PONE-D-20-29104

HIV-related stigma and uptake of antiretroviral treatment among incarcerated individuals living with HIV/AIDS in South African correctional settings: A mixed methods analysis

PLOS ONE

Dear Dr. Chimoyi,

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Andrea Knittel

Academic Editor

PLOS ONE

Additional Editor Comments:

In addition to the comments from the reviewers, please consider the following suggestions:

Person-first language is used inconsistently. You may also wish to consider whether the term "correctional" is the best term for jail, prison, and detention facilities. Many in the field have transitioned to using "criminal legal system" and labeling the specific facility type (e.g., "prisons" or "jails and prisons") rather than the collective noun "correctional facilities." If this change is adopted, the addition of a short paragraph in the introduction or methods may be helpful to clarify terminology.

How were the translations checked for accuracy? Were they back-translated or verified in another way?

The methods state that quantitative data were compared using Chi-squared and Fisher's exact test, but these results are not included in the text or the tables.

In describing the qualitative findings, please take care that the phrasing distinguishes between conclusions or statements by the authors and observations from the interviews. As the reviewers highlighted below, this is a critical distinction. Importantly, conclusions or statements from the authors should be moved to the discussion section and only the interview findings should be included in the results section.

There are many small grammatical errors throughout the manuscript. It would benefit from close editing, perhaps by a professional editor.

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2. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

3. Thank you for stating the following in the Acknowledgments Section of your manuscript:

[The authors thank the study participants and staff of the correctional services. This work was supported by funding from the U.K. Department for International Development (DFID)/ UKAID under grant MMM/EHPDA/AURUM/05150013. The contents of this manuscript are the sole responsibility of the authors and do not reflect the views of DFID, UKAID, or the United Kingdom government. We wish to acknowledge the support from the International AIDS Vaccine Initiative and University of California, San Francisco’s International Traineeships in AIDS Prevention Studies (ITAPS), U.S. NIMH, R25MH0647]

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 [SC received the award

U.K. Department for International Development (DFID)/ UKAID under grant MMM/EHPDA/AURUM/05150013

https://www.gov.uk/government/organisations/department-for-international-development

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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: I Don't Know

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: Yes

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: This manuscript is a cross sectional study of 219 persons with HIV that used mixed methods to evaluate persons with HIV who were incarcerated to assess effect of stigma on ART uptake. The Parent study was conducted between 9/2016-3/2018 in 3 correctional facilities in South Africa . The majority reported HIV stigma (87%) , and self-coping strategies improved engagement in care. Overall the subject matter is important and the interest in stigma as potentially affecting the HIV treatment care cascade to stay in line with Undetectable=Untransmittable ( U=U) process and treatment as prevention. The paper is well written but I had some questions and comments as outlined below.

Abstract:

Please change to person first language, instead of “HIV positive” , change to persons living with HIV ; instead of “ inmates” – persons in prison/ jail….

Results: of the 219 , n=27 reported no stigma and of them 81% had started ART and of the 192 who reported HIV related stigma 91.75 started ART. Those who reported they were comfortable with HIV status 93.4 % had started ART compared with those not comfortable with diagnosis 83.6% had started ART – not clear if this statistically significant in the text? ( please report P value and CI).

Table 1 and 2 missing is P values.

Hard to know what is meaningful statistically?

The ‘Correctional system structural factors and inadvertent disclosure’ section was highly concerning.

Line 250 . the statement that “ the correctional services environment neither promotes confidentiality of HIV diagnosis nor allows for privacy when receiving HIV services.” is this a theme that emerged or a declarative statement by the authors? It is not clear. IN general this is not the same in all correctional settings- There should be confidentiality- other correctional sites do HIV testing and discuss treatment in other settings in confidential manners.

The fact that they authors state this justifies “ involuntary disclosure” as “unavoidable” in lines 251-252 is not correct either. I can’t tell if this is what happened in the research or a theme they are saying is what the participants reported? If this is a theme then can they reframe these sentences to state what came out or what the participants reported?

For the Qualitative data , it is not clear to me how many of the participants reported these themes? Can they show them in a table format? Number reported ?

Discussion:

2nd paragraph “ the structures put in place by correctional health systems to provide HIV care and ….. inadvertently lead to disclosure of HIV status” – sounds like the authors are saying this as a declarative statement of all correctional health systems – which is not true. I am not clear how they state this for small subject number for the qualitative piece?

I am not sure this is generalizable to all correctional settings.. the authors should discuss this as a limitation .

Reviewer #2: Summary:

This is a cross-sectional study employing mixed methods to investigate stigma among incarcerated people living with HIV in South Africa. The study’s key finding is that although ART use was high, which is positive, 87% of inmates experienced stigma related to their HIV status, which is very alarming and has important implications for an already-stigmatised population due to their incarceration status. Although this is a cross-sectional study from which no inference can be drawn, the study’s strength is its use of mixed methods to explore, in-depth, the experience of stigma among an understudied population in a setting where the HIV epidemic and associated stigma is rampant. It is my view that with the below suggestions for improvement, this manuscript would be suitable for publication.

Abstract:

The authors state in their background that they are investigating the “influence of HIV-related stigma on ART uptake” but this does not seem to be the case. Rather, the authors should consider framing their study as an investigation of the prevalence and experience of stigma among incarcerated people living with HIV.

Introduction:

Lines 85-86: See above comment. With uptake of ART having been high and almost all participants who initiated ART also experiencing stigma, it does not appear to be the objective of this study to look at a relational impact of stigma on uptake. Furthermore, there were no quantitative tests of association conducted between HIV-related stigma and ART uptake, which signals to me that this was not the study’s objective. Authors must consider reframing this aim to fit with the Methods, which appear to indicate that authors researched:1) the uptake of ART; 2) the prevalence of HIV-related stigma among ART users; and 3) the experience of HIV-related stigma among incarcerated people living with HIV.

Methods:

Lines 93-94: Authors state that they assessed “associations” with ART uptake, but nowhere in the manuscript is there a statistical test of association comparing those using ART against those not initiating ART. I believe this is a question of how the authors have framed their methods, but this needs to be clarified by reframing this statement to explain that authors descriptively compared people using ART vs not using ART, otherwise authors should conduct a statistical test of association to show factors associated with ART uptake.

Line 112: Authors should explicitly state that data for their study came from the 6-month time point of the larger TaSP study to make it clear at which time point their cross-sectional study took place.

Lines 147-148: Was there any scoring used to determine if HIV-related stigma took place? What did the authors do with after they combined the six HIV-related stigma questions?

Results:

Authors state in the Methods that they conducted chi-2 and Fisher’s exact tests to compare demographics, stima measures and psychosocial characteristics, but they do not present any P-values for their comparisons of ART users and non-users. Could the authors include P-values from their statistical tests in the text and/or tables?

Figure 1:

It appears from this figure that nurses, and HIV counselling and testing staff also formed part of the interview sample. Is that the case? If it is, I would suggest only reporting incarcerated participants living with HIV as your sample. The N=30 is misleading if it includes people whose views are not represented in the results section.

Discussion:

I think it is important for the authors to mention that although stigma was highly prevalent, it did not appear to impact ART use, as 92% of inmates who reported HIV-related stigma initiated ART.

Lines 360-364: Here the authors state their key findings but do not comment on the intersectionality of individual and structural stigma observed in their study. Since intersectionality was a key theme touched on in the introduction and represented in the survey, it would be good for the authors to dedicate some of the discussion to how intersectional stigma played out in their study.

Authors also briefly mention self-coping mechanisms but do not discuss them any further. Could authors discuss the significance or potential implications of the self-coping mechanisms identified in their study? Could the self-coping mechanisms. Identified in this study be leveraged to develop HIV-related stigma reduction interventions for incarcerated people living with HIV?

Conclusion:

The authors mention that their paper “describes HIV status disclosure” but this is not coherent with the previous sections. The paper described ART use and stigma related to HIV status. Please make this clarification. Authors could also consider adding that involuntary disclosure was a key facet of ART distribution in correctional facilities that might be addressed by providing parallel education campaigns to incarcerated people not living with HIV around destigmatisation.

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Reviewer #1: No

Reviewer #2: No

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HIV-related stigma and uptake of antiretroviral treatment among incarcerated individuals living with HIV/AIDS in South African correctional settings: A mixed methods analysis

PONE-D-20-29104R1

Dear Dr. Chimoyi,

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. Thank you for your thoughtful revisions and responses to the reviewers.

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,

Andrea Knittel

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

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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)

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

Reviewer #1: Yes

Reviewer #2: (No Response)

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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: Yes

Reviewer #2: (No Response)

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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)

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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: The authors have markedly improved this manuscript and it now seems suitable for publication. I think this has value to improve reduction in stigma for persons with HIV in correctional settings.

Reviewer #2: (No Response)

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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

Reviewer #2: No