PONE-D-20-25254

Patterns of mobility and its impact on retention in care among people living with HIV in the Manhiça District, Mozambique

PLOS ONE

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'CISM is supported by the Government of Mozambique and the Spanish Agency for International Development

(AECID). ISGlobal acknowledges support from the Spanish Ministry of Science and Innovation

through the “Centro de Excelencia Severo Ochoa 2019-2023” Program (CEX2018-00806-S), and

support from the Generalitat de Catalunya through the CERCA Program.'

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Additional Editor Comments (if provided):

[From the editor]

Methods, line 102: Please describe your statistical power to detect associations between your independent variables and your outcome of interest (retained in care, right?). With 195 persons in each comparison arm, are you well powered to see differences in retention in care, should they exist?

Methods, line 132: This is an outcome (singular) not “outcomes” (plural), right? Or am I misunderstanding something here?

Methods, line 143: “response” variables is what? The outcome (i.e., “retained in care” – one outcome variable?) Or did you also look at mobility? Also you may have gone between self report and pharmacy records; kindly make this more explicit.

Methods, line 143: do not report results in methods (i.e., move “we found no clinically or statistically significant findings” to the results section – is this what you show on line 187?)

Table 2: What is the “other” category that makes up more than two thirds of those didn’t/couldn’t get ART at travel destination? Is it for the reasons explained in the text? Consider adding this as a footer, or making more table rows to clarify.

Line 187 (and stat analysis in methods): is your multivariable analysis have “retention in care” as the outcome, or “self-reported perceived challenges in accessing HIV care”? Or both? Please clarify this in the methods, and do show these results, as no difference (assuming you have power to detect a difference should one exist) is an important result for all these analyses you may be doing.

Results, line 193: What’s the difference between “Most (45%), stated they would prefer a 3 to 6-month dosing schedule, followed by a 3-month dosing schedule (33%),”? These two responses seem to overlap/ include each other, making interpretation of this response challenging.

Line 201+ and Table 4: I am confused about this outcome. Why is the N for Table 4 only 349? I recommend considering a trichotomous outcome regarding retention in care: 1) retained in care, 2) Delayed ART pickups (15-60 days late) and 3) Lost to follow-up (>60 days) so that the entire cohort can be analyzed together. You are further impacting your statistical power by slicing up your study this way.

Table 4: If there is missing data (i.e., 349 vs. 390) please explain and show this so the reader can understand what’s missing and where.

Line 204: I am confused by your statement “This represents just 3% of our total population self-reporting they had ever been lost to follow-up (data not shown).” In table 4, it looks like you are showing the data: 37 report ever being lost to follow up, or 11% of the reduced cohort shown. This section is hard to follow, please revisit.

Discussion: please make note of how well powered your study was to detect a difference in your outcome (outcomes?), particularly in light of the fact that it appears your analysis was affected by missing data (e.g., Table 4 is not n=390)

Line 245: “However, what is striking is the large disparity between what we could document based on pharmacy pick-up records and the participants self-reported perception of their ever being lost to follow-up.” Did I miss this? Where in your results do you present this disparity? This seems like an important piece of data to show. This seems like an important data point to add, perhaps to Table 4. How did this outcome vary between self-report and pharmacy records, and how did this vary across study group (mobile, not-mobile).

Line 271: Kindly remind the reader that the aforementioned study (studies? Several references are listed) are from Lesotho as the next sentence otherwise is a bit confusing.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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Reviewer #1: Partly

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

Reviewer #1: No

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Reviewer #1: Yes

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Reviewer #1: Yes

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Reviewer #1: Feedback to the authors

Major points

Abstract

Some important methodological details are not mentioned: self-reported interview data from mobile and non-mobile patients on ART care were compared with ART uptake data from clinical records, but the former comprised data from 390 participants whilst the latter was only available for 349 of these, thus possibly inviting selection bias. This fact is neither mentioned in the Abstract, nor the limitation discussed.

Methods

1. The statement that ‘consecutive’ patients were enrolled cannot be quite correct, given the matching process used. Please clarify whether all patients reporting to be mobile were consecutively enrolled. Regarding the matched non-mobile participants, please clarify whether they were selected from all those who met the matching criteria and presented to the clinic during the next 7 days. In other words, was the research assistant free to chose a patient who he/she preferred out of all possible matches, thus possibly inviting further selection bias, or was there a systematic rule for the selection that was followed?

2. As mentioned for the Abstract, in the section on Data collection the information is missing that clinical records were only available from subset of 349 of the 390 participants! This needs to be explicitly stated here or latest in the Results section; and an explanation provided on why this difference occurred. This is a limitation that should also be addressed in the Discussion.

3. The definition used for ‘delayed ART pick-ups’ (defined as gaps of more than 15 days after scheduled refills, see line 135) is rather inaccurate and broad, given that viral resistance often develops after much shorter interruptions in adherence. It would be helpful if the authors had studied whether a more stringent definition may be associated with a difference between mobile and non-mobile subgroups with respect to ART uptake.

Results

1. Some key information is missing that is required to understand the context: what is the total number of ART receiving patients registered at the Manhiça District Hospital from where the study population was selected (and of these what is the proportion of patients that achieved viral control at the time of the study)?

2. What are the proportions of study participants in the two comparison groups of this study who were virally controlled at their last visit? Was there a significant difference between study groups in this respect? Data on viral control were available at the time in a data set from another province of Mozambique that I have recently seen, but if such data were not available from the Manhiça HIV care centre at the time, what were the proportions of study participants in the two groups that had a satisfactory CD4 count (say e.g. >200 cells/mm3), and did this differ between study groups? This information would be important to assess the effects of mobility on retention in ART care, and would substantially increase the value of this publication. If no such data were available at all, this would at the very least require mention in the Discussion section.

3. Unfortunately there are many missing data without that this is explicitly stated (and without that the possible implications for the validity of the results are explored in the Discussion section). Examples include the following: (1) In Table 1, I was puzzled to realise that data on age was only available from 328 of 390 participants (16% missing!). How was it possible then to ‘match on age’? - (2) 23% of data were missing for ‘employment’, yet employment features as a key variable in the consecutive analysis. – (3) The one and only clinical information that related to clinical severity was WHO stage, however again data were missing for 33/390 participants (8%). Note that data on clinical severity may well be associated with ART uptake. – (4) Importantly as mentioned, data on ART uptake were missing for 41/390 participants (11%) from the hospital-based data set (Table 4). Further examples of missing data can be found in tables 2 and 3. With so many data missing, one wonders how valid are the results presented? The authors should at least indicate missing data in footnotes to the various tables, mention the more important data gaps when reporting results in the text, and reflect on this issue in the Discussion section.

4. In some cases, reported data do not tally within tables, or between tables and the text. Some examples: Table 1: employment data are 298, but 299 under ‘type of employment’. Table 2: 147 people travelled for work, but 148 of these gave information on what work they did. Also Table 2: 53 / 195 people travelled within the country (27%), but 25% are mentioned in the relevant text.

Discussion

The text is generally well written but the limitations described above (e.g. due to methodological issues and missing data) should be addressed.

Conclusion

The Conclusion section is misleading. It focuses on mobile HIV patients and the challenges that they encounter with respect to HIV care when they travel. This ignores that for the patients registered at the Manhiça Hospital the results underlying these conclusions seem to equally apply to the non-mobile group of patients. In fact, the lack of significant differences between the mobile and non-mobile groups with regards to ART uptake is surprising and should be mentioned as an important result in the Conclusion. The real conclusion should refer to the rather worrying lack of adherence in ART uptake that affects both groups.

General observations

The paper could be substantially shortened by condensing the text. Repeat statements should be deleted (e.g. see lines 262 and 277).

Minor points

1. Please use past tense consistently across the manuscript. (Occasionally the text alternates between past and present tense).

2. Some phrases are long-winded and could be compressed to just entail the essential information.

Methods

3. The section on data collection and management is NOT about data analysis as suggested by its headline.

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Reviewer #1: No

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Patterns of mobility and its impact on retention in care among people living with HIV in the Manhiça District, Mozambique

PONE-D-20-25254R1

Dear Dr. Moon,

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Matt A Price

Academic Editor

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