PONE-D-23-29942Practices and preferences for HIV testing and treatment services amongst partners of transgender women in Lima, Peru: an exploratory, mixed methods studyPLOS ONE

Dear Dr. Tollefson,  Upon reviewing the findings, it is evident that there is significance. In alignment with the reviewers' comments, I concur that major revisions are necessary.,

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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Academic Editor

PLOS ONE

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Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health under grants 5D43TW009345-10 and 2D43TW009345-11 awarded to the Northern Pacific Global Health Fellows Program. We acknowledge support related to the use of ITHS REDCap to carry out this study (UL1 TR002319, KL2 TR002317, and TL1 TR002318 from NCATS/NIH). The content is solely the responsibility of the authors and does not represent the views of the National Institutes of Health.

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Additional Editor Comments:

Thank you for submitting this intriguing study to PLOS ONE. Upon reviewing the findings, it is evident that there is significance. In alignment with the reviewers' comments, I concur that major revisions are necessary.

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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: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: 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: 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: Thank you for the opportunity to review, “Practices and preferences for HIV testing and treatment services amongst partners of transgender women in Lima, Peru: an exploratory, mixed methods study.” The authors present results of a mixed-methods survey of transwomen (TW) and their sexual partners (PTW) in Lima, Peru regarding their preferences and practices for HIV testing and treatment. The results are interesting and important, presenting a relatively large sample of PTW (a population that has been understudied to date) addressing differences in attitudes towards and use of HIV prevention and testing services. The analysis is well done and the manuscript well written. There are a few points for clarification or elaboration prior to publication:

1) The authors describe their sampling method as Respondent Driven Sampling (RDS) but do not use any of the analytic methods inherent to RDS, and the single-wave of recruitment from seeds selected through convenience sampling is not consistent with RDS methods. It may be preferable to describe recruitment as peer recruitment or snowball sampling to avoid methodological disputes over terminology.

2) In the abstract, it would help to specify the numbers of TW and PTW recruited for the study.

3) The Background is brief and does not provide any context for understanding why the authors chose to address differences among PTW according to their partnership status or partner type with TW. Given that Jess Long’s papers, cited in the manuscript, provide a great amount of detail on this topic, it would help to have some discussion of this work in the Background to set the stage for the rest of the analysis.

4) In the Methods, participants are required to have been “literate in Spanish.” Does this comment mean that participants who were unable to read or write were excluded from participation?

5) What were the recruitment patterns for TW seeds and the PTWs (i.e., were a few seeds responsible for a great majority of the PTWs, what was the distribution of PTW characteristics in relation to TW seeds, etc.)?

6) What were the demographic and other characteristics of the subset of participants in the qualitative interviews?

7) Please specify in the Methods how “Stable partners” were defined in the survey (similar to the explanations provided for casual and transactional partners).

8) Was the qualitative data analyzed in the original Spanish or in English translation?

9) Why was Via Libre’s IRB used for this study (a brief explanation would be useful)?

10) The right side of Table 2 is cut off in the current formatting.

11) In the Discussion, the authors suggest that power differentials in the relationships between TW and PTW are partly due to the higher SES of PTW. However, in this sample, over 95% of all participants (and 94% of PTW) report earning less than $400 USD/month. It is more likely that other factors, like gendered power differentials between cis-men and transwomen, and the high frequency of sex workers in the TW sample, play a greater role in defining power differentials in these relationships.

12) The authors seem to gloss over a potentially fascinating observation in their qualitative data, where PTW complained about on-site HIV testing with vans or mobile units as these can increase visibility of individuals waiting outside the van for testing, and some stating that they prefer to attend traditional testing venues as they provide greater privacy and discretion, while the TW interviewed did not have similar complaints. This observation could have critical implications for how HIV testing and treatment is provided to these different groups, and merits greater discussion.

Reviewer #2: In article ‘Practices and preferences for HIV testing and treatment services amongst partners of transgender women in Lima, Peru: an exploratory, mixed methods study’ submitted for review at PLOS One, the authors conducted a cross-sectional mixed methods study among Partners of Transgender Women (PTW) and Transgender Women (TW) in Lima, Peru using an explanatory sequential design where online surveys were administered followed by interviews. Based on the findings, practices and perspectives on HIV testing and treatment were compared quantitatively and qualitatively between PTW and TW participants. Firstly, I want to congratulate the authors for targeting an extremely hard to reach population (PTW) for some very timely research, since the global drive to end the HIV epidemic would not be successful without HIV prevention and care access for all hidden, vulnerable, hard to reach (and understand) populations like the TW and PTW. The article is well written, easy to follow, and the conclusions seem generally plausible given the results of the statistical analyses. However, I do have a few comments:

Major Comments

1. The authors mentioned this as one of their limitations, but I wonder how much of the perceived differences in demographic characteristics between TW and PTW are driven by the difference in recruitment of the respective groups. TW were recruited from clinics and can potentially be more vulnerable than the average TW population in Lima, and PTW were recruited by the TW seeds, by virtue of the definition, were probably from a more general pool of PTWs in Lima.

Do the researchers have any data to support or refute that claim? For example, one metric might be HIV prevalence among recruited TW versus the general TW population, which seems to be similar in this case (30% in GP vs 26.1-37.7% in the study). Another important factor might be sex work status. Sex work is a known risk factor for HIV and other STIs as well and is known to be correlated with lower income and lower education. Can the researchers track the sex work status of all survey TW participants, and compare them with the TW population average in Lima? Any other metric to use perhaps?

2. Another limitation that the authors mention about the statistical analysis is the following:

‘Secondly, we did not adjust for clustering present from respondent driven sampling because this was an exploratory study and there is no gold standard for analysis for this sampling method.’

The authors are probably correct in pointing out that there is no gold standard method for analysis of RDS data in the literature as of yet, however, note that a typical RDS has multiple waves of recruitment with a few initial seeds, which makes statistical modeling quite challenging because of the hierarchy of the different waves. However, the study design pursued here only employed one wave of RDS, and thus the ensuing data can be conceived as clustered, where each cluster consists of a TW seed and the PTWs they recruited. The authors should at least look whether such clustering exists (with respect to outcomes in Tables S3 and S4), for example, one can estimate the intra-cluster correlation coefficient (ICC). If indeed the ICC is high, one can pursue adjusted t-tests/chi-square tests for clustered data or regression approaches like LME to see if the inference is any different from the unadjusted analyses.

Minor Comments

1. Page 11, line 180, Table 1 – Median and IQR are probably better metrics for ‘Age’ than mean and SD.

2. Page 13, line 197, Table 2 – Not fully visible for review. A third of the table seemed to be cut-off, probably that page needs to be in landscape format.

Reviewer #3: The authors evaluated practices and preferences for HIV services in partners of TW, a highly at-risk hidden population.

The paper is clearly written and only minor edits are needed.

For readers who are not familiar with the Peruvian health system and current standard of care, I consider the paper could benefit from the following changes/additions:

-The authors described in the discussion that PrEP was implemented in Peru in June 2023. Since this question arose at the time of the results, I suggest moving this explanation to the introduction.

-On page 3, line 17, the authors mentioned “non-traditional HIV testing options”. I suggest adding in the introduction a short explanation about the standard of care for HIV testing in Peru and clarifying what are the “non-traditional HIV testing options” available.

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Reviewer #1: Yes: Jesse Clark

Reviewer #2: No

Reviewer #3: No

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PONE-D-23-29942R1Practices and preferences for HIV testing and treatment services amongst partners of transgender women in Lima, Peru: an exploratory, mixed methods studyPLOS ONE

Dear Dr. Tollefson,

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:

While the reviewers have already provided their comments, here are my suggestions and concerns:

1. Choose either an English or Spanish abstract.

2. Even though you've discussed the transgender situation globally, please clarify the correlation between your topic and the research question in the introduction.

3. I suggest revising the aim of this study to articulate how this research will make a significant contribution.

4. It appears you are using a mixed-methods approach; please be more specific in the data analysis section.

5. The table 1 presents a detailed breakdown of the characteristics of study participants, including age, education level, nationality, employment status, income, sexual attraction, number of sex partners, and self-reported HIV status, differentiated between TW (transgender women, n=69) and PTW (presumably non-transgender participants, n=165). regarding Education and Employment: Could the authors delve into the factors contributing to the educational and employment disparities observed, particularly the barriers TW face in these areas?

6. How does the cultural and national context influence the study's findings, especially regarding social support systems and healthcare access?

7. The authors are invited to explore how the sexual attraction and partner preferences among TW and PTW inform our understanding of HIV risk and prevention needs within these communities.

8. Given the marked HIV status disparity, what specific, actionable recommendations do the authors propose to mitigate this risk among TW?

==============================

Please submit your revised manuscript by May 16 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.

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,

Alex Siu Wing Chan

Academic 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.

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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 #2: All comments have been addressed

Reviewer #3: 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

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: 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 #1: Yes

Reviewer #2: 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 #2: 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: (No Response)

Reviewer #2: The authors have done an excellent job addressing all the comments left by the Reviewers. I just have one minor comment that is mainly about consistency in presentation of results.

1(i) In Supplementary Tables S3 and S5 (and possibly others), the authors have presented standard deviations (I presume for the data distribution), however, given they present results from hypothesis tests conducted on the means, the more relevant metric would be standard errors for these parameters. Can you present standard errors instead of SDs (or in addition to the SDs) in the Tables?

1(ii) Additionally, to be consistent, can you please add the cluster-adjusted standard errors in Supplementary Table S3-2?

Reviewer #3: the authors have addressed most reviewers comments, corrected tables format and the manuscript is now clear

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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: No

Reviewer #3: No

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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.

Practices and preferences for HIV testing and treatment services amongst partners of transgender women in Lima, Peru: an exploratory, mixed methods study

PONE-D-23-29942R2

Dear Dr. Tollefson,

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,

Miquel Vall-llosera Camps

Senior Staff Editor

PLOS ONE

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

Reviewer #3: 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

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: 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 #1: Yes

Reviewer #2: 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 #2: 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: (No Response)

Reviewer #2: (No Response)

Reviewer #3: Authors addressed comments for the first revision round. No additional comments for this second review

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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: No

Reviewer #3: No

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