Study design and population
This cross-sectional study was nested within a larger mixed-methods study conducted among healthcare workers (including PHC doctors and nurses) that assessed HIV stigma and other barriers to COVID-19 vaccine uptake among Georgian PLWH across Georgia, including the capital, Tbilisi, along with five major regions, such as Kakheti, Imereti, Guria, Samegrelo, and Ajara [20]. The original study employed a purposive sampling to recruit participants identified by the Ministry of Health of Georgia (MoH), based on their professional roles (including primary care doctors, primary care nurses, infectious disease doctors, infectious disease nurses, COVID-19 vaccine providers, and healthcare facility managers), availability, and interest to participate in the study. Participants were recruited from relevant healthcare facilities including both primary and secondary healthcare facilities, located in the above mentioned regions.
Data collection
Data collection for the study was conducted by two interviewers between December 2021 and July 2022. Potential participants were initially approached by a representative of the MoH, who identified them based on their professional roles, availability and interest in participation and approached them at their respective health care facility. The MoH representative explained the aim and objectives of the study to the participants, obtained their preliminary verbal consent, and collected their contact information. Subsequently, the study interviewers contacted those who had agreed to participate to agree on the mode of the interview and to obtain formal written consent. The interviews were interviewer-administered and conducted via various online platforms, such as Zoom, WhatsApp, Viber, Skype, and phone calls, according to each participant’s preferred mode of communication. Interviewers used a 35-item structured questionnaire (supplementary file 1) which was developed as part of a larger interview within the broader mixed-methods study. The part of the questionnaire relevant for PHC providers was developed by adapting selected items from the HIV/AIDS Tool Kit [21], which has been used in multiple programmatic settings [22]. Specifically, we included 11 items from the HIV Knowledge: transmission-related questions assessed knowledge of HIV acquisition through behaviors such as unprotected oral sex, sharing needles, and receiving unscreened blood, as well as common misconceptions (e.g., transmission via bathing, mosquito bites, or shared utensils), while prevention-related items covered strategies such as abstinence, consistent condom use, and sterile injection practices. We also included 4 items assessing ART-related knowledge (including beliefs about whether ART prolongs life, cures HIV, decreases HIV transmission, and causes side effects), and 4 items addressing attitudes toward HIV service provision (e.g., whether HIV-positive clients should be separated from clients of unknown HIV status, perceived risk of HIV transmission in clinical care, willingness to provide HIV care, and belief that primary care providers should care for HIV-positive clients). For our study, all items were translated into Georgian by bilingual experts and then back-translated into English to ensure accuracy and consistency. The items were reviewed by Georgian public health experts and HIV program specialists to ensure content relevance and face validity to the local context. In addition, the adapted tool was pilot tested with a small sample of healthcare providers (n = 5), not included in the final analysis), and minor adjustments were made based on their feedback to enhance clarity and contextual appropriateness. Participants received a 20 Georgian Lari (equivalent of 7$) incentive for completing the interview.
Measurements
The outcome variable, PHC providers’ attitude toward HIV service provision, was assessed using the statement: “Primary care clinicians should take care of HIV patients.” Participants responded on a five-point Likert scale: “Strongly disagree”, “Disagree”, “Uncertain”, “Agree”, and “Strongly agree”. As no respondents selected “Strongly disagree”, the outcome variable was treated as a four-point ordinal scale in the analysis, ranging from “Disagree” to “Strongly agree”, to reflect increasing levels of agreement that primary care providers should provide care to HIV-positive patients.
The independent variables included sex (male/female/other), age (calculated from the participant’s year of birth), region (self-reported by participants), and provider type. The latter variable was used to restrict the analysis to PHC providers, specifically doctors and nurses with direct contact with patients.
HIV knowledge was assessed using 11 questions on HIV transmission and prevention. Participants answered whether specific scenarios (e.g., unprotected oral sex, sharing needles, unscreened blood transfusions) could result in HIV transmission and whether certain actions (e.g., abstaining from sex, using new needles, consistent condom use) could reduce the risk of HIV infection. Original responses included “True,” “False,” or “I’m not sure.” For our analysis HIV knowledge was coded as “Have correct knowledge on HIV” if all 11 responses to the specified questions were correct, and as “Lacks correct knowledge on HIV” if at least one response was incorrect or uncertain.
ART knowledge was assessed using 4 questions about the benefits and limitations of antiretroviral therapy, including whether it helps people with HIV live longer, reduces transmission risk, cures HIV, or causes side effects. Original responses included “True,” “False,” or “I’m not sure.” For our analysis ART knowledge was coded as “Have correct knowledge on ART” if all four responses were correct, and as “Lacks correct knowledge on ART” if at least one response was incorrect or uncertain.
A specific discriminatory belief supporting the separation of PLWH from others was assessed using the statement: “HIV-positive clients should be separated from clients of unknown HIV status to protect uninfected clients.” Participants responded with “True,” “False,” or “I’m not sure.” This item was intended to measure discriminatory attitude toward PLWH in service provision contexts.
Perceived risk of HIV infection among PHC providers was assessed using the question: “How likely is it that a healthcare provider will become infected with HIV by providing care to an HIV–positive client?” Responses included “Very likely,” “Somewhat likely,” ““I’m not sure,” “Not very likely,” and “Not likely at all.”
Willingness to care for HIV patients was assessed using the statement: “I would like to take care of HIV patients while providing primary care.” Participants responded with “Strongly disagree,” “Disagree,” “Uncertain,” “Agree,” or “Strongly agree.”
HIV service provision practice was assessed through a series of questions regarding the types of services participants provided to PLWH. Participants were asked whether they have experience working with PLWH, whether they provide education services, testing and counseling services, referral to HIV treatment and care services, and HIV/AIDS treatment services. For each question, responses were “Yes” or “No.”
Statistical analysis
The sample size calculation for the parent mixed-methods study was done using OpenEpi v 3.03 with a 5% margin of error and 95% CI, considering the estimated size of the target population and setting the response distribution to 50%. By this method, it was determined that the recommended sample size for the original study was 345 healthcare workers. However, as our analysis was restricted to PHC doctors and nurses only (who had direct contact with patients), it resulted in a relatively smaller sample of 256 PHC providers. We estimated post-hoc power using a Monte Carlo simulation (1,000 replications) in Stata [23, 24], based on the observed effect sizes and a significance threshold of α = 0.05. The resulting estimated power was 99.4%, confirming that the sample size (n = 256) was adequate to detect moderate to large effects in the multivariable ordinal logistic regression model.
Descriptive statistics were computed to summarize participants’ demographic characteristics and key variables. The outcome variable, PHC providers’ attitude towards provision of HIV care was measured on a four-point Likert scale (from 1 = disagree that PHC providers should take care of HIV patients, to 4 = strongly agree) and treated as an ordinal variable. Bivariate ordinal logistic regression was conducted to examine the unadjusted associations between each explanatory variable and the level of agreement that primary care providers should provide care to HIV-positive patients. Multivariate ordinal logistic regression was employed to examine factors independently associated with the outcome variable. Sex, age, and professional category (doctor vs. nurse) were included in all models a priori as potential confounders, regardless of statistical significance. Additional variables were selected for inclusion in the model based on their statistical significance in the bivariate analysis (variables with p-values less than 0.05) and their relevance to the pre-specified hypotheses (e.g., the better ART knowledge the more positive attitude towards providing HIV care). Model building followed a forward selection approach, where predictors were added sequentially and retained based on theoretical importance and improvement in model fit, assessed using likelihood ratio tests and information criteria (AIC and BIC). The proportional odds assumption was assessed in preliminary models and was not violated. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were reported. The final model included sex, age, professional category, region, ART knowledge, attitudes toward separation of HIV patients, and perceived probability of healthcare worker infection. Statistical significance was set at p < 0.05. Statistical analysis was performed in Stata version 16 [25].
Ethical considerations
Ethical approval
for the study was obtained from the Georgian National Centre for Disease Control and Public Health (certificate IRB00002150), ensuring that all research procedures adhered to national and international ethical standards. Strict measures were taken to protect the confidentiality and privacy of all participants. Informed consent was obtained from each participant prior to their inclusion in the study, with assurances that their data would be handled with the utmost care and used solely for research purposes. The study’s ethical framework was designed to ensure that participants’ rights and well-being were prioritized throughout the research process.
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