PONE-D-21-36754Prevalence and associated factors of under-nutrition among adults taking anti-retroviral therapy in sub-Saharan Africa: A systematic review and meta-analysisPLOS ONE

Dear Dr. Ali,

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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Joel Msafiri Francis, MD, MS, PhD

Academic Editor

PLOS ONE

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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: Partly

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

Reviewer #1: Yes

Reviewer #2: Yes

**********

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

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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: 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: Prevalence and associated factors of under-nutrition among adults taking anti-retroviral therapy in sub-Saharan Africa: A systematic review and meta-analysis

1. General comment: Relevant topic, consolidating evidence about the relationship between under-nutrition and ART.

However, the whole article needs to be revisited to make sure that English language is well written especially writing the article in a past tense. The authors should define abbreviations used for the first time

2. Abstract:

Background: Lacks the research gap and the broad aim/objective of conducting the study. Method: Some sentences written in present tense instead of past tense.

3. Main body:

Introduction: Revisit the first sentence in the first paragraph (Probably the authors meant that the rate of new HIV infection is decreasing Worldwide). 5th and 6th paragraphs talked about previous studies which also determined prevalence of under-nutrition and associated factors with HIV. However, the authors did not show the gap intended to be filled by the current study. It is not clear why the current meta-analysis was done as there were already some meta-analysis done as indicated in the literature review. However, the rationale is well stated.

Method: Include a table showing the PICO of the systematic review. Search words shown are only those for PubMed. I suggest you list all the search words considered in every search engine without giving the details of how the different search words were related (OR/AND). Give initials for the third author.

Results: Arrange the table and figures e.g. the PRISMA as they are discussed in the results section.

Discussion: Avoid repeating results in the discussion section

Reviewer #2: This was a systematic review to estimate pooled prevalence of under nutrition and associated factors among PLHIV in sSA.

Comment:

Overall:

Manuscript need English proof reading. Several areas past tense have not been used, conjunction missing. Message not clearly communicated

Title: Consider revising it to “Prevalence of under-nutrition and its associated factors among adults taking anti-retroviral therapy in sub-Saharan Africa: A systematic review and meta-analysis”

Define HIV appropriately as Human immunodeficiency virus. Do dot prefer people as HIV infected, you may consider using people living with HIV as the former is regarded as stigmatizing

Introduction:

There are about 7 paragraphs. Not clearly aligned. Consider reducing number of paragraphs to about 4 and each should carry specific message. Stating bidirectional relationship between ART and undernutrition without describing it not enough.

22 times more likely, if the study did not use risk ration, interpretation is not right.

Methods:

Needs English proof reading

Issues such as ‘The review is aimed……’; ‘databases are accessed…..’ needs revision to past tense. The word on the other had was used severally in the manuscript but not showing clear contrast

‘…..to find associated factors of under-nutrition’ could be factors associated with under-nutrition

Results.

There is unnecessary bolding of numbers or reference (eg figure xxx) , a total of 22316 etc

‘Sensitivity analysis is performed…..’ Needs to be past tense through out the manuscript

Odds ratios were not appropriately interpreted. The odds of X is 2 times that of Y. Not 2 times higher

‘……1.94 times more likely ….’ Is not appropriate, can be written 1.94 higher odds of having under-nutrition. This is not a risk ratio, you can’t say more likely

Discussion:

Needs revision

Like introduction, consider few paragraph with specific message

1- Paragraph- summarize main findings

2-3 Paragraphs- consider main factors to expand

4- para- consider limitations and strength

5- conclusion

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Reviewer #1: No

Reviewer #2: No

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Attachments

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Submitted filename: SUmmary of comments.docx

Attachment

Submitted filename: Nutrition.docx

PONE-D-21-36754R1Prevalence of under-nutrition and associated factors among adults taking antiretroviral therapy in sub-Saharan Africa: A systematic review and meta-analysisPLOS ONE

Dear Dr. Ali,

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 Aug 05 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,

Joel Msafiri Francis, MD, MS, PhD

Academic Editor

PLOS ONE

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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 #1: 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 #3: No

**********

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

Reviewer #1: 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 #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 #3: Yes

**********

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: Introduction:

• Third sentence, first paragraph: Look for more than one proof for food insecurity in Africa or better look for a systematic review

• Make sure you define all the abbreviation when used for the first time e.g. ART

• Second paragraph: The bi-directionality was not shown; you only showed that malnutrition worsens HIV. The effect of HIV on malnutrition is missing

Reviewer #3: General comment

The interpretation of this review has a bias towards comparing outcomes for Ethiopia with other published outcomes about Ethiopia. Given that all the authors are from Ethiopia, perhaps the authors want to reframe this study title and objectives to having a particular focus on Ethiopia

Specific comments

Wherever point estimates are provided confidence intervals should be included – for both this study, and the supporting background text

Methods

Inclusion criteria – prospective studies were not included?

How was undernutrition defined?

NewCastle Ottawa is good but it is stated that “A score of greater or equal to 6 points was considered “good” and included in the study”. Summary scores are a misleading way to assess quality.

Further, if this was done, the number of studies excluded because they were not considered “good” should be included in the flow diagram and results section narrative

A funnel plot is noted in the abstract and results, but not in the methods.

Subgroup and sensitivity analyses are described in the results, but not the methods.

12 is not the most appropriate test for heterogeneity when the outcome measure is a proportion. As such, it is unsurprising that 12 is >90%. (Tau2 would have been better)

The search strategy is not highly sensitive (eg “Anti-Retroviral Therapy” is a very limited term) and this should be noted as a limitation. Preferably, standard search terms would have been used (eg see search terms used by Cochrane, or search strings used by other reviews cited by this review, eg ref 10.)

Also, the search strategy has two sets of terms

“Proportion” or “Prevalence” or “Magnitude” AND“Malnutrition” OR “Under-nutrition” OR “Under-weight” OR “Wasting” AND “HIV-positive” OR “HIV-infected” OR “Anti-Retroviral Therapy” AND “Adults” AND “ (each country) in subSaharan Africa”.

AND

“Associated factors” OR “Determinants” OR “Predictors” OR “Correlates” AND “malnutrition” OR “under-nutrition” OR “under-weight” OR “Wasting” AND “HIV-positive” OR “HIV-infected” OR “Anti-Retroviral Therapy” AND “Adults” AND “ (each country) Sub-Saharan Africa”

These two sets of terms have duplicate terms. Limiting the search to studies that contain the words “Proportion” or “Prevalence” or “Magnitude” or “Correlates” is quite a crude limitation, as studies could report these outcomes without using these terms.

Results

“Regarding the publication year, 11 articles were published in 2020 followed by 9 articles in 2017. Besides, only one article was reported in 2010”

This is an anecdotal way of describing year of publication, given that 44 studies were included. Please reconsider how to present these data

Tables need legends to explain the acronyms

Figure 3

This is a very unconventional forest plot that does not display pooled estimates and confidence intervals well

**********

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 #3: 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.

Attachments

Attachment

Submitted filename: Comments.docx

PONE-D-21-36754R2Prevalence of under-nutrition and associated factors among adults taking antiretroviral therapy in sub-Saharan Africa: A systematic review and meta-analysisPLOS ONE

Dear Dr. Ali,

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 Feb 04 2023 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,

Joel Msafiri Francis, MD, MS, PhD

Academic Editor

PLOS ONE

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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 #4: (No Response)

Reviewer #5: All comments have been addressed

**********

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 #4: Partly

Reviewer #5: Partly

**********

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

Reviewer #4: Yes

Reviewer #5: 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 #4: Yes

Reviewer #5: 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 #4: Yes

Reviewer #5: Yes

**********

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 #4: Thank you for inviting me to review this systematic review on the prevalence of under-nutrition among people living with HIV in sub-Saharan Africa. While this topic is of high interest, and the authors have already improved their manuscript during the revision process, I feel the article is not yet ready for publication, and need further details, especially on the methods, results and discussion. Please see below my point-by-point review:

Title: it seems the review includes adults living with HIV, whatever their ART status, fig5 showing sub-analysis by ART status, I would therefore suggest changing the title to fit better with the review.

Abstract:

- Undernutrition has several definitions (low BMI, low weight, small mid-upper arm circumference, micronutrients deficiencies), this needs to be defined clearly in the abstract, especially as the background talks also about food insecurity which can be confusing. There are many terms used (malnutrition, wasting etc..) in the abstract and throughout the paper, which needs to be harmonized

- Methods section needs to be a bit more detailed (inclusion criteria, study period, study design and data extracted, especially related to the associated factors)

- Results section could start with the number of total records identified with the search strategy before to give the final number.

- Given the heterogeneity of the selected studies, whether in terms of study design, population, context, year etc.., I would be extremely careful while comparing the prevalence by country or years. I would rather focus on the HIV-related associated factors, which can be the more useful to target to further improve the nutritional status of people living with HIV.

Introduction: overall this part lacks a bit of structure and justification

- First paragraph should explain the HIV epidemic among adults, and challenges of HIV care, especially in sub-Saharan Africa, I don’t think the part about food insecurity should be there

- Second paragraph about the relationship between nutrition and HIV: ok

- Third paragraph, before objectives and perspectives, about the knowledge gaps on this topic and why it is important to study them: we need to estimate the burden of under-nutrition among people living with HIV in sub-Saharan Africa and understand what are the main risk factors for this population. If the focus in on adults among ART (which again is not clear in the title and abstract), this has to be better justified too

Methods:

- I don’t understand the comparison/control group here. Most studies selected don’t compare the prevalence of under-nutrition by HIV status, and the following results will not really display this. Does the comparative sample was really a criterion of the search strategy?

- Age threshold at age 16 years also need justification, why include youth for which nutritional and growth outcomes are still evolving greatly compared to adults?

- What was the period of time selected for the searching strategy? It is said until November 2021 but no information about the beginning, only in the title of the figures (2009), what is the justification for this threshold?

- I would suggest creating a table for the search strategy rather than putting it in the text, to better highlight it.

Results: Need further details for the reader to understand and have the full picture

- Table 2: Results should be much more specific and includes for each selected article: gender/sex distribution, ART duration (at least +/- 6 months on ART), the type of setting (urban, semi-urban, rural), median age or age range if available, the associated factors measured (so we know for each pooled analysis how many articles you included). I don’t think the response rate is useful here. Add the prevalence with its 95% confidence interval or interquartile range (fig 3 seems to display it but is not easy to read and I would suggest to delete it).

- Fig5: can this figure be stratified also by duration on ART? (whether +/- 6 months, 1 year or 5 years, depending on your results)

- Fig 6,7 and 8: it is not specific what was the reference group for each study. For example for WHO clinical stage, does all the studies compared stage 3-4 with stage 1-2? What was the comparison groups for CD4 count used to calculate the odds ratio? Same question for age and sex, how were the estimates calculated? If the definition and comparison were heterogeneous between studies I don’t see the point of doing a pooled analysis, this could be a narrative review only for this part, with a table explaining the detailed results.

Discussion: overall this part needs to be reinforced and better structured

- 1st paragraph: should summarised the results of the review first, not giving general messages, better suitable for the introduction of the end of the conclusion

- 2nd paragraph: I don’t understand why comparing the results with a population of pregnant women, this is a specific topic. Also, why discussing the effects of undernutrition on mortality here? This outcome was not taken into account in the review.

- In 3rd paragraph, you are discussing and comparing results by sex but this information is not well highlighted in you own article. What was the pooled prevalence by sex in your review? The comparison with results found on children are not necessary here. This will be more relevant to compare with the estimates of under-nutrition among the general population, to see if people living with HIV are more affected by this, and how much more affected.

- Ref28: why discussing of discrepancy with your study while this review measured food insecurity and not under-nutrition, which are, as you said yourself, two different markers?

- Further in the same paragraph, comparing with studies focused on overweight and obesity seems not relevant as well, unless you incorporate those results in your definition of the study outcomes and describe it.

- You briefly described the difference of prevalence per year in your results, I wonder if it would not be worth it to see and discuss if the prevalence has evolved over time, or at least comparing 2009-2015 and 2015-2021 for example. There might have been very few improvements, which is a result in itself, worthwhile to highlight.

- Other limitations need to be highlighted: heterogeneity and lack of comparative group. You should also discuss the risk of publication bias and how you mitigated it.

Reviewer #5: I have reviewed manuscript titled "Prevalence of under-nutrition and associated factors among adults taking antiretroviral therapy in sub-Saharan Africa: A systematic review and meta-analysis"

General comments : Few areas in the manuscript require proof reading. Correct the sentence on page 4, paragraph 1, " For example, a study......times higher odds.............."

If possible remove table 1 and you can just define the PICO questions by text. For this case, P can stand for population, I intervention and C: Comparison..... Also correct the sentence under population to read 16 years instead of 16 year... Also be consistent, is it grey literature or gray literature?

Under Effect measures : Make sure you write that sentence in past tense "We included......"

Methodology : Properly explain why I2 is high

Discussion: Page 13, correct those 2 sentences " Conversely.........." " The study used....

The second paragraph towards the end, you are discussing about children. This article is on adults.

Thank you

**********

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 #4: No

Reviewer #5: 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.

Prevalence of under-nutrition and associated factors among adults taking antiretroviral therapy in sub-Saharan Africa: A systematic review and meta-analysis

PONE-D-21-36754R3

Dear Dr. Ali,

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,

Joel Msafiri Francis, MD, MS, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Please format the figures - and would be helpful to drop Figure 3. It is not informative. It would would be helpful to proof read the English grammar prior to publication. 

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 #5: 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 #5: Yes

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

Reviewer #5: 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 #5: 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 #5: 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 #5: Thank you for responding to reviewers comments. Please verify that UNAIDS identify adults as those aged above 15.

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Reviewer #5: No

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