Professional profile, knowledge, and attitudes in addressing HIV in Primary Health CareAbstract
Objective To analyze the association between the professional profile, knowledge, and attitudes of healthcare professionals and the implementation of HIV/AIDS coping actions in Primary Health Care.
Methods This cross-sectional and analytical study was conducted in the Primary Health Care setting of a municipality in São Paulo State with physicians, nurses, dentists, pharmacists, and psychologists trained to perform rapid tests. Professional profiles, knowledge, and attitudes regarding Sexually Transmitted Infections, HIV, and AIDS were examined, as well as the implementation of coping actions, such as rapid testing, health education, notification, and active partnership seeking. A coping score was calculated by summing the reported actions, and the score was analyzed using multiple linear regression to identify associations with profile, knowledge, and attitude variables. The Family Health Strategy care models and the traditional care model were also compared using the chi-square and Fisher’s exact tests.
Results The sample consisted of 120 professionals, the majority of whom were female (74.2%) and medical professionals (55.0%). More than half of the sample did not participate in training in the last five years (60.0%) and do not provide guidance on the use of condoms (65.0%). Professionals from the Family Health Strategy presented a higher coping score, with a ratio of actions 1.68 higher than that of professionals in traditional Basic Units, highlighting the active search for partnerships, monitoring of pregnant women with HIV, and notification of Sexually Transmitted Infections.
Conclusion The care model directly influences actions to cope with HIV and AIDS, with greater effectiveness in the Family Health Strategy.
Keywords
HIV; Acquired Immunodeficiency Syndrome; Coping Skills; Health personnel; Primary Health Care
Resumo
Objetivo Analisar a associação entre o perfil profissional, o conhecimento e as atitudes dos profissionais de saúde e a realização de ações de enfrentamento ao HIV na Atenção Primária à Saúde.
Métodos Estudo transversal e analítico conduzido na Atenção Primária de um município paulista com médicos, enfermeiros, cirurgiões-dentistas, farmacêutico e psicólogo capacitados para realizar testes rápidos. Foram investigados perfil profissional, conhecimento e atitudes relativas às Infecções Sexualmente Transmissíveis, HIV e AIDS, além da implementação de ações de enfrentamento, como testagem rápida, educação em saúde, notificação e busca ativa de parcerias. Foi calculado um escore de enfrentamento somando as ações reportadas, e o escore foi analisado usando regressão linear múltipla para identificar associações com variáveis de perfil, conhecimento e atitude. Foram ainda comparados os modelos de atenção, Estratégia Saúde da Família e modelo tradicional, usando os testes qui-quadrado e exato de Fisher.
Resultados A amostra foi constituída por 120 profissionais, sendo a maioria do gênero feminino (74,2%) e profissionais médicos (55,0%). Mais da metade não participou de capacitações nos últimos cinco anos (60,0%) e não orienta o uso de preservativos (65,0%). Os profissionais da Estratégia Saúde da Família apresentaram um escore de enfrentamento mais elevado, realizando 1,68 ações de enfrentamento a mais que os profissionais de Unidades Básicas tradicionais, destacando a busca ativa de parcerias, acompanhamento de gestantes com HIV e notificação das Infecções Sexualmente Transmissíveis.
Conclusão O modelo de atenção influencia diretamente as ações de enfrentamento ao HIV e à AIDS, com maior efetividade na Estratégia de Saúde da Família.
Descritores
HIV; Síndrome da Imunodeficiência Adquirida; Enfrentamento; Profissionais de saúde; Atenção Primária à Saúde
Resumen
Objetivo Analizar la relación entre el perfil profesional, los conocimientos y las actitudes de los profesionales de la salud y la realización de acciones para hacer frente al VIH en la atención primaria de salud.
Métodos Estudio transversal y analítico realizado en la atención primaria de un municipio de São Paulo con médicos, enfermeros, cirujanos dentistas, farmacéuticos y psicólogos capacitados para realizar pruebas rápidas. Se investigó el perfil profesional, los conocimientos y las actitudes relativas a las infecciones de transmisión sexual, el VIH y el sida, además de la implementación de acciones de lucha, como pruebas rápidas, educación sanitaria, notificación y búsqueda activa de parejas. Se calculó un puntaje de respuesta sumando las acciones notificadas, y el puntaje se analizó mediante regresión lineal múltiple para identificar asociaciones con variables de perfil, conocimientos y actitudes. También se compararon los modelos de atención, la Estrategia Salud de la Familia y el modelo tradicional, utilizando las pruebas de ji cuadrado y exacta de Fisher.
Resultados La muestra estuvo compuesta por 120 profesionales, en su mayoría mujeres (74,2 %) y médicos (55,0 %). Más de la mitad no había participado en cursos de formación en los últimos cinco años (60,0 %) y no orientaba sobre el uso de preservativos (65,0 %). Los profesionales de la Estrategia Salud de la Familia presentaron un puntaje de afrontamiento más alta, con la realización de 1,68 acciones de afrontamiento más que los profesionales de las Unidades Básicas tradicionales, con énfasis en la búsqueda activa de asociaciones, el seguimiento de las embarazadas con VIH y la notificación de las infecciones de transmisión sexual.
Conclusión El modelo de atención influye directamente en las acciones de enfrentamiento al VIH y al sida, con mayor eficacia en la Estrategia Salud de la Familia.
Descriptores
HIV; Síndrome de Inmunodeficiencia Adquirida; Habilidades de afrontamiento; Personal de salud; Atención Primaria de Salud
Introduction
According to the Joint United Nations Programme on HIV/AIDS, about 39 million people worldwide were living with HIV, with 1.3 million new infections recorded in 2022. It was estimated that 2.2 million people are living with HIV or AIDS in Latin America. In Brazil, 489.594 cases were reported between 2007 and 2023, with 20.237 new cases in 2023, and the highest prevalence in the Southeast region (32.6%).(1,2)
Historically, care for people living with HIV in Brazil was concentrated in Specialized Care Services. However, this model has undergone significant reconfiguration in recent decades. From the 2000s onwards (and with greater emphasis after the National Primary Care Policy of 2006), Primary Health Care has assumed a leading role in coordinating care. This reorganization aimed to decentralize actions, expand access to early diagnosis and antiretroviral therapy, as well as offer comprehensive care in the face of chronic infection and increased life expectancy in this population.(3,4)
With its widespread reach and proximity to the community, Primary Health Care promotes continuous care and facilitates access to services such as testing and treatment for Sexually Transmitted Infections (STIs). Specialized Care Services remain fundamental to the Healthcare Network, offering complementary, matrix-based, and specialized support. However, Primary Health Care faces several obstacles in coping with HIV. They encompass moral, ethical, technical, organizational, and political dimensions, such as inadequate infrastructure, lack of supplies, overburdened teams, devaluation, and lack of training for health professionals, which negatively impact the quality of care.(3-5)
In this new scenario, healthcare professionals working in primary health care are expected to be continuously trained to deal with the HIV and AIDS specificities, considering both advances in treatment and guidelines of public health policies. Training should cover technical, relational, and ethical aspects, which are essential to reduce stigmas and build therapeutic bonds.(3,6)
The relevance of effective actions to cope with HIV in Primary Health Care settings highlights the need to reflect on the factors that condition their implementation. Therefore, the objective of this study was to analyze the association between the professional profile, knowledge, and attitudes of health professionals and the implementation of HIV/AIDS coping actions in Primary Health Care.
Methods
This was a cross-sectional analytical study that investigated the association between profile, knowledge, and attitude of Primary Health Care professionals and their actions to cope with HIV. It was described using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) tool.
The research was conducted in a medium-sized municipality in the central-west of São Paulo, with about 145.155 inhabitants(7)and 21 healthcare units, including 8 traditional Basic Health Units (two of them are called School Health Centers), and 13 Family Health Units with 22 Family Health teams.
The sample projection considered the functional framework of the Basic Health Units, by both Family Health team (one assistant manager nurse, one physician, and one dentist) and Basic Health Units and School Health Center teams: two nurses (manager and assistant), three doctors (general practitioner, pediatrician, and gynecologist), and one dental surgeon, in addition to professionals qualified to perform the rapid test.
The final sample consisted of 120 professionals, including doctors, nurses, and other categories (such as dental surgeons, pharmacists, and psychologists) trained to perform rapid tests. Other professionals, besides doctors and nurses, were included due to the municipal initiative to train other professional categories to perform this procedure, aiming to expand the teams’ reach in coping with HIV and AIDS. All eligible professionals were invited to participate in the study. However, 13 of them declined the invitation (eight doctors, two nurses, and three pharmacists), and four were excluded for not meeting the inclusion criteria.
The inclusion criteria were as follows: to hold a management position, be a physician or nursing assistant, or a qualified senior professional to perform the rapid test, with more than six months of experience in Primary Health Care in the municipality. Professionals on sick leave or vacation during the data collection period and those who refused to participate were excluded.
Data were collected between May and August 2023 following individual interviews conducted in private settings at healthcare facilities. They were led by a nurse and a nursing student who had been previously trained. Two instruments were used: the first was developed by researchers to identify professional profiles, knowledge, and attitudes about STIs, HIV, and AIDS;(8)the second was previously validated to evaluate actions to cope with HIV and AIDS in Primary Health Care.(9)Only the instrument developed by the researchers was previously tested with resident nurses from a Multiprofessional Residency Program to verify the clarity and fluency of the questions before their application in the field.
The profile variables included gender, sexual orientation, gender identity, race and/or skin color, marital status, position, function, care model, and postgraduate education. The participants’ knowledge was assessed based on their understanding of STIs, HIV, and AIDS, Combined Prevention, Pre-exposure Prophylaxis (PrEP), and Post-exposure Prophylaxis (PEP). The participants’ attitude was understood as their predisposition and stance towards care during counseling on STIs, HIV, and AIDS. The participants’ coping actions referred to concrete practices, such as offering rapid testing, health education, notification, and actively seeking partnerships, in the daily routine of the Primary Health Care, as described in the validated and used instrument.
The invitation to participate in the survey was made by email or phone call by the unit managers. These managers also had the role of passing on the research information to the professionals. Those interested had a scheduled time to apply the instruments (mean duration: 30 min). The responses were recorded in Excel® spreadsheets using laptops and tablets. To prevent participants from using the internet to answer the survey questions, which would compromise the reliability of the responses, the researchers decided to administer the instruments in person.
The knowledge and attitude instrument allowed for open-ended responses, which were analyzed qualitatively and classified as sufficient (1) or insufficient (0), thus forming a binary database. To ensure objectivity and standardization, reference material was previously prepared based on technical documents from the Ministry of Health and scientific articles.(10-16)The questions were organized into thematic areas: STIs, HIV, and AIDS, Combined Prevention, PrEP, PEP, vulnerability, and counseling. Each question had an ideal answer and objective criteria for classifying knowledge and attitude as sufficient or insufficient. The participants’ responses were compared with these criteria, allowing for a systematic categorization aligned with the literature.(8)
In the first instrument (data related to the profile regarding knowledge and attitudes towards STIs, HIV, and AIDS), descriptive statistics were used. The score for actions to cope with HIV and AIDS in Primary Health Care was calculated from the validated instrument, containing 18 variables.(9)This score (in the range of 0-18) represented the sum of actions expressed by the professionals in each question. Thus, each “yes” answer added 1 to the score. Then, the raw score was associated with the professionals’ profile, knowledge, and attitude variables. The data were analyzed using the free Statistical Package for the Social Sciences (SPSS) software.
The associations between HIV and AIDS coping scores and the variables profile, knowledge, and attitude of professionals were analyzed using a multiple linear regression model (with normal response), including only the variables with p<0.20 in its deterministic component (bivariate exploration phase). In the final model, associations with p<0.05 were considered statistically significant. This indicates that in these variables, professionals obtained higher coping scores than those obtained in the statistically insignificant variables. The quality of the fitted model was tested by investigating the normality of the residuals (Shapiro-Wilk test). The presence of homoscedasticity was tested using a scatter plot between residual and predicted values, and the existence of influential points was tested using Cook’s distance.
Finally, the healthcare models (Family Health Strategy and traditional model) were compared based on the professionals’ responses, which were obtained using the validated instrument, applying the chi-square or Fisher’s exact tests according to statistical adequacy. Fisher’s exact test was used when the expected frequency in any cell of the contingency table was <5; the chi-square test was used in all other cases. Associations were considered statistically significant for p<0.05.
The project was approved by the Research Ethics Committee of the Faculty of Medicine of Botucatu, SP. (Opinion: 5.961.454; Certificate of Presentation of Ethical Assessment: 60849722.0.0000.5411).
Results
The sample consisted of 120 healthcare professionals, of whom 89 were female (74.2%) and 31 were male (25.8%). All of them identified themselves as cisgender, with no reports of transgender or non-binary identity. The majority of professionals declared to be heterosexual (92.5%); a minority declared to be homosexual (3.3%), bisexual (3.3%), and pansexual (0.8%). Regarding race and/or skin color, professionals self-identified as white (83.3%), brown (10.8%), yellow (3.3%), and black (2.5%); indigenous people were not present in the sample. Regarding marital status, 54.2% were in a stable union (or married), and 45.8% were single, widowed, separated, or divorced.
The professionals were doctors (66; 55.0%), nurses (37; 30.8%), dental surgeons (15; 12.5%), including a pharmacist and a psychologist. Most worked in patient care (89; 74.2%), 21.7% held both management and patient care roles, 3.3% were only managers, and 0.8% were coordinators. Regarding qualifications, 55.8% had residency or specialization, 17.5% had a master’s or doctorate degree, and 26.7% had neither of these qualifications. The professionals worked in traditional model units (65; 54.2%) and in the Family Health Strategy (55; 45.8%). The mean time of professional experience was 14.2 years, and 11.4 years in Primary Health Care.
Regarding knowledge and attitudes towards HIV and AIDS, professionals have not participated in training in the last five years (60.0%) and do not guide on condom use when distributing them (65.0%). Regarding continuity of care, 92.5% of professionals refer patients diagnosed with HIV or AIDS to specialized services. There was good performance in diagnostic actions, and 99.2% of them stated that they offered rapid testing to people with symptoms suggestive of HIV infection. Most of them (95.8%) considered the provision of resources for rapid testing adequate, and 95.0% reported STIs in the Notifiable Diseases Information System (Table 1).
The sum of the actions performed by the participants resulted in a coping score, which is associated with their professional profile, knowledge, and attitudes towards HIV and AIDS. Table 2 presents the variables that showed an association with p<0.20. In the bivariate analysis, higher scores were presented by Family Health Strategy professionals [b=1.70; 95%CI (0.66-2.74), p=0.001], nurses [b=1.96; 95%CI (0.85-3.08), p=0.001], and those with residency or specialization [b=1.00; 95%CI (-0.26-2.25), p=0.119]. Regarding knowledge and attitude, higher scores were observed among those who showed an adequate understanding of PrEP [b=1.00; 95%CI (-0.39-2.38), p=0.158], PEP [b=0.79; 95%CI (-0.38-1.96), p=0.185], vulnerability [b=0.88; 95%CI (-0.36-2.11), p=0.163], and those who provide counseling on STIs, HIV, and AIDS [b=1.78; 95%CI (0.08-3.49), p=0.040] (Table 2).
Although the aforementioned associations are not statistically significant, the variables showed p<0.20. Then, they were adjusted using a multiple linear regression model with a normal response; p<0.05 was considered significant (Table 3). After multiple linear regression, only one association showed to be statistically significant, indicating that professionals with higher coping scores are those working in the Family Health Strategy, performing actions to cope with the pandemic that are 1.68 times greater than professionals in traditional Basic Health Units [b=1.68, 95%CI (0.6-2.70), p=0.001] (Table 3).
The comparison between the care models reinforces the previous analysis, showing that the proportion of professionals who perform actions to cope with HIV and AIDS in the Family Health Strategy is greater than that of professionals in traditional Basic Health Units. This was confirmed in the significant variables: active search for partners after a positive diagnosis (94.5% vs. 76.9%; p=0.009), follow-up of pregnant women with HIV referred to the specialized service (90.9% vs. 67.7%; p=0.003), delivery of serological results during prenatal care (94.5% vs. 73.8%; p=0.003), notification of STIs in the Notifiable Diseases Information System (100% vs. 90.8%; p=0.031), and less difficulty in performing educational actions (61.8% vs. 33.8%; p=0.003) (Table 1).
Discussion
This research associated the characteristics of Primary Health Care professionals (including profile, knowledge, and attitudes) with the implementation of HIV/AIDS coping actions. A predominance of females was observed among the participants. This agrees with the worldwide trend, in which women are about 70% of the health workforce, reflecting sociocultural constructs that historically link care to the female gender.(17)
In addition, most participants reported having postgraduate degrees. However, more than half of the professionals mentioned a lack of specific training on HIV and AIDS in the last five years, revealing a gap in ongoing training. Updating HIV management practices is crucial to ensuring the implementation of evidence-based practices and the provision of comprehensive, high-quality care. Innovative strategies, such as interprofessional education and the use of Digital Technologies, have shown effectiveness in strengthening professionals’ knowledge, safety, and clinical competence.(18,19)
The results of the present research also showed that Family Health Strategy professionals perform significantly more actions to cope with HIV and AIDS compared to those in traditional Basic Health Units. Among the practices, the active search for partnerships, monitoring of pregnant women with HIV, and notification of STIs were highlighted. This difference can be attributed to the Family Health Strategy structural and functional characteristics. They promote building relationships with users and the territory, continuity of care, networking, and a comprehensive approach throughout life, including the management of comorbidities associated with HIV.(20-23)
In coping with HIV, the Family Health Strategy plays a central role by integrating different areas of action, such as identifying vulnerabilities, promoting sexual health education, and offering rapid tests for early diagnosis.(20,23)For people with HIV, the Family Health Strategy ensures the coordination of care with specialized services, strengthening the bond and ensuring continuous follow-up. The success of this approach is visible at the national level, where regions with greater coverage of the Family Health Strategy have achieved a significant reduction in mortality and incidence of AIDS, especially in the low-income population.(20)
In contrast, care follows the biomedical approach and the complaint-conduct logic in traditional Basic Health Units, covering wider territories and serving a larger number of people. This fragmented logic (focused on punctual and curative interventions) contributes little to coping with complex conditions (such as HIV and AIDS) that demand a singular and individual-centered approach.(21,24)Furthermore, in the city where the study was conducted, the hiring of doctors as independent contractors in Basic Health Units is a significant barrier to the quality of care. This precarious and unstable employment relationship restricts labor rights, favors turnover, and compromises continuity of care; in addition, it hinders physicians’ participation in continuing education activities, negatively impacting the services offered.(25,26)
Given the organizational differences between the care models, the Primary Care Assessment Tool (used to measure essential Primary Health Care attributes, such as access, longitudinality, care coordination, and comprehensiveness) is widely used in the literature, in which the Family Health Strategy frequently exceeds the criteria analyzed.(21,22, 24)
Studies conducted with physicians, nurses, and Primary Health Care users in the South and Southeast regions of Brazil showed that traditional Basic Health Units results were lower in the comprehensive care criterion.(22,24)The comparison of healthcare models confirms this analysis, in which a higher proportion of professionals provide comprehensive care in Family Health Strategy. Specifically, Family Health Strategy professionals are more active in reporting STIs and delivering serological tests during the prenatal period. These results highlight the Family Health Strategy ability to offer more comprehensive care, integrating everything from epidemiological surveillance to individualized prenatal care.
The results of this research also indicate that Family Health Strategy professionals perform more efficient care coordination compared to those working in UBS, especially in the follow-up of pregnant women with HIV. This scenario can be understood by the dynamics of traditional units that tend to prioritize programmatic practices, to the detriment of comprehensive, continuous, and coordinated monitoring.(21,24)However, the literature shows that fragilities exist in the care transition mechanisms at different points in the care network, compromising care integration.(21,24)
Finally, we emphasize that the present study makes a significant contribution to understanding the factors associated with actions to cope with HIV and AIDS. However, it was conducted in a single city, and the number of healthcare participants was small. Thus, there are limitations in data representation and generalizing results from different socioeconomic contexts and healthcare structures. These aspects should be considered in the interpretation, reinforcing the importance of future research in diverse settings and with larger samples.
Conclusion
The healthcare model in which primary health care professionals are inserted is determinant for performing actions to cope with HIV and AIDS. This model is powerful for promoting comprehensiveness, longitudinality, and coordination of care, enabling more preventive and follow-up activities. It is important to consolidate the family health strategy as the best model for primary health care to improve HIV management.
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