Abstracts

Introduction

Pre-exposure prophylaxis (PrEP) for HIV is an effective biomedical prevention strategy to address the HIV epidemic worldwide ¹1. Krakower D, Ware N, Mitty JA, Maloney K, Mayer KH. HIV providers' perceived barriers and facilitators to implementing pre-exposure prophylaxis in care settings: a qualitative study. AIDS Behav 2014; 18:1712-21.. However, expanding its offer in low- and middle-income countries is necessary ²2. Schmidt H-MA, Schaefer R, Nguyen VTT, Radebe M, Sued O, Rodolph M, et al. Scaling up access to HIV pre-exposure prophylaxis (PrEP): should nurses do the job? Lancet HIV 2022; 9:e363-6.^,33. Rebe K, Hoosen N, McIntyre JA. Strategies to improve access for MSM in low-income and middle-income countries. Curr Opin HIV AIDS 2019; 14:387-92.. There are still challenges in the organization of services and PrEP prescription by health care providers ⁴4. Pleuhs B, Quinn KG, Walsh JL, Petroll AE, John SA. Health care provider barriers to HIV pre-exposure prophylaxis in the United States: a systematic review. AIDS Patient Care STDS 2020; 34:111-23.^,55. Pimenta MC, Bermúdez XP, Godoi AMM, Maksud I, Benedetti M, Kauss B, et al. Barreiras e facilitadores do acesso de populações vulneráveis à PrEP no Brasil: Estudo ImPrEP Stakeholders. Cad Saúde Pública 2022; 38:e00290620.. The low PrEP coverage can diminish the impact this prevention strategy has on the HIV epidemic. Additionally, certain fragilities in the services have been observed, such as low availability of counselors, low familiarity of teams with HIV preventive strategies, and barriers in the access of laboratory tests to monitor the safety of PrEP use ⁶6. Zucchi EM, Grangeiro A, Ferraz D, Pinheiro TF, Alencar T, Ferguson L, et al. Da evidência à ação: desafios do Sistema Único de Saúde para ofertar a profilaxia pré-exposição sexual (PrEP) ao HIV às pessoas em maior vulnerabilidade. Cad Saúde Pública 2018; 34:e00206617.^,77. Krakower DS, Oldenburg CE, Mitty JA, Wilson IB, Kurth AE, Maloney KM, et al. Knowledge, beliefs and practices regarding antiretroviral medications for HIV prevention: results from a survey of healthcare providers in New England. PLoS One 2015; 10:e0132398..

Barriers to the prescription of PrEP by health care professionals have been reported worldwide ⁸8. Koechlin FM, Fonner VA, Dalglish SL, O'Reilly KR, Baggaley R, Grant RM, et al. Values and preferences on the use of oral pre-exposure prophylaxis (PrEP) for HIV prevention among multiple populations: a systematic review of the literature. AIDS Behav 2017; 21:1325-35.. Among the main barriers are logistical concerns with clinical and laboratory monitoring, high cost of the drug, challenges in finding people who could benefit from PrEP, concerns about viral resistance and drug toxicity, and the belief that its use would increase the risk behavior of some individuals ¹1. Krakower D, Ware N, Mitty JA, Maloney K, Mayer KH. HIV providers' perceived barriers and facilitators to implementing pre-exposure prophylaxis in care settings: a qualitative study. AIDS Behav 2014; 18:1712-21.^,88. Koechlin FM, Fonner VA, Dalglish SL, O'Reilly KR, Baggaley R, Grant RM, et al. Values and preferences on the use of oral pre-exposure prophylaxis (PrEP) for HIV prevention among multiple populations: a systematic review of the literature. AIDS Behav 2017; 21:1325-35.^,99. Bil JP, Hoornenborg E, Prins M, Hogewoning A, Lima FDG, de Vries HJC, et al. The acceptability of pre-exposure prophylaxis: beliefs of health-care professionals working in sexually transmitted infections clinics and hiv treatment centers. Front Public Health 2018; 6:5..

Structural barriers, such as stigmatizing and discriminatory care for young women and adolescents at increased risk of HIV infection, remain in the practices of health care professionals, which results from an existing and entrenched prejudice ¹⁰10. Pilgrim N, Jani N, Mathur S, Kahabuka C, Saria V, Makyao N, et al. Provider perspectives on PrEP for adolescent girls and young women in Tanzania: the role of provider biases and quality of care. PLoS One 2018; 13:e0196280.. Additionally, a high proportion of health care professionals have never heard of PrEP and lack adequate knowledge to prescribe it ¹¹11. Senn H, Wilton J, Sharma M, Fowler S, Tan DHS. Knowledge of and opinions on HIV preexposure prophylaxis among front-line service providers at Canadian AIDS service organizations. AIDS Res Hum Retroviruses 2013; 29:1183-9..

Studies conducted in different countries indicate variation in the proportion of knowledge about PrEP according to the professional category ¹²12. Shaeer KM, Sherman EM, Shafiq S, Hardigan P. Exploratory survey of Florida pharmacists' experience, knowledge, and perception of HIV pre-exposure prophylaxis. J Am Pharm Assoc (2003) 2014; 54:610-7.^,1313. Bepouka BI, Situakibanza H, Kokusa Y, Nkodila A, Kizunga F, Kiazayawoko F. Care providers' knowledge and willingness to prescribe pre-exposure prophylaxis (PrEP) in Kinshasa, Democratic Republic of Congo (DRC). Pan Afr Med J 2019; 34:166.^,1414. Abu-Khalaf S, Dent J, Teti M, Dandachi D. Are we prescribing enough HIV pre-exposure prophylaxis in Missouri? A cross-sectional study at University of Missouri health care. Mo Med 2020; 117:563-8.. A study condicted in Florida (United States, 2014) most pharmacists reported insufficient knowledge to prescribe PrEP for patients ¹²12. Shaeer KM, Sherman EM, Shafiq S, Hardigan P. Exploratory survey of Florida pharmacists' experience, knowledge, and perception of HIV pre-exposure prophylaxis. J Am Pharm Assoc (2003) 2014; 54:610-7.. Another study with physicians and nurses from the Democratic Republic of Congo showed that among the 85 respondents, less than a quarter knew about PrEP, and only half were willing to prescribe it in 2017 ¹³13. Bepouka BI, Situakibanza H, Kokusa Y, Nkodila A, Kizunga F, Kiazayawoko F. Care providers' knowledge and willingness to prescribe pre-exposure prophylaxis (PrEP) in Kinshasa, Democratic Republic of Congo (DRC). Pan Afr Med J 2019; 34:166.. In another study ¹⁴14. Abu-Khalaf S, Dent J, Teti M, Dandachi D. Are we prescribing enough HIV pre-exposure prophylaxis in Missouri? A cross-sectional study at University of Missouri health care. Mo Med 2020; 117:563-8. conducted with health care professionals from different specialties in hospitals in Missouri (United States, 2019), 37% reported that oral PrEP is taken once a day and only 19% knew it consists of the combination of two antiretrovirals. Thus, studies on barriers and facilitators for prescribing PrEP should be investigated.

Furthermore, few studies investigate the health care professionals’ knowledge about PrEP and the factors associated with the unwillingness to prescribe it in Latin America ¹⁵15. Cerqueira N, Vasconcelos R, Hojilla C, Kallas E, Avelino-Silva V. Attitudes and knowledge about HIV PrEP among infectious diseases physicians in Brazil. AIDS Res Hum Retroviruses 2018; 34:275.^,1616. Vega-Ramirez H, Torres TS, Guillen-Diaz C, Pimenta C, Diaz-Sosa D, Konda KA, et al. Awareness, knowledge, and attitudes related to HIV pre-exposure prophylaxis and other prevention strategies among physicians from Brazil and Mexico: cross-sectional web-based survey. BMC Health Serv Res 2022; 22:532.. Most studies have been conducted in North America ⁴4. Pleuhs B, Quinn KG, Walsh JL, Petroll AE, John SA. Health care provider barriers to HIV pre-exposure prophylaxis in the United States: a systematic review. AIDS Patient Care STDS 2020; 34:111-23. and Europe ⁸8. Koechlin FM, Fonner VA, Dalglish SL, O'Reilly KR, Baggaley R, Grant RM, et al. Values and preferences on the use of oral pre-exposure prophylaxis (PrEP) for HIV prevention among multiple populations: a systematic review of the literature. AIDS Behav 2017; 21:1325-35.. Therefore, this study aimed to analyze the factors associated with the unwillingness to prescribe PrEP by health care professionals in HIV/AIDS-specialized care services (SCSs).

Materials and methods

Study design and study location

This is a cross-sectional study that integrates the research protocol Implementation of the National Comprehensive Health Policy for Lesbians, Gays, Bisexuals, Travestis and Transsexuals (PNSI-LGBT) in the State of Bahia. This protocol aimed to understand the historical conditions for the emergence of the National Policy for Comprehensive LGBT Health (PNSI-LGBT) in the state of Bahia, Northeastern Brazil ¹⁷17. Bezerra MVR, Magno L, Prado NMBL, Santos AM. Condições históricas para a emergência da Política Nacional de Saúde Integral LGBT no espaço social da saúde no Estado da Bahia, Brasil. Cad Saúde Pública 2021; 37:e00221420.. One of the secondary objectives was to evaluate the quality of SCSs in the care of HIV/AIDS and other sexually transmitted infections (STIs) for the LGBT population in Bahia ¹⁷17. Bezerra MVR, Magno L, Prado NMBL, Santos AM. Condições históricas para a emergência da Política Nacional de Saúde Integral LGBT no espaço social da saúde no Estado da Bahia, Brasil. Cad Saúde Pública 2021; 37:e00221420..

The study was conducted in 25 SCSs out of a total of 47 SCSs from 21 municipalities in the state of Bahia: Alagoinhas, Barreiras, Bom Jesus da Lapa, Camaçari, Eunápolis, Feira de Santana, Guanambi, Ilhéus, Irecê, Itabuna, Itamaraju, Jequié, Juazeiro, Lauro de Freitas, Paulo Afonso, Porto Seguro, the state capital Salvador (with five SCSs), Senhor do Bonfim, Simões Filho, Teixeira de Freitas, and Vitória da Conquista.

Eligibility criteria

A single-stage cluster sampling selected the municipalities. The selection criteria for the cities considered the highest level of SCSs coverage, different economic and sociopolitical situations, and whether the municipalities offer health services of different technological levels to their populations.

The population corresponded to 252 health care professionals who make up the multidisciplinary team of the SCSs and who worked for at least six months in SCSs and agreed to participate in the study. All professionals available at the services during the period of data collection were invited to participate in the study.

Data collection

Data collection occurred from October 2019 to March 2020 and was conducted by researchers in the selected municipalities after obtaining the consent of the Bahia State Health Department. Following the schedule and planning of the study, the researchers visited the services to get to know the space, meet the team, and apply the questionnaire to the health professionals.

The questionnaire was digitally applied by trained interviewers using tablet computers in a private space within the health service. The questions regarded sociodemographic characteristics, professional identification, prevention methods, and willingness to prescribe PrEP.

Study variables

The unwillingness to prescribe PrEP (yes; no) by health care professionals was considered the outcome variable.

Sociodemographic and professional characteristics

Data were collected on gender (female; male), age (≤ 35; ≥ 36 ≤ 50; > 50 years), educational level (high school; higher education; graduate studies), academic training (nurse; physician; others), HIV/AIDS specialty (yes; no), years of training (up to 10; ≥ 10), the period spent working in SCS (< 14; ≥ 14 years), type of employment (temporary; tenure), and location of the SCS in the capital (yes; no).

General perceptions and knowledge of combined prevention

The following variables related to PrEP had closed-ended responses (i.e., yes, no): knowledge of the PNSI-LGBT; previous knowledge of PrEP; PrEP offer; knowledge about combined prevention; perception of whether public network professionals are trained; provision for prescription of self-testing for the key population of gay/man who have sex with man (MSM); and post-exposure prophylaxis (PEP) for HIV prevention. They were also asked where they heard about PrEP (i.e., in training actions in the facility, in the media (TV, radio, etc.), internet/social networks, through coworkers and others), and what could be done for permanent education of professionals working in the management of PrEP, with questions about professionals’ permanent education, training with more experienced professionals, and courses.

Data analysis

Descriptive analyses were performed with absolute and relative frequency estimation and a 95% confidence interval (95%CI) for categorical variables. The estimation of factors associated with unwillingness to prescribe PrEP was evaluated based on bivariate and multivariate analyses, using odds ratio (OR) and its respective 95%CI. Multivariate analysis was conducted in two steps. Initially, a bivariate analysis model was created for the identification of crude associations between exposure and unwillingness to prescribe PrEP. In the multivariate model, logistic regression was used, including all variables, which presented a p-value < 0.20 in both crude and stratified analyses. For the final model, only variables with p < 0.05 remained using the backward approach ¹⁸18. Hosmer Jr. DW, Lemeshow S, Sturdivant RX. Applied logistic regression. Hoboken: John Wiley & Sons; 2013.. The theoretical relevance of including variables in the final model was considered. The analyses were performed using the Stata software, version 17 (https://www.stata.com).

Ethical aspects

The research was approved by the Research Ethics Committee of the Multidisciplinary Health Institute of the Federal University of Bahia (IMS/UFBA) on August 21, 2019 (process n. 3,082,370). Written informed consent was obtained from all participants. All steps included in this study were conducted in accordance with the ethical and legal issues defined in Resolution n. 466/2012 of the Brazilian National Health Council, which regulates research involving human beings in Brazil.

Results

Characteristics of participants and service

From 490 health care professionals registered in the Brazilian National Register of Health Establishments in March 2020, 252 health professionals from the SCSs were interviewed and included in this study, representing 51.4% of the total population.

Most participants were aged from 36 to 50 years (54.4%), from SCS in the state capital (65.9%), and women (78.2%). Half participants (51%) reported having a specialization course degree, and 53.1% knew about the PNSI-LGBT.

Regarding PrEP prescribers, nurses corresponded to 25.7% and physicians to 11.9%, while 62.4% were other health care professionals with technical and higher education qualifications, such as nursing technicians, psychologists, pharmacists, occupational therapists, physical therapists, social workers, and dentists.

Most participants (73.4%) reported having worked in the SCSs for at least 14 years. Tenure via open selection was the most common mode of employment mentioned by professionals (66.3%), and 23.4% reported having a specialization course degree in the area of HIV/AIDS. More than half (74.2%) reported having more than ten years of education (Table 1).

Table 1 shows that 15.2% (95%CI: 10.8-19.6) of the health care professionals reported unwillingness to prescribe PrEP, even though previous knowledge of it was relatively high (96%). When stratifying the results according to nursing, physicians, and other professionals, no difference regarding knowledge of PrEP and unwillingness to prescribe PrEP was observed (Figure 1). More than half participants (63.7%) indicated knowing PrEP via permanent education programs and training performed in the service, followed by information from coworkers (15.8%), other sources of information (11.5%), media (TV, radio, etc.) (5.1%) and internet or social networks (3.9%). Only 32.9% reported that their services provide PrEP.

The results of bivariate logistic regression analyses showed an increased chance of unwillingness to prescribe PrEP by health care professionals who reported non-prescription of HIV self-testing for key populations nor PEP for the general population (Table 2). Moreover, professionals with graduate degrees had lower chances of not prescribing PrEP, and professionals who reported not prescribing HIV self-testing for key populations and indicate PEP for HIV prevention had a higher chance of unwillingness to prescribe PrEP.

In the multivariate analysis (Table 3), a higher chance of unwillingness to prescribe PrEP was observed among professionals who reported not prescribing HIV self-testing for key populations (_adjustedOR = 5.4; 95%CI: 1.3-22.4) nor PEP (_adjustedOR = 2.00; 95%CI: 1.3-3.1), professionals working in services in the state capital (_adjustedOR = 3.9; 95%CI: 1.4-10.2), and when PrEP was not available in the service (_adjustedOR = 1.7; 95%CI: 1.1-2.8).

Health care professionals who reported no need to attend to training and courses (_adjustedOR = 1.3; 95%CI: 1.1-1.8), or the need to promote activity with more experienced professionals to work in PrEP management (_adjustedOR = 1.8; 95%CI: 1.1-3.8) presented a statistically significant association with the unwillingness to prescribe PrEP. Graduate degrees (_adjustedOR = 0.3; 95%CI: 0.1-0.8) remained associated with a lower proportion of unwillingness to prescribe PrEP (Table 3).

Discussion

This is one of the first studies on the unwillingness to prescribe PrEP by professionals working in the SCSs in Brazil. This study demonstrated that health professionals willing to prescribe PrEP also recognize the need to prescribe other combined HIV prevention measures such as HIV self-testing for populations at increased risk of HIV infection and the use of PEP when the person had been exposed to HIV.

Within this context, our study identified that more than half of the professionals had PrEP knowledge, and the likelihood of unwillingness to prescribe PrEP decreases when they are associated with the willingness to prescribe HIV self-tests for key populations. This can be interpreted as a positive factor for HIV prevention ¹⁹19. Figueroa C, Johnson C, Verster A, Baggaley R. Attitudes and acceptability on HIV self-testing among key populations: a literature review. AIDS Behav 2015; 19:1949-65..

Studies highlight the need to decentralize PrEP to primary health care. An intervention study ²⁰20. Lumsden J, Dave AJ, Johnson C, Blackmore C. Improving access to pre-exposure prophylaxis for HIV prescribing in a primary care setting. BMJ Open Qual 2022; 11:e001749. with targeted clinical education, combined with electronic health record templates, was associated with a significant increase in PrEP prescriptions in the United States. Another study ²¹21. Charest M, Sharma M, Chris A, Schnubb A, Knox DC, Wilton J, et al. Decentralizing PrEP delivery: implementation and dissemination strategies to increase PrEP uptake among MSM in Toronto, Canada. PLoS One 2021; 16:e0248626. with primary care physicians and nurses of a sexual health clinic in Canada found that a nurse-led PrEP and patient-initiated continuing medical education are feasible strategies for increasing PrEP uptake and that most patients preferred the nurse-led PrEP delivery. Therefore, expanding strategies to disseminate the use of PrEP among professionals and users is valid, considering that professionals who reported no need to attend training and courses or training with more experienced professionals were unwilling to prescribe PrEP ²¹21. Charest M, Sharma M, Chris A, Schnubb A, Knox DC, Wilton J, et al. Decentralizing PrEP delivery: implementation and dissemination strategies to increase PrEP uptake among MSM in Toronto, Canada. PLoS One 2021; 16:e0248626..

We also noticed that non-prescription of PEP contributed to the unwillingness to prescribe PrEP, which highlights the importance of training in combination HIV prevention, considering that these strategies components must be jointly prescribes in order to reduce new HIV infections ²²22. DeHaan E, McGowan JP, Fine SM, Vall R, Merrick ST, Radix A, et al. PEP to prevent HIV infection. Baltimore: Johns Hopkins University; 2021..

There are challenges to the provision of combination-prevention technologies in Brazil. A study on HIV prevention in the municipalities of Baixada Fluminense area, state of Rio de Janeiro, highlighted the absence of local prevention planning and testing actions for the key population of these municipalities, as well as a lack of information on PrEP and PEP use ²³23. Monteiro S, Brigeiro M. Prevenção do HIV/Aids em municípios da Baixada Fluminense, Rio de Janeiro, Brasil: hiatos entre a política global atual e as respostas locais. Interface (Botucatu) 2019; 23:e180410.. Managers justified this gap as being due to the difficulty in identifying and approaching this population and the lack of training of health professionals to address sexuality-related issues.

Regarding the knowledge of health workers about PrEP, a high percentage (96%) was found, which is similar to that identified in 2013 a study in the United Kingdom, with 212 professionals, in which 80% of the health care professionals reported a high or medium level of knowledge ²⁴24. Desai M, Gafos M, Dolling D, McCormack S, Nardone A. Healthcare providers' knowledge of, attitudes to and practice of pre-exposure prophylaxis for HIV infection. HIV Med 2016; 17:133-42.. On the other hand in a study conducted in Paraíba (Brazil) ²⁵25. Batista AT. Previnir ou remediar? Atitudes dos profissionais de saúde frente a profilaxia pré-exposição ao HIV/AIDS [Master's Thesis]. João Pessoa: Programa de Pós-gradução em Psicologia Social, Universidade Federal da Paraíba; 2017., in 2017, 29% of health care professionals who also worked in SCSs, testing services, and management of HIV services, reported not knowing about PrEP. This might have occurred because the study was conducted in the year PrEP was implemented in Brazil. A study ¹⁵15. Cerqueira N, Vasconcelos R, Hojilla C, Kallas E, Avelino-Silva V. Attitudes and knowledge about HIV PrEP among infectious diseases physicians in Brazil. AIDS Res Hum Retroviruses 2018; 34:275. conducted in Brazil from 2016 to 2017 reported that 75% of infectious disease physicians knew about PrEP, and 63% to 69% reported willingness to prescribe PrEP for MSM or sex workers with inconsistent condom use. The ImPrEP study ¹⁶16. Vega-Ramirez H, Torres TS, Guillen-Diaz C, Pimenta C, Diaz-Sosa D, Konda KA, et al. Awareness, knowledge, and attitudes related to HIV pre-exposure prophylaxis and other prevention strategies among physicians from Brazil and Mexico: cross-sectional web-based survey. BMC Health Serv Res 2022; 22:532., conducted from January to October 2020, evaluated behaviors related to PrEP and other HIV prevention strategies among Brazilian and Mexican infectious disease physicians with high knowledge about PrEP (84.6%) and reported that 78% were willing to prescribe PrEP. The most frequent barriers regarded assumptions that users could have low knowledge and limited capacity to adhere to PrEP, and a lack of professionals to prescribe PrEP ¹⁶16. Vega-Ramirez H, Torres TS, Guillen-Diaz C, Pimenta C, Diaz-Sosa D, Konda KA, et al. Awareness, knowledge, and attitudes related to HIV pre-exposure prophylaxis and other prevention strategies among physicians from Brazil and Mexico: cross-sectional web-based survey. BMC Health Serv Res 2022; 22:532.. A review of 36 studies on the implementation of PrEP care among health care professionals in the United States ²⁶26. Zhang C, McMahon J, Fiscella K, Przybyla S, Braksmajer A, LeBlanc N, et al. HIV pre-exposure prophylaxis implementation cascade among health care professionals in the United States: implications from a systematic review and meta-analysis. AIDS Patient Care STDS 2019; 33:507-27. showed the following barriers at various levels - drug level: provider’s concerns about efficacy, safety, side effects, and drug resistance; patient level: lack of PrEP requests and low support; provider level: lack of awareness/knowledge/skills, lack of training, workload management, and concerns about potential risk compensation (e.g., reduced condom use after PrEP prescription); and structural level: cost/insurance coverage, lack of PrEP-oriented care models, lack of guidance for specific groups, including adolescents, intravenous drug users, and HIV-serodiscordant couples ²⁶26. Zhang C, McMahon J, Fiscella K, Przybyla S, Braksmajer A, LeBlanc N, et al. HIV pre-exposure prophylaxis implementation cascade among health care professionals in the United States: implications from a systematic review and meta-analysis. AIDS Patient Care STDS 2019; 33:507-27..

In turn, in a cross-sectional online survey conducted with Chinese physicians in 12 provinces of China ²⁷27. Cui S, Ding H, Huang X, Wang H, Tang W, Leuba SI, et al. Factors influencing clinicians' willingness to prescribe pre-exposure prophylaxis for persons at high risk of HIV in China: cross-sectional online survey study. JMIR Public Health Surveill 2021; 7:e24235., due to the absence of guidelines on PrEP, less than half of professionals (47.2%) were willing to provide PrEP for the population at high risk for HIV, which indicates a low awareness of professionals about this prevention strategy. It is noteworthy that health care professionals should act not only based on their knowledge and disposition of prescription but also to break barriers, i.e., prejudices and stigmas related to the population at increased risk of HIV infection.

Additionally, this study indicated that professionals working in the inland municipalities of Bahia are more willing to prescribe PrEP compared to professionals in the capital. This leads us to understand the need to expand PrEP services in the inland municipalities, with consequent expansion of PrEP offer, as well as the training of these professionals for the existing combination-prevention strategies. On the other hand, conducting awareness-raising actions on PrEP aimed at the professionals who make up the capital’s health services is also needed.

The main limitation of our study is its small sample size, which may have hampered the identification of other factors associated with the non-prescription of PrEP. Furthermore, the cross-sectional design makes hinders the evaluation of possible causality relationships. However, our study was carefully planned and involved researchers’ training to reduce the possibility of bias during data collection. We recommend developing further studies with an interdisciplinary approach to a better understanding of different elements that may also explain the non-prescription of PrEP in specialized services.

This study identified a high level of knowledge of PrEP, but still a proportion of health care professionals who are unwilling to prescribe PrEP. Although PrEP is a biomedical strategy, its implementation, acceptance, and adherence occur in the experience of social life, in synergy with a set of elements that involve knowledge, attitudes, values, and power relations that generate tensions and obstacles related to HIV, which persists in being socially seen in its stigmatizing condition. Accordingly, we suggest the expansion of permanent education in combin with HIV prevention among health care professionals, especially for physicians and nurses, as well as the need to expand the offer of PrEP in health services for people at increased risk of HIV infection. Education programs should strengthen knowledge regarding PrEP and address concerns that lead to reluctance to prescribe it.

Acknowledgments

The project was selected and funded by the Brazilian National Research Council - CNPq (Edital CNPq/MS-DIAHV n. 11/2018 - Axis 3 - CNPq Universal Service Management Analysis - 14/2011 - process: 404011/2018-7). Funding: Brazilian Ministry of Health, through the CNPq.

References

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