PONE-D-21-07875What determines HIV self-test Acceptability and Uptake within the MSM community in Nairobi and its Environs? A cross sectional studyPLOS ONE

Dear Dr. Ndungu,

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.

 Three reviewers have evaluated your submission and have identified a number of concerns that need to be addressed carefully in a revision. Please pay particular attention to responding to the points raised regarding the presentation of the manuscript and the need for additional clarity about your study's limitations.

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Jamie Males

Staff Editor

PLOS ONE

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Reviewers' comments:

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Reviewer #1: Partly

Reviewer #2: No

Reviewer #3: No

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

Reviewer #1: No

Reviewer #2: I Don't Know

Reviewer #3: No

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: No

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5. Review Comments to the Author

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Reviewer #1: I appreciate the opportunity to review and provide feedback on the draft manuscript entitled, “What determines HIV self-test Acceptability and Uptake within the MSM community in Nairobi and its Environs? A cross sectional study” by Ndungu et al. The topical matter of the manuscript is important spanning the burgeoning field of HIV self-testing (HIVST) in a key population of MSM/MSW within an Africa context. I commend the authors for undertaking this research particularly in a setting where the population of interest must exist in non-open manner given the legal statutes. The report has valuable information to put forth in the literature and with appropriate revisions (outlined below) will likely be suitable for publication.

General:

There are numerous typos throughout the draft that should be addressed with careful proofreading. Related there are many instances in the prose where the authors write out a numeric result and then immediately report it as numerals, this is not needed and is redundant. See lines 222, 316, 324, and many more.

The database provided has the participant date of birth listed THIS MUST BE REMOVED AS IT IS PROTECTED HEALTH INFORMATION.

Title:

The title is a bit definitive, suggesting that the report will answer the question posed. A preferable phrasing might be “Evaluation of factors associated with HIV self-test Acceptability and Uptake within the MSM community in Nairobi, Kenya: A cross sectional study”

Abstract: The last sentence of the background is a fragment and unclear. The objective seems to be to identify both facilitating and barrier factors for HIVST aspects the way written it only states “facilitating”. There is no description of the analysis here there needs to be at least some. The conclusion that “A significant number of MSM community in Kenya are willing to use HIVST and are likely to seek for care within 30 days and this is a good indicator of linkage” is a bold statement given the data and this should be more tempered given the sample studied.

Introduction: There are a few typos that need to be addressed but overall is well constructed and appropriate for the work.

Methods: Need more detail in all sections. For the Study population it could not have been “all adult men aged 16-60” years as the author’s state. The last two sentences in this section are introduction information and do not belong in the methods section. The sampling technique is not clear and needs more details on when the sampling occurred, over what time period and with what frequency for each of the sites. As well the snowball technique is not a standard approach for a cross-sectional design and is more often used in qualitative sampling so it would be good to have more rational and information on how this was achieved. How was the questionaries administered was it in English or Kiswahili or a different language? The analysis choice to use POR would benefit from some reasoning as to why. It is not wrong to do so mathematically but not overly common so some more information for the reader would be preferable. The number of inferential comparisons preformed is immense (~20) and as such the authors should adjust down their p-value used to make assertions around assumptions and “significant” associations. A simple Bonferroni correction would be acceptable but there are more advanced methods that could be chosen. The reporting of the POR

Results: The prose section of the results is long and can be cut down, the authors should focus in on highlighting only the most key findings in this section. To achieve this focusing in on the inferential analysis with the proportional differences between comparison groups and the PORs would be helpful. As well for all numeric values there is no need to provide more than three significant digits (save for p values <0.001). When describing a POR that is a finding showing lower likelihood of HIVST use it would be easier to understand if the result was framed as a value <1 (see lines 332,333 for example).

Discussion: The discussion raises good points throughout however the authors should aim to be more tempered in their interpretation of the results given the overall limitations. I am not sure if the sub-headings are needed but that is up to the journal. The limitations section should be expanded on there is most certainly selection bias given the sampling approach (snowball) and although this is mentioned more elaboration on this point is needed. Additionally consideration of responder bias and the impact of missing data should be discussed.

Tables and Figures:

Given the design a figure 1 flow diagram to understand those that were screened and did not consent/participate as well as the 22 who were lost to follow up and did not complete data collection.

Table 3 is entirely too large to be digestible by the reader. Recommend breaking up the inferential portions of the analyses and reporting them as separate tables.

Reviewer #2: The article had important problems regarding language.

The use of numbers in parenthesis should be revised. For example, authors said: "The majority of interviewees were Kenyans at (92.6%), followed....".

Numbers of the tables should be revised (Table 1 does not exist).

I do not understand how 6 participants that "used HIV test kit before", answer "no" when asked about "Ever tested for HIV". How did they used the self-test if they were never tested?.

In the same way, 136 participants that "used HIV test kit before", answer "no" when asked about "Ever heard of HIV self test". How did they used the self-test if they never heard about it? It does not make sense.

Reviewer #3: The authors aimed to determine facilitating factors for HIVST acceptability and uptake among MSM community. This area is of great interest and important, however, the manuscript will need significant improvement

Major comments

On abstract

Introduction

• Integrate objective within the introduction section and remove sub heading objective

Methods

• Add the study outcome of interest and how it was defined or measured, and statistical methods used to analyze the data, this will help simplify follow up of the results

Results

• The objective was to determine facilitating factors for HIVST acceptability and uptake among MSM community, however, I don’t see results that support this objective. It looks like you did a simple descriptive analysis. Is it possible to do a regression model on data collected? You present hindrance to testing more than facilitators

Conclusion

• Conclusion is not backed by results and not aligned with the main objective and title of the study of the study. Please, clarify

Background

• The opening statement needs figures to back that urgent of “There has been significant progress in HIV prevention efforts across Africa, however men who have sex with men (MSM) continue to bear a disproportionately heavy burden of HIV infection compared to the general adult population”.

• Reference two is so old, please, cite the most recent data and citation

• The back ground is too long, and not clearly written in line with objective and title of study. I suggest, they write in funnel shape- start with MSM global HIV risk and testing rates, narrowing to Kenya, then to HIV self-testing acceptability and uptake, finally state the clear problem they intent to address/study and end with what they did to address this problem

Methods

• Start with study design, then study area etc. I have seen study design is under sampling techniques which makes following up of the manuscript difficult.

• Under data analysis, I think it can be improved better by using a suitable regression model depending on how they will define their outcome of interest

• Results too are too long, I suggest the author aligns the results to study objectives and topic and concentrate on that. For now, the authors present a lot of data which is good, but should be aligned to the topic/objectives. The results are broad ranging from HIVST Acceptability, Uptake, Facilitators, willingness and Barriers

Discussion

• The entire opening paragraph is not necessary. The first paragraph should summarize the main findings of your study and then you continue to compare it with other published studies.

• Again, the discussion is very long and discusses different themes that are not aligned with the topic and objective of the study. Too much data presented

• Conclusions needs to be aligned with topic and main objectives

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Reviewer #1: Yes: Adam R. Aluisio

Reviewer #2: No

Reviewer #3: No

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PONE-D-21-07875R1Reviewers & Authors Comments.

Evaluation of factors associated with HIV self-testing Acceptability and Uptake within the MSM community in Nairobi, Kenya: A cross sectional study.PLOS ONE

Dear Dr. Ndungu,

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 Jul 29 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.

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• 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,

Adam R Aluisio, M.D MSc., DTM&H

Guest Editor

PLOS ONE

Additional Editor Comments (if provided):

I served as an initial reviewer on this submission and now as a guest editor. Good progress on this work but there was inadequate response to some of the reviewers' comments. Specifically no information on bias or missing data although the response letter states this was done. As the primary outcome is based on self-report of past HIVST use this needs to be acknowledged at least in the limitations. Also the main outcome metric of HIV self-testing needs to be better described in the methods. It seems that is based on participant report solely, which is fine but needs to be more clearly stated and how that also could suffer from bias. The updated draft with the regression model is difficult to follow on how it was constructed and run. Associated with that the reporting of the model is confusing as to what the main findings are and the tables have too much information on statical outputs (there is no need to report coefficients and the aPOR or the SE and the CIs). These aspects need to be corrected for publication.

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Reviewers' comments:

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PONE-D-21-07875R2Evaluation of factors associated with HIV self-testing Acceptability and Uptake within the MSM community in Nairobi, Kenya: A cross sectional study.PLOS ONE

Dear Dr. Ndungu,

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 Sep 26 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:

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• 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,

Adam R Aluisio, M.D MSc., DTM&H

Guest 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.

Additional Editor Comments (if provided):

Good progress by the author team. This is an improved draft.

Two required points to revise.

1.) The authors state the missing data were MCAR to justify the listwise deletion. Please provide the information on how this was assessed and add that to the methods and/or results as appropriate. If a graphical method was utilized this can be provided as a supplement for the readers.

2.) The tables are more understandable in this format. For the aPOR table please indicate (perhaps footnotes) what the reference categories are. All tables and figures should be interpretable by themselves.

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Reviewers' comments:

N/A

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Evaluation of factors associated with HIV self-testing Acceptability and Uptake among the MSM community in Nairobi, Kenya: A cross sectional study.

PONE-D-21-07875R3

Dear Dr. Ndungu,

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,

Adam R Aluisio, M.D MSc., DTM&H

Guest Editor

PLOS ONE

Additional Editor Comments (optional):

The revisions have been completed with no additional major concerns. I thank the authors for their hard work and contribution to the field.

Reviewers' comments: