PONE-D-23-42499Systematic review and meta-analysis on the effect of depression on ART adherence among women living with HIVPLOS ONE

Dear Dr. Zeleke,

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Academic Editor

PLOS ONE

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Additional Editor Comments:

Please address all comments from reviewers.

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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: Partly

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

Reviewer #1: N/A

Reviewer #2: No

Reviewer #3: I Don't Know

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: 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: Yes

Reviewer #2: Yes

Reviewer #3: 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: The manuscript can be accepted. This research is technically sound and well written. As such I recommend that it be published in this journal to enable the findings to be shared widely. Well dine to the authors

Reviewer #2: Reviewer’s Comment

Overview

The manuscript, entitled "Systematic Review and Meta-Analysis on the Impact of Depression on ART Adherence Among Women Living with HIV," is well-written. It addresses a crucial aspect of the HIV program, particularly in the context of improving adherence among women on ART. This work is significant due to its potential to influence strategies and interventions aimed at improving health outcomes for this vulnerable population. I have the following suggestions to improve the manuscript:

Abstract

• On page 2, line 34, the authors’ stated objective, “to pool the effect of depression on ART adherence among women living with HIV,” is generally clear but could be improved for precision and clarity. An improved objective might be: “To conduct a meta-analysis on the correlation between depression and adherence to antiretroviral therapy among women living with HIV in Sub-Saharan Africa.”

Introduction

• This section effectively introduces the topic and establishes the relevance of studying the effect of depression on ART adherence in women living with HIV. It might benefit from a more concise summary of existing literature and a clearer articulation of the knowledge gap this study addresses.

Objective

• On page 7, line 2, the objective is clearly stated and aligns well with the introduction. However, the gap the study was trying to address was not clearly described.

• Authors should ensure that the objective is clear and directly linked to the gaps or issues identified in the introduction. This creates a cohesive narrative from the problem to the study's aim.

• It was unclear why the authors stated the objective separately rather than integrating it with the introduction section. Authors should review journal guidelines and ensure this format aligns with journal requirements.

Method

• This section describes the systematic review process, including database search strategies and criteria for inclusion and exclusion of studies. It is detailed and provides a clear understanding of the methodology. However, in the introduction, (page 4, lines 86), the authors described the challenges of defining the etiology of the exposure variable. Therefore, it is important to be sure that all articles are describing the same exposure variable.

• The exposure variable “depression” was not well defined for the studies selected. A table summarizing the definition of depression for each of the eight articles studied will ensure that we are not comparing “apples with oranges.”

Data Analysis

The manuscript uses a fixed-effect model for the meta-analysis and employs the Newcastle-Ottawa Scale for the quality assessment of the included studies. While these are standard practices, there are several areas for potential improvement:

� Choice of Meta-Analytic Model: The fixed-effect model assumes that the effect size is constant across all studies, which might not be the case here given the varied contexts of the studies. A random-effects model could provide a more generalizable estimate.

� Heterogeneity Analysis: It's crucial to assess the heterogeneity among the included studies. If significant heterogeneity is present, exploring its sources (e.g., through subgroup analyses or meta-regression) can provide valuable insights.

Results

• The entire result section will need to be formatted to align with the style of other sections of the paper.

• The results are presented with sufficient detail, including the number of studies reviewed and the main findings. To improve this section, authors may provide a more nuanced analysis of the results, including subgroup analyses or meta-regressions if possible.

• Graphical representations like forest plots or funnel plots could be included to visually demonstrate the results and potential biases.

Conclusion and Recommendation

• The conclusions drawn align with the objective and results. Recommendations are practical and relevant. However, emphasizing the implications of these findings for future research and public health practice would enhance this section.

Reviewer #3: In this systematic review and meta-analysis, what you are trying to establish is the relationship of depression in WLWH and the ART adherence. The period of study is large (from 2000 to 2022) in which ART has changed a lot, going from high pill burden, less tolerable to more friendly treatments. In the abstract and introduction you state that there is not clear how depression affects ART adherence in WLWH. Although this is debatable, because there is an important amount of studies and information on this regard, my concern is that with this study and design this questions is not addressable; causality is very difficult to prove... so I recommend to rephrase and be more accurate with what the analysis is performed. In the introduction you also mention that mention that HIV affects the brian and the rest of the nervous system, causing depression, which is not accurate and the reference you are providing are old and not alined with that statement. Also in the Intro you use the term "women" "female" and "female gender"... please be consistent. Sex at birth is what normally is collected in clinical database, which nor necesarily is alined with the gender, very few cohorts address properly the difference.

Regarding the results and interpretation, I´m concerned that there are 3 studies before 2016 in which treatments were not 1 pill a day and harder to tlerate and also only 2 are from LMIC (India). These limitations are not addressed in the limitation section and therefore, very hard to extrapolate to wider population. Perhaps given these results you should give a perspective and propose more studies in LMIC on this regard.

The figure of the algorithm followed is not clear to me and for example, it is not shown that the NOS is applied.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

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Attachments

Attachment

Submitted filename: Review comment for Plosone.docx

Systematic review and meta-analysis on the effect of depression on ART adherence among women living with HIV

PONE-D-23-42499R1

Dear Dr. Zeleke,

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,

Amos Buh, BSc., MPH, 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

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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

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

Reviewer #1: 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

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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

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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: The authors have adequately addressed all the review recommendations. The manuscript is ready for publishing.

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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

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