The Unseen Architecture of Trust: Seven-Year Mixed-Methods Evidence on Nurse-Led HIV Prevention and the Paradox of Stigma in Uzbekistan

Background Nurses constitute the largest healthcare workforce globally and serve as the primary point of contact for patients, positioning them as critical agents in HIV prevention. Yet the paradox that nurses may simultaneously educate communities about HIV while harboring stigmatizing attitudes toward people living with HIV (PLHIV) remains inadequately characterized. We investigated this dual role through a seven-year mixed-methods investigation in Uzbekistan. Methods We conducted a longitudinal educational intervention among 1,247 secondary school participants (students, teachers, parents) who received nurse-led HIV education in Tashkent, Uzbekistan (2019–2026), with follow-up at 6, 12, 24, and 36 months. Concurrently, we administered repeated cross-sectional surveys to 892 practicing nurses (2025) with comparative data from 2019–2023, and conducted semi-structured interviews with 42 nurses and 18 PLHIV. Primary outcomes were HIV knowledge (validated 25-item scale) and stigmatizing attitudes (Healthcare Provider HIV Stigma Scale, HPHSS). Multivariable logistic regression identified predictors of high stigma. Findings: Among 1,247 school participants, nurse-led education produced substantial knowledge gains (22.4 ± 3.8 to 74.6 ± 5.2 points, p < 0.001, Cohen's d = 1.82), with 68.9% retention at 36 months. Stigmatizing attitudes toward HIV-positive peers declined from 86.4% to 9.2% (p < 0.001). However, among 892 nurses surveyed in 2025, 29.7% reported fear or hostility toward PLHIV, 41.8% were unwilling to share a toilet with PLHIV, and 45.7% were unwilling to eat with PLHIV. Comprehensive HIV training was the strongest predictor of reduced stigma (adjusted OR = 0.32; 95% CI: 0.24–0.43), while working in primary care (OR = 2.34; 95% CI: 1.76–3.11) and perceived infection risk (OR = 3.42; 95% CI: 2.54–4.61) predicted higher stigma. Qualitative analysis revealed a profound disjuncture: nurses effectively educated communities about HIV while privately expressing fear, avoidance, and discriminatory attitudes. Interpretation: Nurses demonstrate remarkable capacity as HIV educators but simultaneously harbor stigmatizing attitudes that may undermine their effectiveness. We propose the Unseen Architecture of Trust —a conceptual framework comprising three pillars (Transformative Education, Empathic Care, Sustainable Systems) that must be systematically constructed to align nurses' professional roles with their personal attitudes. Without targeted interventions addressing the paradox of nurse stigma, the full potential of nursing as a prevention force will remain unrealized.