PONE-D-20-16385

Factors influencing use of early infant diagnosis of HIV services in Greater Accra, Ghana: a qualitative study

PLOS ONE

Dear Dr. Ankrah,

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 Aug 14 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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We look forward to receiving your revised manuscript.

Kind regards,

Emma Sacks

Academic Editor

PLOS ONE

Additional Editor Comments:

This is an important topic, but a number of edits are required to strengthen the analysis methods and presentation of results. Please see the comments below and from the reviewer. Thank you.

Overall, a nicely done study which addresses an important issue of EID, but many revisions are required.

• The section on “consequences after disclosure” needs to be rewritten to answer the primary question about barriers to EID services. Does the disclosure dissuade people from testing? If so, this needs to be supported with data. Similarly, does the “attitude of health workers” encourage earlier care seeking, or does it discourage seeking later?

• Given that there are only 2 hospitals and the authors are comparing practices, consider using pseudonyms. Further, are there funding/resource differences between the hospitals? It would be good to understand better why one hospital was able to innovate more than the other.

• Is it better to discuss risk reduction rather than prevention of transmission where possible

• Is the timing of the 6 week visit aligned with a vaccine visit?

• Line 68: please define “HIV advancement”

• Not only are only 54% of exposed infants tested, but an even smaller percent receive results

• Line 96: what is the age range of this prevalence?

• What is “Models of hope”? (text and tables)

• Can you please format the table to be smaller (should fit on less than one page)?

• If the participants were only those who were enrolled in PMTCT, there may be bias because those who disengaged from care or did not seek care are not included. Please be sure to include this is the limitation.

• If the sample size was determined by evaluating data saturation, then was data analysis conducted simultaneous to collection, or was another process like interim debriefings used?

• 15-20 min is very short for an interview. Can the authors explain why so short, and perhaps include this in the limitations.

• Line 130 please list the languages

• Lines 224-226 should be moved to the discussion

• Line 244: was the “policy” on testing at birth something decided by each facility, or something happening commonly across the region/country?

• WHO has recommended that official birth testing programs only begin once a 6 week program has been well established; are there concerns about the impact of birth testing on the 6 week program

• Some studies on birth testing should be cited: for example:

o https://pubmed.ncbi.nlm.nih.gov/27540110

o https://pubmed.ncbi.nlm.nih.gov/32183751

o https://pubmed.ncbi.nlm.nih.gov/32329186

o https://pubmed.ncbi.nlm.nih.gov/32520911

• Line 284: instead of “the study” please say who pointed out the barrier

• Line 308: which clinical symptoms are cognized by families? And at what age of infants?

• Line 345: this is unclear if there is a cost or not. Similary, in line 474, was the only cost about transport or are there other costs?

• Line 351-353: this could be clearer: is the barrier only about the importance of testing, regardless of finance? This seems to contradict the previous.

• Line 390: the information about cleaners and driver is new information, so should first be in the results before the discussion.

• Line 391: what similar findings? From where?

• Line 413: the use of the word “average” is too quantifiable for this paper. Better to say something like “many people reported”

• Line 452: presenting with clinical symptoms may be too late; it would be helpful to understand more about the severity of symptoms and age of presentation

• Line 457: how do women manage testing and treatment when they have not disclosed?

• Like 460: what about other family members, for example grandparents?

• Line 482: may want to cite additional literature about “Respectful care”

• It’s a nice finding that the staff have been able to be creative; perhaps this could be further emphasized in the discussion.

• Please be careful when citing a rate – not every prevalence is a rate

• Citation #32 should be replaced with a peer review article, for example: https://linkinghub.elsevier.com/retrieve/pii/S2352-3018(19)30033-5

• While this is not a quantitative study, it is helpful to include a bit more about when the respondents fully agreed vs where there was more disagreement

• The paper requires some grammar editing; there are many sentences which should be more clearly written for a scientific publication

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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: No

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

Reviewer #1: N/A

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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

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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

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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 authors explore an important and current issue in on-going battle against HIV: ensuring the service capacity and patient uptake of early infant diagnosis. Overall, the article needs great improvement to clarify the methods of analysis, central objectives, and how the categories of results presented connect to an overarching thesis. It will be a lot of work, but this is an important topic, so I hope the authors are up for the challenge. The major revisions I suggest are:

Intro

1. The data on lowering the risk of MTCT with pre-natal ART is not clearly connected to the central topic of the paper: ensuring EID after birth. The statistics on MTCT in the abstract and the intro get confusing, and I would recommend establishing a stronger focus on EID right at the beginning.

2. The intro could be strengthened with some review of the literature from other sub-Saharan African countries. Much of this is reviewed in the discussion. I would recommend moving some of the literature to the intro that helps establish the goal of the paper and lays out what is already known on health care and maternal factors and why the context of Ghana might be different and in need of further study.

3. The final sentence in the intro states the goal of the study. I am wondering about the word “use” as it does not seem as if the authors are looking at EID use only, but also functionality of services. Indeed, it is unclear how many of the themes in the results relate to use (e.g. Do you have evidence that the availability of logistics and supplies is affecting use?) I would carefully reword this objective sentence and ensure that all results clearly relate to the stated objective.

4. There is also an important distinction between initiating EID and completing the full EID cascade. Please describe the EID cascade according to Ghanaian guidelines and clarify which outcome (initiation or completion) relates to the literature you review and the objective of your study.

Methods:

5. There are many essential details of the methods missing. I strongly recommend the authors reference the COREQ checklist in their reporting and include the checklist in their resubmission. http://cdn.elsevier.com/promis_misc/ISSM_COREQ_Checklist.pdf. Importantly, the authors need to be more about what qualitative approach was used (Was there a theoretical framework? Did the authors intend use grounded theory or to build a theory?)

6. The authors state they used purposive sampling, but not the criteria that guided the sampling. How was it purposive? Was there a specific type of purposive sampling you employed (e.g. maximum diversity, criterion, etc.) What sort of representation were you aiming to achieve? Was there other formal eligibility criteria (e.g. age).

Results

7. I recommend reworking the results section once the objective and theoretical framework are clarified. Each sub-section of the results needs to clearly feed into the central objective. Right now, it if unclear how certain sections work into the goal of assessing facilitators and barriers of EID use. For example, “Lost to follow-up” seems more like a consequence, not a barrier/facilitator; “Disclosure of HIV status” is not clearly connected to EID in the data presented

8. I’m unsure if the quote in “Denial of HIV Status” is saying that this is a barrier or a facilitator of EID.

9. I would recommend if the “Adequacy of skilled staff” section remains to clarify that you are assessing perceptions of adequacy of skilled staff, not actually using any formal criteria.

10. How does the turnaround time relate to the steps in the EID cascade? The months of waiting referenced- was for a final result (and completion of the cascade) or for the result of the more recent test? There is a big difference here.

Discussion:

11. Please include a Limitations section

12. I am curious why the authors chose the subheading for the Discussion as they do not correspond to the stated goals of the study nor the organization of the results section.

13. There are often some results stated in the Discussion that were not stated in the Results section. Please ensure the Discussion interprets results already reported and does not bring in new findings.

14. Consider reviewing the following recent literature that gives more depth into:

o System-level interventions for EID

� Finocchario-Kessler, S., Gautney, B., Cheng, A., Wexler, C., Maloba, M., Nazir, N., Khamadi, S., Lwembe, R., Brown, M., Odeny, T.A., Dariotis, J.K., Sandbulte, M., Mabachi, N., Goggin, K., 2018. Evaluation of the HIV Infant Tracking System (HITSystem) to optimise quality and efficiency of early infant diagnosis: a cluster-randomised trial in Kenya. Lancet HIV. https://doi.org/10.1016/S2352-3018(18)30245-5

� Schmitz, K., Basera, T.J., Egbujie, B., Mistri, P., Naidoo, N., Mapanga, W., Goudge, J., Mbule, M., Burtt, F., Scheepers, E., Igumbor, J., 2019. Impact of lay health worker programmes on the health outcomes of mother-child pairs of HIV exposed children in Africa: A scoping review. PLoS One. https://doi.org/10.1371/journal.pone.0211439

o Complexities of the EID Casade

� Mofenson, L. M., Cohn, J., & Sacks, E. (2020). Challenges in the Early Infant HIV Diagnosis and Treatment Cascade. JAIDS Journal of Acquired Immune Deficiency Syndromes, 84, S1-S4.

o Motherhood identify and EID completion

� Hurley, E. A., Odeny, B., Wexler, C., Brown, M., MacKenzie, A., Goggin, K., ... & Finocchario-Kessler, S. (2020). “It was my obligation as mother”: 18-Month completion of Early Infant Diagnosis as identity control for mothers living with HIV in Kenya. Social Science & Medicine, 112866.

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Reviewer #1: No

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PONE-D-20-16385R1

Factors influencing the delivery and uptake of early infant diagnosis of HIV services in Greater Accra, Ghana: a qualitative study

PLOS ONE

Dear Dr. Ankrah,

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 Dec 10 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.
  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,

Emma Sacks

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

The authors have done a commendable job in addressing the reviewer and editor comments. The objectives and overall focus are much clearer. However, there are some additional minor points to address. Please see the further comments from the reviewer. In particular, it is unclear if the authors used the COREQ checklist, and we feel it would be helpful for ensuring that the various aspects of qualitative methodology are covered.

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

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)

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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: N/A

**********

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

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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

**********

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 see that the authors have made many revisions to their manuscript. I especially appreciate the clarification of the objective and the reorganization of the intro, results, and headings of the discussion. I have some new comments on the draft and am requesting some clarifications on the responses to my original comments:

New comment: It would be wonderful if the new objective was reflected in the abstract.

New comment: Second paragraph of the discussion, it is not clear to me if you are suggesting the WHO revise it’s guidelines? I would word this carefully, as your data does not directly suggest guidelines should be revised, but that people are practicing earlier testing in other settings and calling into question the guidelines.

New comment: Please reflect on the generalizability of the findings. You allude to limitations of generalizability in the mothers you sampled. Was there anything about the health care workers or sites you collected data from that allows or doesn’t allow you to generalize results to other settings/populations? Expand on any limits to generalizability in the limitations section.

New comment: The discussion is much improved, but still lacks some key take-aways in terms of public health recommendations. Some of the literature I suggested in my previous comment #14 on system-level interventions might be worth reflecting on, or any other comments the authors want to make about what their findings mean for developing better EID systems.

Original comment #2: The intro has been much improved, especially since the objective has now been widened to include “facilitators and barriers”. However, the authors need to point out the gaps in the literature that their study sought to address. If all of this is known about facilitators and barriers to EID, why conduct the study? It may be that simply no study like this has been conducted in the Ghanaian context, in which case, the authors should point out.

Original comment #4: When I asked for clarification of the outcome, I meant the health behavior outcome of interest in this study. I see you said “the obvious outcome is therefore the completion of the cascade” but it does seem like most of the research inquiry is focused on general uptake of EID (beginning the process). I think that would be important to clarify that you were interested in facilitators and barriers both to initiating EID and to completing it once started. Adding details of the EID cascade into the text would be helpful too- the end of the first paragraph of the introduction is currently misleading in making it seem like the virologic test within 4-6 weeks is all that encompasses EID.

Original comment #5: I don’t see the checklist but perhaps the editor does. In any case, it does look like the authors incorporated much of these criteria. Thank you.

Original comment #6: I appreciate the authors saying they used “criterion sampling” but it would be beneficial to understand what the criterion was they were sampling on (mothers with certain characteristics, experiences…?) Saying you used criterion sampling is good, but you need to go a step further and elaborate on the criteria applied. You also mention “eligibility criteria” so should define that somewhere as well.

Original comment #7: The section looks better, but the quote is still a little difficult to comprehend (“so they seeking treatment…”). Can the syntax be improved? (perhaps “so [the idea of] seeking treatment…”)

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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

[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.]

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.

Factors influencing the delivery and uptake of early infant diagnosis of HIV services in Greater Accra, Ghana: a qualitative study

PONE-D-20-16385R2

Dear Dr. Ankah,

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,

Claudia Marotta

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

dear authors congratulations

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: N/A

**********

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: Thank you for addressing my comments adequately. I believe this manuscript is now suitable for publication.

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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.

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