PONE-D-21-00344

Improving Linkage to Care for Patients Diagnosed with HIV: A Qualitative Study at a Rural Health Centre in Southwestern Uganda

PLOS ONE

Dear Dr. Kabakyenga,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Reviewer 1:

1- General comments on the article and its content

• The concept ‘’ Linkage to care’’ discussed within this article is not clear and consistent along the article. Some time, it refers to linkage to ART; sometimes, it refers to linkage to ART, retention up to access to VL.... In brief, it’s not very clear whether what was studied is linkage to ART treatment or linkage to care 1-month or 3 -6 months, etc. following HIV diagnosis?
• The article is discussing about facilitators and barriers to improve linkage to care of HIV positive clients from the providers perspective. It’s true that key respondents are Expert clients and linkage facilitators but, for the provider perspective not the client’s perspective; That precision is missing along the article

2- Comments on the Introduction section:

Example 1: Line 79 to 81. You have a sentence like: ‘’ Similarly, a country progress report on access to ART services in one of the 80 health facilities in Kabale District in southwestern Uganda, reported that linkage to care was at 81 67% [8].’’

• The Sentence started with report on access to ART services
• Concluded with a percentage on linkage to care

Example 2: Line 83 to 85. The sentence is about linkage to care but compared to the second 90 (UNAIDS-goal which is about linkage to ART treatment)

These 2 examples are illustration of mix-up between linkage to care and linkage to ART treatment observed all-over the article

2- Comments on the Methods section:

Line 122. The sentence says: ‘’ The interview guides were translated and back translated to maintain the flow of the information ‘’.

• Translation during interview is very important
• The authors should share more details about the translators’ characteristics (certified or not; experience in translation in health sector; etc..) and approval process of translation
• This can influence enough the in-depth interview, the understanding of the question and the answers

3- Comments on the Results section:

• Participants were providers, not really patients using the services; not all (like health care workers; etc..)
• Difficult understand some of the conclusion like line 160 to 161 ‘’ Most of the participants reported receiving good services at the health facility.’’ Some of the participants being health care workers
• Line 165 to 172 : it’s a linkage facilitator answer and perspective. We should have love having the client perspective on all those aspect to better understand acceptance or refusal
• Line 173 to 176 : The head of familly is not sharing his personal experience but the experience of the Mother..
• This is the caregiver perspective ; not really the patient perspective
• Line 190 to 192. The expert client enrolled in the study for the perspective of provider (see description in Methods section) is interviewed for the perspective of patient ; nothing is clear whether, the experience of client described is at one of the study facility or Elsewhere
• Individual barriers are from the providers perspective not the patient perspective [see Line 228 (feedback from linkage facilitator) and line 230 (feedback from Health care worker)]
• We are missing view of patients missing in care ( defaulters or LTFU) and re-engaging later

4- Comments on the Discussion section:

• The construction of themes using both Health belief Models and Ecological Models was not really discussed to help better understand the results
• The health belief model focus on individual factors; and in this study, the provider perspective was considered not the patient perspective; in particular patients re-engaging in care who are in better place to inform us about individual barriers. 

Reviewer 2: 

1. Introduction

The introduction is relatively short with minimal information on what is already known about linkage to care, there are so many articles in this topic the authors may wish to add more literature.

It is always nice  to start with information about the magnitude of the problem  worldwide,  in Africa or Sub Saharan Africa,  East Africa and then  in Uganda,  below are some of the articles you may wish to include for East Africa, studies conducted in  Kenya, Tanzania etc

You may wish to start with line 72: Globally, in 2019, only 67% of HIV positive clients were linked to HIV care .....Then follow with the definition and the effects of failure or poor linkage....

Line 76-78: The results showed that only 53% of the HIV positive 77 clients were linked to care within one month after testing while 14.5% never returned for follow 78 up [7]

This statement does not fit here, unless the authors will also address the issues of time to linkage and retention issues, if not I suggest dropping it.

Some of the articles

• Ruzagira et al., 2017: Linkage to HIV care ..... in sub-Saharan Africa: a systematic review: https://onlinelibrary.wiley.com/doi/10.1111/tmi.12888
• Sanga, E.S. et al., 2019: Understanding factors influencing linkage to HIV care .... Mbeya- Tanzania: qualitative findings of a mixed methods study. BMC Public Health 19, 383 (2019). https://doi.org/10.1186/s12889-019-6691-7
• Kegoli S et al., 2019: increasing linkage to HIV care and ... HIV patients at 14 EDARP health facilities in Nairobi, Kenya. https://www.ajol.info/index.php/eamj/article/view/198131

1. Methodology

About sampling, the authors said it was purposive sampling, i would like to know if the did consider factors like age, sex, occupation, education level and may be distance from the health facility/ HIC clinic offering HIV services to increase the diversity in respondents?

Line 122 and 127: The authors reported that, the interview guides were translated and back translated ... it would be nice to also mention the languages the guide were translated

 to /from

Line 131-136...As the first step of data analysis, all 132 audio recordings were transcribed... It could just be okay to say XX and XX cross-checked or verified the transcription and translation of data before analysis

Line137-142: the authors mentioned the Health belief and ecological models, i think it would be nice to briefly mention their components and probably link it to how the used the model to analyze the study findings

Result section

Line 150-157: Socio demographic characteristics of participants- The authors may wish to put these in a table, I see more qualitative papers nowadays have these presented in tables,

Just after the Participants characteristics, I suggest you start with an overview of the study, i.e. six /five/two/ theme related to .... Study topic were identified and categorized in the following sub headings. You only mention in this paragraph and then you start explaining the details one by one. This guides the reader to know beforehand that okay there ... themes/sub-heading to come

Line 158-161: Availability of services; At least one quotation is needed to back up the explanations in this paragraph

Also when you have long quotations is good to indent them

Discussion

In this section is good to start by mentioning what was the study looking for and then what are the main findings in your study then you continue with explaining the importance and implications of the finding and how are their comparable to other r similar studies. I noted some repetition of results in the discussion; is okay to refer to the result, not to report again

Conclusion:

 Excellent no comments

Please submit your revised manuscript by Sep 11 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Habakkuk A. Yumo, MD, MSc, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Dear Dr. xxxxxxxx

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The manuscript has been evaluated

by two reviewers, and their comments are available below.

The reviewers have raised a number of concerns that need attention. They request clarity on the definition of some concepts, the methodological aspects of the study and on the presentation of some findings in results and discussion sections.

Could you please revise the manuscript to carefully address the concerns raised?

In addition, please kindly ensure your revising style is consistent with PLOS ONE guideline (https://journals.plos.org/plosone/s/submission-guidelines).

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at 

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and 

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service. 

Whilst you may use any professional scientific editing service of your choice, PLOS has partnered with both American Journal Experts (AJE) and Editage to provide discounted services to PLOS authors. Both organizations have experience helping authors meet PLOS guidelines and can provide language editing, translation, manuscript formatting, and figure formatting to ensure your manuscript meets our submission guidelines. To take advantage of our partnership with AJE, visit the AJE website (http://learn.aje.com/plos/) for a 15% discount off AJE services. To take advantage of our partnership with Editage, visit the Editage website (www.editage.com) and enter referral code PLOSEDIT for a 15% discount off Editage services.  If the PLOS editorial team finds any language issues in text that either AJE or Editage has edited, the service provider will re-edit the text for free.

Upon resubmission, please provide the following:

The name of the colleague or the details of the professional service that edited your manuscript

A copy of your manuscript showing your changes by either highlighting them or using track changes (uploaded as a *supporting information* file)

A clean copy of the edited manuscript (uploaded as the new *manuscript* file).

3. Thank you for submitting an English version of your questionnaire. Please also include a copy of the questionnaire in the original language, as Supporting Information, or include a citation if it has been published previously

4. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. 

When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section.

5. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability.

Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized.

Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access.

We will update your Data Availability statement to reflect the information you provide in your cover letter.

6. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 

[Note: HTML markup is below. Please do not edit.]

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

**********

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

Reviewer #1: Yes

Reviewer #2: N/A

**********

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: No

**********

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: No

Reviewer #2: Yes

**********

6. 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

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Perspectives on linkage to care for patients diagnosed with HIV: A qualitative study at a rural health center in South Western Uganda

PONE-D-21-00344R1

Dear Dr. Kabakyenga,

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.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Habakkuk A. Yumo, MD, MSc, 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 #2: All comments have been addressed

**********

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 #2: Yes

**********

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

Reviewer #2: Yes

**********

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 #2: No

**********

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 #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 #2: The authors have addressed all comments to my satisfaction , i have no further comment, I recommend the manuscript to be published in this journal, unless the other reviewers have more comments

**********

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 #2: Yes: Dr Erica Samson Sanga- The National institute for Medical Research- Mwanza, Tanzania