PONE-D-20-25583

MAGNITUDE AND ATTRIBUTES OF ANTI-RETROVIRAL THERAPY ADHERENCE AMONG CHILDREN (1-14 YEARS) ATTENDING HIV CARE AND TREATMENT CLINICS IN DAR ES SALAAM, TANZANIA

PLOS ONE

Dear Dr. Mussa,

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 submit your revised manuscript by January 29, 2021. 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

We look forward to receiving your revised manuscript.

Kind regards,

Satya Surbhi, PhD

Academic Editor

PLOS ONE

Journal Requirements:

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2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified whether consent was informed.

3. Please provide your sample size calculation.

4. In your Methods section, please provide additional information about the participant recruitment method and the demographic details of your participants. Please ensure you have provided sufficient details to replicate the analyses such as:

a) the recruitment date range (month and year),

b) a statement as to whether your sample can be considered representative of a larger population, and

c) a description of how participants were recruited.

5. Please include a copy of the interview guide used in the study to interview caregivers, in both the original language and English, as Supporting Information, or include a citation if it has been published previously.

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"The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

At this time, please address the following queries:

1. Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.
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3. If any authors received a salary from any of your funders, please state which authors and which funders.
4. If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

8. Please amend either the title on the online submission form (via Edit Submission) or the title in the manuscript so that they are identical.

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10. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 1 in your text; if accepted, production will need this reference to link the reader to the Table.

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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

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

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: Yes

Reviewer #3: No

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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

Reviewer #3: No

**********

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 manuscript needs revision especially on data analysis, methods and discussion section. Besides this the ascent should be stated in ethical clearance for children from their parents or guardian. The factors that are insignificant should be deleted.

Reviewer #2: The manuscript is well-prepared. It is scientifically sound. It will be more clear and precise if the authors include the analysis tools in the methodology section of the abstract, give more background information on the pediatric ART programme in the country like the regimens introduced etc. In addition, even if the number of references are enough better to include more recent related publications. The paper cites references dated back to 2000 to 2018.

Reviewer #3: First, I would like to congratulate the authors for exploring such an important topic. Magnitude and Attributes Of Anti-Retroviral Therapy Adherence Among Children (1-14 Years) Attending HIV Care And Treatment Clinics In Dar Es Salaam, Tanzania. However I have some comments and questions for them, these are found below

Abstract:

Introduction:

Line 1: In Epidemiological disease level classification HIV is a Pandemic disease; use this term instead of Epidemic. In addition at the end of the introduction please add justification/the need to conduct this study in a line or two.

Objectives: Correct the English (Among HIV positive children). Objective must be SMART which includes the “T” which stands for time bound. Therefore specify the time of the study.

Methods: The first statement is not even a full sentence. The method presented is too shallow. The sample size, the method of data analysis, level of significance, the measurement of association, the model fitness assessment, the software used all are lacking.

Result: The magnitude of good adherence reported (60%) is a point estimate, you should provide the confidence interval. Take the type of analysis used in the method section, use the term multivariable logistic regression instead of multivariate (Multivariate is when you have multiple outcome variables). Age is better reported as a range instead of <25 for children of very young (underage) mothers may not have the same association. Belief in ART effectiveness is not clear (Negative or Positive?? And how did you assess it??). After all the associated factors were written the sentence was concluded as “”… were less likely to be associated poor adherence.” Yet all the significant variables are not negatively associated with the outcome variable. Besides, though, the authors reported the magnitude of good adherence, they reported associated factors for poor adherence, you need to be consistent.

Conclusion and recommendations: The authors should re-write this section. Most of it is wrong and the recommendations given are not based on the findings.

Methods and Materials

Study design and area: In the first line authors mentioned “This was hospital based descriptive cross-sectional study” which is totally wrong. You have assessed factors that affecting adherence therefore it is not mere description. (Use hospital based cross-sectional study)

Participants and eligibility criteria

The minimum sample size determination must be clearly presented. There is no such a thing as “quota sampling calculation” Quota sampling is a sampling technique (How you distribute the sample size you determined across quotas).

How was the three study places identified?? Why none probability sampling???

How can you take consent form under 14 years old children?? (This must be clearly described in the Ethical consideration)

Variables and measurements

Clearly put the outcome variable and list of independent variables considered.

Statistical analysis

What method of goodness of fit assessment did you use?? What was its value??

Generally the method part lacks the following: Study period, Sample size determination, Sampling Procedures, Data collection procedure and quality assurance.

Results

The first paragraph must be part of the method section. You should focus on what you have found and not how you did it in the result section.

The order of the result presentation is full of flaws. First report the characteristics of study participants be it socio-demographic characteristics or co-morbidities. Then go to the descriptive findings of your study which the level/magnitude of adherence, finally you can present the factors associated. The level/magnitude of adherence also needs to be reported using confidence intervals.

Factors associated with ART adherence

Why are the authors reporting the associated factors as socio-demographic and participant related and the like all variables must be adjusted in the multivariable analysis and be reported as one multivariable table.

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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: Yes: Abebe Dilie Afenigus

Reviewer #2: Yes: Yesunesh Teshome

Reviewer #3: Yes: Adhanom Gebreegziabher Baraki

[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.

Attachments

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Submitted filename: comments for Plos One.docx

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Submitted filename: PONE-D-20-25583_reviewer.pdf

Attachment

Submitted filename: Reviewer comment for PONE-D-20-25583.docx

PONE-D-20-25583R1

MAGNITUDE AND ASSOCIATED FACTORS OF ANTI-RETROVIRAL THERAPY ADHERENCE AMONG CHILDREN ATTENDING HIV CARE AND TREATMENT CLINICS IN DAR ES SALAAM, TANZANIA

PLOS ONE

Dear Dr. Mussa,

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 submit your revised manuscript by May 12, 2021. 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,

Satya Surbhi, PhD

Academic Editor

PLOS ONE

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

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

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

**********

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

Reviewer #2: Yes

Reviewer #3: Partly

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: (No Response)

**********

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: I would like to appreciate the authors for studying a public health problem. Magnitude and associated factors of Anti-Retroviral Therapy Adherence Among Children (1-14 Years) Attending HIV Care and Treatment Clinics in Dar Salaam, Tanzania)

The response and revision given by the authors for my previous concerns is plausible.

# Discussion

In the discussion section, it better to write an introductory paragraph what your study focuses on (magnitude and factors associated with ART adherence) at the beginning and then proceed to discuss pertinent findings as you did already.

Reviewer #2: The authors have addressed the comments from my reviews in an intelligent and scientific way. I accept that the manuscript is worth publishing.

Reviewer #3: Thank you all the authors for making the requested revisions. I believe you have made a significant improvement from the original manuscript. But I have some issues I asked but not well addressed.

Here are my comments and questions

Abstract

1. The English of the manuscript is still poor. For instance in the method section of the abstract I have commented the first sentence is not even a full sentence yet it is not corrected. It has no verb.

2. In the result I requested the authors to put a confidence interval for the point estimate of adherence level which is 60%. But I don’t think they have got the idea of confidence interval. As long as you determine proportion (which actually is a prevalence) you can always determine the confidence interval for it. You just have to check the boostrap in the SPSS while you run to determine the prevalence (Proportion). If you want to use STATA, you have a total of 200 children with good adherence therefore using the command (cii 333 200) you can find the point estimate to be 60% with 95% CI of (54.58, 65.36).

3. In the previous comment I have also asked the authors to put the age range for caregivers/Mothers instead of putting < 25 for the case may not be the same for very young or teen mothers than the others. It will also has implication in terms of showing the effect of teen pregnancy or motherhood. All the associated factors do not have the same direction but the statement in the result section is closed as ” … less likely to be associated” this is not appropriate even if all are negatively associated the phrase “less likely associated does not give sense”. All these comments were previously given but no improvement is made or no explanation is given.

4. The conclusion given is not based on the results. For example WHO stage of the disease was not significantly associated factor, yet Adherence counseling is recommended for children with advanced disease. You do not just give recommendations by your idea of what should be done, it must be based on the evidence/finding you have.

MAIN PART OF THE MANUSCRIPT

5. In the sample size calculation you should put reference for the study you took the prevalence (24.6%) from. The allocation of study participants in each clinic looks proportional. Therefore it is better put as “The sample was proportionally allocated to the three clinics/hospitals” than quota.

6. In the variables of the study the authors write the Dependent variable to be Adherence whereas the associated factors to be independent variables. How could you just say the associated factors are independent variables?? This is just telling the other name for independent variables. What you are asked is to list the independent variables considered in this study. This comment was previously given as well.

7. In the data processing and analysis section the question of goodness of fit was raised but it was not addressed. P-value tells us if the variable is significantly associated with the outcome, it does not tell us if the model used appropriate for the data. We use the Hosmer-Lemshow goodness of fit test to show this in logistic regression. This was not addressed.

8. In the result section: if the sample size is 316 why 333 people are included in the study? The table showing the multivariable outcome (Table 6) should also include the crude odds ratios.

**********

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 #1: No

Reviewer #2: No

Reviewer #3: Yes: Adhanom Gebreegziabher Baraki

[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.

PONE-D-20-25583R2MAGNITUDE AND ASSOCIATED FACTORS OF ANTI-RETROVIRALTHERAPY ADHERENCE AMONG CHILDREN ATTENDING HIV CARE AND TREATMENT CLINICS IN DAR ES SALAAM, TANZANIAPLOS ONE

Dear Dr. Mussa,

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 submit your revised manuscript by January 15, 2021. 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,

Satya Surbhi, PhD

Academic Editor

PLOS ONE

Journal Requirements:

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

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

Reviewer #3: (No Response)

**********

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

Reviewer #3: Partly

**********

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

Reviewer #2: Yes

Reviewer #3: 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: Yes

Reviewer #3: 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

Reviewer #3: No

**********

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: (No Response)

Reviewer #3: Thank you, all the authors, for making the requested revisions. I believe you have made improvement from R1. But I have some issues I asked but not well addressed. Here are my comments and questions.

General Comment:

I think it could be better if the authors give the manuscript to a native English speaker or language expert to do proof reading. The overall quality of the language used is still poor.

2. You added the confidence interval in the result section of the main manuscript only put it in the abstract too.

3. The age range 17-25 years was mentioned in the table but not in the other parts of the manuscript like the abstract. When you do corrections in one part try to make it consistent across all parts of the manuscript.

4. In the result section of the abstract. All the associated factors do not have the same direction but the statement in the result section is closed as ” … less likely to be associated” this is not appropriate even if all are negatively associated. The phrase “less likely associated” is not the right way to interpret odds ratio. I recommend reading more on interpretation of Odds ratios.

Main manuscript:

METHOD

5. I am afraid the authors get the philosophy behind quota sampling. The participants are taken from each institution either proportionally or in equal number in this study but not using quota sampling. Quota sampling is a non-probability sampling, and the participants are selected based on specific qualities and traits. There is no such considerations here.

6. The definition of what dependent variable is and what independent variable is not needed here. You just have to mention what the dependent variable is and what independent variables are considered in this study. For instance you can say: The dependent variable in this study was Adherence where as the independent variables were socio-demographic characteristics like age, gender, marital status . . .; Treatment related factors like type of regimen, duration on ART. . .

7. The authors just write the phrase “Goodness of fit” in their response about how the goodness of fit of the model was addressed. In the result section it says 0.243 for the P-value of the model fitness test. I recommend to mention Hosmer-Lemshow goodness of fit was used to test the association.

8. Including sample of study participants above the minimum may not have weaken the study. Actually, it increases the power. The thing is participants are not supposed to be included just because they wanted to participate. This is why we needed the sample size and sampling procedure. 10% is also to replace non-responders and it is considered in the final sample size; It is not in addition to the final sample size you have. The authors need to give scientific justification as this may affect rigor in conducting research and its replicability.

9. The final multi-variable table shall have all the sections provided below

Variable | Adherence (frequency and percentage for both good and poor) | COR(95% CI) | AOR (95% CI)

There is also no need to write P-values for COR and AOR. P-value for AOR is enough or you can use * for P-value less than 0.05 and mention this as a footnote.

**********

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

Reviewer #3: Yes: Adhanom Gebreegziabher Baraki

[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.

PONE-D-20-25583R3MAGNITUDE AND ASSOCIATED FACTORS OF ANTI-RETROVIRALTHERAPY ADHERENCE AMONG CHILDREN ATTENDING HIV CARE AND TREATMENT CLINICS IN DAR ES SALAAM, TANZANIAPLOS ONE

Dear Dr. Mussa,

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Academic Editor

PLOS ONE

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Reviewers' comments:

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Comments to the Author

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Reviewer #2: (No Response)

Reviewer #4: (No Response)

Reviewer #5: (No Response)

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Reviewer #2: Partly

Reviewer #4: Yes

Reviewer #5: Yes

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

Reviewer #2: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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Reviewer #2: Yes

Reviewer #4: No

Reviewer #5: Yes

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Reviewer #2: Yes

Reviewer #4: Yes

Reviewer #5: Yes

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6. Review Comments to the Author

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Reviewer #2: The author has addressed the comments previously provided by the reviewers. However, there are still issues that the author must address in order to get a sound research work worth publishing. My additional comments are the below:

• Better to put AOR which are significant (i.e., p<=0.05) instead of OR as final results in the results section for factors.

• The AOR can be presented as (AOR=xx, 95% CI[xx,yy]) or (AOR=xx, 95%CI(xx-yy)) after the variable under discussion. The p-value is not needed here as the confidence interval speaks if the test is significant or not.

• In the conclusion section, factors contributing to low adherence from Table 6 must be mentioned (like age of care giver, child inter-current illness, believes on effectiveness of ART, and clinical stage).

• Usually, sample sizes are denoted by n and population by N. So, better to denote your sample size by n.

Reviewer #4: Methodology Concerns:

1. Study Design and study area:

Reference was made to National guidelines. It is useful to state the country of origin of the guidelines. Is this the Tanzanian National guidelines? Please clarify.

2. Methodology is silent on the specific factors affecting adherence only to surface in the results. Unless this is the journal preference, mention should be made in methodology of the specific factors affecting ART adherence.

3. The description of the quota sampling technique was inadequate. This requires more detail to understand the populations of the patients at the CTC sites and how representative the sampled research participants are of the CTC sites. Given the drawbacks of Quota Sampling methodology – Non-probability sampling, researcher’s bias in selection of study participants and limitations with generalization of study findings, a lot more detail would be required. Was the sampling controlled or not controlled for instance.

Results:

4. Socio-demographic factors affecting adherence:

a. Child age grouping of 1-9 years and 10-14 years lumps children with different needs together. The Under—five children age group is entirely dependent on the care giver for medication administration as opposed to the older age groups. School age children attending day school would have different challenges when compared with children in boarding school. Combining all these children together into just two groups with different needs may hide information that is inimical to adherence. Consider age groups of U5, 6-10, 11-14.

b. Similarly, parental grouping could be further revised to Single parents, both parents, grandparents and other caregivers. The challenges for each group differ from the other and may impact differently on adherence.

c. Care giver marital status also appears to be lumped together. Married, cohabiting, single, Divorced, widowed caregivers could be assessed separately. Married and cohabiting on one hand and single divorced and widowed caregivers on the other hand may not have the same challenges. It is possible that evaluating each group may be more informative that combining them.

Conclusion:

5. Pill burden

Specify the type of pill burden, high or low.

Recommendation:

6. Adherence counseling:

The authors’ results show that there is no association between lack of adherence counseling and poor ART adherence and yet recommended the necessity of counseling. This needs clarification.

Reviewer #5: This is a good and generally well-written manuscript.

However, I noted some points that need to be addressed.

1. Line 4 of the 2nd paragraph of the introduction says 1.7 million children (1-14 years) were living with HIV and 1.9 million of them were in sub-Saharan Africa. I think this is a typo as the number is about 1.09 million (64% of the 1.7 million).

2. In statistical analysis, it is mentioned that measures of central tendency were used to summarize discrete data; the only measure of central tendency that can be applied to discrete data is mode and this should be stated if it was used.

3. In the results section: for age groups, 25 years appears in 2 strata: 17-25 years and 25-34 years. This should be appropriately revised; either 17 -<25 years and 25-35 years, OR 17-25 years and >25 - 34 years.

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Reviewer #2: No

Reviewer #4: No

Reviewer #5: Yes: Agatha N. David

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MAGNITUDE AND ASSOCIATED FACTORS OF ANTI-RETROVIRALTHERAPY ADHERENCE AMONG CHILDREN ATTENDING HIV CARE AND TREATMENT CLINICS IN DAR ES SALAAM, TANZANIA

PONE-D-20-25583R4

Dear Dr. Mussa,

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,

Chika Kingsley Onwuamah, Ph.D.

Academic Editor

PLOS ONE

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