PONE-D-21-34621Prevalence and Predictors of HIV and Sexually Transmitted Infections among Vulnerable Women Engaged In Sex Work: Findings from the Kyaterekera Project in Southern UgandaPLOS ONE

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We are grateful to women engaged in sex work in Southern Uganda who agreed to participate in the study; this work could not be possible without them. Special thanks to the team at the International Centre for Child Health and Development (ICHAD), who coordinated the study in Uganda with study partners, Rakai Health Sciences Program and Reach the Youth Uganda. Lastly, to the research teams at Washington University in St. Louis, Columbia University in New York, Indiana University, and New York University.   

Kyaterekera study is funded by the National Institute of Mental Health (NIMH) under award number R01MH116768 (MPIs: Fred Ssewamala, PhD & Susan Witte, PhD). NIMH was not involved in the study design, data collection, analysis, findings interpretation and manuscript preparation. The content in this article does not reflect the views of NIMH or the National Institutes of Health.

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Kyaterekera study is funded by the National Institute of Mental Health (NIMH) https://www.nimh.nih.gov

under award number R01MH116768 (MPIs: FMS and SW). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Reviewers' comments:

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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: Yes

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: No

Reviewer #2: Yes

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Reviewer #1: No

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: thank you for the opportunity to review this paper. It provides interesting insights into a group that is of particular interest for HIV prevention.

General comments:

1)Please run the paper through a program like grammarly as there are a number of grammatical errors

2)Write out full name of bacterial STI’s

3)Why not include syphilis testing if rates in WESW are so high

Intro/Methods/results/Conclusions

4)STI prevalence instead of STIs prevalence

5) What is the general population STI prevalence

6) STI prevalence is estimated at 13% for gonorrhea, 9% chlamydia, 10% syphilis and 17% for trichomonas [4]. Is this for genital STI’s ?

7) Please give the names of the tests you used for HIV and STI

8) Participants who were found to have STIs received single dose of treatment – rather say received targeted treatment for that STI.

9)Age usually reported as a median

10) STI levels seem lower than expected

11) Report results consistently xx% (n= yy)

12) Women with more than one STI were 0.7%, - this does not make sense. Rather say xx women (0.7%) tested positive for more than one bacterial STI.

13) STIs prevalence is estimated at 13% for gonorrhea, 9% chlamydia, 10% syphilis and 17% for trichomonas [4]. From intro.

Same sentence in discussion says syphilis is 17% with same citation

14) Line 294 is obscured

15)The discussion makes some statements that seem to be more author opinion than actual study conclusions. The authors should refrain from hypothesizing reasons for associations unless these can be backed up by literature. For example saying that older women fear stigma more than young women could be completely incorrect. This is an author hypothesis and not a study result. You could say that xxx study showed this to be true and this could explain the association you found in your study. In the same way the authors should be very careful of suggesting interventions based on associations. It would be preferable to say “we noted an association between xxx and yyy and further research is needed to understand this association.

16) The discussion should also compare predictors of HIV in the general female population with WESW. It is understood that HIV prevalence is higher but would be interesting to understand if predictors are different.

17) Line 298 – Prevalence of HIV tends to increase with increasing age. The trend of increasing prevalence in HIV in WESW seems to be the same as for the general population and is an epidemiological phenomenon with a disease like HIV that is incurable.

18) Please provide evidence from your study supporting these statements:

This may be attributed to stigma or fear of accessing preventive methods (e.g., buying condoms, PrEP and PEP services) by older women.

19) Line 306 – please provide evidence for the following statement

Women from households with more children may be less likely to engage in high risk behaviours for fear that children will notice. They may also be more likely to think about the continuity of providing for their children if they are the primary caregivers, therefore taking extra precautions/preventive measures about their lives compared to those with less children

20)Line 306 should be “fewer” children. Do you have any evidence to back up your theories of why fewer children would be a risk factor for HIV. Could this be confounding?

21) Line 330 needs to be rewritten

22) Line 333 – Do you mean accepting attitudes rather than approving attitudes?

23) Line 342 is incomplete

24) A major limitation of this study is potential confounding. The association between low levels of education and HIV may actually be caused by poverty. Educational programs may not be helpful in this context but poverty alleviation programs may work. The authors should be careful about speculating on interventions based on associations found.

Reviewer #2: This study is important for understanding and acting on the health conditions of women sex workers in Uganda. It is guided by syndromic theory, which states that, within the population, the co-occurrence and interaction of multiple adverse conditions produce stronger and more intense overall health outcomes than if each condition were experienced separately.

It shows a major interest in taking care of these disadvantaged women and allowing them to enter an HIV prevention program by administering PrEP in Africa.

The article is well written.

General comments:

Although not the focus of this study, the authors did not explore the prevalence of HPV, which could have been an important opportunity for cervical cancer screening and prevention.

Were patients with a bacterial STI symptomatic?

Were patients with a detected STI treated and with what treatment?

Minor comments

Line 139: could the author precise the apparatus and kit use for NAAT

Line 222: The average age of participants was 31.4% in the text and 31.6% in the table 1

The status married was 25.7 in the text and 25.6 in the table 1

Table 1:

- Titre “Sample characteristics” change for “Description and characteristics of population studied “

- Legends of the Table: “Total Sample (N=542) % (n)” could be precise to understand that the author gives sometimes the %, or the number or the average score.

- What means the number 7.18?

- The total of % is not correct, change 87.7%(473) to 87.3%

Line 292: While the percentage of HIV-positive people is very high, the author observed a low level of bacterial STIs. How can this be explained in this high risk population? Is the NAAT test used for CT/NG/TV screening sufficiently sensitive?

Line 293: Trichomonas without capitalization

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Reviewer #1: No

Reviewer #2: No

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Prevalence and Predictors of HIV and Sexually Transmitted Infections among Vulnerable Women Engaged In Sex Work: Findings from the Kyaterekera Project in Southern Uganda

PONE-D-21-34621R1

Dear Dr. Ssewamala,

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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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

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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

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

Reviewer #1: Yes

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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

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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

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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: No further comments - all reviewer comments have been addressed

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Reviewer #1: Yes: Katherine Gill

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