PONE-D-20-18756

Using repeated home-based HIV testing services to reach and diagnose HIV infection among persons who have never tested for HIV, Chókwè Health Demographic Surveillance System, Chókwè District, Mozambique, 2014–2017

PLOS ONE

Dear Dr. Lin:

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.

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We look forward to receiving your revised manuscript.

Kind regards,

Joseph K.B. Matovu, Ph.D.

Academic Editor

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

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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: No

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: It is a well written manuscript. The language is simple and easy to understand for readers. However, i believe that the manuscript could be technically more sound especially the methods section. Some steps in the methods section could be explained more vividly to give a better picture of how the study was conducted. Overall, the paper was a good attempt at explaining the HBHTS process.

Reviewer #2: The authors report a study titled “Using repeated home-based HIV testing services to reach and diagnose HIV infection among persons who have never tested for HIV, Chókwè Health Demographic Surveillance System, Chókwè District, Mozambique, 2014–2017”, a serial cross-sectional survey.

The authors cite a high background HIV prevalence in this setting and yet a large proportion ~ 40% of the PLWHIV have never accessed HIV testing and are therefore unaware that they are HIV-infected and not on readily available life-prolonging ART. This study sought to better understand how to bridge the access/utilization gap through a repeat home-based HIV-testing strategy.

With the benefit of survey data from four annual cycles, the research team was able to demonstrate that the highest risk categories of ‘never-tested’ in this study population were adolescents (both boys and girls) and adult men, relative to adult women. Reassuringly, the proportion of never-tested individuals decreased over-time in this relatively stable population; the majority ~ 90% accepted HIV testing and the HIV-positive yield decreased with time. The team concludes that the repeat home -based HIV-testing strategy improved HIV testing in Chókwè study area and recommend implementing similar HIV-testing strategies in high HIV-prevalence settings with low testing coverage, to increase HIV testing uptake and diagnosis among never-tested individuals.

This study presents crucial data to better understand effective HIV testing strategies to increase uptake, especially among those persons who have never been tested. In addition to the information value, the manuscript is well written, and therefore should be considered for publication. There were minor observations for consideration/clarification.

Methods:

1. Lines 111-114 need revision for grammatical typos..

Statistical analysis.

1. Lines 143-145. “The observed data were analyzed using SAS® (version 9.3, SAS Institute, Inc., Cary, North Carolina, USA) survey procedures that account for correlations among participants within a household following by a sensitivity analysis.”

a. It is prudent to indicate the survey method(s) used to account for correlations with citation where applicable.

b. Sentence needs revision re: grammar.

2. Lines 147-151. Please indicate the statistical method(s) used for the two sample comparisons of the proportions.

Results:

1. Lines 203-211. It would be interesting to know how many of those who self-reported never having had sex and accepted testing were HIV-positive?

2. Lines 212-213 need revision. Not clear.

Discussion:

1. Lines 242-249. The authors state in their discussion “These findings suggest that when HBHTS is repeated, screening for sexual risk behavior should be considered to avoid unnecessary costs associated with testing persons who are pre-sexual debut and are likely not to have not been exposed to HIV.”

This was overstated and not entirely supported by the data as presented. While, the authors write, “Among NTs aged ≥25 years (97% of whom had sex), the positive yield was ~20% …”, there was no mention of the HIV-positive yield among the 3% self-reported virgins? What about the adolescents who self-reported never had sex?

Additionally, self-reported sexual behavior variable has limitations (desirability bias), prone to misclassification of the intended construct. Caution should be exercised in making strong recommendations. Also, please note that there have been occurrences of young adolescents with no sexual experience who were unaware of their perinatally acquired HIV-infection. Lastly, the authors articulate in another section of the discussion about the potential behavior change benefits after a negative test, so it would be counterproductive to deny an HIV-screen test in this high-risk age group under the pretext of a self-reported sexual virginity.

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: PONE-D-20-18756_reviewer_comments.pdf

PONE-D-20-18756R1

Using repeated home-based HIV testing services to reach and diagnose HIV infection among persons who have never tested for HIV, Chókwè Health Demographic Surveillance System, Chókwè District, Mozambique, 2014–2017

PLOS ONE

Dear Dr. Carol Lin:

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.

This paper is well written and I would like to commend the authors for this. Here are a few minor comments that the authors need to address prior to acceptance:

1. Repeat HBHTS is a useful and powerful approach to reach non-testers. However, home-based HIV testing comes at a cost and most programs, including governments -- especially in LMICs -- might not be able to implement HBHTS without additional donor support. I suggest that the authors include a discussion around the cost of HBHTS vis-a-vis the scalability and sustainability of such programs in poor-resource settings.

2. The authors report that the HIV yield reduced from 13% in 2014 to 2% in 2015-17. Similar reductions were observed across sex and age-groups. I expected to see a clear discussion on why HIV prevalence declined significantly in the four-year period. Definitely, I would imagine that HBHTS is not the reason for the decline; so, what caused the decline? Even if the authors did not set out to explore why the HIV yield declined, it would be important to discuss what could have caused the observed decline in the HIV yield over time. Is it that HBHTS reached less risky individuals over subsequent rounds? Characteristically speaking, would the authors argue that NTs were generally a high-risk group (initially, e.g. in 2014) but that the demographic profile changed with continued repeat HBHTS?

3. Related to item 2 above; as the HIV yield reduces significantly, the cost per HIV-positive person identified increases subsequently. I think this aspect should be discussed along with the authors' response to item 1 above.

4. In line 243, the authors should use 'were' in place of 'was' after '...high prevalence settings...'

5. In lines 256-57, reference is made to 6% during 2017 but in lines 218-19, this percentage is given as 5%. The authors should harmonize these figures.

Please submit your revised manuscript by October 14, 2020. 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.

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). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

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,

Joseph K.B. Matovu, Ph.D.

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 #2: 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 #2: Yes

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

Reviewer #2: 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 #2: Yes

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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 #2: 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 #2: (No Response)

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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 #2: No

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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 PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

PONE-D-20-18756R2

Using repeated home-based HIV testing services to reach and diagnose HIV infection among persons who have never tested for HIV, Chókwè Health Demographic Surveillance System, Chókwè District, Mozambique, 2014–2017

PLOS ONE

Dear Dr. Carol Lin,

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 October 23, 2020. 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.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor. You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

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,

Joseph K.B. Matovu, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

I would like to thank the authors for adequately responding to my comments.

As we move to the finishing line, the authors should now pay attention to the following errors in the 'References' section:

1. PLoS ONE uses the Vancouver style while formatting references. The authors should check refs 9,27, 39 and 43 and ensure these are well aligned to the journal's referencing style. The authors may find it helpful to visit this link for additional information: https://journals.plos.org/plosone/s/submission-guidelines#loc-references 

2. In ref 40, the journal name is not provided.

3. The authors should ensure that journal names are written in a consistent way, for example, in ref 4, the journal name is given as "PLoS One"; while in ref 8, the same journal is given as "Plos one". The authors should check other journal names to correct them accordingly.

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Reviewers' comments:

[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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Using repeated home-based HIV testing services to reach and diagnose HIV infection among persons who have never tested for HIV, Chókwè Health Demographic Surveillance System, Chókwè District, Mozambique, 2014–2017

PONE-D-20-18756R3

Dear Dr. Carol Lin:

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.

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Kind regards,

Joseph K.B. Matovu, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: