PONE-D-19-23579

Trends and determinants of ever having tested for HIV among youth and adults in South Africa from 2005–2017: Results from four repeated cross-sectional nationally representative household-based HIV Prevalence, Incidence, and Behaviour surveys

PLOS ONE

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PLOS ONE

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'This paper has been supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the CDC under the terms of 5U2GGH000570, U2GGH000357, and NU2GGH001629. Its contents a 348 re solely the responsibility of the authors and do not necessarily represent the official views of CDC.  Financial support was received from the Nelson Mandela Foundation and the Swiss Agency for Development and Cooperation for 2005 survey. Bill & Melinda Gates Foundation provided support for the 2012, while the United Nations Children’s Fund (UNICEF) funded the 2008, 2012 and 2017 survey. The South African National AIDS Council (SANAC), United States Agency for International Development (USAID), Soul City; LoveLife, the Centre for Communication Impact (CCI) provided funding for the 2017 survey.'

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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?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The work from this group and the national analyses they have conducted have been extremely crucial to understanding the HIV epidemic in South Africa and the impact of health policy changes on the HIV care cascade. While the data presented is regionally specific, the trends they demonstrate likely mirror other parts of sub Saharan Africa and thus the study may be of interest as it can likely be reproduced in other countries to develop a longitudinal understanding.

While the article is well written and the data are robust, I strongly believe that the paper can be substantially be improved by the addition of the following suggestion and an overall reframing on how this analysis can help us understand the impact of national health policy and make recommendations for future health policy priorities. Please see my specific comments below.

Introduction: In paragraph two the authors present a very generic discussion around barriers to testing and linkage to care. They further discuss that, “Although some studies found that individual factors affect uptake of HIV testing, some found mixed results that included factors relating to community, society and relationships’ type” This argument and sentence feels somewhat mis-placed since statics cross sectional population based surveys are unlikely to provide the depth to understand these associations.

What is missing and necessary is two things:

1. How has health policy around HIV testing, and LTC changed in South Africa for the last fifteen years - these authors are experts and should be able to pain the picture.

2. What is the benefit of this type of longitudinal analysis, has these been done elsewhere , has it changed policy, why did the authors write this paper?

Methods: Nil to add, well written and thorough

Results:

Table 1 and 2, are necessary and complete

Couple of comments:

1. The paragraphs under determinants of health is extremely dense and difficult to read and thus asorb. May be the authors should draw a conceptual model with the demographic and behavioral factors tested, with some color distinction for those with stronger associations and those with weaker associations. This would be more meaningful, than the paragraphs written.

2. While I like figure 1, it is too much data for the reader to absorb, also the figure need s to be edited – font/spacing etc so that it is more readable on a web-based platform.

3. I would love to see a graphical representation of the care cascade over time, I would also like to see and interrupted time-series analysis that high lights temporal impact of national policy roles outs and on the subsequent household survey. This should be before tables 1 and 2, and should show the big picture.

Discussion:

While the discussion is well written it could be further strengthened. The authors are presenting really rich data, and so should end the discussion with key policy recommendations. Maybe this is a summary box, that ties together the key findings from each paragraph.

Reviewer #2: This manuscript is well written and provides a descriptive analysis of trends and associations in ever HIV testing in South Africa.

Introduction

The introduction provides a sound rational for the study/analysis questions. The authors describe the multiple layers (individual, social, and structural) that influence HIV testing. Would consider grounding it in the eco-social framework for HIV transmission (Baral et al BMC Public Health 2013).

Methods

The methodology was well described, however it would be helpful to have additional information on the adjustments made for the complex survey analysis, and how missing data was handled.

The authors described DBS for HIV testing, but these results were not presented in the manuscript. If they were not used in the analysis, then I would limit the description of the HIV testing to a procedure that was done as part of the survey, but data from testing was not presented.

Results

The results were well described and the tables were easy to read.

For the multivariate analysis, all the odds ratios should be adjusted odds ratios given that there were multiple variables used for adjustment.

Minor point - there should be a space between 95% CI, it's missing for several lines in this part of the results.

Figure 1 is very blurry. It would also be helpful to included "Education" for "Secondary" and "Tertiary" for the model.

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Reviewer #1: Yes: b Hansoti

Reviewer #2: No

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Trends and determinants of ever having tested for HIV among youth and adults in South Africa from 2005–2017: Results from four repeated cross-sectional nationally representative household-based HIV Prevalence, Incidence, and Behaviour surveys

PONE-D-19-23579R1

Dear Dr. Jooste,

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

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

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With kind regards,

Florian Fischer

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

**********

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

Reviewer #1: Yes

**********

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

**********

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The manuscript is greatly improved thank you for making the suggested edits and modifying the discussion as suggested.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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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 #1: No