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  Athenkosi Sobada, John Meyer, Elroy Cameron, Glenhael Carolus (Author)

  Beyond the Checklist: A Scaffolded, Experiential Learning Framework for Medical Rescue Simulation (Part 1 of 2)

  The effective training of Technical Rescue Specialists (TRS) for high-stakes dynamic environments requires a sophisticated pedagogical approach. This article introduces a comprehensive framework for Simulation-based Education (SBE) designed to elevate Medical Rescue Simulation (MRS). The framework is built upon four interconnected pillars: Foundational Learning Theory, Systematic Skill Scaffolding, Integrated Physical Preparedness, and Stringent Safety Protocols. This article will concentrate specifically on Kolb's learning cycles and the principles of scaffolding. Grounded in Kolb's Experiential Learning Cycle, the framework ensures that learning moves beyond rote memorisation to foster deep understanding and adaptive expertise. The core pedagogical strategy involves scaffolding complex medical rescue procedures, by deconstructing them into isolated, manageable skills. Students’ progress through scenarios of increasing fidelity and complexity, from low-fidelity drills and Visually Enhanced Mental Rescue Simulations (VEMRS) to immersive, high-fidelity exercises, that mirror real-world pressures. This structured progression manages cognitive load, and is designed to cultivate the "emergence" of proficient practice by ensuring foundational competencies are robustly established, thereby preventing the "absence" of critical skills in high-stakes situations.
  
  

  Introduction

  The effective training of Technical Rescue Specialists (TRS) within higher education institutions, particularly in the demanding and high-stakes context of medical rescue operations, requires a pedagogically sound and integrated approach. These environments are characterised by dynamic, unpredictable scenarios that demand not only technical proficiency but also rapid decision-making, physical endurance, and cohesive teamwork [1]. In response to these challenges, Simulation-based Education (SBE) has emerged as a cornerstone methodology, offering a controlled yet realistic platform for the development of critical competencies, reflective practice, and performance assessment [2]. Central to the success of SBE in medical rescue training is a framework built upon four interconnected pedagogical pillars: Foundational Learning Theory, Systematic Skill Scaffolding, Integrated Physical Preparedness, and Stringent Safety Protocols.

  These pillars collectively support the development of resilient, competent TRS capable of navigating the complexities of real-world emergencies. However, this article focuses specifically on the first two pillars, foundational learning theory and systematic skill scaffolding, as the primary mechanisms for effective learning within Medical Rescue Simulation (MRS). While the importance of physical conditioning and safety protocols is acknowledged, their detailed exploration falls outside the scope of this article.

  The theoretical foundation of this framework draws on Kolb’s Experiential Learning Cycle (ELC), which conceptualises learning as a cyclical process involving concrete experience, reflective observation, abstract conceptualisation, and active experimentation [3,4]. This model ensures that learners engage deeply with simulation scenarios, moving beyond passive participation to develop adaptive expertise through structured reflection and iterative practice. Complementing this, is the principle of scaffolding, informed by Vygotsky’s Zone of Proximal Development (ZPD), which provides a systematic approach to managing cognitive load. By deconstructing complex procedures into isolated skills and gradually increasing scenario fidelity and complexity, scaffolding enables learners to acquire competence incrementally, and with appropriate support [12,15].

  This article aims to articulate a theoretically grounded and practically applicable framework for SBE in MRS. By focusing on the foundational mechanisms that underpin effective learning, it offers educators and programme developers a structured guide to optimise simulation design and delivery. Ultimately, this approach seeks to foster the emergence of competent practice while mitigating the risk of absence in critical skills, ensuring that TRS are not only prepared to perform effectively but also to adapt and thrive in the unpredictable realities of emergency medical operations.

  Guiding Educational Philosophies for Medical Rescue Simulation (MRS)

  The effective training of TRS, particularly within the demanding context of South Africa, necessitates a robust pedagogical foundation. Medical rescue operations are characterised by high stakes, dynamic environments, and the critical need for skilled individuals to work within teams [1]. Simulation-based training has emerged as a cornerstone for developing the requisite competencies, offering a safe and controlled environment for practice and assessment [2].

  Central to effective MRS is the principle of experiential learning, best exemplified by David Kolb's ELC [3]. This model posits that learning is a cyclical process involving four distinct stages: Concrete Experience (CE), Reflective Observation (RO), Abstract Conceptualisation (AC), and Active Experimentation (AE). This cycle provides a comprehensive framework for designing MRS sequences, that move beyond rote memorisation to foster deep understanding, critical reflection, and adaptive expertise [4].

  The integration of Kolb's ELC into a structured MRS curriculum is illustrated below (Figure 2).

  ●     AC - Theory Lectures: The learning journey commences with the introduction of foundational knowledge. During theory lectures, students are exposed to the core concepts, principles, operational protocols, and theoretical underpinnings essential for medical rescue operations. This stage is vital as it establishes the cognitive architecture upon which practical skills and experiential understanding will be built. Without this initial framework, subsequent hands-on activities may lack the necessary context and depth, hindering the development of true comprehension. This aligns with the broader imperative for evidence-based practice in medical rescue, where actions are informed by established knowledge [5].

  ●     CE & AC - Equipment Orientation: This phase serves as a crucial bridge between theoretical knowledge and its tangible application. Students engage in an initial Concrete Experience by physically handling and familiarising themselves with medical rescue equipment. Simultaneously, this interaction reinforces Abstract Conceptualisation, by allowing students to connect the theoretical functions and principles of the equipment (learned in lectures) to its actual features, operation, and limitations. This transitional stage is significant because it embodies the understanding that knowledge must not only be intellectually grasped but also practically engaged with to become meaningful [6].

  ●     CE & RO - Isolated Skills Practice and Sign-off: This stage places a strong emphasis on Concrete Experience through the active practice of specific, discrete medical rescue skills. Students repeatedly perform these skills in a controlled setting. The "sign-off" component, which involves assessment and feedback from instructors, directly facilitates Reflective Observation. Students are prompted to reflect on their performance of each skill, identify areas requiring improvement, and consider the effectiveness of their techniques. This reflection can lead to a refined understanding (AC) of how to execute the skill proficiently. This stage underscores the value of deliberate practice and the indispensable role of structured reflection and feedback in skill acquisition and refinement, linking directly to professional accountability and standards of competence [6].

  ●     CE - Team MRS Practice: Following the mastery of isolated skills, students progress to a more complex and richer experience. Here, they must apply their theoretical knowledge, equipment handling abilities, and individual procedural skills, within a dynamic, interactive, and often immersive team environment. These MRS are designed to mirror the complexities and pressures of real-world medical rescue scenarios. This stage represents the core of experiential learning for professions that rely heavily on teamwork. It shifts the focus from individual skill execution to integrated team performance, fostering an understanding of team dynamics, communication, and coordinated action elements, crucial for successful medical rescue outcomes [7].

  The immersive nature of these MRS promotes situated cognition, where learning is deeply embedded in the context of practice [8].

  ●     RO & AC - Team Assessment: This critical stage is heavily weighted towards Reflective Observation and the subsequent development of new Abstract Conceptualisations. Through comprehensive debriefing sessions, performance reviews, and multi-source feedback (including self-assessment, peer feedback, and instructor evaluations), students and teams meticulously analyse what occurred during the MRS. They explore the rationale behind actions taken, the consequences of those actions, and how their collective performance aligned with established principles, protocols, and objectives. This structured reflection is not merely a feedback mechanism; it is a profound learning process that facilitates the deconstruction of the experience, an understanding of cause-and-effect relationships, and the re-conceptualisation of their mental models and approaches [9]. This leads to new insights, modified strategies, and a deeper, more nuanced understanding (AC) of medical rescue operations.

  ●     AE - Application and Iteration: The cycle culminates in Active Experimentation. Based on the rich RO and refined AC generated during the team assessment and debriefing, students plan how to apply their revised understandings and newly acquired insights in future contexts. This could involve subsequent, more challenging MRS, further targeted practice, or, ultimately, application in real-world medical rescue situations, which becomes a new Concrete Experience, restarting the cycle, ideally at a progressively higher level of competence. This stage emphasises that learning is not a terminal event but a continuous, recurring process of action, reflection, and adaptation. This iterative nature is fundamental for professions like medical rescue that demand lifelong learning, continuous quality improvement, and the constant pursuit of enhanced performance [10].

  The consistent application of Kolb's ELC in MRS naturally fosters a pedagogical shift from a predominantly didactic, teacher-centred approach, to a more facilitative, student-centred philosophy. The emphasis on students actively engaging in experiences (CE) and critically reflecting on those experiences (RO) empowers them to construct their own understanding and meaning.

  Scaffolding the Complex Medical Rescue Procedures Through MRS

  The development of proficient and adaptable TRS necessitates pedagogical approaches, that can effectively bridge the gap between theoretical knowledge and the complex, often chaotic, realities of emergency situations [11]. SBE has emerged as a cornerstone in this endeavour, providing a safe yet realistic environment for students to practice and refine critical skills. Within SBE, the principle of scaffolding offers a robust framework for structuring learning experiences, enabling the incremental acquisition of complex medical rescue competencies [15].

  The Principle of Scaffolding in SBE

  Scaffolding, in an educational context, refers to a process whereby students are provided with temporary, tailored support to achieve learning outcomes that would otherwise be beyond their unassisted reach. This support is gradually withdrawn as the student's proficiency and independence increase [15]. The concept, most famously associated with Vygotsky's (1978) notion of the Zone of Proximal Development (ZPD), posits that learning is most effective when it occurs in the space between what a student can do independently and what they can achieve with guidance [12, 13].

  In SBE for complex medical rescue procedures, scaffolding is not merely about simplifying tasks, but about structuring the learning environment to make complex cognitive and psychomotor processes accessible. Medical rescue operations are characterised by high stakes, significant time pressures, dynamic environments, and the need for sophisticated team coordination. These elements can generate considerable cognitive load, potentially overwhelming novice students, and hindering the development of robust skills [14].

  A scaffolded approach systematically manages this load, allowing students to focus on specific aspects of performance at different stages of their development [15]. Effective scaffolding aims to reveal the underlying causal mechanisms that constitute competent performance [16]. By providing structured support, instructors can help students identify, understand, and internalise these mechanisms, such as critical decision-making heuristics, effective communication strategies, or precise motor skills, rather than merely mimicking superficial actions [17]. The "emergence" of expert performance is thus cultivated through a carefully modulated process that respects the student's current capacities while strategically expanding them [18].

  Breaking Down Procedures: Practising Isolated Skills

  Many complex medical rescue procedures are, in reality, a concatenation of several discrete skills and decision points. Attempting to teach or practice such multifaceted procedures, holistically from the outset, can be counterproductive.

  The principle of "part-task training," a core element of scaffolding, involves deconstructing a complex skill into its constituent components, allowing students to practice and achieve mastery of these isolated elements before integrating them into a more fluid and comprehensive performance [6].

  Figure 3. offers a broad perspective of a high-angle rescue scenario, highlighting the diverse competencies, that rescue students are expected to develop. These constructs, when merged, will showcase, although simplistic and generalised, the activities that will take place during such a medical rescue operation.

  Fidelity Progression

  Low-fidelity Environment: These may involve basic rope work, like knot making or tabletop exercises. The focus is on fundamental concepts, decision-making processes, and basic procedural steps, without the distraction of highly realistic but potentially overwhelming environmental cues. For example, practising communication protocols or anchor point identification, knot making, etc. To address the multifaceted demands of modern medical rescue incidents, we developed the Visually Enhanced Mental Rescue Simulation (VEMRS) as demonstrated in Figure 4. This low-cost, highly interactive modality is an adaptation of the Visual Enhanced Mental Simulation (VEMS) methodology created for training in resource-constrained environments [19]. VEMRS deliberately shifts the focus from singular patient care to the wider operational landscape, challenging students with issues of incident command, inter-agency communication, and strategic decision-making under pressure [20]. Adopting VEMRS functions as more than a training tool; it is a research platform for identifying the deep-seated causal mechanisms, like team dynamics and communication habits, that are pivotal in determining medical rescue outcomes [21].

  Medium-fidelity Environment: These might incorporate controlled outdoor training sites capable of exhibiting physiological responses, more realistic equipment, and some environmental distractors. Students begin to integrate skills in a more contextualised manner.

  High-fidelity Environment: These are designed to closely mirror the complex and unpredictable nature of real-world situations. By incorporating authentic locations, such as mountainous terrain, these environments introduce genuine uncertainty and time pressures, requiring participants to quickly adapt. The involvement of live actor patients further increases the realism, compelling participants to integrate all necessary skills while under significant stress.

  The pursuit of authenticity, however, increases the risk of physical injury. The dynamic and uncontrolled elements present in such environments, require strong safety measures. To mitigate these risks, it is essential to conduct comprehensive risk assessments, hold mandatory safety briefings, ensure the presence of dedicated safety officers with clear authority to intervene, and establish emergency protocols. These measures are vital to guarantee that the valuable and immersive learning experience does not compromise students' well-being, balancing realism with strict safety oversight.

  Complexity Progression

  Complexity can be increased by manipulating variables such as:

  Number of Tasks: Starting with single-focus scenarios, and moving towards multi-tasking requirements.

  Information Load: Initially providing clear and unambiguous information, then introducing incomplete or conflicting data.

  Environmental Stressors: Adding background noise, weather, or challenging physical spaces.

  Team Dynamics: Progressing from individual tasks to scenarios requiring intricate interprofessional collaboration and communication.

  Patient Condition: Starting with stable patients or single pathologies and advancing to deteriorating patients with multiple co-morbidities.

   This progressive approach ensures that students are continually challenged but not excessively overwhelmed. Each stage builds upon the last, allowing for the consolidation of learning and the gradual development of resilience and adaptability. From a critical realist standpoint, the increasing complexity and fidelity seen in Figure 5. allow for the interaction of more numerous and varied causal mechanisms, providing students with insight into how these mechanisms interplay in real-world settings to produce outcomes [22]. The "geo-history" of the student, their prior experiences and learning trajectories, also informs their engagement with these progressively complex scenarios, highlighting the individualised nature of skill emergence [23].

  Principles of Scaffolding in High-Angle Medical Rescue Training

  In SBE, the concepts of fidelity and complexity progression are closely intertwined. For example, when applying scaffolding principles in high-angle rescue training, students progress from scenarios with low complexity and high levels of support to those with greater complexity and reduced support. Throughout this progression, the level of instruction, hands-on practice, and feedback is gradually adjusted to match the student’s development and needs [24].

  Basic Knot Tying and Equipment Familiarisation

  Low Complexity, High Support:

  ●       Instruction: Direct, step-by-step demonstration of each knot (e.g., figure-eight, double fisherman's) and explanation of each equipment piece (e.g., carabiners, belay devices, ascenders).

  ●       Practice: Repetitive, isolated practice of individual knots on a rope segment or familiarisation with equipment function in a low-pressure setting.

  ●       Feedback: Immediate, prescriptive correction and verification of accuracy by the instructor.

  Set Up of a Single Person Ascend and Descend Line

  Medium Complexity, Medium Support:

  ●       Instruction: Guided demonstration of how to integrate known knots and equipment (harness, descender/ascender, belay device, anchor) for personal ascent/descent.

  ●       Practice: Supervised students practice on a low, stable structure (e.g., a training tower or short wall) with redundant safety systems in place.

  ●       Feedback: Real-time coaching on body mechanics, safety checks, and procedural flow; interventions for significant errors.

  Set Up of a Basic Mechanical Advantage System

  Medium Complexity, Medium Support:

  ●       Instruction: Explanation of principles of mechanical advantage (e.g., 3:1, 5:1 systems) and demonstration of combining rope, pulleys/carabiners, and anchors to build a simple system.

  ●       Practice: Team-based exercises to assemble and operate the system with a non-critical load (e.g., a rescue dummy) on flat ground or a gentle slope.

  ●       Feedback: Focus on correct rigging, load management, and team communication; troubleshooting common issues as they arise.

  Apply Medical Rescue Techniques to Different and Novel Environments

  High Complexity, Low Support:

  ●       Instruction: Scenario-based briefings with minimal direct instruction on specific techniques; emphasis on problem-solving and adaptation.

  ●       Practice: Full-scale exercises in varied, less predictable environments (e.g., multi-story structures, natural rock faces, confined spaces) with complex scenarios and potential stressors (e.g., noise, limited visibility).

  ●       Feedback: Instructor primarily observes, intervenes only for critical safety concerns, and facilitates comprehensive debriefings focused on decision-making, risk assessment, team coordination, and adaptive problem-solving under pressure. Students are encouraged to self-assess and provide peer feedback.

  This allows students to develop the specific motor skills and cognitive understanding required for each step without the immediate pressure of managing the entire scenario. Once proficiency in these isolated skills is demonstrated, they can be progressively chained together. This methodical approach ensures that foundational competencies are robustly established, which is critical for the successful "emergence" of the more complex, integrated skill. The "absence" of a specific foundational skill can lead to cascading failures in a real-world medical rescue operation; isolated practice helps identify and remediate such potential absences early in the MRS process. This aligns with a critical realist emphasis on understanding how component parts (mechanisms) contribute to the functioning (or dysfunctioning) of the whole system [25].

  Progressive Scenario Design: From Low to High Fidelity and Complexity

  Effective scaffolding in SBE extends beyond individual skills to the overall design of MRS scenarios. Progressive scenario design involves a deliberate and incremental increase in both the fidelity and complexity of MRS as students advance [26].

  Techniques for Effective Scaffolding (Micro-level)

  Beyond the macro-level design of curricula and scenarios, effective scaffolding relies on specific techniques employed by instructors during the MRS and debriefing phases. These micro-level interactions provide crucial real-time support and guidance [27].

  Clear Pre-briefing: Before a scenario begins, instructors must clearly articulate the learning objectives, the expected level of performance, the available resources, and the degree of support that will be offered. This manages student expectations and focuses their attention [28].

   Thinking Aloud: Encouraging students to verbalise their thought processes during a scenario can provide instructors with insights into their decision-making and allow for timely, targeted guidance. It also helps students to self-monitor and reflect-in-action [29].

   Prompting and Cueing: When students encounter difficulties, instructors can provide subtle hints, questions, or direct cues to guide them towards appropriate actions or considerations. This might involve drawing attention to a critical piece of data or suggesting a potential intervention. The level of prompting should be inversely proportional to the student's developing expertise [30].

   Structured Feedback: Providing specific, objective, and constructive feedback, both during (if appropriate and aligned with the scaffolding strategy) and after the scenario, is essential. This feedback should focus on observed behaviours and their consequences, linking them to the underlying principles and mechanisms of effective care [31, 32].

   Pause and Discuss: In some instances, particularly during formative learning, it can be beneficial to temporarily pause the MRS to discuss a critical decision point, clarify a misunderstanding, or reinforce a teaching point before resuming the scenario [33].

   Gradual Withdrawal of Support (Fading): As students demonstrate increased competence and confidence, the instructor systematically reduces the level of prompting, cueing, and direct intervention. This encourages greater autonomy and allows students to take fuller ownership of the problem-solving process [30].

   Effective Debriefing: The post-scenario debriefing is a cornerstone of SBE and a critical component of scaffolding. Instructors should guide a reflective discussion that encourages students to explore not only what happened, but why it happened and how it could be improved. This involves examining the causal chains of events, the decisions made (and their rationales), and the impact of team interactions [34]. An informed debriefing might explicitly probe the interplay of contextual factors, individual actions, and underlying mechanisms that shaped the scenario's outcomes [35]. These micro-level techniques, when skilfully applied, create a dynamic and responsive learning environment that supports students in navigating complex challenges and internalising the deep structures of proficient medical rescue practice [27].

   Scaffolding complex medical rescue procedures through SBE is a powerful pedagogical strategy that aligns with the demands of preparing TRS for high-stakes environments. By systematically breaking down procedures, progressively designing scenarios from low to high fidelity and complexity, and employing effective micro-level support techniques, instructors can create pathways for students to develop the robust, adaptable competencies required in medical rescue. This approach not only fosters the emergence of proficient performance but also cultivates a deeper understanding of the causal mechanisms that underpin successful outcomes in medical rescue situations. Such a structured, yet adaptable, pedagogical framework is indispensable for programmes aiming to produce critically thinking and highly capable TRS.

  Conclusion

  The systematic scaffolding of complex medical rescue procedures, through deliberate progression in simulation fidelity and task complexity, alongside the decomposition of procedures into discrete, manageable skills, effectively mitigates cognitive and psychomotor overload. This structured approach facilitates the incremental development of proficiency, enabling learners to build upon foundational competencies in a manner that supports the emergence of expert performance.

  While the broader framework of MRS encompasses four interconnected pillars, this article has primarily focused on the pedagogical dimensions of foundational learning theory, and systematic skill scaffolding as critical drivers of effective SBE. The remaining pillars, which are integrated physical preparedness and stringent safety protocols, although acknowledged as essential to the holistic development of TRS, were not the central focus of this article. Their roles in ensuring physical readiness and safeguarding psychological and physical well-being warrant dedicated exploration in future work.

  By emphasising the theoretical and instructional foundations of simulation, this article contributes to the advancement of evidence-informed practices in medical rescue training. Institutions committed to producing competent, resilient, and critically thinking TRS must adopt such structured and theory-driven approaches to SBE, ensuring that learners are equipped not only with technical expertise, but also with the cognitive agility required to navigate the complexities of real-world emergencies.

  Author contributions
  All authors contributed equally and validated the final version of record.
  Declarations
  Conflicts Of Interests
  The Authors declare that there is no conflict of interest.
  Funding
  This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
  Registration
  No registration applicable.
  Data availability statement
  The data that support the findings of this study are available from the corresponding author upon reasonable request.
  Ethical approval
  Ethical approval for this study was not required.

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• 

  Hilal Abdessamad, Zeinab Roumieh, Jacques E. Mokhbat (Author)

  Knowledge and Stigma Regarding HIV and Homosexuality: An Exploratory Survey of Responding Physicians in Lebanon

  Background
       HIV remains a major public health challenge in the Middle East and North Africa (MENA), where stigma against people with HIV (PWH) and men who have sex with men (MSM) hinders access to care. In Lebanon, little is known about physicians’ current knowledge, attitudes, and willingness to provide care for PWH.
  Methods
       We conducted an exploratory online survey of all Lebanese physicians registered with the Ministry of Public Health, distributed in four waves between 2023 and 2025. The 58-item questionnaire assessed HIV knowledge, attitudes toward PWH and homosexual colleagues, willingness to provide medical care, and practices related to sexual history and pre-exposure prophylaxis (PrEP). Out of 4,331 emails, 760 were invalid and 127 physicians responded (3.2%).

  Results
       Interpretation is limited by a low response rate, and findings should be  considered for hypothesis generation rather than prevalence estimates.  Respondents were mostly male (63%), with varied specialties and practice
  settings. Knowledge of HIV transmission was generally high, though gaps were identified: 54% did not recognize breastmilk as a transmission route, 20% were unaware of confidential testing facilities, and only 64% knew that PrEP prevents transmission. While 86% were willing to medically examine PWH and over 90% would perform minor or major procedures, 29% believed physicians have the right to refuse care due to fear of infection. Stigmatizing attitudes were also noted, where 13% would not buy food from PWH, 33% would not allow their child
  to play with PWH, and 39% would not accept surgery from a surgeon living with HIV. Regarding homosexuality, 10–12% opposed accepting homosexual applicants to medical training or granting them practicing privileges. Most respondents (61%) did not routinely take sexual histories, and 84% had never prescribed PrEP, while 96% agreed on the need for further education.

  Conclusion
       In this exploratory sample, respondents had adequate HIV knowledge, but signs of stigma and prevention gaps (PrEP/sexual history) were identified toward PWH and homosexual colleagues, coupled with significant gaps in awareness of PrEP and HIV testing. Physician-targeted educational campaigns focusing on transmission, PrEP, and non-discrimination may help reduce barriers to HIV care and align Lebanon with WHO’s goal of ending the epidemic.

  INTRODUCTION
       As of 2025, HIV remains one of the longest on-going pandemics [1]. Affecting diverse populations, different areas of the world deal with it differently [2]. Thus, the barriers to HIV care tend to be unique to certain areas of the world, dictated by the prevalence of certain modes of transmission, access to care, availability and cost of medication, ease of diagnosis, lack of awareness and stigma and social barriers [3]. As of 2019, the United Nations Programme on HIV/AIDS (UNAIDS) reported a 95% surge in HIV incidence in the Middle East and North Africa (MENA) region [4]. With a high proportion of new infections occurring in the population of men who have sex with men (MSM) [5], these populations face a lot of stigma and stereotype that challenges their access to HIV-related care. In addition, insurances are able to legally refuse and deny coverage for a person living with HIV (PWH) [6]. Moreover, not all Lebanese physicians are willing to assess PWH or people belonging to the Lesbian/Gay/Bisexual/Transsexual+ (LGBT+) community [7]. These people often face discrimination when seeking medical care, which can
  root from discrimination or lack of proper training due to excessive stigma [8].

       With the Lebanese Ministry of Public Health (MoPH), the National AIDS Control Program and the local NGOs, awareness was improved and medication was provided for free, in an attempt to improve sexual health, prevention and HIV care [9]. There was a decrease of 52% in HIV incidence in 2020 [10]. However, despite
  evidence of continued transmission during coronavirus lockdown years [11], little data exists about the progress related to stigma and awareness, especially with a big outflow of physicians and an economic crisis [12].

       Among the tools available to assess physicians’ perspective on this matter, surveys provide valuable data, but they are challenged by low response rates, leading to selection bias [13, 14]. Despite these challenges, nationwide surveys provide very meaningful exploratory information in such settings in the most cost-effective way [15].

       To assess the current situation, we conducted an exploratory survey sent to all registered Lebanese physicians to assess their attitudes towards HIV and homosexuality as well as their knowledge about HIV. This would provide a descriptive assessment of the current situation amongst Lebanese providers and their current willingness to engage, treat and assist in the care of PWH in  Lebanon. As we have little data regarding this area in Lebanon, recording such
  responses would provide valuable information about the nature of the situation and help identify areas to focus efforts for future intervention for a more effective approach towards the World Health Organization (WHO) goals to ending the HIV epidemic.

       Emergency and acute care settings are usually the first point of contact for people with undiagnosed HIV, patients presenting after occupational exposure or sexual assault, and those requiring urgent interventions. Physician knowledge of HIV transmission risk, comfort with procedural care, and familiarity with HIV  prevention strategies affect patient safety, occupational safety, and equity of care.

  METHODS
       Analyses were planned as primarily descriptive given the exploratory study design and anticipated low response rate.

       To assess the current attitudes of Lebanese physicians towards PWH and homosexual patients, we conducted an online survey that was sent to all
  registered Lebanese physicians via email, in 4 waves between 2023 and 2025.

       The survey consisted of 58 multiple-choice questions regarding HIV  transmission awareness, attitude towards PWH, experience and willingness to
  provide medical care to PWH, healthcare professionals living with HIV and colleagues who are homosexual and sexual history and pre-exposure prophylaxis (PrEP).

       The 58-item instrument was developed for exploratory use based on domains relevant to HIV care and stigma (transmission knowledge, willingness to provide care/procedures, occupational exposure/PEP/PrEP awareness, sexual history  practices, and attitudes toward colleagues). Items were reviewed by the study team for clarity and validity prior to distribution. The questionnaire was not  normally psychometrically validated.

       We used a registry of emails provided by the Lebanese AIDS Society which  contains emails of all registered Lebanese physicians in the MoPH as of 2019. This yielded 4331 email addresses. A special email address was used to send the IRB-approved email template containing the google docs link to the survey.

       Out of the email addressed contacted, 760 addressed were unreachable due to a wrong, inactive or outdated address. The remaining 3571 addresses received all 4 email invitations, which yielded 127 (3.2%) responses.

       Given the low response rate, results are subject to nonresponse and selection bias, and are presented as exploratory findings rather than population estimates.

  STATISTICAL ANALYSIS
       Responses were summarized using counts and percentages. Given the exploratory design and limited sample size, we restricted analyses to descriptive statistics and bivariate comparisons. Associations between physician characteristics and outcomes related to HIV stigma and prevention were explored by chi-square or Fisher’s exact tests, as appropriate. Univariable logistic regression was performed to estimate odds ratios (ORs) with 95% confidence intervals when possible. No multivariable modeling was planned. All analyses were considered hypothesis-generating, and p-values were interpreted descriptively without adjustment for multiple comparisons.

  ETHICS
       This project was reviewed and granted approval by the Lebanese American University Institutional Review Board. All survey answers were kept anonymous.

  RESULTS
       Out of the 127 responses, 81 (63%) were male, 12 (9.4%) graduated before 1989, 19 (15%) between 1990 and 1999, 44 (35%) between 2000 and 2009 and 52 (41%) after 2010. Among respondents, 81 (64%) graduated from Lebanese private universities, 25 (19.6%) graduated from the Lebanese University and 20 (15.7%) graduated from outside Lebanon. They practiced in different specialties, with family medicine, pediatrics, anesthesiology, obstetrics and gynecology and infectious diseases being the most reported specialties reported. Regarding studies, 94 (74%) of respondents reported to have studied abroad at some point in their careers, and 75 (59%) of them reported practicing medicine at some point outside Lebanon. As for practice, 77 (60.6%) reported practicing in a university medical center and 64 (50.3%) reported engaging in teaching activities at least 2 times weekly. 93 (73.2%) of them reported seeing on average more than 10 patients per day.

  Questions regarding HIV and transmission awareness
       The vast majority (125; 98.4%) of respondents knew HIV cannot be transmitted by sharing eating and drinking utensils or by sharing towels and toilets with PWH. Regarding other sexually transmitted infections (STIs) like gonorrhea and genital herpes, 88 (69.2%) of respondents knew they increase the likelihood of HIV transmission if untreated. For vertical transmission, 111 (87.4%) knew a mother with HIV can have an uninfected baby. However, 69 (54.3%) respondents did not know that HIV can be transmitted to the baby by breastmilk. As for routine antibody-based testing, 114 respondents (89.7%) were certain these tests are not able to detect HIV antibodies within a few days of infection, and 25 (19.7%) of respondents did not know there are facilities in Lebanon that provide confidential testing. Furthermore, 3 (2.3%) physicians responded that they can tell if someone is a PWH by their appearance. 108 (85%) responded that antiretroviral therapy (ART) prolongs the life of PWH, and 81 (64%) knew that oral PrEP is effective in HIV prevention.

  Questions regarding general attitude towards PWH
       When asked about interactions with PWH, 9 (7%) respondents did not agree to go to a store owned by a PWH, 17 (13.3%) did not agree to buy food from a PWH, 42 (33.1%) did not agree to let their child play with a PWH, 19 (15%) did not agree to play sports with someone with HIV, 16 (12.6%) were reluctant to accept a dinner invitation from a friend living with HIV and 2 (1.6%) thought that PWH should be isolated.

  Questions regarding experience and willingness to provide medical care to PWH
       When it came to experience with PWH, 89 (70.1%) of respondents have treated a PWH at some point in their careers, and 122 (86.1%) of them expressed willingness to medically examine a PWH. If that person is a relative, 117 (92.1%) were willing to medically care for them. When asked if they were willing to perform minor procedures on PWH, such as venipuncture, abscess drainage, mole excision, chest tube placement, 81 of the 87 (93.1%) eligible respondents expressed willingness to do so, and with open surgery, 56 of the 60 (93.33%) eligible respondents were willing to do so. A third of respondents (37, 29.1%) agreed that physicians have the right to refuse medical care to PWH for fear of contamination.

  Questions regarding healthcare professionals living with HIV and colleagues who are homosexual
       Among the physicians who responded to the survey, 12 (9.4%) reported they would not accept to be treated by a doctor who lives with HIV, and 50 (39.4%) reported not accepting to be operated on by a surgeon living with HIV. While 124 (97.6%) expressed willingness to get tested for HIV if exposed, 22 (17.3%) have never been tested before.

       Regarding colleagues with HIV, 15 respondents (11.8%) were unwilling to refer patients to a colleague with HIV, 9 (7.%) think a colleague who gets infected with HIV should not be allowed to continue working and 15 (11.8%) think a qualified applicant with HIV should not be admitted to medical school or residency programs.
       Regarding homosexuality, 15 (11.8%) would not refer a patient to a colleague who is homosexual, 13 (10.2%) think such a colleague should be denied practicing privileges and 12 (9.4%) think a qualified applicant who is homosexual should not be admitted to medical school or residency programs.

  Questions regarding sexual history and PrEP
       Most respondents (78, 61.4%) did not take sexual history in their routine history taking, and 107 (84.2%) had never prescribed PreP. Furthermore, 61 (48%) expressed unwillingness to prescribe it for someone with high risk of HIV infection, and 62 (49%) believed it will decrease safe sex practices and increase the incidence of STIs. Similarly, 23 (18.1%) would not advise an exposed colleague to start PrEP, and 44 (34.6%) believed PreP will cause ART resistance. The majority of respondents (122, 96.1%) believed more education around PrEP should be implemented before prescribing it routinely.

  Exploratory Association Analyses
       We performed exploratory bivariate analyses to assess if certain physician characteristics were associated with stigma and prevention outcomes. No statistically significant associations were observed for routine sexual history taking, PrEP prescribing, belief in the right to refuse care, or willingness to accept surgery from a surgeon/dentist living with HIV (all p>0.05). Univariable logistic regression similarly did not identify significant predictors; however, there was a trend toward lower refusal of surgery among physicians who had studied abroad (OR 0.51, 95% CI 0.23–1.14; p=0.10).

  DISCUSSION
       While we had different demographic profiles of respondents, most younger graduates, who work in educational institutions and had some international experience with a big patient load. This coincides with the known profile of physicians who are more likely to respond to survey invitations, are they are more familiar with such an approach [16]. Furthermore, such profiles are generally more accepting and less stigmatizing of patient populations, due to general and educational trends, making them more inclined to answer surveys related to stigma around HIV and homosexuality [17, 18].

       In general, our exploratory survey showed a high awareness of the general knowledge about HIV transmission and the safety of sharing utensils and toilets with PWH, which is a good baseline. This situation is better than the 1990s, where PWH were discriminated against because of misinformation around this topic. Back then even nurses would not enter the rooms of PWH and they would be left alone, stigmatized, and quarantined [19].

       However, our results show significant gaps in knowledge around HIV transmission and its interaction with other STIs. Only 69% of respondents knew that untreated gonorrhea and herpes increase HIV transmission risk, and around 46% not being sure or not knowing that HIV can be transmitted via breastmilk might be indicators of an awareness gap, worthy of a focused intervention in future campaigns.

       Furthermore, around 10% of respondents were not certain about antibody testing windows and 20% were not aware of confidential testing facilities. These can be barriers to effective testing, where some PWH might not know their status. In addition, while 85% of provider respondents knew that ART prolongs life or PWH, only 65% of them knew PrEP is effective in prevention, which can be an awareness gap to target for future campaigns.

       While a small number, still having some providers think they can tell PWH by appearance and that they should be quarantined, is a significant indicator that stigma and misinformation are not fully eradicated, even among physicians. This is especially evident in a quantifiable stigma attitude towards PWH, which ranges from somewhere around 7% with minimal interaction (buying groceries from shopper) to around 33% when a respondent’s child is playing with a PWH. The 1996-2004 Lebanese study showed a gap between HIV awareness and declining knowledge in prevention and safe practices. When this stigma is not eradicated, even among physicians, this can impede public health interventions. This shows there is a multi-layered problem where misinformation not only affects the general public, but also some healthcare providers [20].

       However, when it comes to providing care, the general trend was positive, with more than 85% of respondents willing to examine PWH or caring for relatives with HIV and performing minor procedures or surgeries on them. This can represent an improvement from the 50-50 willingness of physician care for PWH in 2014(7). Nevertheless, 29% of them agreeing that physicians have the right to refuse care for PWH because of fear of contamination might be a point to target in future campaigns to stress on non-transmissibility of the virus in treated PWH with controlled viral loads [21]. This hesitation is concerning in emergency departments, where delays in triage or refusal of urgent procedures due to fear of transmission can impact patient morbidity [22]. Therefore, more education about basic infection control barriers and their effectiveness in prevention of any blood-borne illness prevention should always be implemented, especially that most patients are not routinely tested for HIV. If all barriers fail and a needlestick injury happens, post-exposure prophylaxis, or PEP, is available and effective [23].

       This remains better than the situation in the 1990s, where physicians and dentists in the west would deny PWH care due to fear of the infection and of stigma, despite effective treatment emergence [24].

       Furthermore, the percentages of respondents who discriminate against medical (9.4%) or surgical (39.4%) colleagues with HIV was alarming. Their unwillingness to refer patients to colleagues who live with HIV (11.8%), and similar percentages of respondents thinking colleagues with HIV or who are homosexual should be denied practicing privileges or prevented from admission to medical school or residency programs shows some clear discriminatory points in the medical community against PWH and LGBT+ people.

       Regarding sexual history taking and PrEP, having 61% of respondents admitting to not routinely taking sexual history shows possible missed opportunity for detecting new exposure and preventing new infection. However, 84% of respondents have never prescribed PrEP and 48% are not willing to do so with one-third of them lack up-to-date knowledge about its use or safety.

       Surveys responses can be low, sometimes less than 5%, especially in uncompensated surveys as in our case. 13 Physician surveys are especially known to have low response rates [25]. Furthermore, the coronavirus pandemic induced a “survey fatigue”, further decreasing response rates [26]. Some invitations would have been lost in the high volume of emails received daily by physicians. Furthermore, since there is no perceived benefit from filling the surveys, many would have just ignored the invitation [13, 27, 28]. The financial crisis and general stress and burnout would be demotivating to fill a survey, and the outflow of physicians to outside the country means that many of them might have abandoned the previously registered email accounts. Moreover, it is impossible for us to know with certainty the number of active email addresses in the registry, so our calculated 3.2% response rate might be an underestimation of the actual rate of response from physicians who received the invitation and filled the survey. Therefore, percentages in this study should be interpreted as signals among respondents, not as estimates of stigma prevalence among Lebanese physicians overall.

       This low response rate would lead to a selection and a nonresponse bias, which affects data representativeness and accuracy. However, the exploratory nature of this study in a topic that is stigmatized and faced with the obstacles mentioned makes our findings important. While our study was not made to draw generalizable conclusions, it aims to gain insight into the current situation among physicians, providing us with potential areas of focus for future interventions in the country to mitigate challenges PWH face while seeking healthcare.

       These results would help us make some recommendations for prevention efforts against HIV in Lebanon in the coming years based on the possible gaps identified in our exploratory survey. These recommendations would be for awareness campaigns targeted for physicians practicing medicine in Lebanon. Based on these findings, we recommend that future educational campaigns for Lebanese physicians prioritize three areas. First, interventions must correct persistent misconceptions regarding horizontal transmission and teach the concept that Undetectable = Untransmissible (U=U) to reduce refusal of care. Second, training should focus on practical protocols regarding indications for PrEP, the window periods for different HIV tests, and the availability of confidential testing sites. Finally, to ensure occupational safety and reduce delays in procedures, education should include efficacy of PEP following needle-stick injuries, ensuring that fear of contamination does not compromise urgent surgical or emergency interventions.

  LIMITATIONS
       Our study has some limitations, especially its low response rate. This is mitigated by the exploratory nature of the study. The questionnaire was not pilot-tested or psychometrically validated, which may affect reliability and comparability across studies. In addition, the list of emails used was from 2019, which was largely due to the unavailability of a more updated list after the COVID-19 pandemic. As a lot of physicians left Lebanon after the pandemic, this can be a contributing factor to the low response rate.

  CONCLUSION
       With stigma and misinformation affecting the public and healthcare professionals regarding HIV and homosexuality in Lebanon, it is important to identify areas of actionable concern. This exploratory survey revealed knowledge gaps, especially in PrEP use, HIV testing and transmission. In general, physician-targeted campaigns on HIV awareness regarding transmission, screening, testing, availability of confidential testing sites, PrEP and PEP might play a role in promoting acceptance, especially in the emergency department. These targeted campaigns, identified by our survey, might be very promising in changing Lebanese physicians’ attitudes towards HIV in Lebanon, and subsequently their attitude towards homosexuality. This would lead to more testing, more treatment and more viral control, contributing eventually to the WHO goals to end HIV.

  Author contributions
  All authors contributed equally and validated the final version of record.
  Declarations
  Conflicts Of Interests
  The Author declares that there is no conflict of interest.
  Funding
  This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
  Registration
  No registration applicable.
  Data availability statement
  The data that support the findings of this study are available from the corresponding author upon reasonable request.
  Ethical approval
  This project was reviewed and granted approval by the Lebanese American University Institutional Review Board. All survey answers were kept anonymous.

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