Re-shaping professional boundaries to scale-up HIV pre-exposure prophylaxis (PrEP) services: collaborative care and power dynamics in Belgium

Scaling HIV pre-exposure prophylaxis (PrEP) services in health systems will require collaboration and clear role distinction among professionals, and between specialist and primary care. This study examined how power dynamics shape efforts to expand PrEP care beyond specialised HIV clinics in Belgium. We conducted semi-structured interviews with 36 HIV clinic providers and two community-based organisation (CBO) representatives, and 16 online group discussions with general practitioners (GPs). We analysed data thematically, guided by the concepts of collaborative and competitive power to examine how providers negotiated expertise and role division in PrEP delivery across professional and organisational boundaries. We found that reimbursement regulations anchored PrEP initiation and follow-up within HIV clinics, embedding specialist jurisdiction in care pathways. HIV specialists reinforced this position by drawing on their recognised expertise in HIV medicine to justify clinical coordination and authority in determining standards of care. GPs emphasised accessibility and preventive care roles but made limited claims to PrEP provision, linked to misaligned organisational incentives, role blurring, limited training opportunities, and the historical concentration of HIV care in specialist services. CBOs facilitated access, enabling coordination between vulnerable communities and clinics while remaining weakly embedded in formal care structures. Findings show that expanding integrated PrEP services beyond specialised care is not only shaped by operational issues such as training and resources but also by the structural dynamics of regulations, institutional mandates, and professional jurisdictions that influence collaboration. Effective scale-up will require policies that align incentives, clarify responsibilities, and support collaboration across specialised, primary care, and community settings.