Dear Dr. Sperle,

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Jason T. Blackard, PhD

Academic Editor

PLOS ONE

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Additional Editor Comments:

This is a cross-sectional, mixed methods study of facilitators and barriers to HIV and viral hepatitis in the Kyrgyz Republic.

The study rationale and methods utilized are well described and appropriate.

It is unclear who the HCWs are?  Doctors?  Nurses?  Medical students?  Who identified the HCWs that would be told about the online survey?  How representative are the HCW survey respondents of the entire HCW population in the Kyrgyz Republic?

Are there substantive differences across different regions of the country?

Are HIV, HBV, and HCV testing and treatment offered free of charge in every region of the country?

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: No

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: No

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: As many other WHO supported countries Kirgiz Republic underwent a significant reform in HIV care delivery, namely decentralization of HIV and hepatitis care. It is therefore of great importance and interest to review barriers and facilitators for HIV and hepatitis testing in this new settings. The paper shows strong methodological construct of work performed and delivers important message directly from HCWs. Therefore I strongly support its publication with some minor additions listed below:

General comments:

1. Please revise the language throughout the paper to meet “People first language” consensus (eg. Do not use abbreviations like PLHIV or PWID).

2. Please provide details for the approval by the ethics committee of the institutional review board in the Kyrgyz Republic, which is the name of the board, location and the decision number.

3. Please provide in introduction a short description of the structure of care for HIV and hepatitis in KR, including the information that after decentralization each primary care center has infectiologist who is responsible for HIV and hepatitis patients. At the same time family doctors received new task of HIV and hepatitis testing. There are also several systematic barriers here, such as lack of access to rapid tests (except for pregnant women) and responsibility of delivering epidemiological investigation for the epidemiology (sometimes performed by epidemiologist depending of particular settings).

4. An important finding is that HCWs are interested in receiving more professional postgraduate training in additional to internal training provided under auspices of MoH. Could you reflect more on that, basing on the qualitative interviews? This could provide a guidance for international societies on the need and guide their actions.

Reviewer #2: This manuscript reports on a mixed qualitative and quantitative examination of primary healthcare workers’ perceived barriers and facilitators of HIV and viral hepatitis testing in the Kryrgyz Republic. They report on qualitative interviews conducted with 21 primary healthcare providers and quantitative survey data from 1080 providers. Descriptive statistics were used to characterize HIV and viral hepatitis testing barriers and facilitators. Key facilitators of testing included access to free testing, knowledge regarding indicators for testing, and ability to provide linkage to vaccination; the core barrier was lack of experience working with this patient population.

The following are suggestions for the authors to improve the manuscript.

-The introduction is well-written. It would be helpful to provide some additional information to characterize the nature of primary healthcare within the Kyrgyz Republic as some readers may not be familiar with the services provided, the extent to which healthcare is covered (e.g., cost, insurance, etc.), and the extent to which the general population and specialized populations noted (e.g., individuals who inject drugs) utilize these services. Additionally, national (or local) guidelines for screening (e.g., risk screening questionnaires within primary healthcare) or testing would be helpful.

-I would have liked to know a bit more about the population of healthcare workers sampled for both the qualitative and quantitative portions of the study. For example, what professions were included?

-The qualitative analytic approach is well described and rigorous. Could the authors provide additional rationale for the use of the COM-B framework employed? The introduction and methods did not indicate a particular framework would be utilized, so it would be helpful to provide some additional rationale.

-I would have liked to see a bit more robust approach to the quantitative analyses. While presenting the descriptive information is useful, I found myself wondering why additional analyses weren’t considered (e.g., grouping all clinics into Northern vs Southern, dichotomizing age into 18-50 and 51+). I found the qualitative methods and presentation of results to be rigorous, but the quantitative portion was lacking in the similar level of rigor.

-For the quantitative survey, the results could be more clearly presented. For example, when reporting on vaccination status, was this for the participants or for patients in their clinics?

-I would like to have seen a bit more information about future research directions. For example, any consideration of examining the extent to which identified barriers/facilitators map onto actual clinical practice (e.g., prevalence of testing in clinics)?

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what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1: Yes:  Justyna Kowalska, Medical University of Warsaw, Poland

Reviewer #2: No

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Barriers and Facilitators to HIV and Viral Hepatitis Testing in Primary Healthcare Settings in the Kyrgyz Republic: A Mixed-Methods Study Using the COM-B Framework

PONE-D-25-34739R1

Dear Dr. Sperle,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Jason T. Blackard, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

None

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #2: No

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5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #2: Yes

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Reviewer #2: (No Response)

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what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #2: No

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