PONE-D-24-35095Facilitators, barriers, and strategies for the implementation of peer-led tuberculosis active case finding among people who use drugs in Dar es Salaam, Tanzania.PLOS ONE

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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: Partly

Reviewer #2: Partly

Reviewer #3: Partly

Reviewer #4: Yes

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

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: 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: No

Reviewer #3: No

Reviewer #4: 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

Reviewer #4: 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 study entitled “Facilitators, barriers, and strategies for the implementation of peer-led tuberculosis active case finding among people who use drugs in Dar es Salaam, Tanzania” is a study that investigates an area that has not been extensively researched in Tanzania. However, some issues need clarification and improvements as detailed in the following sections:

Title: Well written

Abstract: well written

Introduction: Line 62-63: Citation is missing in this sentence.

Methods:

• Lines 102-104 (page 5), what are these three districts from which the participants were recruited? It is better to specify for clarity.

• Lines 108-112 (page 5) is not in its appropriate section. It should be included in a separate section for ethics approval. This section (of ethical approval) describes exactly how the informed consent was performed and obtained.

• Line 113 of the Checklist is not well filled out, as the authors claim. When counterchecked with the manuscript, the analysis section misses a lot of information.

• Lines 136-138: This sentence is odd as the qualitative interview is flexible and the tool may be modified during the interview to fit the merging themes. I suggest to be revised

• Line 146: Refusing to be recorded for a participant does not justify exclusion. You could have interviewed without recording and get useful information for your study. This sentence needs to be deleted or provide a good reason for such an abnormal exclusion.

• Line 156: How and who translated the data?

• Lines 162-166: This section needs extensive descriptions to understand how were the data analyzed (how were codes formed? how reliable were the codes? how did you arrive at the themes? Is there any supportive evidence of rigor in the analysis? This information is important as it informs the true findings in the results section.

Results:

• Lines 178: I suggest the facilitators be described separately from barriers. E.g. individual and social facilitators. This will improve the clarity of the findings.

• Line 295: Is this a facilitator or barrier? This is not clear. While counterchecking with Fig. 1, I found that this subtheme is written as an inadequate TB Screening Tool. This is not support what is written in narratives and the figure. Please correct this

Discussion:

Should also be structured in terms of individual and social facilitators discussed separately from barriers and then discussed logically and sequentially as appears in the results

Conclusion

What is the conclusion? The conclusion is missing the author only provided a recommendation.

Reviewer #2: Interesting article focusing on an important population. Given the importance of HIV as the number one risk factor for TB in Tanzania (estimated 20,000 are coinfected) and the increased rates of HIV in PWUD the lack of mentioning of HIV throughout the article needs addressed - a 2017 IBBS survey estimated the overall prevalence of HIV infection in PWUD in Tanzania was 8.7% (95% CI 6.5–10.9). Several studies conducted in Tanzania between 2010 and 2018 have reported that the prevalence of HIV infection among PWID ranges between 11.0 and 51.1% (Likindikoki, S.L., Mmbaga, E.J., Leyna, G.H. et al. Prevalence and risk factors associated with HIV-1 infection among people who inject drugs in Dar es Salaam, Tanzania: a sign of successful intervention?. Harm Reduct J 17, 18 (2020). From reviewing the questionnaires, for the Peer PWUD the HUV status was requested but not for the PWUD, which was a missed opportunity given the importance of this as a risk factor.

For the introduction section:

- please use the latest numbers from WHO Global TB report 2024, for example WHO Global TB report 2024 reports the incidence is now 183 per 100,000 for Tanzania.

- Can more information be given on the situation regarding PWUD in Tanzania; any updated IBBS or other data on rates of coinfection with HIV/HCV, what is the estimated burden of PWUD in Tanzania? Any data on the number of people who inject drugs, what is the legal situation regarding drug use in Tanzania (this may impact discussions around stigmatization and accessing care)

- With regards to current community active case finding activities more generally, can sputum samples be collected in the community or do people have to attend a health care facility? This knowledge can help understand the recommendation regarding access to diagnostic services/strengthening peer ACF if they can collect samples in the community.

For the Recruitment and sample selection:

- Was any consideration given to HIV status in the sample selection given prevalence and risk factor for TB?

- More information regarding the Peer PWUD would be helpful, such as what other peer activities do they perform (if any), were all of them involved in TB ACF? Reading later in the article it would seem that is the case but would be good to have the specifically stated when outlining the groups interviewed? Was any duration of time involved in ACF discussed, given that that was one of the questions asked?

- Was the interview location in a private room? It mentions being in the treatment center but did not say if it was in a more public/open space or private space.

Results:

- Were there any perceived issues or reflections regarding the population being interviewed being mainly male and the interviewees mainly female? Were the interviewees given any choice regarding who interviewed them?

- The previous TB history is important and more information regarding how many of the interviewees had a past history as this may have an impact on their responses regarding TB ACF and starting/staying in treatment, where peer PWUD more likely to have had a previous episode of TB? Did this help their work in engaging with PWUD? This data appears to have been recorded in both groups.

- The lack of information on HIV status makes the statements on IPC being identified as a risk factor for multiple episodes of TB when the main risk factor for TB is unknown (HIV). Additional risk factors such as malnutrition are als0 not mentioned. These multiple episodes of TB, was any time frame collected on this? Was this seen in Peer PWUD who had been doing it for a long period of time? What was the experience range of the peer PWUD?

- The discussions around usefulness of the TB screening questions when a positive symptom screen results in a negative test can not be fully understood without knowledge of the HIV status of the population - PLHIV are more likely to be paucibacillary and therefore more likely to have negative bacteriological samples regardless of PWUD status.

For Line 355 regarding the drop in services - are they already offering any TB screening/diagnostic services? It isn't clear if this is something that needs to start or can be expanded.

Reviewer #3: A review of the manuscript entitled “Facilitators, barriers, and strategies for the implementation of peer-led tuberculosis active case finding among people who use drugs in Dar es Salaam, Tanzania.”

1. (page 3, lines 58-60): Please use the most updated data on the number of TB cases in the Tanzanian population.

2. (page 3, lines 55-56): This sentence “Globally, tuberculosis (TB) is again the leading cause of death from a single infectious agent” will be more significant if it’s also supported by another relevant study. For example, “Risk factors for viral hepatitis in pulmonary tuberculosis patients undergoing treatment: A systematic review and meta-analysis”.

3. (page 5, lines 93-95): The motivation of the research is not clearly presented. What are the novelty aspects of this work?

4. (page 5, study setting and design): Why did the authors only recruit participants from three MAT clinics? In my view, a larger sample size will make the study findings stronger and more powerful. The current number of sample size seems somehow small to make the conclusion drawn from this study significant.

5. (page 8, lines 162-166): The data analysis part seems somewhat questionable as the authors did not give detailed information on how the data was analysed.

6. (page 18, lines 373-375): This sentence “Nonetheless, studies from COVID-19 suggest that uptake of wearing face masks can be enhanced by strengthening the belief of solidarity and promotion of positive social messages” also shares the same idea with a similar study by Hamdan et al entitled “Coping strategies used by healthcare professionals during COVID-19 pandemic in Dubai: A descriptive cross-sectional study”. Kindly include this reference to make the sentence stronger.

7. (page 19, lines 392-399): The last paragraph of the discussion part should be rewritten, especially in terms of highlighting the limitations of your study. The current wording is incorrect because the authors mentioned that this study has numerous strengths, and then in the elaboration they included the study’s weaknesses, which does not flow well with the previous statement of study strengths. Please revise.

Reviewer #4: The manuscript is well-written, and depicts the need to enhance TB services for PWUD to provide indiscriminate care and support. The discussion part is well-versed and highlights the ways forward. Although mobile TB van services are available, it is sad to know it only runs a couple times in a year, indicating the need to improve the integrated services. Overall, an informative and much needed manuscript for this specific population.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

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Facilitators, barriers, and strategies for the implementation of peer-led tuberculosis active case finding among people who use drugs in Dar es Salaam, Tanzania.

PONE-D-24-35095R1

Dear Dr. Minja,

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,

Harapan Harapan, MD, 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 #3: All comments have been addressed

Reviewer #4: 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 #3: Yes

Reviewer #4: Yes

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

Reviewer #3: Yes

Reviewer #4: I Don't Know

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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 #3: Yes

Reviewer #4: 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 #3: Yes

Reviewer #4: 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 #3: I commend the authors for addressing my concerns. Now this manuscript has improved a lot and is ready for further consideration.

Reviewer #4: Thank you for revising the manuscript, and responding to the comments. Informative and much needed voice of the specific population.

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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 #3: No

Reviewer #4: No

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