptake and the psychological relief achieved in those patients able to participate in a training programme.

Conclusions
In the present study 46% of respondents indicated that they would play against HIV-positive sportspersons, 18% indicated that they would not, and 34% of respondents were unsure of their views.Most athletes (85%) knew that contact sport was more of a risk for transmission than non-contact sport.
Fifty-eight per cent of respondents believed that AIDS should be a notifiable disease in sport.A fear of contracting AIDS during sport was indicated by 59%, while 37% were not afraid of transmission during sport.The largest percentage (24%) of the respondents who indicated their fear of transmission through sport came from the high-risk category.
Eighty-seven per cent of these sportspersons wanted more information on AIDS.Coaches and doctors contributed the least towards education on the risk of HIV transmission in sport.The athletes felt strongly that coaches and doctors should go through HIV training programmes so that they can provide informed knowledge to the athletes under their supervision.
Most respondents believed that exercise should form an integral part of HIV/AIDS patients lives as it improves quality of life.

Recommendations
All athletes should complete an HIV education programme and be informed about the possibility of transmission.
Physicians, coaches and managers should counsel HIVinfected patients, especially those in boxing, as they are tested twice a year.
Coaches and managers should complete a compulsory HIV training programme before being appointed to these positions.

TABLE III . Knowledge of HIV transmission through sport, compared by risk category
* All significant (p < 0.05) at the 5% level among the different risk categories.