PONE-D-21-23818Uninterrupted HIV treatment for women: policies and practices for care transitions during pregnancy and breastfeeding in Côte d’Ivoire, Lesotho and MalawiPLOS ONE

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: Yes

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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Reviewer #1: No

Reviewer #2: No

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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: The researchers carried out the study to understand perspectives and experiences of stakeholders in three PMTCT priority countries (Malawi, Lesotho and Cote D’Ivoire) regarding the transition of women between PMTCT and ART clinics during and after pregnancy. This was done to inform key policy actors and stakeholders on the existing landscape, challenges, and opportunities for improving transitions and progress towards the elimination of MTCT. They used a qualitative approach in which they conducted key informant interviews with 15 conveniently selected stakeholders from the three countries, five from each country. Study findings were summarized and related to several existing studies on the topic published from Sub-Saharan African. The authors concluded that their study findings provide important insights into the challenges and opportunities for improving the transitions and retaining patients in care, supporting the findings with a lot of quotations from the informants.

I see this as an important and well conducted study whose findings reflect the current situation in many countries and point to a critical gap in the effort’s countries are making to enroll and keep pregnant women living with HIV in care for their health and to prevent MTCT. The publication of these findings will remind and motivate program implementers to implement suggested strategies to fill the gaps. In reviewing the manuscript using the Plos One criterion for publication, author guidelines, the Standards for Reporting Qualitative Research (SRQR) published by Bridget C. O’Brien in 2014 and the Consolidated criteria for reporting qualitative studies (COREQ) published by Allison Tong in 2007, I found some minor gaps in the manuscript that may need revisions. I will strongly recommend the publication of the article once the revisions are made.

Key observations

The section on the study design is well outlined and with clarity. However, it leaves out some basic but important details such as follows;

• There is no mention anywhere in the article that it was a qualitative study. There is also no mention of piloting of the interview guide, the use of repeat interviews to check consistency and the average duration for each interview. There is equally no mention of whether the interviews stopped when saturation was achieved and no idea if the transcripts were shared with the participants for review or validation as stipulated in the COREQ guidelines (Tong, 2007). There is also no mention of where the interviews took place. Including statements on these will enhance the credibility and trustworthiness of the findings.

• There was no mention of any theory or conceptual framework guiding the study and no indication if the study led to the development of any theory. This is usually required for qualitative studies and good to be included (Obrien, 2014).

• It may be important to add more on the characteristics of the researcher, his or her experience on the topic, relationship with participants, their assumptions, and personal interests in the topic. These will increase transparency in the conduct of the study and interpretation of findings.

• A total of 53% of participants were from international partner organizations and since participant selection was done by convenience, there is a possibility of bias which could have been included in the limitations. The limitations were presented but did not include this one.

References

Allison Tong, Peter Sainsbury, Jonathan Craig, Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups, International Journal for Quality in Health Care, Volume 19, Issue 6, December 2007, Pages 349–357, https://doi.org/10.1093/intqhc/mzm042

O’Brien, Bridget C. PhD; Harris, Ilene B. PhD; Beckman, Thomas J. MD; Reed, Darcy A. MD, MPH; Cook, David A. MD, MHPE Standards for Reporting Qualitative Research, Academic Medicine: September 2014 - Volume 89 - Issue 9 - p 1245-1251 doi: 10.1097/ACM.0000000000000388

Reviewer #2: - Findings from 15 interviews with key stakeholders across 3 countries to explore barriers to successful ART transitions of care during pregnancy and postpartum.

- Small study about a big topic across 3 diverse countries.

- Some interesting, important, grim - but not particularly novel - findings around barriers to continuity of ART care for women before, during, after pregnancy are presented with suggestions for improvements in policy.

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- Suggestions to improve the manuscript:

- More background in the “settings” section would be helpful for readers not familiar with the 3 countries (e.g., some details about their HIV epidemic/fertility rates/MTCT key indicators.) Also some more reflection in the discussion about how typical these 3 countries might/might not be.

- Would love to see the authors go a little bolder in terms of recommendations. It seems like average fertility rates, family size goals, time between births, access and use of contraception in the local setting should also be factored into how/when/where care transitions occur. Can you make an argument about how pre-conception care / immunizations / contraception / could all perhaps be improved - and thus satisfy other public health metrics - if this problem were sorted out. Any bold ideas to suggest?

- Would be helpful to outline for readers (maybe within Figure 1?) what services take place in the different places/models. E.g. what is provided in ANC that is not part of HIV care for women. Of course, the goal is ART without interruption, but the reason services change during preg and postpartum is bc women have unique needs during these times that cannot be met through simple ART care. This is clearly known to this writing team, but it’s not well articulated in the manuscript.

- Introduction: “successful transition between services….” Would be helpful to define what this means. Or if there is not a clear definition worth pointing that out early.

Methods:

- Current draft missing a description of the process for developing the interview guides, the content explored, the process of piloting, a conceptual framework, etc.

- Details on whether / how coding team worked to include feedback from local / collaborating teams is missing. The section on author contributions reads as though first author (UCT) and 2nd author (ICAP) conducted all analyses. Would be nice to spell this out and if no feedback from relevant country partners would explain why / include in limitations.

- Discussions of limitations of social desirability bias are not included – seems important when research sponsored by CDC/PEPFAR.

RESULTS

- In findings would report how many invite / how many responded / how many agreed to participate.

- Understanding the nature of the interview guide, what was explored in the interview guide, how it was developed will also help inform interpretations of the analysis. e.g., is this the primary paper or is this an additional analysis?

- Can you further explore some of the findings? E.g., why would women just go to ANC to “have belly measured” (pg. 8) and go elsewhere for ARVs? Sounds like the policies are also confusing for patients. How does this work align with what research conducted with pregnant / postpartum people with HIV say? Can you think of creative ways why controversies like what we all experienced with DTG a few years ago would be better managed if women’s care was more longitudinal/ less fragmented? Can you make arguments about cost effectiveness? Cost? In discussion?

- 2nd paragraph only gl mentioned that maybe need to be developed / refined are time to postpartum transition to routine ART. The findings uncovered a lot of additional metrics that seem to need definition. Seems like a great opportunity for the authors to lay out some suggested metrics, solutions. Describing the band-aids being developed (e.g., a country-wide line-listing of preg women in India?!?!) seems like an opportunity to explain why these micro level approaches reflect a lack of uniform guidance and support and offer a way forward.

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Minor ethics comment:

- It is unclear why CDC would consider this not research? They have ethics approvals from CUMC and the local research committees in the reference countries, so all is in order. It just seems odd that CDC would count this as non-research.

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Reviewer #1: Yes: Mboh Khan Eveline, MPH, PhD

Reviewer #2: No

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Uninterrupted HIV treatment for women: policies and practices for care transitions during pregnancy and breastfeeding in Côte d’Ivoire, Lesotho and Malawi

PONE-D-21-23818R1

Dear Dr. Phillips,

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Kind regards,

Jodie Dionne-Odom, MD

Academic Editor

PLOS ONE

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