PONE-D-22-32487Transitions in sexual behaviour and the predictors among gay, bisexual, and other men who have sex with men in England: data from a prospective studyPLOS ONE

Dear Dr. Hanum,

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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Additional Editor Comments:

As you can see from the below comments from the reviewers, there are a number of small, but important, areas across the different sections of the manuscript, that need either clarification and/or to be expanded. I feel these comments are not unreasonable and will result in a stronger, more publishable paper. 

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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: No

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: 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: Many thanks for presenting me with this opportunity to review this paper. In the paper, the authors examine patterns of sexual behaviour and transitions between sexual behaviour levels among gay men in England. Within what is a somewhat unwieldly / lengthy paper there are a number of key findings of interest. Having read the paper a few times, I would suggest less is more in communicating these findings and making recommendations against them. Although of interest, the submission currently lacks a “so what”. Below I present a number of comments / suggestions to hopefully strengthen the submission. As a comment to the authors and journal, the version of the manuscript I received for first review had tracked changes presented.

Title

Consider a slight revision to the title to tie in / position “predictors” better – it currently floats somewhat independently.

Abstract

Rather than positioning the necessity for the research in relation to it being the first, it would be better to make clear the problem / need to be addressed – this is not made clear in the abstract (also a focus on being the first in the discussion which is unnecessary).

Does the journal require a structured abstract? If so, then sub-headers would be helpful.

Please make clear the annual cycle is in addition to the four monthly cycles (if this is indeed the case).

Be helpful to provide summary description of what consists as higher and lower risk and to be consistent in use of n/N and % - e.g. present 622 also as % of 1162.

Could you ensure the abstract results support directly the conclusion that “at any one point in time the majority of GBMSM are at low risk….”

The authors suggest their research “might” help identify people likely to increase their risk – consider rephrasing to highight how this analysis can inform progress.

Introduction

The first half of the introduction focuses on literature suggesting individual heterogeneity is important and that the “majority of data” (be good to consider another phrase or quantify) sits outside of the UK and that no previous study has been conducted. It would be helpful to utilise the introduction to provide supporting statements as to why such heterogeneity is important (what are the mechanisms, the challenges……?) and to focus less on where data are and more on the “so-what” of the issues being raised and the need for this exploration. The introduction currently feels slight.

It is unclear what the sentence about person-centred approaches adds – consider removing or repositioning.

The last paragraph says the same thing twice. Suggest focus less on what hasn’t been done and more on what is proposed here.

Methods

I assume at every third cycle of the four monthly questionnaire participants were expected to complete both the four monthly and annual questions – is that correct? Please make clear.

Under measures there is a discussion of the literature as well as a defence of the methods chosen – the review of the literature would be better placed in the introduction, and the defence better placed in the discussion.

Under measures it is stated that CLS2+ was the “main measure” of higher-risk – please make clear what the other measures were.

In the measure section we are informed that U=U was not widely “spread” and that PrEP use was “relatively” low – in the context of methods it is unclear why poorly defined and unreferenced statements such as these are being presented – please remove or amend so it is clear and supported.

I suggest the measures section be rewritten so reflects methods only and so that the approach taken is clear.

Under “Socio-demographic….” It would be helpful to add a little context as to how / why the variables listed are presented as a-priori predictors.

Results

As a general comment (and the comment that shifted my recommendation from minor to major revision), there is a lot to digest in the results. Given there is a good degree of overlap (for example, numerous ways of presenting changed states) in the results, and that methods are also included, please revise and reduce so that key findings are clear and potential actionable results (that are then deliberated on in the discussion) are focused on. Consolidate the different ways transition is tackled and presented and ensure there is a clear pathway through the results for the reader.

Small point, but no need for terms such as “Approximately” when presenting figures as specific as 12.2%

It would be transparent to present 622 and 411 as a % of 1162.

Helpful to compare those proceeding with those not-proceeding – hopefully in the discussion these numerous differences are discussed in depth in relation to limitations / interpretation.

In the 2nd paragraph of the results please rephrase so it is clear the comparison is 622 v 540 (currently presented only within brackets).

Again small point, in table 1 would be helpful to make clear 622 = completed baseline and at least one online follow-up questionnaire.

In trends of CLS2+ section it is suggested trends are shown among all 1162 men for 2013 to 2018 – however, I believe subsequent baseline data points were only available for 622 men, and of these only 411 engaged up to within final six months – please clarify? Also please make clear how there are 1665 baseline reports among the 1162 baselines (please make clear the two sets of figures are respective to baseline and follow-up).

I would suggest removing comment about decline up to end 2014 given paucity of data points and that you then state both measures rose from 2013. Given lack of data up to end 2014 consider censoring data up to then.

In relation to the sentence “….among 622 men, from the first online questionnaire to the last online questionnaire” should read “their” as not all 622 completed the first and last questionnaires in this study. Under this section on “Within person changes” please include denominators (e.g. in relation to excluding missing etc).

Please standardise definitions (e.g. either CLS2 or “CLS with two or more partners”), presentation of results (sometime only %, other times % and n/N, and also sometimes described qualitatively, e.g. “majority”, “appeared to be reasonably high stability”, “tended to decrease over time” & “relatively small”) and sub-headers (sometimes describe risk factors (e.g. within-person changes) and at other times tools (lasagna plot)). In a quantitative analysis such as this please qualify / quantify statements such as those listed above (i.e. “tended to decrease…” etc).

Throughout the results there is a fair amount of methodological rather than results-focused description of the figures – suggest ensuring the footnotes to each figures clearly explain what is being presented, and remove from results text, so to focus instead on the key findings.

A point of positioning – figure 3 presents the participants / time-point specific data that inform the more actionable summary results presented in figures 1 and 2 – consider first presenting figure 3 and then figures 1 and 2.

Discussion & conclusion

Remove repetition at start of discussions – I would suggest that there is no need to state your observed 2015 to 2018 trend was similar to your observed 2013 to 2018 trend.

Amend sentence “Among GBMSM with at least two consecutive data during follow-up…”

As with introduction, not clear why the issue of there potentially not having been a similar study in UK is repeated – please amend.

Although over 1500 words in the discussion focus on comparing the results of this analysis with the literature base, key findings are neither reflected on or have recommendations assigned against them – for example, having been a focus on the results, housing is only mentioned once in the discussion and then only to repeat what is presented in the results (no in-depth discussion or aligned recommendation for action).

The limitations needs to be expanded and I would suggest amending “there are some limitations” to something along the lines of “there are important limitations…” . Instead of focusing on the 60% of men enrolled in online follow-up who finished, please instead describe the limitation of 35% of men enrolled finishing. A reflection of the difference observed between the various enrolled populations is warranted. Given how much has changed since 2013 and 2018, please describe the potential limitation of these now somewhat aging data.

In addition to calling for future studies and suggesting nurses and clinicians “might” utilise this information, could more concrete actions / recommendations be put forward (whilst considering the important limitations of this study)?

Reviewer #2: I commend the authors for putting for a strong paper that aims to characterize "longitudinal patterns of sexual behaviour and determine transitions between sexual behaviour levels based on participants' reported condomless anal sex with two or more partners in a three-month period, among HIV-negative GBMSM participating in the AURAH2 study.

The study builds upon the existing AURAH questionnaire, limited due to its cross-sectional design, by allowing for longitudinal analyses. It is helpful to understand the strengths and limitations of AURAH2, which the authors did a fine job describing.

Minor corrections, if possible, include defining even the most obvious acronyms. The authors defined the United States (US) but not UK, for example. U=U should also include a definition.

If possible, the authors could elaborate on how missingness was addressed in greater detail and further provide a rationale for their decision. This should also be discussed in the limitations section.

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Reviewer #1: Yes:  Brian Rice

Reviewer #2: No

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PONE-D-22-32487R1Transitions in sexual behaviour among gay, bisexual, and other men who have sex with men in England: data from a prospective studyPLOS ONE

Dear Dr. Hanum,

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. Although nearly ready to be accepted, the reviewer suggests some very minor comments which we kindly request to be addressed.

Please submit your revised manuscript by Jul 25 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,

Avanti Dey, PhD

Staff Editor

PLOS ONE

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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.

Additional Editor Comments (if provided):

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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

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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: 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 #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: I have recommended to accept this paper.

That said, I make here a couple of recommendations for further strengthening (not essential).

Another read through by the authors would be helpful just to ensure little errors are corrected, e.g. paragraph 1 of Introduction = “Identification of the behavioural windows associated with elevated HIV risk, i.e. the timely initiation and termination of such interventions is essential for successful prevention and to prevent medication overuse.”; 1st paragraph of results “(see table 1 [N]).”; 2nd paragraph of results “Of the 1,162 men enrolled, 622 (53.5%) men completed…”

Not critical, but the results, although much improved in structure, are still very long – if there is a way to further reduce / focus on key issues, then that would be helpful

Results (line 249; top of page 14) – could you qualify / quantify what is meant by “There appeared to be reasonably high stability among the group of men who reported lower-risk behaviour from one questionnaire to the next….”.

Results (lines 253 – 258) – “The high proportions of skipping questionnaires at the last online questionnaire was because not all participants had the opportunity to fill in the last online questionnaire. The online phase of the study closed at the end of March 2018, and therefore some participants (who joined the study after March 2015) would not have been scheduled to receive a final questionnaire (if their previous questionnaire was less than four months preceding the end of follow-up).” – could you please rephrase so clear what is being said and then move to your discussion as these are not results.

Results (line 291 – first sentence of new section entitled “Explanatory variables…” – sentence starts as “Similarly,……” – as new section, it is not clear what is being referred to – please rephrase.

Another read through of the discussion may be helpful to ensure small errors are removed (e.g. line 355 = “In the ACS, risk levels were classified into three (based on sexual behaviour score)” and to reduce the body of text (e.g. perhaps less repetition of the results) and break up long paragraphs and sentences.

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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: Yes:  Brian D Rice

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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.

Transitions in sexual behaviour among gay, bisexual, and other men who have sex with men in England: data from a prospective study

PONE-D-22-32487R2

Dear Dr. Hanum,

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. I would like to apologise for the delay in our communication.

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,

Daniel Demant, PhD, MPH, GradCertHEd, BAppSocSc

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: