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. 2025 Nov 7;60:103304. doi: 10.1016/j.pmedr.2025.103304

Global insights into healthcare providers' knowledge, attitudes, practices, and concerns on pre-exposure prophylaxis: A systematic review and meta-analysis

Tesfaye Engdaw Habtie a,⁎, Tegene Atamenta Kitaw a, Amsalu Baylie Taye a, Molalign Aligaz Adisu b
PMCID: PMC12648478  PMID: 41312424

Abstract

Objective

To systematically synthesize global evidence on healthcare providers' knowledge, attitudes, practices, and barriers toward HIV pre-exposure prophylaxis (PrEP.

Methods

A systematic review and meta-analysis was conducted following a PROSPERO-registered protocol (CRD42025632990) and the PRISMA 2020 guidelines. Four electronic databases (PubMed, Web of Science, Cochrane Library, and Google Scholar) were systematically searched for literature published between May 1, 2014 and December 31, 2024. Study selection, guided by the PICoS framework, involved independent screening by two reviewers.

Results

This review includes twenty seven observational studies, with a total of 8960 participants globally. The pooled knowledge of healthcare providers' regarding pre-exposure prophylaxis was 65 % (95 % CI, 60–70 %), the attitude rate was 78 % (95 % CI, 71–85 %), and the practice rate was 37 % (95 % CI, 32–41 %). Healthcare providers with a positive attitude were more likely to have good knowledge [OR = 2.28, (95 % CI, 1.52–3.04)].

Conclusion

Despite generally favorable attitudes and moderate knowledge, pre-exposure prophylaxis practice among healthcare providers remains low. Targeted interventions to improve training, resource access, and guideline awareness, along with strategies to reduce stigma and misconceptions, are essential. Continuous education and innovations, including long-acting pre-exposure prophylaxis formulations, may further enhance adoption and strengthen global HIV prevention efforts.

Keywords: Attitude, Healthcare providers, Knowledge, Practice, Pre-exposure prophylaxis

Highlights

  • •

    Despite favorable knowledge and attitudes, healthcare providers' practice remains low.

  • •

    Positive attitudes improve knowledge and highlight the need to engage providers in programs.

  • •

    Reducing stigma is key to strengthening global human immunodeficiency virus prevention.

  • •

    Training and long-acting pre-exposure prophylaxis can enhance adherence and prevention.

1. Introduction

The primary prevention of HIV infection remains a fundamental priority; with 36.9 million cases reported in 2019, accounting for 0.5 % of the world's population (Govender et al., 2021). By the end of 2023, an estimated 39.9 million people were living with HIV, with 65 % residing in the World Health Organization (WHO) African Region (WHO, 2024).

Despite remarkable advancements in understanding, treatment, and prevention, HIV/AIDS continues to impose a profound global burden on personal and public health. Beyond its direct impact on individual well-being, HIV/AIDS drives a series of cascading challenges, including diminished workforce productivity, escalating healthcare costs, and deepening poverty, which collectively reinforces disparities across communities (Payagala and Pozniak, 2024).

Eradicating AIDS by 2030 has been established as a global target. However, achieving this goal remains challenging due to the persistent transmission of HIV worldwide (WHO, 2024). In recent years, prevention research has explored novel biomedical strategies such as HIV vaccines, microbicidal gels, and non-occupational post-exposure prophylaxis, with varying levels of success (Ramjee et al., 2010). Among these, pre-exposure prophylaxis (PrEP) has emerged as the most promising approach. Since the U.S. Centers for Disease Control and Prevention (CDC) first issued PrEP guidelines in 2014, the World Health Organization (WHO) followed in 2015, and both were later updated in 2021 to include long-acting injectable Cabotegravir alongside oral regimens of Emtricitabine (FTC) and Tenofovir disoproxil fumarate (TDF), PrEP has now been shown to be highly effective and cost-efficient when used consistently (Service UPH, 2014; Control CfD, Prevention, Service UPH, 2018; WHO, 2015; Molina et al., 2017; United States, 2021).

Despite its proven effectiveness, the global uptake and implementation of PrEP remain suboptimal. One key determinant of this implementation gap is the role of healthcare providers (HCPs), who serve as the primary gatekeepers for PrEP prescription, counseling, and follow-up. Evidence suggests that HCPs' knowledge, attitudes, and practices significantly shape patients' access to and adherence with PrEP services. However, findings across studies have been inconsistent with some reporting high levels of provider readiness and others identifying substantial gaps in awareness, comfort, or willingness to prescribe. Moreover, uncertainty persists regarding the relative contribution of these factors to the broader PrEP implementation gap, including how concerns about resistance, safety, or risk compensation may influence provider engagement (Cáceres et al., 2015).

Given these inconsistencies, a systematic review and meta-analysis are necessary to synthesize global evidence on HCPs' knowledge, attitudes, practices, concerns, and perceived barriers toward PrEP. Such a synthesis will help quantify the magnitude of these factors, explore regional and contextual variations, and identify the specific provider-related determinants that most hinder PrEP delivery. This evidence is crucial for designing targeted educational and policy interventions that can enhance provider capacity and accelerate PrEP scale-up worldwide. By considering studies conducted across the evolution of PrEP guidelines, including the 2021 CDC and WHO updates, this review aims to provide actionable insights that can inform sustainable strategies for improving PrEP access and uptake in diverse healthcare settings.

2. Methods

2.1. Searching strategy and information sources

To identify all relevant literature published in the decade following the introduction of the CDC recommendations, a systematic search was executed on December 31, 2024, covering the period from May 1, 2014, to December 31, 2024. The search encompassed the major electronic databases PubMed, Web of Science, and the Cochrane Library, supplemented by a search of Google Scholar. For articles not available through open access, corresponding authors were contacted to obtain full texts; studies that could not be obtained were excluded.

The study protocol was registered with PROSPERO (Registration Number: CRD42025632990) to ensure transparency and adherence to standardized methodological practices. The entire review process followed the PRISMA 2020 guidelines for systematic reviews (Page et al., 2021) to ensure a comprehensive and unbiased synthesis of the evidence.

A detailed search strategy was developed using a combination of keywords and Medical Subject Headings (MeSH) terms to improve precision and relevance. Boolean operators (“AND” and “OR”) were applied to systematically combine search terms. The final search string was: (((((Knowledge) OR (Attitude)) OR (Practice)) AND (PrEP)) AND (Healthcare providers). In addition, a snowball search of the reference lists of all retrieved articles was conducted to identify additional relevant studies.

2.2. Study selection and eligibility criteria

Articles were independently screened by two investigators (TE and AB) through electronic databases, beginning with the assessment of titles and abstracts to identify studies for potential inclusion. This critical step helped narrow down relevant publications before full-text evaluation. Any disagreements between reviewers were resolved through detailed discussions to reach consensus on study inclusion or exclusion.

Study selection was guided by the PICoS framework (Participants, Phenomenon of Interest, Context, and Study Design). Studies were included if they empirically investigated any or all of the following: knowledge, attitudes, practices, concerns, or perceived barriers. Studies were excluded based on the following criteria: Studies that measured outcomes using Likert scales with more than two response categories (e.g., “very low,” “low,” “moderate,” and “high”) (Sammons et al., 2021; Martínez-Cajas et al., 2022) were excluded because the cut points in these studies differed from those in dichotomized studies, making it impossible to standardize or combine. Studies where outcomes were not explicitly defined or clearly stated, Studies with insufficient sample sizes (fewer than 10 participants per independent variable) (Plomer et al., 2020; Lane et al., 2019), Publications in languages other than English (Bepouka et al., 2019), Studies published in non-reputable or predatory journal (Zimamu et al., 2024), Low-quality studies, assessed as having a JBI score ≤ 3 (applicable to cross-sectional or survey studies (Institute JB and Institute J, 2017)), Studies including students or non-healthcare providers as participants, and Studies lacking sufficient data for analysis.

2.3. Operational definitions

Knowledge: The level of awareness and understanding that healthcare providers have regarding HIV PrEP, including indications, eligibility criteria, dosing regimens, effectiveness, safety, and guideline recommendations (Kozieł et al., 2025).

Attitudes: Providers' perceptions, beliefs, and feelings toward PrEP, such as comfort with prescribing it, perceived benefits and risks, willingness to discuss it with patients, and support for its use as an HIV prevention strategy (Kozieł et al., 2025).

Practices: The actions that providers take related to PrEP in clinical settings. This includes whether they have prescribed PrEP, counseled patients about PrEP, referred patients to specialists, assessed patients' HIV risk, or followed up on adherence (Kozieł et al., 2025).

Concerns: Specific apprehensions or worries that providers have regarding PrEP use, such as potential adverse effects, risk compensation (increased risky behavior), development of drug resistance, or interactions with other medications.

Perceived barriers: Factors that providers identify as hindering their ability to deliver PrEP services effectively. These may include system-level barriers (e.g., lack of training, time constraints, limited access to PrEP), patient-level barriers (e.g., stigma, low adherence), or policy-level barriers (e.g., restrictive guidelines, cost coverage).

2.4. Data extraction

To describe the included studies, the following data were extracted and documented in a standardized spreadsheet: study design and methodology, sample size, sampling methods, response rates or proportions, and study quality. Information on healthcare providers' knowledge, attitudes, and practices was quantitatively extracted and entered into the spreadsheet, while concerns and perceived barriers were qualitatively extracted and organized into thematic tables (Table S1). Two reviewers independently extracted all data, and discrepancies were resolved through discussion to ensure accuracy and consistency.

2.5. Methodological quality (Study Quality)

The methodological quality of the included studies was independently appraised by two investigators (TE and AB) using the Joanna Briggs Institute (JBI) Critical Appraisal Tools for observational studies (cross-sectional and cross-sectional survey designs) (Institute JB and Institute JB, 2017). Quality scores ranged from 4 to 8, with a mean score of 6.3, indicating generally good methodological quality. Inter-rater reliability between the reviewers was substantial (Cohen's κ = 0.672; P < 0.01). Of the 27 included studies, three (11.1 %) scored 4 out of 8 (50 %) on the quality scale, whereas the remaining 24 (88.9 %) achieved scores of ≥5 out of 8 (≥63.7 %). On average, the studies satisfied six of the eight quality criteria. Detailed quality assessments for each study are available upon request.

2.6. Statistical analysis

A random-effects meta-analysis was conducted using the Restricted Maximum Likelihood (REML) method to synthesize data from outcomes reported in two or more studies. Descriptive and narrative summaries were provided for all included findings. For outcomes with multiple estimates, pooled proportions were calculated with 95 % confidence intervals (CIs) and presented using forest plots. Heterogeneity across studies was evaluated using Cochrane's Q test, the I2 statistic, and corresponding p-values. Sensitivity analysis was performed to examine the influence of individual studies on the pooled estimates. Publication bias was assessed visually using funnel plots and statistically using Egger's and Begg's tests. All statistical analyses were performed using STATA version 17.0.

2.7. Ethical considerations

This study is a systematic review and meta-analysis of previously published studies. It did not involve the collection of primary data or direct contact with human participants; therefore, ethical approval and informed consent were not required.

3. Results

A total of 796 primary studies were identified through the initial electronic database search for possible inclusion. After an in-depth review, 27 articles met the inclusion criteria and were included in the systematic review and meta-analysis (Fig. 1). All are Cross-sectional studies. Among these, 14 were conducted in USA (Agovi et al., 2020; Edelman et al., 2017; Blaylock, 2018; Hakre et al., 2016; Terndrup et al., 2019; Bacon et al., 2017; Sell et al., 2023; Hart-Cooper et al., 2018; Petroll et al., 2017; Wood et al., 2018; Moore et al., 2020; Wilson et al., 2020; Tiruneh et al., 2024; Maude et al., 2017) and the rest 13 studies were conducted in 12 different countries (Cerqueira et al., 2020; Kambutse et al., 2018; Reyniers et al., 2018; Magagula et al., 2023; Mahlare et al., 2023; Wisutep et al., 2021; Baptista-Gonçalves et al., 2018; Mekonnen et al., 2024; Palummieri et al., 2017; Vega-Ramirez et al., 2022; Hu et al., 2024; Sinno et al., 2021).

Fig. 1.

Fig. 1

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PRISMA flow diagram illustrating the search strategy for studies published from 2014 to 2024.

3.1. Characteristics of the included studies

Among the included studies, physicians were the predominant participants. Sixteen studies assessed the proportion of healthcare provider's knowledge, ten assessed attitude, and sixteen evaluated practice. Most of the included studies involved multidisciplinary teams, comprising two or more of the following professionals: nurses, pharmacists, HIV testing counselors, healthcare promoters, public health officers, infectious and non-infectious disease physicians, internal medicine residents, and general medical practitioners (Table 1).

Table 1.

Summary of recent studies on healthcare providers' knowledge, attitudes, and practices regarding HIV pre-exposure prophylaxis (PrEP).

Authors with respective publication year Location Study design Provider type
Vega-Ramirez et al. (2022a) ac Brazil CS HIV Physician
Vega-Ramirez et al. (2022b) ac Mexico HIV Physician
Mahlare E et al.(2023) ad South Africa CS Nurses, HIV testing service counselors, and Health promoter
Mekonnen G et al.(2024)abd Ethiopia CS Physician, Public Health Officer, and Nurses
Kambutse I et al.(2018)b Rwanda CS Physicians, Resident Doctors, Medical Officers, Registered Nurses and voluntary counseling and testing (VCT) workers
Baptista-Gonçalves et al.(2018)bc Portugal CS Consenting Health Care Providers
Wisutep et al.(2021)abcd Thailand survey Infectious and non- infectious disease physicians, nurses, pharmacists, and others
A.M.-A. Agovi et al.(2020)ac USA survey Clinician/Physicians only
AE Petroll et al.(2017)bc USA CS Physicians, nurse practitioners, and physician assistants
Edelman EJ et al. (2017)c USA Survey Academic general internists
Blaylock, Jason M(2018)ac USA Survey Military health care providers including (ID physician)
Hakre S. et al.(2016)abd USA Survey Physicians, physician assistants, nurse practitioners) and infectious disease physicians
Terndrup et al.(2019)a USA Survey Internal medicine residents
T. Reyniers et al.(2018)b Belgium CS survey Primary care physician(‘family physician’, ‘family physician in training’ or a physician in a sexual health organization targeting key populations)
Magagula N. et al. (2023)b Eswatini CS Registered nurses working in TB-HIV and PMTCT clinic
NB Cerqueira et al.(2020)ac Brazil CS Infectious disease physicians
Bacon et al.(2017)c USA Survey Primary care providers
Sell J et al.(2023)ac USA CS survey All primary care providers, including faculty, advance practice providers, and residents, in Family, Community and Internal Medicine
GD Hart-Cooper et al.(2018)bc USA Survey Adult and adolescent health care provider
A Palummieri et al.(2017)a Italy CS Physicians in HIV centers
Wood BR et al. (2018)a USA Survey Registered Nurse, Doctor of (Medicine, Osteopathic Medicine), and Physician Assistant
Maude et al.(2017)ab USA Survey Registered Nurse, Doctor of (Medicine, Osteopathic Medicine), and Physician Assistant
YM Tiruneh et al.(2024)ac USA Survey Medical doctors, doctors of osteopathy, nurse practitioners, and physician assistants
Moore et al.(2020)c USA Survey physicians, nurse, physician assistants, pharmacists, Family Medicine, and ID physician
J Sinno et al.(2021)c Canada Survey Doctors, nurse practitioners as well as medical residents
J Hu et al.(2024)ac China CS HCPs from Infectious Dis ease Departments
K Wilson et al.(2020)d USA Survey Physicians, physician assistants, registered nurses
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NB: “CS”-Cross-sectional, “a”- indicates “Knowledge”, “b”- Attitude”, “c”- Practice”, “d”- Factors, “IM”-Internal Medicine, and “PrEP” pre-exposure prophylaxis.

Healthcare providers' key concerns regarding HIV pre-exposure prophylaxis.

Barriers to PrEP implementation include the high cost of the medication, especially in settings without government or NGO coverage. Both healthcare providers and users often have limited knowledge about PrEP. Providers face time constraints that hinder effective risk education, counseling, and discussions about PrEP. Additional challenges include inadequate staff and clinical capacity, as well as the need for follow-up visits to monitor PrEP usage (Petroll et al., 2017). For users, low knowledge about PrEP and difficulties with adherence further complicate its implementation (Mullins et al., 2019).

In addition, healthcare providers commonly express concerns about patient adherence, uncertainty in identifying suitable candidates for PrEP, potential risk compensation leading to increased risky sexual behavior, the risk of antiretroviral (ARV) drug resistance, and the possibility of severe adverse effects (Wood et al., 2018; Vega-Ramirez et al., 2022) (Table S1).

Assessment of publication bias and heterogeneity for healthcare providers' Knowledge.

Heterogeneity among the included studies was assessed using Cochrane's Q test and the I2 statistic. The random-effects model indicated high heterogeneity (I2 = 95.11 %, p < 0.001; Q(15) = 454.65, p < 0.001)(Fig. 2). Publication bias was initially evaluated using a funnel plot, which appeared asymmetrical, suggesting potential bias (Fig. S1). To more rigorously assess this, we conducted statistical tests, including Egger's and Begg's regression tests. However, Egger's (SE = 1.902, p = 0.3828) and Begg's tests (SE = 22.211, p = 0.7526) provided no strong statistical evidence of publication bias. A trim-and-fill analysis under the random-effects model added no imputed studies. Sensitivity analysis revealed that pooled estimates of healthcare providers' knowledge regarding PrEP were significantly influenced by studies from Vega-Ramirez et al. (2022a) and J Hu et al.(2024)(Fig. S2).

Fig. 2.

Fig. 2

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Forest plot for the pooled proportion of healthcare providers with knowledge of Human Immunodeficiency Virus pre-exposure prophylaxis from global studies (2014–2024).

3.2. Pooled proportion of health care providers' Knowledge

This systematic review and meta-analysis found that the pooled proportion of healthcare providers' knowledge regarding human immunodeficiency virus pre-exposure prophylaxis globally was 65 % (95 % CI, 60–70 %, p = 0.00, Fig. 1).

3.3. Assessment of publication bias and heterogeneity for healthcare providers' attitudes

Heterogeneity among studies was evaluated using Cochrane's Q test and the I2 statistic, with the random-effects model indicating substantial heterogeneity (I2 = 96.3 %, Q(9) = 257.41, p < 0.001; Fig. 3). Visual inspection of the funnel plot suggested potential publication bias due to asymmetry; however, Egger's regression test showed no significant statistical evidence of publication bias (SE = 3.226, p = 0.1884). Consistently, a trim-and-fill analysis under the random-effects model did not impute any additional studies. Sensitivity analysis revealed that the pooled estimates of healthcare providers' attitudes toward pre-exposure prophylaxis (PrEP) were largely influenced by the studies of Mekonnen G et al. (2024) and GD Hart-Cooper et al. (2018).

Fig. 3.

Fig. 3

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Forest plot for the pooled proportion of healthcare providers with a positive attitude toward Human Immunodeficiency Virus pre-exposure prophylaxis from global studies (2014–2024).

3.4. Pooled proportion of health care providers' attitudes

This systematic review and meta-analysis estimated that the global pooled proportion of healthcare providers' attitudes toward human immunodeficiency virus pre-exposure prophylaxis was 78 % (95 % CI,71 %–85 %, p < 0.001), based on individual study estimates and the overall pooled estimate (Fig. 3).

3.5. Assessment of publication bias and heterogeneity for healthcare providers' practice

Heterogeneity among the included studies was assessed using Cochrane's Q test and the I2 statistic, with the random-effects model revealing high heterogeneity (I2 = 90.83 %, p < 0.001; Q(15) = 207.93, p < 0.001)(Fig. 4). Publication bias was evaluated using a funnel plot, which displayed an asymmetrical distribution, with most studies clustering on the left side. Some studies fell outside the gray (pseudo 95 % CI) lines, potentially representing outliers or a higher likelihood of publication bias (Fig. S3). Recognizing the limitations of visual inspection, we performed more robust statistical tests, including Egger's and Begg's regression. Egger's test (SE = 1.622, p = 0.9805) indicated weak evidence of publication bias, while Begg's test (p = 1.0000) suggested no evidence of bias.

Fig. 4.

Fig. 4

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Forest plot of the pooled proportions of healthcare providers' practices regarding human immunodeficiency virus pre-exposure prophylaxis across global studies from global studies (2014–2024).

To further explore potential bias, we conducted a trim-and-fill analysis using a random-effects model, which added no imputed studies. Additionally, a leave-one-out sensitivity analysis examined the impact of individual studies on the pooled estimate of healthcare providers' level of practice to HIV PrEP. This analysis revealed that findings were not significantly influenced by individual studies (Fig. S4).

3.6. Pooled proportion of healthcare providers' practice

This systematic review and meta-analysis estimated that the global pooled proportion of healthcare providers' practices regarding human immunodeficiency virus (HIV) pre-exposure prophylaxis was 37 % (95 % CI, 32 %–41 %, p < 0.001), based on individual study estimates and the overall pooled estimate(Fig. 4).

3.7. Effect of a positive attitude on healthcare providers' knowledge regarding pre-exposure prophylaxis

In this meta-analysis, a significant association was observed between healthcare providers' attitudes and their knowledge regarding pre-exposure prophylaxis (PrEP), with those holding a positive attitude being more than twice as likely to have good knowledge (odds ratio (OR = 2.28, 95 % CI, 1.52–3.04; Fig. 5).

Fig. 5.

Fig. 5

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Factors associated with knowledge of Human Immunodeficiency Virus pre-exposure prophylaxis among healthcare providers globally, 2014–2024.

4. Discussion

According to UNAIDS and WHO report, an estimated 1 to 1.7 million people averaging 1.3 million were newly infected with HIV in 2023. While this reflects a 39 % decrease since 2010 (UNIDS, 2024), some scholars emphasize that incidence rates are rising alarmingly in specific regions, driven by factors such as ongoing civil conflicts. Among newly infected individuals, the majority are within the 15–49 age group, representing the most economically and socially productive segment of the population. This highlights the urgent need for innovative and effective prevention strategies. To address this ongoing challenge, the CDC and WHO introduced guidelines for a drug-focused preventive strategy called pre-exposure prophylaxis (PrEP) in 2014 and 2015, respectively aiming to reduce the incidence of infections. However, the success of this strategy heavily relies on healthcare providers' knowledge, attitudes, practices, and perceived concerns regarding PrEP. A systematic review conducted in 2017 by Zablotska et al. reported that only about 5 % of the target population had accessed PrEP, highlighting the need for greater efforts to improve implementation and uptake (Zablotska and O'Connor, 2017).

This systematic review and meta-analysis aim to estimate the pooled knowledge, attitude, practice, and perceived concerns of HCP's regarding to HIV PrEP after the introduction of CDC and WHO guideline globally. By providing comprehensive aggregated estimate, this analysis addresses the limitations of smaller, isolated studies. By synthesizing global evidence, it offers a vital understanding of the overall healthcare providers' knowledge, attitudes, level of practice, and perceived concern regarding to the implementation of HIV PrEP, highlights existing gaps, and identifies key contributing factors to guide improvement efforts worldwide.

Overall, the findings revealed that the pooled levels of knowledge, attitude, and practice among healthcare providers (HCPs) were 65 % (95 % CI,60 %–70 %), 78 % (95 % CI,71 %–85 %), and 37 % (95 % CI,32 %–41 %), respectively. The level of pooled HCPs' knowledge in this meta-analysis is unsatisfactory, with only 65 % of respondents demonstrating sufficient knowledge to explain or elaborate on HIV PrEP, including the recommended drug, risk categories, benefits and risks, and guidelines for initiation and discontinuation. Many studies indicated that targeted education/training is needed to improve HCPs' knowledge of PrEP (Zablotska and O'Connor, 2017). This is supported by a systematic review conducted by FM Koechlin et al.(2017) (Koechlin et al., 2017).

The pooled level of HCPs attitudes toward PrEP in this meta-analysis is 78 %, indicating strong initial acceptance but with room for improvement. This finding reflects a generally favorable attitude toward PrEP among HCPs, with a majority demonstrating confidence in its use and effectiveness. Such positive attitudes are crucial for advancing HIV prevention efforts, as they directly influence providers' willingness to recommend and prescribe PrEP (Pleuhs et al., 2020). However, the remaining 22 % of providers with less favorable attitudes represent a critical target group for interventions aimed at increasing awareness, addressing misconceptions, and mitigating perceived concerns about PrEP.

The pooled level of HCPs practice regarding [specific topic, e.g., HIV pre-exposure prophylaxis (PrEP)] in this meta-analysis is 37 %, indicating suboptimal implementation despite a generally favorable attitude (78 %). This finding underscores a significant gap between positive attitudes and actual practices among HCPs. The low practice level suggests that favorable knowledge/attitudes alone may not be sufficient to translate into actionable behaviors. This might be related to, limited access to resources, insufficient training, lack of awareness of guidelines, or institutional support may hinder the practical application of knowledge (Zablotska and O'Connor, 2017; Pleuhs et al., 2020).

In this meta-analysis, a significant association was observed between attitude and knowledge toward PrEP, whereby healthcare professionals with a positive attitude were more likely to have good knowledge [OR = 2.28, (95 % CI,1.52–3.04)]. However, this finding should be interpreted with caution, as the analysis reflects an association rather than a causal relationship. It is equally plausible that improved knowledge fosters a positive attitude, or vice versa, highlighting the interdependent nature of these constructs.

The presence of moderate to high heterogeneity in this meta-analysis could be attributed to several factors. First, variations in the study population may contribute significantly. This includes differences in demographic characteristics such as age and professions of participants (Tong and Guo, 2022). Second, statistical factors, such as differences in sample sizes among the included studies, can lead to variability in effect sizes. Notably, most primary studies included in this meta-analysis were online surveys, which often lacked proper sample size calculation; this limitation may have contributed to the overall heterogeneity (Stanley et al., 2022). Furthermore, despite our strict efforts to exclude studies conducted before the release of the CDC and WHO guidelines on HIV pre-exposure prophylaxis (PrEP), variations in study periods may still contribute to heterogeneity. Studies conducted at different times often reflect changes in advancements in technologies, or shifts in standard-of-care practices, all of which can influence outcomes and increase variability (Deeks et al., 2019). Heterogeneity may result from studies carried out in various locations reflecting distinct socioeconomic circumstances, medical procedures, and resource accessibility. Cultural beliefs and practices regarding healthcare interventions can vary widely, affecting both the uptake and outcomes of treatments (Holzmeister et al., 2024).

Most current studies assess healthcare providers' (HCPs) concerns and barriers qualitatively, without offering objective magnitudes. This represents a critical research gap, as quantifying these barriers could provide clearer guidance for targeted interventions. HCPs play a pivotal role in the successful implementation of HIV pre-exposure prophylaxis (PrEP), with their knowledge, attitudes, practice, and concerns being key determinants of the program's success. (Muwonge et al., 2022). However, barriers such as concerns about risk compensation behaviors, concerns about drug toxicity, resistance, the acceptance of PrEP among both HCPs and patients, where patients may abandon safe sex practices assuming PrEP provides full STI protection, and fears of increased STI rates due to reduced condom use hinder providers' practice to initiate PrEP. HIV-related stigma deters some clients from using PrEP, with nearly half of participants in a Thailand study preferring to conceal their pill use (Chautrakarn et al., 2022). To address this stigma and improve adherence a key concern for healthcare providers distinct packaging labeled for HIV prevention could be effective. Long-acting injectable formulations may also provide a dual solution to these challenges. The other significant barrier to effective PrEP implementation is the lack of adequate training for HCPs. Future research should focus on addressing these challenges and investigating additional factors that influence HCPs' knowledge, attitudes, and practices regarding HIV PrEP.

This review synthesizes findings from a large number of primary studies, strengthening the reliability and generalizability of the pooled prevalence estimates. The use of a comprehensive search strategy, rigorous inclusion criteria, and robust meta-analytic methods further enhances the credibility of the findings.

However, the review is not without limitations. Potential publication bias, language restrictions, and reliance on self-reported or online survey data may have affected the precision of the pooled estimates. Despite these limitations, the study provides valuable pooled evidence on healthcare providers' knowledge, attitudes, and practices regarding HIV pre-exposure prophylaxis (PrEP).

5. Conclusions

This meta-analysis indicates that healthcare providers generally hold favorable attitudes toward HIV pre-exposure prophylaxis (PrEP). However, despite this positivity, actual engagement in PrEP practice remains considerably lower, revealing a gap between intention and implementation. The strong association observed between knowledge and attitude underscores the importance of enhancing healthcare providers' understanding and addressing systemic barriers to improve the delivery and uptake of PrEP services.

To bridge this gap, targeted interventions should prioritize improving access to resources, training, and institutional support. Efforts must also focus on reducing misconceptions, stigma, and concerns surrounding PrEP use while promoting awareness of updated clinical guidelines. Future research should quantify the specific barriers healthcare providers face and explore innovative approaches such as distinct packaging or long-acting injectable formulations to enhance acceptance and adherence. These measures are essential to strengthening PrEP implementation and advancing global HIV prevention efforts.

CRediT authorship contribution statement

Tesfaye Engdaw Habtie: Writing – review & editing, Writing – original draft, Software, Methodology, Formal analysis, Data curation, Conceptualization. Tegene Atamenta Kitaw: Writing – review & editing, Writing – original draft, Validation, Methodology, Formal analysis, Data curation. Amsalu Baylie Taye: Writing – review & editing, Writing – original draft, Supervision, Methodology, Formal analysis, Data curation. Molalign Aligaz Adisu: Writing – review & editing, Writing – original draft, Software, Methodology, Formal analysis, Data curation.

Funding

The authors received no specific funding for this work.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Footnotes

Appendix A

Supplementary data to this article can be found online at https://doi.org/10.1016/j.pmedr.2025.103304.

Appendix A. Supplementary data

Supplementary material 1: Funnel plot assessing publication bias in studies evaluating healthcare providers’ knowledge regarding HIV pre-exposure prophylaxis globally, 2014–2024.

mmc1.docx (107KB, docx)

Supplementary material 2: Leave-one-out sensitivity analysis showing the effect of individual studies on pooled healthcare providers’ knowledge regarding HIV pre-exposure prophylaxis globally, 2014–2024.

mmc2.docx (179KB, docx)

Supplementary material 3: Funnel plot assessing publication bias in studies evaluating healthcare providers’ practice regarding HIV pre-exposure prophylaxis globally, 2014–2024.

mmc3.docx (107.2KB, docx)

Supplementary material 4: Leave-one-out sensitivity analysis showing the effect of individual studies on pooled healthcare providers’ practice regarding HIV pre-exposure prophylaxis globally, 2014–2024.

mmc4.docx (183.6KB, docx)

Supplementary material 5: Categorization of barriers, concerns, and facilitators to providing HIV pre-exposure prophylaxis, as reported by healthcare providers in global studies 2014–2024.

mmc5.docx (41KB, docx)

Data availability

All relevant data are included in the manuscript and its supporting files

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary material 1: Funnel plot assessing publication bias in studies evaluating healthcare providers’ knowledge regarding HIV pre-exposure prophylaxis globally, 2014–2024.

mmc1.docx (107KB, docx)

Supplementary material 2: Leave-one-out sensitivity analysis showing the effect of individual studies on pooled healthcare providers’ knowledge regarding HIV pre-exposure prophylaxis globally, 2014–2024.

mmc2.docx (179KB, docx)

Supplementary material 3: Funnel plot assessing publication bias in studies evaluating healthcare providers’ practice regarding HIV pre-exposure prophylaxis globally, 2014–2024.

mmc3.docx (107.2KB, docx)

Supplementary material 4: Leave-one-out sensitivity analysis showing the effect of individual studies on pooled healthcare providers’ practice regarding HIV pre-exposure prophylaxis globally, 2014–2024.

mmc4.docx (183.6KB, docx)

Supplementary material 5: Categorization of barriers, concerns, and facilitators to providing HIV pre-exposure prophylaxis, as reported by healthcare providers in global studies 2014–2024.

mmc5.docx (41KB, docx)

Data Availability Statement

All relevant data are included in the manuscript and its supporting files

Articles from Preventive Medicine Reports are provided here courtesy of Elsevier

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