PONE-D-24-03550Clinic-level complexities prevent effective engagement of people living with HIV who are out-of-carePLOS ONE

Dear Dr. Kalokhe,

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.

ACADEMIC EDITOR's comments: 1. Introduction: The introduction should be revised to include some literature reviews on HIV retention in line with the study objectives. The review should identify what has been done by other studies, state any gaps that may exist and how your study seeks to bridge these gaps and contribute to the body of knowledge on the topic.2. Methodology: It was stated that the study design is a qualitative analysis embeded within a larger mix-method design. However, a review shows this study to be largely qualitative in nature, if there is data to support a mixed-method design (qualitative/quantitative), please provide it, especially related to coding of qualitative data.

Please submit your revised manuscript by May 10 2024 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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We look forward to receiving your revised manuscript.

Kind regards,

Moses Katbi, MD, MPH, MBA, DrPH, FRSPH

Academic Editor

PLOS ONE

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2. Thank you for stating the following in the Acknowledgments Section of your manuscript:

“This work was supported through an administrative supplement by the Center for AIDS Research at Emory University (P30AI050409). We express utmost gratitude toward each of the individuals who participated in the study and openly shared their perspectives with us.”

We note that you have provided funding information that is currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

“This work was supported through an administrative supplement by the Center for AIDS Research at Emory University (P30AI050409; https://cfar.emory.edu/) to Ameeta Kalokhe and Jonathan Colasanti. The funders played no role in the study design, data collection, analysis, decision to pbulish nor preparation of the manuscript.”

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

3. In this instance it seems there may be acceptable restrictions in place that prevent the public sharing of your minimal data. However, in line with our goal of ensuring long-term data availability to all interested researchers, PLOS’ Data Policy states that authors cannot be the sole named individuals responsible for ensuring data access (http://journals.plos.org/plosone/s/data-availability#loc-acceptable-data-sharing-methods).

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Before we proceed with your manuscript, please also provide non-author contact information (phone/email/hyperlink) for a data access committee, ethics committee, or other institutional body to which data requests may be sent. If no institutional body is available to respond to requests for your minimal data, please consider if there any institutional representatives who did not collaborate in the study, and are not listed as authors on the manuscript, who would be able to hold the data and respond to external requests for data access? If so, please provide their contact information (i.e., email address). Please also provide details on how you will ensure persistent or long-term data storage and availability.

4. 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.

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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

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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: Yes

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: 1. Summary of the research

This qualitative study explored barriers and facilitators to HIV care engagement in an urban setting in Atlanta, Georgia. Eighteen in-depth interviews were conducted with HIV service providers, administrators, social workers and people living with HIV who have experienced being out of HIV care. The authors reported a number of clinic level barriers, including high coordination burden on patients, inflexible clinic schedules, issues with identification of patients at risk of disengaging, poorly resourced hospital-to-clinic transitions, challenges with follow up, and stigma by health professionals. They authors identified strategies to address the barriers, including co-location of services, community-based care options, use of peer navigators, dedicated staff to support PLWH and support in collecting documentation for subsidized care.

The authors claim that this study adds to the body of evidence because it is the first study to examine clinic level factors that impact on retention in care, and it identifies burden of documentation and gaps in clinic processes.

The manuscript abstract, introduction and methods are well written. However, the findings will do with some editing to improve flow. Some of the results statements in the findings are too summarized and may need to be augmented to better reflect the participant discussions.

My overall recommendation is that the authors edit the findings section to improve flow, and augment some of the results statements.

2. Examples and evidence

2.1. Major issues

2.1.1. The results section does not flow well, with concepts being mixed under some sub-sections where they don’t seem to belong. For example, a section describing high care coordination (starting line 144) speaks to transport issues and prescription issues, which are covered under other sub-sections. Furthermore, the section generally does not flow well and has some language issues that need address. I would like to suggest that the whole section be edited to address the above issues and improve its flow.

2.1.2. A number of results statements seem to be too summarized and may not have adequate content. They may need to be augmented with more content to better reflect the discussions and what is provided in the quotations. The result statements that may need to be revised include those in the following: line 165-166; line 186-188; line 225; line 263-264; line 273-274; line 293-294; line 317-320; line 337; line 347-348; line 360; line 375-376; line 388-389; line 398-399; and line 409-410.

2.1.3. The results section participant characteristics (line 1329-132) do not include baseline characteristics. I would suggest that these be added.

2.2. Minor issues

2.2.1. Difference tenses are used in different parts of the manuscript, varying from present to past tense. It would be better to harmonize the tenses used throughout the manuscript.

2.2.2. The abstract is generally well written, but the following may need address:

• Since this is a study on engagement of out of care PLWH, it may be better for the first sentence (line 26-27) to be written such that it reflects the negative situation in the study, so that it refers to those who not retained in HIV care.

• The word “automated” in line 40 may be better dropped because it does not seem to be supported by the findings.

2.2.3. The introduction is well written. However, different viral suppression levels are quoted in the introduction (line 58, reference 5) compared to what is in the discussion (line 425). Consider harmonizing, otherwise if there is need to quote both, provide clear justify for that.

2.2.4. The research methods are well written and technically sound. The following minor issues may however need address:

• The sentence starting “In comparing and contrasting …… “ in line 110-113 sounds more like a funding than part of the methods. If it is to be retained, it may be better to rewrite it so that it sounds more of the methods.

• Though it is mentioned in the results section that the research team was trained, it may be better to also mention it in the methods that the research assistants were trained especially in research ethics.

• Please correct the typographical error one-one-one in line 114.

• In line 119, you may want to rephrase the part of the sentence reading “devoid of identifying information”.

2.2.5. The results section does not flow well. I would suggest that you consider revising as follows:

• For point 5 in line 139-141, it may be better to use the description as provided in line 262 but possibly without the word “automated” which does not seem to be supported by the findings.

• It is not clear why the phrase “care coordination” is used in line 145 as it does not seem to be supported by the presented findings.

• The bulk of what is in the quotation from line 151-158 does not seem relevant to the header (line 144). If it is to be kept, it may be better to ensure that it is reflected elsewhere. I would suggest you consider deleting “Transportation, co-pays” (line 151) and the rest of the quotation from “You know, and then ….” right up to the end of the quotation (line 153-158).

• The quotation in line 160-163 does not seem relevant to this section and may need to be moved to a sub-section that relates to referrals.

• The statement in line 165-166 in addition to speaking to program eligibility paperwork, also speak to transport and knowledge gap issues, the latter two issues which are not related to care coordination issues that the sub-section header refers to (line 144). The quotation also speaks to both transportation and paperwork issues. For better flow of this sub-section, I would like to suggest that only issues related to this sub-heading (line 144) be included while other issues and quotations would be better moved to relevant sub-sections.

• The results statement in line 178-179 is not very clear and the author could consider revising it.

• There does not seem to be adequate evidence provided to support the first half of the statement in line 195-196 as the quotation 199-202 does not adequately refer to it. It could be helpful to provide another quotation to provide supporting evidence for that first part of the statement.

• The second part of the sentence that starts “…. Their feedback highlighting now …..” in line 253-254 seems unclear. The authors could consider revising or deleting it.

• The sub-heading in line 262 includes the word “automated”, but there does not seem to be findings to support its inclusion. I would suggest that the authors consider dropping it if there are no findings to support its inclusion. Furthermore, line 262 is very broad while the quotation provided is very specific to issues around hepatitis vaccination. I would suggest adding findings or quotations to support the statement.

• The results statement in line 304-306 and the quotation in line 308-315 do not seem to be well aligned, and the conclusion may therefore be an overreach of the findings. I would suggest that the authors consider using quotations that more clearly talk to co-location, and not just the need for the other non-HIV services referred to.

• There is need to consider replacing the word “longitudinal” in the statement in line 388-389 to possibly make this statement clearer.

2.2.6. The discussion section is generally well written though it could do with some editing to improve flow. A few issues that may need address include:

• In line 463, child-care obligations are mentioned, but do not seem to have been included in the study findings. The authors may want to clearly indicate that it’s a suggestion to include them though they were not study findings.

• The analogy “Long-Acting Injectable Therapies (LAIs) in advancing HIV care” in line 470 may not be the best for this situation and the authors could consider using a different analogy.

• The statement that starts “Nonetheless, the CAB members ….. “ in line 486-488 refers to the experience of CAB members in other clinic settings, but I am not sure that the finding was presented anywhere else in the manuscript. I would suggest as a finding it be included in the results section before it is referred to in the discussion section.

• The statement that stigma within health care settings must be addressed through education (line 496-497) may not be adequate. I would like to suggest that the authors consider including other strategies to me more complete.

Reviewer #2: The study was well conducted important details included. However, methodology did not include the demographics of the participants, I will be good to have that information.

Under the result, The study provides a unique opportunity to compare the perceived reason for dropping out of care from patients' and healthcare workers. But this was not well highlighted. It be good to compare and contrast this findings to see areas of agreement and areas where they differ This will help in understanding the deeper dynamics involved in deciding to drop out of care. An effort was made to do this but it fails to address it well. Distinct themes and sub themes for the CAB member and care providers'

The discussion should compare that findings with more similar studies and not just repeat what has already been written in the result.

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Reviewer #1: Yes: Brian C Chirombo, MBChB, MPH

Reviewer #2: No

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Clinic-level complexities prevent effective engagement of people living with HIV who are out-of-care

PONE-D-24-03550R1

Dear Kalokhe Ameeta,

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,

Moses Katbi, MD, MPH, MBA, FRSPH

Academic Editor

PLOS ONE

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