PONE-D-23-00937Pre-exposure Prophylaxis Uptake Concerns in the Democratic Republic of the Congo: Key Population and Healthcare Workers PerspectivesPLOS ONE

Dear Dr. Shen,

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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: 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: 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: Yes

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: This is a well-written paper that explores Pre-exposure prophylaxis attitudes and concerns among members of key impacted populations for HIV as well as a sample of healthcare workers that provides clinical care and services to key populations in the Democratic Republic of the Congo. The manuscript reports some of the first data from DRC regarding PrEP attitudes, as PrEP services have only recently become available, therefore there is good novelty in presenting emerging data from this region. The authors seek to examine timely and important questions around PrEP attitudes that can inform optimized care, which is of high significance. The exploratory analysis conducted does shed new light on a number of points, including patient specific and HCW barriers to PrEP utilization.

Despite the merits of the paper, there are also some weaknesses that warrant attention.

The introduction of the paper notes HIV prevalence data on FSWs in the DRC, but does not provide background information on other KPs. Are these data available? It would seem particularly important if data on TGW are available since this group is heavily represented in the survey responders for the current study.

In the methods, the authors note that all data was self-reported, no medical records data were utilized, yet the data statement contradicts this. Some clarification appears warranted.

I had some concern regarding the survey instruments that were used to assess attitudes and concerns, these adapted items are from somewhat dated HIV treatment research using the IMB model, and no information was provided on their reliability or validity. Were PrEP instruments actually considered for the data collection? Justification for the choice of measures would strengthen the paper.

In the results section, it was somewhat surprising to see that 67% the KP reported the primary concern of side effects from PrEP, especially since this is a sample of PrEP users. Since these are PrEP users I wondered if this is reflective of actual experienced side effects, and if so, this is quite elevated compared to other reports. The reported adherence barriers seem to indicate that 31% had concerns or actual experienced side effects with the PrEP medication, so this would seem to warrant clarification for the reader. Also, there was a fairly high refusal rate on the adherence item. How should we interpret that? I had some challenges interpreting the items in supplementary Table 1 as well, for example, what is “sensitization of KP”? A few of these items would benefit from further explanation.

The discussion is well written and nicely touches on the role of stigma in PrEP uptake, but in some ways it is fairly general regarding the role of additional training for HCWs. Perhaps the authors could include and reinforce more specific actions needed based on their findings.

Reviewer #2: This manuscript presents descriptive data about the access and use of oral PrEP by key populations in the Democratic Republic of the Congo, from the perspective of PrEP clients and health care workers. With some additional clarifications, this will be an important contribution to the evidence base on real-world implementation of oral PrEP services. Below please find a summary of recommended additions or revisions.

Introduction:

- The introduction is currently very brief and would benefit from additional contextual information. I would recommend adding a paragraph to summarize available data on the main reasons why key populations are disproportionately affected by HIV; a paragraph on any available data on PrEP use among key populations in the DRC; and a paragraph summarizing available information on relevant norms and attitudes surrounding key populations and HIV in the DRC.

- The second paragraph would benefit from the addition of adding data on HIV incidence or prevalence among key populations groups not already mentioned in this paragraph, such as trans individuals, people who use injection drugs, and men who have sex with men. If these data are not available, either a statement about this knowledge gap or a summary of available data on the regional level might be appropriate.

- Please add the aim of this study to the introduction section.

Methods:

-If possible, please link to or describe in further detail the training materials used to prepare providers for PrEP provision. Describing if/how the training addressed stigma, if it included values clarification, and what the KP Classification Tool consisted of would help the reader understand the context in which this research was conducted.

- Please clarify how PrEP clients were asked to report their gender. Were participants given the response options shown in Table 1? This would help the reader understand how the two trans women were identified.

- Table 1 states that the study was conducted in 7 health facilities. Is it possible to provide further details about these facilities? For example, are they KP-focused facilities, are they located in an urban or rural setting, etc.

Results:

-The part of Table 1 that shows KP classification would be better represented visually, if possible. I would encourage the authors to consider creating a diagram of overlapping circles to indicate the multiple and overlapping KP identities.

- Regarding client barriers to PrEP adherence, there is a discrepancy in how data are reported in Table 1 and how they are reported in the body of the manuscript. It appears as though a different denominator is used. It would be more straightforward for the reader if these percentages were the same in these two places.

Discussion:

- There were some findings that I personally found interesting that were not discussed at length in the discussion. I would encourage the authors to consider discussing the following finding: Although all providers were comfortable providing PrEP to most KP groups, almost one-quarter of providers believed that HIV is a punishment for inappropriate behavior. This seems to further emphasize the need to improve provider attitudes as discussed in the third paragraph of the discussion.

- The final paragraph of the discussion points to PrEP-associated stigma. It is worth discussing whether the authors expect there to be any KP-specific stigma also at play.

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Reviewer #1: No

Reviewer #2: Yes: Kathleen Ridgeway

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Pre-exposure Prophylaxis Uptake Concerns in the Democratic Republic of the Congo: Key Population and Healthcare Workers Perspectives

PONE-D-23-00937R1

Dear Dr. Shen,

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.

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Kind regards,

Edward Nicol, 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 #1: All comments have been addressed

Reviewer #2: 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

Reviewer #2: Yes

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

Reviewer #1: Yes

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 #1: Yes

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 #1: Yes

Reviewer #2: 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: Thank you for the careful attention and response to initial review comments. Two minor notes: Figure 3 appears to be without a title, this should be added. Also, please clarify in the abstract and full manuscript the % who experienced PrEP side effects; it is stated that 31% experienced side effects but Table 1 shows this to be 14%. I believe that 31% includes those who were concerned about side effects even though they did not experience them, this should be made clear for the reader.

Reviewer #2: (No Response)

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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 #1: No

Reviewer #2: Yes: Kathleen Ridgeway

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