PONE-D-20-04813

Low coverage of HIV testing among adolescents and young adults in Nigeria: implication for achieving the UNAIDS first 90

PLOS ONE

Dear Dr Ajayi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

We would appreciate receiving your revised manuscript by Jun 01 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Olanrewaju Oladimeji

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

In addition to the reviewers comments, the authors should keep the flowchart vertically downward and easure that the references are in vancouver square bracket.

Journal requirements:

When submitting your revision, we need you to address these additional requirements:

1.  Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at http://www.plosone.org/attachments/PLOSOne_formatting_sample_main_body.pdf and http://www.plosone.org/attachments/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please ensure that you refer to Figure 1 in your text as, if accepted, production will need this reference to link the reader to the figure.

3. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 4 in your text; if accepted, production will need this reference to link the reader to the Table.

 

[Note: HTML markup is below. Please do not edit.]

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

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

**********

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: No

**********

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: This article is a secondary analysis is publicly available data and establishes low HIV testing coverage among adolescent and young adults (AYA). The article is well written with logical presentation of its findings.

However, the bivarate analysis on table 2 seems not to add up. For instance, there were a total of 14312 eligible AYA. Of these, 3599 responded to ever tested for HIV which gives 25.1% (i.e. 3599/14312) but the tables shows "23.69%". The same is true for all the variables on table 2. Though minor, it would be helpful to either explain why there is a variation or correct the error if that is the case.

Secondly, table 5 show the multivariate logistics regression, is there any reason for adding variables that do not show any bivariate association (e.g. "knowledge of HIV; marital status") in the final model?

Reviewer #2: This paper presents an analysis of MICS data with respect to HIV testing coverage and associated factors among 15 to 24 yr olds in Nigeria. It is a timely analysis for Nigeria in the transition from 90-90-90 UNAIDS targets to 95-95-95 targets.

GENERAL:

1. Please check the tense in the Methods and Results. Best to use past tense for what was done and the results obtained.

2. Add "years" whenever age is mentioned eg 15-24 years, and not simply 15-24.

ABSTRACT:

1. Note and correct the transposition of MICS: Multiple Indicator Cluster Survey (not MCIS)

2. Would be important to add gender info to Abstract results ie stats on higher testing rates among girls than boys

3. "The HIV testing coverage among AYA in Nigeria is well below the national target of 95% testing indicated in the national HIV/AIDS strategic framework (2017-2021)." Suggest delete the word "testing" after "95%"

4. "reducing negative stigma belief through the media campaign". Suggest delete the word "the" and add "s" to campaign.

INTRO:The info is fairly well-written but noticeably devoid of actual epi numbers and the source refs.

1. The first, and especially second para narrate epi info but do not actually state the numbers. Please state and reference the actual epi numbers so that the reader is well-informed. At least, state and reference the actual data for sub-Saharan Africa.

2. Suggest: "AYA aged 15-24 years bear a disproportionate burden of HIV, particularly for new infections and AIDS-related deaths. In sub-Saharan Africa," ...State the proportions for SSA.

3. "Also, they are more unlikely (*suggest less likely*) to have tested for HIV, have the lowest level of adherence to ART and viral load suppression." As I stated above, please provide the actual numbers on likelihood of HIV testing, adherence, and VL suppression. Please do that for the rest of the Intro section.

4. Define WHO acronym at first use; no need to use the acronym since it is used only once in the paper. Similar for SSA...no need for the acronym; used only twice.

5. I strongly suggest replacing 90-90-90 definition with 95-95-95 and providing a reference for the definition. We are in 2020 and 90-90-90 is no longer relevant.

6. ...couples' (apostrophe added) open communication about HIV, expanding access to HIV testing and treatment, *as* well as having a social support network...

7. Suggest: *At 1.5%*, Nigeria has a low prevalence of HIV, but the country’s large population *of >200 million* (ref) means that the number of people living with HIV in the country is *substantial*.

8. *A significant proportion; up to xx%* of new infections occurs among adolescents and young adults in the country." Provide actual epi data and reference.

9. "Most studies on HIV testing among young people in Nigeria are not nationally representative or

are now *outdated* 4,5,16,26"

10. "As such, recent nationally representative data, such as the Multiple Indicator (no "s")

Cluster Survey (MICS) *(suggest capitalize first letters)*, could help assess current HIV testing rates among young people and progress recorded since the scaling *up* of such services in Nigeria."

11. Health Belief Model (capitalize first letters please)

12. Suggest deleting this sentence. Other adjacent statements send the same message in more formal language. "People can test for HIV knowing they could lead a normal and healthy life."

MATERIALS AND METHODS

1. Use the term fifth or 5th (superscript th)

2. Use past tense in Methods, including in Ethical Statement: We *did* not need...

3. Study Population:suggest "There were 52,690 MICS respondents (xx male and xx female). However, the focus of this study was AYA 15-24 yrs, who comprised 18, xxx (xx% out of all respondents), who met selection criteria. The analysis was further limited to 14, xxx AYA who responded to the questions on HIV testing".

4. "Our dependent variables of interest in this study are two two-category nominal measure of uptake

of HIV testing." Is the repeat of the word "two" a typo?

5. The demographic variable should be "formerly married" (not formally). Also correct that in the Tables.

6. Use quotation marks if variables are not in brackets: "The behavioural variables are "ever had sex" and "condom use".

7. The first question probed whether they *had* ever heard of AIDS.

8. with a score of 0-3 Categorised as low knowledge (use small c)

9. I believe term is household wealth, not house wealth? "The variable was already computed (delete "as")

before making the data public." "Model 2", not "Models 2"

10. "...who had low knowledge of HIV (12.4%%)"-delete second %

RESULTS

1. Again, please check your tenses and use past tense

2. it is also critical that regions of low *prevalence* are not neglected

3. (UDOH & USHIE, 2019)-please format this ref

4. "Undetectable Equals Untransmittable" best to write in quotes and capitalize first letters. It's a brand strategic message.

DISCUSSION

1. Study strengths and limitations: "the data is a cross-sectional" -delete "a"

2. Conclusions: The findings indicate a slight increase in the rate of HIV testing among young people in the country but the rate of increase however too slow and fell far short of the standard required to achieve the UNAIDS first 90 and the national goal of testing 95% of people in the country by 2020.-this sentence is too long. Please break it up for easier reading and comprehension.

3. A significant concern for this section is the lack of mention of age of consent and legal barriers to access to testing. Nigeria still has an applied age of consent to HIV testing of 18 years. There is however a 2014 National Consensus document that recommends age 14 yrs for the lower age of consent (Ref: Guidelines for Young Persons' Participation in Research and Access to Sexual and Reproductive Health Services in Nigeria). I strongly recommend a short narrative on this issue, making reference to the Child Rights Act, the 2014 consensus as above, some of the articles by Prof Morenike Folayan and colleagues on adolescent rights and access to SRH services, and the recent Bulletin of the WHO publication by McKinnon and Vandermorris: National age-of-consent laws and adolescent HIV testing in sub-Saharan Africa: a propensity-score matched study.

**********

6. 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.

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 #1: Yes: Okpokoro Evaezi

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

Low coverage of HIV testing among adolescents and young adults in Nigeria: implication for achieving the UNAIDS first 95

PONE-D-20-04813R1

Dear Dr. Ajayi,

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.

Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

With kind regards,

Olanrewaju Oladimeji, MB;BS, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Authors have addressed almost all the critical issues raised and the manuscript reads well

Reviewers' comments: