Access to healthcare services, including HIV prevention by all individuals, is the key to winning the battle against Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Virus (AIDS). Primary healthcare (PHC) is the first level of healthcare at which most patients access the health system. It is committed to increasing access to quality care and improving healthcare delivery, and providing clear guidance to support equitable access to essential healthcare services by focusing on access, equity, efficiency, quality and sustainability [1]. In South Africa, the PHC approach was adopted at Alma Ata in 1978; it is a nurse-based healthcare system. The PHC Re-engineering Program strengthens nurses' role in the healthcare system as they contribute to family health. Research emphasizes that the role of the nurses at the PHC level is paramount in this regard [2].

In the fiscal year 2017/18, an acceleration plan was initiated to improve health outcomes and achieve the 90-90-90 targets aimed at ending the global AIDS epidemic. These targets involve identifying 90% of people living with HIV through expanded testing, placing 90% of those identified as HIV positive on antiretroviral therapy (ART) and ensuring that 90% of those on therapy achieve undetectable viral loads [3]. The outcomes saw over 4.1 million people living with HIV retained on treatment and over 13 million people tested for HIV [4]. The National Department of Health (NDoH) and the National Treasury launched the Ideal Clinic (IC) initiative in 2013 to systematically reduce deficiencies in PHC clinics in the public sector. At the end of 2018, 1 507 facilities qualified as ICs [4]. However, a study conducted by Treatment Action Campaign (TAC) in Gauteng indicates that ensuring access to quality healthcare services and treatment for everyone living with HIV and TB depends on the availability of enough qualified and committed workforce [5]. It was stated that human resource shortages cause long waiting times, patients being turned away from clinics, a higher risk of death, and increased pressure on the few available staff. This study reports that 25% of health facility staff was generally friendly; 70.8% of the staff was recorded as sometimes friendly, and 4.2% of the staff was considered not friendly. These attitudes, classified as “Bad staff attitudes,” were reportedly witnessed in all cadres in the healthcare system and attributed to factors that affect patients' ability to access healthcare [6]. These attitudes were focused on the general population living with HIV without considering other vulnerabilities, such as being gender or sexually diverse. Studies indicated that healthcare providers have negative attitudes toward the lesbian, gay, bisexual, transgender, intersex, queer, and plus (LGBTIQ+) community which is considered to be one of the vulnerable populations to HIV regardless of their HIV status [7]. Moreover, LGBTIQ+ people experience stigma and discrimination in most communities. The negative attitude towards LGBTIQ+ individuals is not only portrayed in the community but also extends to public institutions [7]. One such institution is healthcare. The negative attitudes affect their access to services, including healthcare. There is evidence that LGBTIQ+ individuals are sometimes mistreated, harassed, discriminated against or even denied access to healthcare services [8]. Very few healthcare providers are properly trained about transgender health issues [5]. This leads to limited healthcare access and negative healthcare encounters for transgender people. A study presented evidence of a chain of homophobia linked to poor health outcomes for men who have sex with men (MSM); they face more challenges associated with marginalization and oppression across the health sector [6].

However, several studies report on the general challenges of LGBTIQ+ individuals in accessing health care services without specifically focusing on HIV services. Access to HIV services by LGBTIQ+ individuals is the key to the Agenda for Zero Discrimination in Health-Care settings to affirm governments' commitment to redress inequalities in health practices that undermine key populations, such as LGBTIQ+ people living with HIV [9]. As professional nurses are the key drivers of HIV healthcare services in government/public settings, there is a need to understand their readiness to render such services to LGBTIQ+ individuals who can be considered dually marginalized because of HIV status and being gender or sexually non-binary. Against this background, this paper presents the preparedness of professional nurses to render HIV healthcare services to LGBTIQ+ people at public PHC clinics in Gauteng province, South Africa.

This study's results indicate that professional nurses find it challenging to know whether a patient is an LGBTIQ+ person or cisgender heterosexual [21]. They feel uncomfortable asking about LGBTIQ+ people's sexual identities and sexual health in general or specific cases during consultations. Some nurses do not know how to ask about LGBTIQ+ individuals' self-identifications or how they prefer to be referred to. They, therefore, avoid serving LGBTIQ+ people, limiting engagement with them. Findings suggest that nurses avoid LGBTIQ+ people’s sexual discussions when addressing HIV prevention issues because they are not knowledgeable about their sexuality or their coital preferences. Some older female nurses report that they find it hard to probe deeper when collecting medical histories of younger LGBTIQ+ patients, as they are not used to talking to younger people about sex and sexuality issues. Other results show that nurses need training to help them learn how to reduce biases and enhance sensitivity in their interviewing skills [22]. Findings, however, indicate that younger professional nurses alluded to their awareness of the conflict experienced between cultural and personal beliefs and professional healthcare practices. In their view, the latter should supersede interactions with LGBTIQ+ people in the clinic setting.

The findings indicate that professional nurses assume that all people are heterosexual and not diverse in their sexuality or gender [23, 24]. they thus continue to use heteronormative approaches to healthcare provision for all patients. The study findings emphasized that healthcare should be based on scientifically informed practices that challenge old practices through evidence-based methods. It is essential to ensure that HIV healthcare practices are inclusive, innovative, dynamic and delivered through multi-disciplinary approaches. Healthcare providers' training on gender diversity as a turn-around strategy can improve the quality of services to LGBTIQ+ people [25]. The lack of LGBTIQ+ people’s information amongst nurses increases the disparities in LGBTIQ+ patients’ healthcare, given that LGBTIQ+ people have worse healthcare outcomes than the larger population [26, 27].

Research shows that LGBTIQ+ people are disproportionately affected by HIV, but most nurses consider sexual orientation and gender identity not relevant to individuals' clinical healthcare needs, Evidence in earlier studies aligns with this study's findings [28, 29]. Professional nurses believe that they supply LGBTIQ+ patients with sufficient treatment and preventive materials. They are, however, unaware that some of these services do not address some of the LGBTIQ+ patients' unique HIV healthcare and prevention needs and that readily offered male condoms are not suitable for all people within the LGBTIQ+ spectrum. Latex male condoms are regularly available at most public clinics. However, some clinics reported that they do not get supplies of femidoms. Nurses are confident in promoting the consistent and correct use of male and /female condoms as effective methods for reducing the risks of HIV infection and contracting STIs, as well as preventing unwanted pregnancies. Health promoters and nurses regularly organize health talks and demonstrations at clinics to educate the general population about the safe use of condoms. Safe sex education targeting LGBTIQ+ people is generalized, emphasizing the proper use of condoms as the best available protection method against HIV and STIs. Current HIV prevention promotion efforts aimed at LGBTIQ+ people are more focused on MSMs' needs than those of others in the LGBTIQ+ spectrum [30].

This study results also revealed that most nurses working in public PHC clinics have never seen dental dams; they do not know how they look or how they are effectively used as barriers between mouths and genitals to prevent STIs and HIV transmission [31]. Dental dams are not provided as part of free preventive commodities like male condoms and female condoms in the public healthcare sector. Therefore, nurses find that they cannot adequately advise women who have sex with women (WSW) to adhere to self-protection using dental dams during the sexual engagement, including oral sex. The concept of making dental dams from condoms or latex gloves, which are effective ‘do it yourself’ (DIY) alternatives, remains foreign to most nurses rendering HIV healthcare services to LGBTIQ+ people at public clinics. Research indicates that sex education and practical demonstration of the safe use of preventive materials promote talks between partners and change perceptions and norms about protection and prevention [32].

This study shows that pre-exposure prophylaxis (PrEP) uptake is incredibly low amongst LGBTIQ+ people at the PHC level. Most professional nurses are not confident with the application of PrEP as an effective biomedical HIV prevention strategy for MSMs. Lack of intensive training in this area disadvantages a substantial number of the LGBTIQ+ population whose risks of re-infections could be effectively reduced. However, results of a multivariable analysis in another study indicated an increase in PrEP initiation amongst gay men in recent years and promoted it as a harm reduction strategy [33].

Relatedly, nurses reflect limited knowledge of post-exposure prophylaxis (PEP) administration amongst LGBTIQ+ people. They are familiar with protocols to administer PEP in cases of possible exposure to HIV in female rape cases. However, most of them are not aware of its beneficial usage amongst MSMs and WSW who engage with partners of unknown HIV status or partners who are HIV positive but not virally suppressed, and LGBTIQ+ victims of sexual assaults. These findings were corroborated by a study that found the levels of PEP knowledge and practices among nurses to be exceptionally low [34].

Professional nurses need training on the concept of undetectable equals untransmittable (U=U). It is one of the areas that this research identified as presenting a vast knowledge gap among nurses. Their lack of information regarding the scientific discovery that there are people who live with HIV but have an undetectable viral load in the blood and that they can maintain this status by strict adherence to antiretroviral therapy (ART). It is crucial that nurses should be equipped with such updated knowledge to be able to raise awareness and robustly promote testing, early diagnosis and early initiation of treatment. They will also be able to advocate for treatment adherence and the availability of appropriate preventive materials for the general population and all LGBTIQ+ people to maintain the inactive transmission of the virus to others. Clinical evidence has established that U=U relies on a prompt treatment start to suppress the virus and eventually eliminate its transmission [35].

The results are congruent with WHO’s declaration that Universal Health Coverage (UHC) success is dependent on the implementation of human rights-based approaches and investments in gender equality and equity [36]. These imply that it is impossible to achieve the envisaged UHC if fundamental requirements of availability, accessibility, acceptability, and quality under the right to healthcare are not in place.

The findings reveal that professional nurses find it challenging to deliver culturally competent HIV healthcare without adequate gender diversity knowledge and the necessary sensitivity required to meet LGBTIQ+ people’s specific healthcare needs. They cannot deny that LGBTIQ+ people feel prejudiced and stigmatized in the PHC environment. There is a continued need for the creation and promotion of clinics as safe community spaces for vital response to HIV healthcare, for awareness raising and dissemination of information about HIV, for reduction of stigma, and for empowering LBTIQ+ individuals to fearlessly express their identity and sexuality. The environment should promote care and be conducive to the protection of privacy and confidentiality, affirming LGBTIQ+ people’s gender identities and sexual orientations. Some nurses are oblivious to the effects of their behavior in the health facility environment that it can influence or threaten a sense of security, connection and belonging among LGBTIQ+ people. Similar research supports that such spaces are key settings for LGBTIQ+ healthcare promotions that are critical in response to HIV [37].

Reports reflect that nurses are aware of patients’ hesitations to seek help from clinics, fearing the double stigma of identifying as LGBTIQ+ and living with HIV, judgments, blame and secondary victimization. Results in this study also support previous findings pointing out that nurses are ill-informed about the impact of their attitudes on their healthcare delivery to LGBTIQ+ people [23]. A study concurs that healthcare providers are inclined to gender and sexuality biases founded on cultural stereotypes that have been embedded in their belief systems since they were young [38]. Their personal beliefs, socialization, learned behaviors and assimilated stereotypes about LGBTIQ+ people get transferred to their work world. They undermine the potential of their perceptions and behavior to influence the responses of patients toward treatment.

The results highlighted that in cases where nurses are interested in LGBTIQ+ issues and have some level of awareness concerning their mental health vulnerabilities, they made time to render counseling to LGBTIQ+ patients who need psycho-social support. Minority stress, often caused by discrimination, stigma, prejudice amongst other factors, depression, and suicidality were identified as predominant mental health issues in most cases, which were congruent to other studies [39, 40]. Isolation stress and anxiety have noticeably increased due to COVID-19 restrictions, as also reported in related research [41]. Other nurses do not feel competent to deal with LGBTIQ+ mental health issues and thus refer them to social workers employed by non-government organizations (NGOs) closely collaborating with the clinics. The PHC clinics only offer mental health screening services.

The study found that nurses reported incidents of emergency healthcare interventions due to excessive alcohol intake; these included self-inflicted injuries and injuries caused by violent attacks by strangers and intimate partners. The findings emphasize that substance abuse-related health promotion initiatives and campaigns are designed to reach the broader population and do not target LGBTIQ+ people’s specific substance dependency and abuse issues. Therefore, healthcare services pay less essential attention to the high rates of drug and alcohol abuse among LGBTIQ+ people, although it is well established that they are at a greater risk for substance abuse affecting their mental health compared to heterosexual people. Other research shows that the majority of LGBTIQ+ people, including those living with HIV, use alcohol and drug dependency as a coping mechanism [42].

Evidence indicates that some nurses take the initiatives to learn about LGBTIQ+ health issues independently [43]. They use a mix of contemporary and conventional methods to raise their awareness and address their knowledge gaps. Results show that television, radio, the internet, and social media sites are a mixture of informal learning platforms that professional nurses depend on to derive information about gender diversity issues; they also use word-of-mouth strategies. Some professional nurses turn to their LGBTIQ+ friends and acquaintances outside the healthcare sector to gain new information. There is further indication that some nurses also improve their awareness by engaging more meaningfully with LGBTIQ+ patients, willing to share information with them and answer direct questions openly. Inclusive healthcare delivery strategies ensure that services are appropriate to LGBTIQ+ people and that they feel secure and, therefore, willing to disclose their health concerns to attending healthcare providers [44].

Findings also reveal that there are professional nurses who sometimes ask LGBTIQ+ people questions to satisfy their curiosity [45]. Moreover, an LGBTIQ+ professional nurse disclosed that she seldom gets any questions from her colleagues, so she also does not often offer LGBTIQ+ people-related information unless specifically asked. However, she feels uninhibited about sharing information with LGBTIQ+ people; she shares HIV healthcare and prevention-related information and social support advice, drawing from her familiarity with their general life contexts.

Findings indicate that institutionalized heteronormativity and lack of nurse training on LGBTIQ+ health issues at the PHC level subject LGBTIQ+ people to structural barriers, such as gender access inequalities, prevention commodity inequities, systemic gender binaries, LGBTIQ+ invisibility in promotion materials and messaging, and gender insensitive language. Even though the South African constitution and Human Rights protect LGBTIQ+ people, translation on the ground is vital. Nurses must be equipped with relevant knowledge to uphold the rights of LGBTIQ+ people in healthcare service delivery. Like all other healthcare professionals working in South Africa, nurses are bound by professional codes of conduct prohibiting discrimination based on the provisions of the constitution [46]. Health equity strategies should aim to provide services in the right, fair and just manner. It is essential that PHC-based HIV healthcare services are connected, coherent and consistent. Nurses’ respect for LGBTIQ+ patients' rights and sensitive delivery of healthcare interventions without judgment and negative attitudes are imperative to ensure effective program implementation at the clinic level [47].

This study provides a unique opportunity to understand professional nurses’ experiences from their own perspectives. It comprised a diverse sample recruited from a range of locations and used in-depth interviews, which enhanced the richness and generalizability of the results.

The lack of skills training and knowledge of nurses concerning LGBTIQ+ people’s HIV healthcare needs and inadequate provision of preventive commodities at PHC clinics have detrimental effects on this community. It also worsens the health outcomes of LGBTIQ+ individuals and leads to unnecessary complications of opportunistic infections. Nurses’ training and skills equipment in LGBTIQ+ people’s HIV healthcare provision, appropriate preventive measures and effective use of commodities are imperative. An integrated person-centered healthcare strategy and practice focusing on LGBTIQ+ people’s HIV healthcare provision at the PHC level is critical. The LGBTIQ+ population in South Africa needs enhanced awareness raising and information about HIV healthcare issues and prevention. Future research will include a larger representation of LGBTIQ+ healthcare providers in the sample.