PONE-D-20-35332

Compliance to HIV testing and counseling guidelines at antenatal care clinics in the Kassena-Nankana districts of northern Ghana: A qualitative study

PLOS ONE

Dear Dr. Aborigo,

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.

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Kind regards,

Juliet Kiguli, MA, PhD

Academic Editor

PLOS ONE

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Please address all comments carefully and resubmit.

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2) Please include additional information regarding the qualitative 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, or include a citation if it has been published previously.

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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: Yes

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

Reviewer #1: 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

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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

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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: 1. Introduction section: Update literature on prevalence of HIV among pregnant women at ANC in study area . There is also relevant literature in Ghana e.g by Osei et al 2015 on prevention of MTCT of HIV and should be included. Probable reason for very low uptake of ARV services among HIV-positive pregnant women should be stated.

2. Study location: Provide more information on the health system context by way of facilities or services available at the different levels of health facilities especially as it relates to ANC and prevention of MTCT. Dates or period study was conducted should be stated.

3. Population and sampling approach: Consider systematically organizing this section into paragraphs of first the study population, sampling at the district level, zones and health facilities by levels of care for clarity. Please indicate the reasons for the sampling approaches used for the different populations.

4. Results: Please provide demographic characteristics of study participants. Please include information on availability of treatment for the prevention of MTCT of HIV since it could also impact on compliance to the guidelines being assessed. Additionally it could be an important discussion point.

5. Consenting: Reason provided for oral consenting is not accurate since most respondents were health workers and may be considered as a limitation instead.

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Reviewer #1: Yes: Livesy Naafoe Abokyi (PhD)

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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.

PONE-D-20-35332R1Compliance to HIV testing and counseling guidelines at antenatal care clinics in the Kassena-Nankana districts of northern Ghana: A qualitative studyPLOS ONE

Dear Dr. Aborigo,

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. Please respond carefully to all of the reviewer comments when revising your manuscript, incorporating the clarifications and presentational improvements they have requested.

Please submit your revised manuscript by Apr 12 2022 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: https://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,

Jamie Males

Staff Editor

PLOS ONE

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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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: (No Response)

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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 #2: Partly

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

Reviewer #2: N/A

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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 #2: 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 #2: No

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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 #2: First, I should say, I have enjoyed reading this piece of work. Understanding adherence to a given guideline in a clinical setting is an important area of research that potentially may inform the effort to enhance the quality of HIV testing services in Ghana in particular and SSA in general. I only have a few comments to enhance the manuscript's readability and technical soundness.

Introduction

Some of the paragraphs need a revisit. For example, the paragraph from 55-63 is hard to follow, given that it began with a very long sentence. It also specifies "The third and fourth components of this strategy . . .", but not sure if the reader will pick up which third & fourth components the authors are referring to.

It would be more informative in lines 65-67 if the authors provided the period and the change in ANC service use proportion.

Methods

The methods section provides a helpful and detailed description of how the study was conducted to address the research question. A few things to have a look at:

The authors have indicated in Line 149-150 that Grounded Theory underpinned the study design. There are various schools of thought on Grounded Theory as methodology and method one can apply in qualitative studies. Please provide more information on which (whether the classical/traditional or constructive grounded theory informed the inquiry process – subsequently reflect how the framework informed your process of data collection, sampling, & analysis. Please also include references in your method section as appropriate.

In Line 160-163, the authors described as they have used theoretical sampling, which allows them to set criteria based on the research question, and ongoing analysis to recruit more participants from various population groups and settings. They have also said they used random sampling to document ethnic variation of any. This looks a purposive sampling as a random sample is not commonly used term in a qualitative study.

As the authors have provided background to describe the health care system in Uganda, several health facilities provide ANC services with midwives. So, in Lines 144-165, it would help your readers know the types and how many health facilities were selected. Also, please explain why you selected those health facilities. This is crucial to the research objective provided in the paper, which aims to provide crucial information on whether there is adherence to the guide inline of HIV testing across different health facilities.

Data analysis and Results

The result section presented the findings using a pre-defined sub-heading/themes that are likely driven from the interview guides. As the authors have used open, axial, and selective coding underpinned by grounded theory, it would be more informative to present here the key themes that were selected/emerged from the account of participants than using themes of the interview guides. For instance, “Lack of privacy and breach of confidentiality” could be one example theme that the authors discussed but presented under the process of HIS Testing and counseling at ANC.

· In Line 215, it says the transcripts were corrected to facilitate coding. Not sure what the authors mean by that. Changing participants' wording while doing a verbatim transcription will risk the principle of authenticity, but there are situations where making the change are reasonable. It could be to maintain the grammatical flow of sentences as sometimes participants may provide an incomplete speech. Or to make an oral speech into written sentences and paragraphs. This has to be reflected in the quotes used in the result section. Some of the quotes are hard to follow. Line 326-330 is a good example of a quote with many pronouns, which makes it hard to follow the message. This is a typical example that transcribing correction/changing or adding additional information within [ ] required to help readers understand what the participant is referring to when they are using pronouns. Please revisit the quotes to ensure its readability.

· Involvement of male partners in either using the services or women's decision making to use HIV testing services seems overlooked in the method (Line 128-146), result (line 334-335 & 340 – "male unfriendly perception among healthcare providers"), and discussion section (line 552). Please provide context if the guideline also addresses how male partners should be involved in PMTCT & how the services providers should engage with them.

· There are a few grammatical issues (e.g., Line 280), and a few hard-to-follow sentences, especially the quotes (lines 343-344).

Discussion

If key themes emerged/were selected from the open, axial, and selective coding process, readers would expect a summary paragraph at the beginning of the discussion section. Since the results are presented differently, the discussion started with one of the key themes – setting HTC as a compulsory vs. voluntary option. Please reconsider revising the paragraph to summarize the attributes/themes that show loose adherence to the national guidelines on HTC in ANC settings.

Limitation:

The study to assess whether healthcare provides comply with the national guidelines on HIV testing used snowball sampling (Line 172-174) of women who used the services may have created bias. There is a chance that the healthcare providers are likely to suggest recruiting women whom they think can speak the best experiences they had in the health facilities when they receive HIV testing. As such, this limitation has to be reflected in the limitation of the study. Also, the study used interviews to assess compliance of a practice. A study design like ethnography would be more stronger to provide the existing practice of HIV testing. This can be reflected in the limitation as well.

Conclusion

In Line 604-615, strong recommendations have been made. However, based on this single study, the reader may not know if there are ongoing efforts related to the actions listed within the recommendations made by the authors. It is also not clear whether these actions recommended by the authors can be taken as effective measures to address the grab identified regarding healthcare providers' compliance in providing HIV testing services. Instead, it would be more pragmatic to suggest that more studies be conducted using different research designs (such as ethnography or observational quantitative designs) to directly measure healthcare providers' compliance in providing HIV testing and counseling services against the national guideline.

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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 #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.

Compliance to HIV testing and counseling guidelines at antenatal care clinics in the Kassena-Nankana districts of northern Ghana: A qualitative study

PONE-D-20-35332R2

Dear Dr. Aborigo,

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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James Mockridge

Staff Editor

PLOS ONE