PONE-D-21-07606

‘It is not fashionable to suffer nowadays’: Community motivations to repeatedly participate in outreach HIV testing indicate UHC potential in Tanzania

PLOS ONE

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Bidhubhusan Mahapatra, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments:

Very informative and well written paper. I have only two suggestions. First, some of the quote texts are too lengthy. I suggest authors to reduce the length wherever possible. Second, I suggest authors to include a conceptual framework based on the study findings, if possible.

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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2. For qualitative studies, PLOS ONE suggests  consulting the COREQ guidelines: http://intqhc.oxfordjournals.org/content/19/6/349 to ensure that all relevant information is provided . In this case we would appreciate more information about: the number  and training of interviewers; how participants were selected ( we note that also community leaders quotes are reported; please describe in the methods how they were selected and recruited);  if a pilot study was tested; how data was coded; if bias issues were considered. Moreover, please provide the interview guide used (in the original language and in English) as a Supplementary file.

3. Please ensure you have included the registration number for the clinical trial referenced in the manuscript.

4. Thank you for stating the following in the Financial Disclosure section:

"The Shinyanga and Simiyu Test & Treat program in Tanzania is supported by Gilead Sciences (USA) https://www.gilead.com/purpose/giving/funding-requests

and the Diocese of Shinyanga through the Good Samaritan Foundation (Vatican). https://www.humandevelopment.va/en/il-dicastero/fondazioni/il-buon-samaritano.html

Grant Number: xxxxx

TRdW is a co-recipient of this this award. All other authors were employed under its auspices. The funders did not play an active role in study design, data collection, analysis, decision to publish or preparation of the manuscript."

We note that you received funding from a commercial source: Gilead Sciences.

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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: Yes

Reviewer #2: Yes

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

Reviewer #1: N/A

Reviewer #2: 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: Yes

Reviewer #2: No

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

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Reviewer #1: Reviewer’s comments

1. The study presents the results of the original research.

Reviewer: Yes

2. Results reported have not been published elsewhere.

Reviewer: Yes

3. Experiments, statistics, and other analyses are performed to a high technical standard and are described in sufficient detail.

Reviewer: Yes

4. Conclusions are presented appropriately and are supported by the data.

Reviewer: Yes

5. The article is presented in an intelligible fashion and is written in standard English.

Reviewer: Yes

6. The research meets all applicable standards for the ethics of experimentation and research integrity.

Reviewer: Yes

7. The article adheres to appropriate reporting guidelines and community standards for data availability.

Reviewer: Yes

Additional comments.

Introduction: The citation on page # 3, line 65 makes it difficult for the reader to follow. I suggest that it should be inserted at the end of the sentence (e.g., urban Shinyanga (reference).

Re-cast the citations on page # 3, line 69-70 (e.g., Sharma et al. 2015; Sabapathy et al. 2012)

Define “ yields” on page # 4, line 78.

A citation at the end of the sentence “….Tanzania is in transition period…..” is missing, on page # 4, line 82-83.

Move the 51.1% just after the words “…At least half (51.1%) of the population…..”, On page # 4, line 85.

Define “ethnographic study” on page # 4,line 92.

It will be beneficial for the readers to know how information from this study will be utilized in the study setting (i.e., who are the primary, secondary, and tertiary beneficiaries). I suggest this should be described after the last sentence on page #4, line 94.

Study setting and project background: On page # 5, line 98, kindly provide the approximated population of the Shinyanga Region, and the male: female ratio.

On page # 5, line 102-103, kindly provide (n=) for government dispensaries, Heath clinics, private faith-based Heath centres, and private laboratories. And add a citation to support that data.

On page # 5, line 111-the authors provide the distance-time by cycling….I was curious why only cycling, and not walking/or by a motor vehicle? Any justification for that?

On page #5, line 116-the authors mentioned in town, work and school hours affect….I suggest that providing the time range(e.g, from 7.00 am-4.30 pm) will make it clear for a reader to follow.

Data collection: On page #6, line 123, the authors should provide the number of trained Tanzanian researchers who conducted the structured observations (e.g., N=? male: female ratio).

On page # 6, line 140-the authors should provide examples of questions asked for each category (e.g., their testing experiences, their motivation for testing…etc.).

On page # 6, line 143-142, the authors mentioned that participants were asked about the new Treat All policy. How did participant get access to the new policy?

Did the data collection tools pilot test before data collection? I suggest the authors should provide this information and provide the number of participants who participated in the pilot testing and how was the information from the pilot test used.

Data analysis: On page #6, line 145, the authors used Qualitative content analysis. I suggest the authors should justify using content analysis instead of other alternative data analysis methods.

On page #6, lines 148-149, the authors describe how the analysis was done. I would like the authors to provide more information for the following: (1) What were the major coding categories?, (2 ). Did the study assessed coder consistency between coders?, (3). Post-coding: did coders examined, compared, and contrast the distribution of themes within and across subgroups, and whether this is reflected in the results section?, (4). Did the in-depth interviews transcripts and direct observation notes analyzed together or separate and later combined?. I suggest authors should describe how they handled this. (5). I did not see mentioned how the study observed reflexivity (i.e., conscious self-reflection to make explicit individual's potential influence on the research process), and steps taken to ensure study rigour. I suggest the author address these two important issues in the qualitative study.

Results: A table of participant characteristics would be beneficial to the readers.

Reviewer #2: This is a very well written manuscript. I really like the title which attracted me to chosse to review this manuscript. The issue is important in the context of test and treat and overobsession with yield. I really like the discussion session and the recommendation to use the HIV outreach testing spaces to integate other diseases in th era of UHC.

In addition, the autors can make few minor changes

1. Add one or two Tanzanian co authors. As the study was conducted and implemented in Tanzania, I am sure there may have been Tanzanian researchers who have either contributed or can contribute to this paper

2. It would be good to provide a bit more information about the context. The risk behaviours of people in the region, vulnerability factors and AIDS related deaths. AIDS related deaths are mentioned later but as I was reading, I felt that I needed to understand the context a bit more which would help me understand the respondents testing behaviours and motivations

3. In the method section, I got a bit confused about the different methods. It may be good to either present the method and the sample in a tabular form or a bullet form for the reader to understand

4. Though there were quotes of men and women across age, I was looking for some differences based on gender in the results and discussion section. The paper seemed blind to differences in motivation based on gender though literature does indicate that motivation of testing among men and women are different. A bit more exploration using a gender lens may improve the paper

5. In the discusison section while I like the critique of doing testing to find PLHIV and link them to treatment, I was expectecting a bit more about the value of testing for prevention. That section can be expanded.

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Reviewer #1: No

Reviewer #2: No

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Submitted filename: Response to Reviewers Comments_PLOS ONE.edited.docx

‘ It is not fashionable to suffer nowadays’: Community motivations to repeatedly participate in outreach HIV testing indicate UHC potential in Tanzania

PONE-D-21-07606R1

Dear Dr. Moyer,

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.

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Kind regards,

Bidhubhusan Mahapatra, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: