Study design and setting

This study used the NGT to identify and prioritize a disclosure DA intervention, based on existing interventions described in the literature, for adaptation to the Georgian context. NGT is a structured consensus method that supports balanced participation and is commonly used in health research to generate ideas, discuss priorities, and rank options within a group [18,19]. Its core stages include silent idea generation, round-robin sharing, clarification of ideas, and independent ranking. This study used the following approach: first we conducted two sessions: a NGT session with HIV care providers and a NGT session with PLWH, followed by a final joint session to review findings from the two separate groups and reach consensus on the intervention to be adapted. This multi-group application of NGT is consistent with its flexible use in health research, including examples where separate stakeholder perspectives are elicited and subsequently integrated through additional group discussion and consensus processes [18].

All sessions took place at T. Tsertsvadze Infectious Diseases, AIDS and Clinical Immunology Research Center in Tbilisi (AIDS Center), the capital of Georgia. The center is the main national institution responsible for the development, coordination, and implementation of activities related to HIV/AIDS prevention, diagnosis, treatment, and research in Georgia.

Participant recruitment

Participants were recruited separately for the provider and PLWH sessions from February 9 to March 3 2026. HIV care providers were recruited at the AIDS Center. A research focal point at the AIDS center who was responsible for providers’ recruitment for the NGT session approached potential participants who were involved in HIV care and support services, briefly explained the purpose of the study, obtained oral agreement to participate, and invited interested individuals to attend the scheduled NGT session. PLWH were recruited through the community-based organization Real People Real Vision, a PLWH-led organization working with the HIV community in Georgia. A community leader from the organization approached potential participants, explained the study, obtained oral agreement to participate, and invited them to attend the scheduled NGT session. Written informed consent was obtained from all participants before the start of the NGT session. To protect participant confidentiality, informed consent forms were stored separately from session materials and were not linked to ranking forms or discussion notes. Participants who preferred not to sign the consent form themselves were offered the option of having their consent documented by the recruiter, who signed the consent form on their behalf in accordance with the IRB-approved consent procedures. No personal identifiers were recorded in the discussion notes. All notes and ranking data were de-identified prior to analysis.

Identification and preparation of candidate interventions

Prior to the NGT sessions, a desk review was conducted to identify existing interventions designed to support disclosure decision-making. Interventions were selected based on predefined criteria, including evidence of effectiveness (e.g., randomized controlled trials or pilot evaluations), relevance to disclosure decision-making in stigmatized conditions (such as HIV, mental health, substance use), and feasibility for adaptation to the Georgian context. Particular consideration was given to interventions that are low-cost, scalable, and can be delivered within routine service settings. A total of nine interventions meeting these criteria were identified and grouped into three categories based on their primary format: session-based interventions, paper-based interventions, and digital interventions.

NGT procedure

For the NGT sessions, the research team prepared one-page summaries of the nine interventions described above, including information on their target population, format, duration, main components, and available evidence. Both the provider and PLWH sessions followed the standard NGT procedure and each lasted approximately 60 minutes. At the beginning of each session, participants received printed copies of the intervention summaries, and the moderator briefly presented each intervention and its format. Participants were given time to review the materials and ask clarification questions. Participants were also provided with standardized verbal instructions on the ranking process. They were asked to consider multiple factors when evaluating and ranking the interventions, including their perceived appropriateness for PLWH in Georgia, potential acceptability to end users, feasibility of implementation within the Georgian healthcare context, scalability, and overall potential to reduce HIV-related stigma. For the first exercise, participants were asked to discuss the advantages and disadvantages of the three intervention formats (session-based, paper-based, and digital) for use in the Georgian context. Participants first generated ideas individually and silently. This was followed by a round-robin sharing process, during which participants presented their ideas one at a time. A rapporteur recorded all ideas on a flip chart without discussion or critique. After all ideas had been listed, the group engaged in a structured discussion to clarify and elaborate on the points raised. Participants then independently ranked the intervention formats. Each participant was given three points that could be allocated across the options according to their preference. Participants could assign all three points to a single option, distribute one point to each of the three options, or allocate two points to one option and one point to another. The points assigned by all participants were then aggregated to produce a prioritized list of intervention formats. Following the identification of the preferred intervention format in each group, a second ranking exercise was conducted to compare the interventions within that format (in the provider session, participants compared the three digital interventions, while in the PLWH session participants compared the three session-based interventions). Participants discussed the strengths and limitations of each intervention and then independently ranked them using the same scoring procedure as in the first exercise. In the final part of each session, participants were asked what adaptations would be necessary to make the highest-ranked intervention appropriate for the Georgian context of PLWH. This part of the discussion was conducted as an open brainstorming exercise rather than a formal ranking process. After the two separate NGT sessions, a 40-minute joint session was conducted with representatives from both groups. During this session, the facilitator presented a summary of the findings from the provider and PLWH sessions, and participants discussed similarities and differences between the two groups’ perspectives. The discussion aimed to reach consensus on the intervention that would be prioritized for adaptation. Consensus was reached through facilitated group discussion rather than a formal consensus method. Consensus was defined as general agreement among participants regarding the intervention to be prioritized for adaptation. Although providers and PLWH expressed different viewpoints regarding the intervention selection, no major disagreements emerged during the joint session. Minor differences in opinion were addressed through facilitated discussion, allowing participants to clarify their perspectives and consider the views of others before reaching a shared decision. The final selection process was designed to prioritize the perspectives of PLWH as the primary end users of the intervention, while also incorporating provider views on feasibility and implementation. Each NGT session was conducted as a single plenary group. Participants were not divided into smaller groups at any stage of the process, and all idea generation, discussion, ranking, and consensus activities were completed with the full group present. To enhance the credibility of the qualitative findings, discussion notes were recorded by a designated rapporteur during each session and were reviewed by members of the research team immediately after the sessions to ensure completeness and accuracy.

Data analysis

Data generated during the NGT sessions included ideas recorded on flip charts during the discussions and the ranking scores assigned by participants (S1 File). Ranking scores were aggregated to identify the preferred intervention format and the preferred intervention within each format. Discussion notes from the NGT sessions (S2 File) were reviewed using a descriptive content analysis approach [27]. Given the concise nature of the notes, formal coding procedures were not applied. Instead, notes were organized and summarized into categories reflecting perceived advantages, limitations, and suggested adaptations of the selected interventions to the Georgian context. Selected illustrative quotations from the discussion notes were used to provide examples of participants’ perspectives. All discussion notes were reviewed in de-identified form. To preserve confidentiality while providing context for quotations, illustrative quotations are presented with participants’ stakeholder group (provider or PLWH), age, and gender only. No names or other potentially identifying information were retained in the research materials or reported in the manuscript.

Ethical considerations

Ethical approval for this study was obtained from the Institutional Review Board of the National Center for Disease Control and Public Health of Georgia (IRB # 2025−017). All participants provided written informed consent before the session began.

Selection of the most appropriate intervention format

In the provider NGT session, participants compared session-based, paper-based, and digital intervention formats in terms of their appropriateness for the Georgian HIV care context. Session-based approaches were viewed as potentially useful for older age groups and for building trust through direct interaction, but participants also noted that group-based formats may be uncomfortable for some individuals and that the quality of facilitation would be critical. As one participant noted, “Older patients may prefer talking to someone directly rather than using a phone or computer” [52-year-old female, provider]. At the same time, others observed that “group discussions may not be comfortable for everyone, especially when the topic is very personal” [35-year-old female, provider]. Paper-based materials were considered easy to distribute and potentially useful for people with limited access to digital resources, but were generally viewed as less effective because participants felt that such materials are often not read carefully and may be too passive to support complex decision-making. One participant noted that “people often receive brochures but do not actually read them” [51-year-old male, provider]. Digital interventions received the highest ranking score, compared with session-based and paper-based. Providers emphasized the accessibility, convenience, and appeal of digital tools, particularly for younger users, although they also noted that such tools should avoid overly technical language and may be less suitable for older adults or those with limited digital literacy. As reflected in the discussion notes, digital tools were seen as “easy to access” and “more suitable for younger age groups.”

In the PLWH NGT session, participants also compared the three intervention formats, but their preferences differed from those of providers. Session-based interventions received the highest ranking score, followed by digital interventions, while paper-based interventions received no support. Participants emphasized the importance of direct communication, trust, and opportunities to hear from others with similar experiences when discussing HIV disclosure. One participant explained that “it is easier to talk about these issues with someone who understands your situation” [34-year-old female, PLWH]. Session-based approaches were seen as especially valuable because they allow space for questions, shared experiences, and support during a highly stressful period following diagnosis. By contrast, paper-based materials were viewed as burdensome and unlikely to be read, especially when individuals are emotionally overwhelmed. As one participant noted, “when someone has just learned about their diagnosis, reading long materials can be very difficult” [55-year-old male, PLWH]. Digital interventions were recognized as offering privacy, anonymity, and broad accessibility, but some participants expressed doubts about the credibility of digital sources unless references were clearly indicated, noting that “people need to know where the information comes from in order to trust it” [48-year-old female, PLWH]. Across the discussion, participants emphasized that no single format would be ideal for everyone and that peer involvement should be an essential component of any intervention. As one participant summarized, “it is important to hear from people who have already gone through this experience” [40-year-old female, PLWH]. Ranking scores for intervention format from both groups are summarized in Table 1.

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Table 1. Ranking scores for intervention format by participant group.

https://doi.org/10.1371/journal.pone.0353949.t001

Selection of the most appropriate intervention and suggestion for adaptation

Among providers, the second ranking exercise focused on the three digital interventions. Two interventions were viewed favorably, but READY received the highest ranking score, narrowly exceeding DISCLOSURE, while “Who, When, How to Share” received substantially lower support. READY was preferred because participants considered it compact, clearly structured, and easier for users to complete in manageable steps. DISCLOSURE was also viewed positively, especially because of its visual and video components, but providers considered READY slightly more practical and adaptable. In the final adaptation discussion, providers emphasized that the selected intervention should address disclosure to different categories of people, including spouses or partners, family members, friends, and healthcare personnel. Particular importance was placed on disclosure to a spouse or sexual partner, which participants linked both to prevention concerns and to legal obligations in Georgia. As one provider noted, “Disclosure to a spouse or partner is especially important, both for prevention and because there are legal responsibilities involved” [65-year-old female, provider]. Providers also recommended including HIV-specific content on legal and legislative issues, access to legal consultation, post-exposure issues, patients’ rights, and available support services.

Among PLWH, the second ranking exercise focused on the three session-based interventions. Family disclosure DA intervention received the highest ranking score, while HOP and POP received lower scores. Participants expressed a clear preference for an intervention that begins with individual sessions, particularly during the period immediately following diagnosis, when people may not yet feel ready to discuss disclosure in a group. Individual sessions were viewed as allowing more personalized, confidential, and emotionally responsive support, even though participants acknowledged that such an approach may be more time-consuming. In the adaptation discussion, PLWH emphasized that the first sessions should remain individual, that peer educators should play a central role in delivery, and that the number and duration of sessions should be flexible. Participants explained that immediately after diagnosis many individuals need private time and space to process their situation before engaging in group discussions. As one participant noted, “At the beginning, it is easier to talk one-on-one. People may not be ready to discuss these issues in a group” [55-year-old male, PLWH]. They also highlighted the need for guidance on disclosure to family members, friends, and healthcare professionals outside specialized HIV services, such as general practitioners and dentists. As one participant explained, “Sometimes you do not know whether you should tell a dentist or another doctor about your HIV status, so clear guidance would be helpful” [43-year-old female, PLWH]. Additional suggested content included HIV-related rights and legal protections, treatment adherence, consequences of not initiating or discontinuing treatment, support services, management of medication confidentiality, and common misconceptions about HIV. Participants also noted that confidentiality can be challenging when family members are unaware of the diagnosis, with one participant explaining that “some people have to hide their medication at home if their family does not know” [48-year-old female, PLWH]. Ranking scores for interventions within the preferred format from both groups are summarized in Table 2.

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Table 2. Ranking scores for interventions within the preferred format by participant group.

https://doi.org/10.1371/journal.pone.0353949.t002

Following the two separate NGT sessions, a joint session was held with representatives from both groups to review the findings and reach consensus on the intervention to be adapted. The facilitator presented the intervention ranking results, the main points raised during discussion, and the intervention adaptation suggestions generated during the provider and PLWH NGT sessions. Participants noted that providers had placed greater emphasis on feasibility, accessibility, and scalability, whereas PLWH had emphasized trust, individualized support, peer involvement, and the emotional realities of disclosure decision-making after diagnosis. During the joint discussion, consensus emerged that the preferences of PLWH should be given priority because they represent the primary target population of the intervention. The group therefore selected the Family disclosure DA intervention as the final intervention for adaptation in the Georgian context. Participants considered this intervention most responsive to the need for individualized, flexible, and supportive decision-making around HIV disclosure.