PONE-D-19-32681

Noncommunicable disease burden among Key Population on Care and Treatment: a retrospective cross-sectional analysis of HIV-care outcomes from the Sex Workers Outreach Program in Kenya, 2012-2015

PLOS ONE

Dear Dr. Achwoka,

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PLOS ONE

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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: Partly

Reviewer #2: Yes

Reviewer #3: Partly

Reviewer #4: Partly

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: 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: No

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

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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

Reviewer #3: Yes

Reviewer #4: 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: This paper show an interesting topic and information on NCD among key population living with HIV in Kenya. It shows a relatively high prevalence of NCDs in this population. The data is valuable but some aspects of the analysis and presentation of results are very unclear to me at present and require substantial improvement. I am also not convinced yet why the data cannot be share for publication with the reason explained. However, I found it is required a major revision with some initial comments and would like to see the revise version for additional comment.

Overall comments:

1- You may read the submission guideline of Plos One and adjust your manuscript organization as suggested such as page and line number, abbreviation used in abstract, and then resubmit it

2- I feel hard to give the specific comment because the manuscript miss the line number in page 1 to page 13

Specific comments:

1- I think the title of the paper is interesting. However, you may consider making it simpler and easier to catch up.

2- In your abstract you may consider to used less abbreviation as suggested by the submission guideline of Plos One

3- You used the team "HIV-infected Key Populations" in some lines it make reader confused. You may use the other term such as key population living with HIV or HIV positive key populations.

Reviewer #2: The research provides some interesting infos about NCDs burden in HIV+ KP.

Some minor revision to be made:

1. the abstract could be divided in sections to make it easier to read

2. among the limitations in the discussion section, maybe you could add something about the fact that it was not possible to diagnose hypertension according to international recommendations (3 measurements at the same time, etc...). It is clear that it was not possibile, but it would

3. I would suggest to add some other interesting papers to the references list, as:

a. Ibrahim MM, Damasceno A. Hypertension in developing countries. The Lancet. 2012;380(9841):611-9.

b. Mbanya JC, Squire S, Cazap E, Puska P. Mobilising the world for chronic NCDs. The Lancet. 2011;377(9765):536-7.

c. Bloomfield GS, Hogan JW, Keter A, Sang E, Carter EJ, Velazquez EJ, et al. Hypertension and Obesity as Cardiovascular Risk Factors among HIV Seropositive Patients in Western Kenya. PLOS ONE. 2011;6(7):e22288.

d. Ciccacci F, Tolno VT, Doro Altan A, Liotta G, Orlando S, Mancinelli S, et al. Non communicable diseases burden and risk factors in a cohort of HIV+ elderly patients in Malawi. AIDS Res Hum Retroviruses. 2019.

With this minor revision, I think the paper is valuable to be published, as provides new results for a particular group of patients that should receive more attention by the public health programs, also from and NCDs point of view.

Reviewer #3: This is great piece of work given the attention that HIV/NCD comorbidity is receiving currently especially in countries with high HIV burden undergoing rapid epidemiological transition. The manuscript presents a clear and transparent research process with results emanating from appropriate analyses.However, the author is advised to consider making the following changes to improve manuscript readability and technical soundness.

Comment 1: Table headings ought to be in uniform format. Table 1 and Table 2 headings appear to have inconsistent formats.

comment 2: Table 2 column N should be described either by a footnote or by column heading to avoid confusing the reader with another N=271. Table 3 footnotes should be numbered consecutively:1,2,3 and not 2,2,3.

Comment 3:Could you please make the last columns for Table 2 wider in order to cover confidence intervals in one line other than two lines as is the case now?This would help your Table 2 look tidier.

Comment 4:The sentence in line 53 could read better if you removed "albeit" and replaced "comparable" with "comparably".

Comment 5:Please interpret statistically significant odds ratios in univariate analyses.Also in line number 35,"unadjusted model" should be changed to unadjusted analyses or univariate analyses since this is not one model perse, all variables assessed in univariate analyses represent individual univariate logistic models.

Comment 6: A sentence in line 37 reads "When the model was adjusted, all prior significant associations between NCD diagnosis and increased age, unemployment status, BMI and CD4 ceased"

Consider changing this sentence to "even though increased age, unemployment status, BMI and CD4 were associated with NCD diagnosis in unadjusted analyses, they were not significantly associated with NCD diagnosis in the multivariate,adjusted analyses".The authors should also explain why variables with P> 0.2 such as sex, alcohol use and smoking were included in the multivariate model as this is not consistent with their analysis plan in which an automated stepwise backward logistic regression approach was selected to build a multivariate model to determine predictors for NCD prevalence from

independent predictors of NCDs with a p-value of 0.2 or less in univariate

analyses.

Comment 7: The author should consider adding references to his claim in line number 89 "Studies have

90 documented harmful consumption of alcohol, smoking tobacco, illicit drug use, and risky sexual behaviors

91 among KPs as factors that increase their risk for NCDs."

Comment 8: The author tries to contradict ealier research findings that they did not find an association between ART use and NCD prevalence in line number 66. This should be avoided as the study was not designed to show association between ART use and NCD prevalence since the study enrolled no participants without exposure to ART .On the same note,the author also reports lack of association between NCD and detected viral load.In this study, at no point were viral load measurements reported. Therefore such claims are not supported and should be removed from the manuscript.

Comment 8: The author should remove any references in the conclusion section of the manuscript.

Reviewer #4: The empirical analysis is competent, and the authors reference much of the relevant literature. A review on NCDs among key populations (KPs) is generally valuable, in light of concerns on the burden of NCDs among PLWH in general and specifically of the role and specific needs of key populations.

My reservations on publication of the paper in its present form primarily regard two aspects:

First, does the paper provide an analysis on NCDs among KPS? Not really. 94 percent of the sample are FSWs, and only 6 percent (n=86) MSMs. 86 percent of the cases of NCDs (total NCDs: n=271) are instances of high blood pressure (n=233), and the number instances of chronic respiratory disease (n=16) or cancers (n=10) do not allow a substantial empirical analysis. Against these numbers, is puzzling why much of the paper is cast in terms of "NCDs" among KPs – it really is about high blood pressure among FSWs, and – because implications and determinants of NCDs arguably differ – focusing the empirical analysis on instances of any NCD blurs the lessons which could be learned.

Second, are there any useful findings? Note sure – the results broadly mirror the empirical evidence on risk factors for hypertension – prevalence is increasing with age and with BMI. Other factors appear irrelevant (this could be tested more explicitly – do factors pervasive with respect to key populations play any role?). However, we would also want to understand whether prevalence of NCDs differs from prevalence in the general population. Doing such a comparison explicitly is beyond the scope of this paper (sample on KPs only), but the authors do not exhaust possibilities on comparing their findings with data on the general population (e.g., from DHS and related data). Relatedly, what is the relevance of the findings with regard to the management of HIV or NCDs among key populations?

Minor points:

It is not clear on what basis variables have been excluded in the multivariate analysis (Table 4). Excluding ART regimen and prior TB history appears sensible (p-value>0.9 in univariate regression), but there are numerous other variables with p-values in the vicinity or 0.7 or 0.8 in the multivariate analysis which are included in the regression.

Table 4: Review p-value of 1.11, BMI 30+ adjusted odds ratio.

In a couple of places, I felt that the paper would benefit from a round of copy-editing to improve precision.

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Reviewer #1: Yes: Pheak CHHOUN

Reviewer #2: No

Reviewer #3: Yes: Blessings Gausi, MD MPH.

Reviewer #4: No

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PONE-D-19-32681R1

High prevalence of noncommunicable diseases among Key populations enrolled at a large HIV prevention and treatment program in Kenya

PLOS ONE

Dear Dr. Achwoka,

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.

Please submit your revised manuscript by Jul 11 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're 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.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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

We look forward to receiving your revised manuscript.

Kind regards,

Joel Msafiri Francis, MD, MS, PhD

Academic Editor

PLOS ONE

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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: (No Response)

Reviewer #2: All comments have been addressed

Reviewer #4: (No Response)

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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

Reviewer #2: Yes

Reviewer #4: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #4: 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: No

Reviewer #2: No

Reviewer #4: No

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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: No

Reviewer #2: Yes

Reviewer #4: 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: Many thanks for your revision. I found a great improvement with the revised version. To move on further process, I am suggesting for a few more minor revisions as described below;

1- I think you should remove capital letter of “Key populations” in the title and a few other places in the manuscript

2- I think you should add in text citation and reference for first sentence in the second paragraph (line 51-53).

3- I think you should use less human possessive term in the manuscript. You should make the language use to more academic. You should consider removing those words such as in line 72 “we only…”, line 107 “Our analyses”, line 136 “We analyzed”, line 216 “Our proxy”, line 270 “our study”, line 271 “In our study”, line 274 “ours among”, line 286, line 289, “in our study”, line 295 “we…” … “our”… please check for the rest and you may use term “this study” to replace “our study”…

4- Do you have any rational why age, gender, alcohol use and smoking were considered as priori as potential confounder? Any learning from other literature?

5- In line 274, you mention “studies similar to ours among…” it seems does not fully completed yet.

6- At the end of the data collection or the starting of data analysis, you may add another sentence indicating that data is cleaned and imported into Stata for data analysis.

7- In the data analysis, you may need to also describe how will you report the result of of the analysis such mean, median, SD, 95% CI… and abbreviate any possible term here than you don’t have to write full word in the result (eg. in line 160, 95% confident interval (CI)).

8- In line 136-138, I think this seem reported the data collection and analysis section. You may start directly reporting the result of analysis to be concise.

9- In line 139, I think you can use abbreviation of FSWs and MSM as they been abbreviated already in the introduction. You may also need to check other line to make it consistent.

10- Could you please add concrete list of inclusion / exclusion criteria for administer abstracted data? I found pieces of information from line 85 to 90 but not so convinced yet.

11- I still would like to suggest, the author consider to discuss their finding with the other studies such as “High prevalence of non-communicable diseases and associated risk factors amongst adults living with HIV in Cambodia” and/or “Non-communicable diseases and related risk behaviors among men and women living with HIV in Cambodia: Findings from a cross-sectional study” because I found this study is quite similar in some setting this study participant are people living with HIV even it focus to key population.

Reviewer #2: The authors considered and addressed all the comments. The concerns related to the availability of data have been clarified.

Reviewer #4: The authors provide competent and diligent responses to reviewers' comments, specifically those by myself but also (according to a cursory overview) those from other reviewers.

One - I believe - important shortcoming remains. The authors do not provide a substantial discussion comparing NCDs among key populations (KPs) with the prevalence of NCDs in the general population or among PLWH overall. Understanding these differences, though, would be important for interpreting the findings and drawing policy-relevant conclusions. Are there factors specific to KPs driving high prevalence of NCDs? The findings suggest that this may not be the case, as pointers for risk behaviour come out largely insignificant (the statistically significant variables are age and BMI 30+). A pointer to the findings of the paper referred to in the response to comments (Noncommunicable disease burden among HIV patients in care: a national retrospective longitudinal analysis...), with some author overlap with the present paper, would also contribute to placing the findings of the present paper in context, and I find it puzzling to see that the authors do not make such connections.

This shortcoming may not preclude publication, as the analysis per se is competent, but the value of the paper is clearly diminished by the authors' reluctance to place their findings in this wider population or PLWH context.

On the editorial side, I sense that while the language is clear throughout, the paper would benefit from one round of professional copy-editing.

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Reviewer #1: Yes: Pheak Chhoun

Reviewer #2: No

Reviewer #4: 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.]

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High prevalence of non-communicable diseases among key populations enrolled at a large HIV prevention and treatment program in Kenya

PONE-D-19-32681R2

Dear Dr. Achwoka,

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

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. 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 help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- 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.

Kind regards,

Joel Msafiri Francis, MD, MS, PhD

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

Reviewer #2: All comments have been addressed

Reviewer #4: 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

Reviewer #2: (No Response)

Reviewer #4: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: (No Response)

Reviewer #4: 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

Reviewer #2: (No Response)

Reviewer #4: No

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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

Reviewer #2: (No Response)

Reviewer #4: 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: I would like to thank the authors for considering the comments and revised the entires manuscript according. I have any specific comment to the manuscript in this round. Well done and should be off for the hard work.

Reviewer #2: (No Response)

Reviewer #4: The draft now reads much better, thanks also to the very thorough and specific comments from reviewer #1, and is fit to see the light of day.

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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.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: No

Reviewer #2: No

Reviewer #4: No