Study team

The research team was composed of one research team based at the Robert Koch Institute (RKI) in Germany and one research team in the Kyrgyz Republic. The research team in the Kyrgyz Republic comprised of national partners from the local public health authorities such as the National Institute of Public Health of the MoH and the Republican Center for Blood-borne Viral Hepatitis аnd HIV/AIDS Control at the MoH.

The research team in the Kyrgyz Republic coordinated in-country activities including the organisation of the IDIs and the distribution of the online questionnaire through regional health coordinators, who then contacted the PHC facilities. Regional health coordinators are appointed medical doctors responsible for overseeing HIV and viral hepatitis work in remote areas.

Study population

We included medical doctors currently working in PHC regardless of professional background for both phase I and II. We included PHC doctors working in the regions Bishkek (the capital city), Chuy Oblast, Issyk-Kul Oblast, Talas Oblast, Osh Oblast (including Osh City), and Manas Oblast, representing both urban and rural areas with different population densities and levels of primary health infrastructure.

Sampling and recruitment

Data collection

Data analysis

Author reflexivity and positionality in analysis of qualitative data

For the qualitative part of this study, we provide a detailed analysis of reflexivity, focusing on how our professional and personal experiences might have influenced our methodological approach and interpretation of findings.

Ethics approval and consent to participate

This study was approved by the ethics committee of the institutional review board, journal of health care, in the Kyrgyz Republic, under approval number 01–3115. All study participants, in both the qualitative and quantitative part, provided written informed consent prior to participation.

Part I: qualitative results

This section presents the findings from our qualitative analysis of barriers and facilitators to HIV and viral hepatitis testing in PHC in the Kyrgyz Republic. The analysis is structured according to the COM-B framework, examining how capability, opportunity, and motivation factors influence testing practices among doctors in PHC.

Barriers to HIV and viral hepatitis testing

Capability: Heterogeneous distribution of knowledge and training gaps. Doctors in PHC demonstrated varying levels of competence in HIV and viral hepatitis testing in PHC settings. While participants demonstrated adequate knowledge of clinical indicators for testing, including signs and presenting symptoms for both HIV and viral hepatitis, they described significant challenges in recognising epidemiological criteria, particularly those related to sexual transmission and substance use behaviours that go beyond a number of sexual partners and condom use. Doctors mentioned that they were able to list the clinical indications for HIV testing better than for viral hepatitis, because national protocols for viral hepatitis do not provide similar clear guidance on indications for testing. They also highlighted important gaps in knowledge that may exist among their colleagues about the practical aspects of testing, including the proper provision of testing and follow-up of positive results. As one doctor noted:

In the last six months, we haven’t had any training on HIV, AIDS or viral hepatitis. The training sessions have covered other topics. (P4)

Notably, participants reported that their knowledge of HIV testing came mainly from specialised training provided by organisations such as [the Republican AIDS Centre] or [ICAP], rather than from standard medical education or predominant in-house training. This reliance on external training mechanisms contributed to an uneven distribution of knowledge among health care providers, as one doctor explained:

“...my knowledge is mostly gained through training I attended; I can’t say that everyone [...] is well-informed. (P4)

Health workers also pointed to a clear disparity in training opportunities between HIV and other non-communicable diseases:

I would like them [Ministry of Health] to offer additional courses [...]. We have a lot of training courses on diabetes and hypertension, and nothing about HIV. (P18)

In addition to HIV-specific training gaps, participants described inadequate training in viral hepatitis testing protocols, interpretation of results and approaches to patient counselling.

Capability: Clinical (in)experience and population (in)visibility. Clinicians reported minimal exposure to and experience with both people living with HIV and key populations in their primary care practice. Some participants reported a complete lack of encounters with people living with HIV and key populations in their clinical practice throughout their careers. As one participant put it:

Honestly, I have never had an HIV-positive case in my practice. (P2)

This limited clinical exposure was particularly pronounced in relation to key populations, with doctors often expressing doubt about the very existence of such groups in their practice setting or area of residence. When discussing sex workers, people who inject drugs and men who have sex with men, participants often suggested that these populations were absent from their communities, either because it was difficult for them to exist due to high levels of stigma and potential exposure to violence, or because of ‘high moral standards’ in the communities. One participant noted:

I have never seen such patients [key populations] in outpatient clinics. (P3)

while another, working in a rural setting, remarked:

No, we don’t have sex workers here. Where would you find sex workers in the village? (P15)

While participants in all regions described limited contact with key populations, doctors from southern regions of the Kyrgyz Republic had very different attitudes and experiences than their northern counterparts. Thus, we observed among northern participants more open and less judgmental attitudes among doctors. Doctors mentioned challenges in identifying key populations among their patients, noting that discussions about sexual behaviour or substance use were uncommon in their practice, or that they would feel extremely uncomfortable doing so with their patients. Some participants also described having limited information on how to work with key populations when encountering them in their healthcare facility.

Opportunity – Physical: Time, space and resource. Our study participants described substantial resource constraints that limited their ability to provide HIV and viral hepatitis testing services in PHC settings. These constraints manifested themselves in several areas of healthcare delivery, from basic infrastructure such as the laboratories themselves to specialised testing equipment. Some of the health facilities, particularly those in remote areas, faced significant challenges with laboratory infrastructure, with some of them reporting operating without basic laboratory facilities. One study participant practising in one of the regions highlighted the deterioration of laboratory infrastructure over time:

We are the only district that doesn’t have a laboratory. We used to have one but now we don’t have one. (P12)

Doctors in PHC described limitations in test supplies, particularly for viral hepatitis testing. The lack of comprehensive test supplies emerged as a significant barrier, with one participant noting:

We’ve never had tests for Hepatitis D. As for Hepatitis C, they [local lab facility] recently told us they couldn’t perform quantitative PCR anymore, only qualitative PCR tests. Regarding Hepatitis B, they also stopped doing quantitative PCR…. (P20)

Staff shortages emerged as another critical barrier, with doctors in PHC reporting significant understaffing in their facilities. This shortage affected not only testing services, but the overall capacity of health facilities to provide care to their patients. As another study participant described the situation:

…we are talking about the primary care level, where it is expected that 8 family physicians should work, there are only two physicians working, or there are 2-3 villages to be covered, and there is only one physician available for a population of 5-6 thousand people, it could be even more. (P19)

These resource constraints were particularly vocal in remote health facilities, where doctors in PHC described working with minimal staff while trying to maintain testing services alongside other primary care responsibilities such as diagnostics, preventive care, vaccination, and chronic non-communicable disease management. Doctors repeatedly emphasized challenges in maintaining adequate supplies of test materials and ensuring proper test storage conditions, particularly in facilities with unreliable electricity or lack of proper refrigeration:

…there are power outages, and the Internet sometimes goes down too. It happens quite often. We have generators at every PHC facility to support power supply. But if the Internet goes out, we just have to wait. (P17)

At the same time, several participants highlighted the lack of private space for individual patient counselling as a structural barrier in some healthcare facilities. Doctors reported that they often had to share consulting rooms with other doctors or medical staff, which limited their ability to have confidential discussions. This was seen as a significant barrier for both providers and users – particularly when discussing sensitive issues such as sexual behaviour or substance use, where privacy is essential:

Two physicians and three nurses share the office, and when patients visit each physician at the same time, there are 8 people in one room, and if they have children, there are even more, it’s like a bazaar. (P10)

Beyond the resource constraints, time and geographical barriers were perceived by participants to make access to testing services more difficult. The organisation of service delivery, particularly in terms of opening hours, emerged as a recurring narrative and a challenge for the working population. Doctors in PHC acknowledged that standard clinic hours often coincided with typical working hours of the general population complicating access to testing. Doctors in PHC also described geographical barriers to testing services, particularly in remote areas where patients sometimes had to travel long distances to reach testing facilities.

Opportunity – Social: Social perceptions, culture and their role in testing uptake. Study participants described how societal stigma and discrimination as well as religious and cultural norms created barriers for people seeking HIV and viral hepatitis testing services. They described how patients often reacted defensively to testing offers, as doctors in PHC perceived, mainly due to fear of being associated with key populations. This fear of association often manifested itself in immediate defensive reactions from patients, as one doctor told us:

When they hear HIV, they immediately associate it with prostitutes, people who use drugs and say, ‘who do you think I am?’ (P15)

Religious beliefs and cultural expectations appeared to be intertwined with social perceptions, shaping not only how testing was viewed, but also how conversations about testing evolved. These norms often influenced patients’ (dis)comfort in discussing sensitive topics such as sexual behaviour and often dictated their openness to testing. As one doctor in PHC told us:

We have patients who are religious, for example. They have difficulty with answering questions. It is difficult to ask them about such a topic as family relations. (P18)

The influence of religious beliefs on health-seeking behaviour was particularly evident in certain areas, where healthcare workers noted varying levels of resistance to testing services. Some patients demonstrated a complete refusal of medical intervention, relying on divine protection. One study participant told us:

I also have very religious patients who just say: ‘God will protect me’ and they deny any treatment. (P4)

Doctors in PHC described specific challenges in working with religious families, particularly in relation to gender dynamics and spousal testing. These challenges were felt most acutely in the context of antenatal care, where doctors struggled to engage male partners in testing services. The interplay between religious beliefs and gender norms created additional barriers to testing uptake, particularly when trying to involve both partners in health services:

We are Muslims, yes. Our religious provisions. When we examine pregnant women, we tell their husbands to get tested. There are cases in which they refuse. There are men like that. (P7)

Motivation: Moral judgements and professional conflicts. While doctors in PHC recognised stigma, cultural and religious norms as socially-caused barriers to testing, they often held stigmatising attitudes themselves during interviews without self-awareness, particularly in relation to perceived (im)moral behaviour and patterns of disease transmission in their communities. Some participants attributed rising infection rates to what they perceived as a decline in social and moral values and changes in sexual behaviour, such as an increase in the number of sexual partners. These perceptions were often framed within a broader narrative of moral decline:

Our generations have also changed in a bad way. Sexual promiscuity, that is why HIV is growing, and hepatitis is growing somehow. (P7)

The complexity of stigma was further illustrated by the seemingly contradictory attitudes of doctors in PHC towards key populations. While some doctors dismissed the existence of key populations in their service areas (see ‘Clinical (in)experience and population (in)visibility’), they also made moral judgements about transmission routes, often focusing on sexual transmission and potentially downplaying other routes of infection, which may have minimised their motivation to test:

We don’t have drug addicts, for God’s sake. So, the main transmission is sexual. (P15)

Motivation: Patient misconceptions, misbeliefs and indifference about testing practice. Finally, doctors described their perceptions of strong misconceptions about testing and disease risk that negatively affect their patients’ motivation to be tested. According to the participants, many patients underestimate the seriousness of HIV and viral hepatitis and do not recognise the importance of early testing and prevention:

They [patients] don’t have this information and do little self-education regarding medical care. They don’t think about the possible consequences for themselves. They don’t come for examination until they get concerned about their complaints. (P18)

Another recurring theme in the interviews was peoples’ lack of understanding of their personal responsibility for their health. They believed that this attitude manifested itself in indifference or denial of potential health risks, creating self-imposed barriers to testing. Doctors described encountering consistent patterns of avoidance and procrastination, with people prioritising other activities over their health needs, or waiting until symptoms became severe before seeking care:

I would say that we feel more responsibility than the patients. They act like ‘if you’d invited me, if you’d explained it to me, if you’d told me, then I would come’. They don’t have that level of responsibility, and they don’t think like: ‘It’s time to get tested, I have to do it now’. (P16)

This lack of proactive health-seeking behaviour was seen by doctors as an important barrier to early testing.

Facilitators to HIV and viral hepatitis testing

Capability: Increased awareness through public health communication. While doctors noted persistent misconceptions and indifference among some patients about testing (see “Patient misconceptions, misbeliefs and indifference about testing practice”), they also observed a gradual improvement in overall public awareness of HIV and viral hepatitis testing. This progress was attributed to increased media coverage and improved access to health information among other things enabled by digital platforms and social media. This shift in information accessibility was perceived to facilitate testing uptake, as described by one participant:

Those who come to me, they are all tested, because the information is now given through the TV, the media, they are now fully informed. (P3)

Not surprisingly, doctors perceived that the transition to digital health communication appeared to be particularly effective among younger populations, who demonstrated more proactive health-seeking behaviour. Doctors in PHC noticed that some patients were increasingly arriving at facilities with prior knowledge of testing, albeit with varying levels of understanding the difference between HIV and viral hepatitis. This evolution in patient knowledge and engagement was seen as a positive change, with doctors noting a marked change in patient-provider interactions around HIV and viral hepatitis testing:

Younger people are generally well-informed because they’re online a lot. They look things up immediately and sometimes even correct me. (P4)

According to participants, this increased public awareness through multiple media channels reduced stigma around testing and created opportunities for people and their patients to be better informed about prevention, testing and treatment options.

Capability: Improving professional awareness and knowledge. Interviewees demonstrated a deep understanding of the public health implications of HIV and viral hepatitis in primary care settings, and described knowledge-sharing mechanisms within their organisations to enable them to improve the response to HIV and viral hepatitis. First, doctors in PHC articulated a clear recognition of the impact of those diseases on the health and well-being of the population, identifying both short and longer-term public health effects. This awareness was particularly pronounced in relation to the age distribution of the populations affected and the potential progression to serious health consequences if infections are left undiagnosed or untreated:

…they are chronic infections, chronic diseases, in my experience generally they occur in the working age from 20 to 40, 40 to 50 years of age. They have a detrimental effect on health and even this leads to disability and with subsequent mortality if it is detected at a late stage. (P14)

Second, they described how health facilities had established regular information-sharing mechanisms to ensure that doctors were kept up to date with new guidelines and protocols. As described by participants, once a new regulation is issued by the MoH, it is published on the MoH website shortly afterwards, and the regulation is also emailed to primary care facilities and then to all doctors.

Our administration gives them to us. There is a meeting once a week to discuss it. It is given to the whole department. The new order comes to us immediately. (P3)

In order to ensure that the document is not just widely circulated, the participants told us that they have regular meetings where these regulations are discussed. The doctors saw this mechanism not only as a quick way of disseminating knowledge and information about the new regulations, but also as a useful approach to raising awareness in remote areas and thus improving uptake of testing.

Opportunity – Physical: Technology and outreach solutions. Doctors described several successful initiatives and technological advances that have transformed their ability to deliver testing services, particularly in overcoming traditional barriers to access. The use of mobile testing units emerged as a particularly effective solution for reaching underserved populations and remote communities. These mobile clinics, equipped with testing facilities, brought comprehensive services directly to where people live and work, including remote areas of Kyrgyzstan. Our study participants emphasised that this approach removed transport barriers and saved time for patients:

Yes, we work with schools, and we have voluntary blood donation campaigns... It’s convenient so they don’t have to come here. They also test there on the spot and draw blood samples for the testing. It is convenient for local communities’ dwellers not to come here, not to spend extra money, not to spend extra time. This is what we have well organised, and it has a good effect. (P19)

This expanded access was further enhanced by the introduction of rapid testing technologies, which were consistently identified by doctors in PHC as a key facilitator for more efficient and accessible services. The shift from traditional laboratory-based testing to point-of-care diagnostics was an important improvement, specifically, in HIV service delivery, as noted by another doctor:

With the introduction of rapid tests, it has become better, people started coming to us... Before the rapid tests we had ELISA for this testing. It took about a week to get the result, but that rapid test is very sensitive, it gives the result in 20 minutes, and we can refer this patient to a specialist for consultation and register the patient and take him to treatment from the first detection to reduce the time. (P14)

Doctors in PHC felt that this synergy between mobile outreach services and rapid testing technologies had created a more responsive and accessible testing infrastructure, particularly benefiting communities that traditionally faced barriers to facility-based services, while increasing patient engagement and follow-up opportunities.

Opportunity – Social: Adapting to reality and building bridges to testing services. A major shift in health policy and service delivery emerged as a key facilitator with the introduction of free testing and treatment services. Doctors in PHC consistently highlighted how the removal of financial barriers had changed service delivery and peoples’ willingness to engage with testing services. As one provider noted:

Previously, as I said, until May last year, these tests were paid for, about 260 soms [approximately 3 Euro] according to the price list, now these tests are free... Well, I think the fact that we have free treatment for HIV and hepatitis, the fact that we have free treatment and testing, that’s what has increased coverage. (P11)

This health system transformation has also fostered a collaborative approach between the public and private sectors, creating multiple pathways for people to access HIV and viral hepatitis testing services. While public facilities successfully implemented free basic testing programmes, they recognised limitations in their diagnostic capacity, particularly for specialised tests such as quantitative PCR for hepatitis D. In response, health facilities developed innovative solutions through formal partnerships with private laboratories, ensuring that patients could access a full range of necessary diagnostic services at reduced costs:

Our director has even contracted [private] laboratory to do it... If earlier these tests were very expensive, it was unaffordable for the patient. And now the hospital has a contract, we refer them for hepatitis D testing... And I personally refer them there, there is a 50% discount. (P7)

Finally, the national hepatitis B vaccination programme has created additional opportunities to expand testing coverage in primary care settings. By offering vaccination to everyone, the programme has helped to normalise hepatitis testing as part of routine preventive care and reached people who might not otherwise seek testing. As one doctor explained:

 ...we have been testing since 2023, we have a program on hepatitis B [...], especially on hepatitis B immunisation. For example, absolutely healthy people, we invited them, they came to us, we had a separate room for testing [...] after 20 minutes the result was negative, then we took them to the immunisation room. (P14)

Motivation: Professional responsibility as a driving force. Doctors in PHC expressed a strong sense of professional responsibility that acted as a key motivator for providing testing services. This commitment manifested itself in a stronger awareness of their role in both individual patient care and wider public health surveillance. Doctors in PHC recognised their obligation to maintain ongoing relationships with patients and ensure continuity of care, as one doctor pointed out:

I have said I tell them to come back to us after some time, it’s our responsibility, we have to monitor the patients for life. (P3)

We found that doctors saw themselves as guardians of public health, emphasising the need for vigilance and proactive approaches to testing. This professional commitment was reflected in their approach to testing decisions and their understanding of their broader societal role:

First of all, perhaps doctors should be more responsible. We should be vigilant. (P2)

This sense of professional duty acted as a counterbalance to the perceived lack of patient responsibility described above, with PHC doctors seeing their own accountability as crucial to effective testing. At the same time, doctors demonstrated strong willingness to learn more about HIV and viral hepatitis testing, mentioning that these trainings not only enhance their knowledge about these infections, but also help to develop some soft skills to communicate with patients.

Part II: quantitative results

This section presents the findings from our quantitative analysis of barriers and facilitators to HIV and viral hepatitis testing in PHC in the Kyrgyz Republic. In total, 1,096 doctors in PHC completed the online questionnaire. We excluded 16 respondents due to reporting working outside PHC. This led to a final dataset of 1,080 doctors in PHC who were included in our analyses.

The majority of the participants were female (89%), and most respondents were in the age groups 51–60 years (27%) and 31–40 years (23%) followed by the age group of 61+ (20%). When asked about hepatitis B vaccination, 85% of doctors participating in the survey responded ever being vaccinated, of which 82% reported being fully vaccinated (at least three doses). Detailed sociodemographic and healthcare practice characteristics are reported in Table 1.

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Table 1. Distribution of socio-demographic and PHC facility characteristics of the study population (n = 1,080).

https://doi.org/10.1371/journal.pone.0336257.t001

Testing activities

Of the 1,080 participants, 892 (91%) reported that free hepatitis B tests were available in their facility, 641 (65%) had free hepatitis C tests and 749 (76%) had free HIV tests. In total, 845 (80%), 633 (60%) and 704 (67%) reported having performed HBV, HCV or HIV testing in the past 12 months.

Of those who had performed testing of either HBV, HCV or HIV in the past 12 months (n = 904), 739 participants (82%) indicated that they had also performed integrated testing of patients. Of those who had not performed integrated testing (n = 160), the most common reasons for not offering were that patients presented with viral hepatitis symptoms and therefore HIV test was not offered (n = 37 (23%)), that tests for integrated testing were not available (22 (14%)) and 19 participants (12%) indicated that they did not think integrated testing was a good approach. Knowledge was an issue for 14 participants (8.8%) who indicated not knowing what integrated testing was, and 8 (5.0%) who reported not being able to explain integrated testing to patients. Of the overall 1,080 participants, 134 (13%) reported not to have tested patients despite presenting with clinical indications the last 12 months.

Barriers and facilitators to HIV and viral hepatitis testing

Overall, the barriers for HBV, HCV and/or HIV testing, to which most participants agreed or strongly agreed were the need of more viral hepatitis (66%) and HIV (62%) training, lack of free testing and treatment for HDV (60%) and that patients decline hepatitis (24%) and HIV (26%) testing when offered in the healthcare facility (Fig 1).

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Fig 1. Barriers for HBV, HCV and HIV testing (n = 1,080).

https://doi.org/10.1371/journal.pone.0336257.g001

The facilitators for HBV, HCV and/or HIV testing to which most participants agreed or strongly agreed were access to free testing and treatment for hepatitis B and C (92%) and HIV (89%) makes it easier to offer testing, and their knowledge whom to test for HBV and HCV (79%) and HIV (83%) (Fig 2).

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Fig 2. Facilitators for HBV, HCV and HIV testing (n = 1,080).

https://doi.org/10.1371/journal.pone.0336257.g002

When stratifying the three most frequently reported barriers (defined by responses of agree or strongly agree) by geographical location no significant differences were observed between doctors in PHC working in rural versus urban settings, nor between those in the Northern versus Southern regions (of the Kyrgyz Republic. Similarly, stratification by age group revealed comparable proportions across categories, with no statistically significant differences identified (all p > .05) [see S4 Appendix].

Key populations

In total, 781 participants (77%) reported not seeing any members of key populations as patients in their PHC facility. Overall, 159 (16%) of participants reported seeing people who inject drugs in their practice, 107 (11%) reported seeing sex workers, and 96 (9.0%) reported seeing people in prison and other closed settings. In total, 92 (9.0%) and 62 (6.0%) participants reported seeing men who have sex with men and trans and gender diverse people in their practice, respectively.

Participants were asked, if given the choice, if they would prefer not to provide care or services to key population groups. People who inject drugs and men who have sex with men were the groups to which most doctors responded that they would prefer not to provide services for (Fig 3).

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Fig 3. Would prefer to not to offer healthcare service to key populations (n = 1,080).

https://doi.org/10.1371/journal.pone.0336257.g003

The participants who agreed to not wanting to offer healthcare services to key populations were asked what the main reasons were. Across all key populations, lack of training was frequently reported, while the other reasons differed according to key population group (Table 2).

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Table 2. Reasons for not wanting to provide services to key populations.

https://doi.org/10.1371/journal.pone.0336257.t002