PONE-D-20-24729

Access to HIV-prevention in female sex workers in Ukraine between 2009 and 2017: coverage, barriers and facilitators

PLOS ONE

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Zixin Wang, PhD.

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

Reviewer #3: Yes

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

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

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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

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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: No

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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: In this study, the authors carried out a comprehensive literature search, a document analysis, and a quantitative analysis of survey data collected between 2009 and 2017 to identify factors associated with the access of HIV prevention in Ukraine sex workers. The topic is significant, and the description of methodological details are sufficient. However, I find that the current form of the manuscript is rather lengthy. Specifically, it is difficult to understand how the document search of the Ukrainian prevention package relates to the other objectives. Only very basic bivariate-level descriptive analysis was used to analyze the survey data. Please see below for my specific comments.

Major comments:

1. Four objectives were stated in this study, which can be distracting. I find the essential question of this study is to assess the coverage of PP in Ukraine over time and understand factors associated with the access. The development of a conceptual framework, rather than presenting it as a separate objective, can be considered as the necessary step of literature review for identifying putative factors of interest.

2. How is the document search relates to the analysis of the questionnaire data? I think it can be more clearly explained.

3. The authors repeatedly used “factors that influence” access to PP throughout the manuscript. However, limited by the current cross-sectional design and bivariate analysis, I think such wording infers a causal relationship and should be revised to “factors associated”.

4. About the sampling design, it seems that the surveys are conducted independently of each other. Is it possible that one respondent was selected multiple times? Any identifier that can explore this issue?

5. Regarding the survey question design, to what extent are the questions comparable? If the questions are designed in similar ways and there are ways to uniquely identify the participants, one way to improve the analysis is to pool the data together, and include calendar year as an independent variable to test the effect of calendar year. If one individual is sampled multiple times, multilevel analysis can be considered by treating the individual as a level two variable. The study in its current form is a rather scattered analysis of survey data conducted in different years. Given that these surveys essentially adopted a non-probability sampling approach, any conclusions regarding trends or trajectory are weak.

6. In the variable selection section, only the outcome variables were described. Independent variables should also be systematically presented in the Method section.

7. To understand factors associated with access, rather than presenting a big table of descriptive analysis by group, the authors may consider using multiple logistic regressions. The outcome variable should be whether access to PP, while the independent variables should be a selection of variables investigated in Table 3.

8. If I understand correctly, measures of the macrostructural factors are all obtained from individual-level response. They are not upper-level objective measures and are subject to measurement bias. In general, these independent variables need to be much more carefully presented and discussed.

9. Did the authors obtain ethical approvals as human subjects were involved?

Minor comments:

1. Objectives do not need to be presented as a separate section.

2. In the Introduction, the WHO guideline was published in 2014. The authors then stated that in 2006, the Alliance launched a PP in Ukraine adhering to WHO guidelines. The timeline is a bit confusing. Better to clarify.

3. What does it mean by “no missing data were excluded”. Are there missing values?

Reviewer #2: The authors of this manuscript managed to present the overall picture of access to HIV-prevention among female sex workers in Ukraine over nearly a decade. After reading the manuscript, it is obvious that the authors have done extensive work and put in many efforts to explore the barriers and facilitators of access to prevention service in key populations. The manuscript is clearly structured and well-written, supported by literature, data and other materials indicating how the author performed the literature review and exploratory analysis. There are only several questions I would like the author to give a more detailed explanation.

1. In method, the author mentioned that the definition of extended PP receipt was adapted by increasing the timeframe. Is the any modification in the number of service received given the timeframe was longer in the new definition? The definition of extended PP receipt was not clearly stated either in the main document or in the supporting material. As far as I am concerned, even the package was different year from year, the number of service received should stay consistent, just like the UNAIDS definition (i.e. two service received in three months)

2. In method, the author suggested no missing data were excluded. Judging from the data, numbers of missing values were not indicated in the table. It would be great if the author could give further explanation about how the missing data were processed.

3. In results, the author compared characteristics between recipients and non-recipients, but there was no statistical testing. If possible, it could be great if the author could provide more statistical support for between group comparison.

4. In discussion, the authors mentioned the armed conflicts in the eastern Ukraine might affect the service coverage. It would be great if the author could brief us about the location of sampling cities in method so that the audience could have a clearer understanding about the extent of the impact the conflicts had on the service coverage.

5. In discussion, the authors suggested GBV was more common in PP recipients than non-recipients. Yet, in the table, only data of the year 2013 and 2015 support this claim. It would be better if the author could provide data to better explain this statement.

6. Besides, the authors showed that consistent condom use and GBV were both more prevalent among PP recipients, meanwhile suggested FSW experienced GBV may be less inclined to seek condoms. These two facts contradicted with each other. It could be great if the author could settle this contradiction that why PP recipient which experienced more GBV than non-recipients displayed more consistent condom use behavior.

7. Given the fact that the current design and analysis were inadequate for a causal reference, the statement in discussion: “sex without a condom may impede access to the PP” sounds a little inappropriate.

8. Overall, this manuscript utilized longitudinal data from a series of national survey with about 5 waves. However, the “trend” of service coverage in this paper was not supported by testing for trends. It would be great if the author could provide more statistical evidence to support the description of coverage changes over the years.

Reviewer #3: Comments:

This paper has comprehensively described the access to HIV-prevention in female sex workers in Ukraine between 2009 and 2017: coverage, barriers and facilitators. While this article has provided numerous information including literature review, document analysis, exploratory analysis. The rich information is not easy to follow to generate a whole story to a specific research question. It has four objectives, which in my opinion is way too long for an article. The contents look more like a project report instead of one original research. I would suggest the authors to shorten the article and specify research questions instead of lump everything together and resubmit again.

Line 82, the reference is not right.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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Access to HIV-prevention in female sex workers in Ukraine between 2009 and 2017: coverage, barriers and facilitators

PONE-D-20-24729R1

Dear Dr. Blumer,

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.

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Kind regards,

Zixin Wang, 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: (No Response)

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 #1: (No Response)

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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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: 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 #1: Yes

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 #1: My comments have been adressed very well by the authors and the manuscript has improved a lot. I have no further comments.

Reviewer #2: The authors addressed all my comments. Though it remained confusing that PP-recipients experienced higher gender-based violence as well as showed higher condom use behavior, the authors stated clearly that further study is warranted particularly for this phenomenon. Hopefully further research will be conducted to address this problem.

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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