“They recognize me as a doctor”: A peer mobilisation training programme to promote oral HIV self-testing and referral for acute HIV infection screening among gay and bisexual men and transgender women in coastal Kenya, an exploratory study

Shaun Palmer; Maartje Dijkstra; Alex Kigoro; Khamisi Mohamed; Nana Mukuria; Shally Mahmoud; Evanson Gichuru; Elise M. van der Elst; Eduard J. Sanders

doi:10.1371/journal.pone.0322255

Peer Review History

Original SubmissionMarch 17, 2025
9 Jun 2025 Decision Letter - Juan Pablo Gutierrez, Editor Dear Dr. Palmer, 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. Please submit your revised manuscript by Jul 24 2025 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. 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'. 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If your ethics statement is written in any section besides the Methods, please move it to the Methods section and delete it from any other section. Please ensure that your ethics statement is included in your manuscript, as the ethics statement entered into the online submission form will not be published alongside your manuscript. Additional Editor Comments: 1. There are two main concerns with the paper. The first one is that it is not clear what type of evaluation authors are reporting. Is this about design, processes, impact? This is not clear neither in the objective nor in the methods. The described study seems not to be an evaluation, but rather an exploration of the “experience with the mobilization process”. It is also concerning the quantitative reporting of a qualitative study. The second concern is about the reporting from participants. It is unclear if —for example— what they value is the specific training or the interaction with the research team. That is, was the training what increased self-confidence? Are there specific topics on this soft-skills? From the description of the training this is not clear. 2. The discussion needs to focus on the findings, that is, avoid generalizations. As an exploratory study, it is no accident that demonstration of the approach, but rather identifies factors that could help to strengthen the training, as well as highlight the relevance of the context that may limit the potential of the intervention. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: N/A ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ******** Reviewer #1: I recommend minor revisions in the following aspects: * Please provide a clear explanation on how the representative sample was arrived at both for the parent study and this one. There's lack of clarity on the actual sample involved in this study and justification the choice. An average reader will be very confused on the study sample. Was paying the mobilisers and the clients a stipend not a way of inducement? How did the study protocol guard against possible connivance between mobilisers and clients who could pretend as gay or transgender in order to receive the financial incentive? In figure 1, in the chart for partner notification services under the "disclosure" section, there is an apparent contradictory message-"You don't need to disclose your HIV status". Please clarify. Reviewer #2: I believe the topic of OST is very relevant in the field of HIV given that is relatively new in most parts of the world. I think the paper reflects very well the implementation of the program and its evaluation. While I do understand the relevance of including AHI as an important element, I believe there were probably other broader issues that could have been imore relevant such as the importance of testing overall. Can you maybe clarify why the team chose AHI? I'm glad the team took into consideration some key elements for the local population such as the materials in swahili, the involvement of LGBT organizations and the services available. Even though the importance of peer mobilization is acknowledged, I think there's room for a stronger statement about how crucial the peers have been in the implementation of new methods for testing, prevention and treatment within the HIV world. ******** 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 Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". 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Revision 1
17 Oct 2025 Author Response Editor comments 1. There are two main concerns with the paper. a. The first one is that it is not clear what type of evaluation authors are reporting. Is this about design, processes, impact? This is not clear neither in the objective nor in the methods. The described study seems not to be an evaluation, but rather an exploration of the “experience with the mobilization process”. It is also concerning the quantitative reporting of a qualitative study. • Thank you for this useful comment. We appreciate that it was unclear in the original draft on the type of evaluation we conducted. We agree with your interpretation that it is indeed an exploratory study of the experience with the mobilization training and process. As such, we have clarified this in several instances: - Title: On lines 1-4 we edited the title to clarify that this is an exploratory study. - Abstract: On line 24 of the background section we state that “We describe a qualitative exploration.” - Introduction: Stated on lines 101-105 that we qualitatively explore the experience with the mobilization training programme and the related mobilisation processes. - Methods: Clarified on lines 205-208 that the report is a qualitative exploration of the mobilization training programme the related mobilization processes, using focus group discussions to explore the perspectives of mobilisers and in-depth interviews for clients newly diagnosed with HIV. - Discussion: On Line 373 we have restated that this is an exploratory study. b. The second concern is about the reporting from participants. It is unclear if —for example— what they value is the specific training or the interaction with the research team. That is, was the training what increased self-confidence? Are there specific topics on this soft-skills? From the description of the training this is not clear. • Thank you for flagging this relevant concern. Regarding whether what mobilisers value is the specific training or interaction with the research team, we endeavoured in the manuscript to demonstrate that it was both the training and interaction with the research team that they valued, as well as the interaction with their fellow mobilisers. • For example, on lines 244-246, we have clarified that mobilisers valued both the training and the interaction with the research team: “They highlighted that both the interactive format of the training sessions and regular interactions with the study team during weekly meetings as were key to helping them understand and remember the training content.” • We further emphasize on lines 248-250 the importance of interacting with the research team and the interaction of mobilisers with each other, adding the text in bold to the following: “They further commented that the weekly meetings with their fellow mobilisers and the study team motivated them in their role by providing regular opportunities to discuss challenges and identify solutions together” • More broadly, the participants reported that the training benefited their mobilisation, as is described in the results on Mobilisation skills from lines 257-292. • Regarding whether there were specific topics on soft skills, we have clarified on line 161-166 that peer mobilization skills also refer to soft skills, including clarity of communication and empathy, and that they were trained through iterative review and discussion with the study team and fellow mobilisers to explore what these concepts mean, why they are important, and how they can be applied. This included mobilisers sharing reflections on how they applied these skills during mobilisation and any challenges that arose and potential solutions. • It is also already mentioned in lines 190-191 that these skills were practiced via role plays during the training sessions. We added additional detail from lines 191-195 describing that these skills were practiced via role plays during the training sessions. We detail that “The role plays were led by one of the local study team members in Kiswahili with individuals mobilisers where they would simulate an interaction with a peer. The role plays focused on how to clearly and accurately communicate about OST, AHI testing, and sexual health and how to do so in a patient and empathetic way in order to more effectively addresses the questions and concerns of peers.” 2. The discussion needs to focus on the findings, that is, avoid generalizations. As an exploratory study, it is no accident that demonstration of the approach, but rather identifies factors that could help to strengthen the training, as well as highlight the relevance of the context that may limit the potential of the intervention. • Thank you for this considerate feedback. We acknowledge the importance of avoiding generalizations, particularly in an exploratory study. We have reviewed the Discussion and revised several statements. These revisions can be found on lines 373, 377-379, 385, 392, 395, 401, 425, 430, 432, and in the conclusion from lines 447-454. Review #1 comments I recommend minor revisions in the following aspects: 1. Please provide a clear explanation on how the representative sample was arrived at both for the parent study and this one. There's lack of clarity on the actual sample involved in this study and justification of the choice. An average reader will be very confused on the study sample. • Thank you for this constructive comment. Regarding selection of the peer mobilizers, we detail in paragraph one of the Methods section (lines 114-115) that mobilizers were purposively selected by clinic staff due to participation in previous studies and being representative of their GBMSM and TGW peers. We did not however assess whether the study sample of the parent study was representative of the wider population of GBMSM and TGW, in part due to detailed demographic information of the wider GBMSM and TGW community not being available at the time of the study. • Regarding the sample of the clients in the parent study, we detail the eligibility of peers in the methods (lines 128-132). Eligibility was based on age and a set of behaviours previously identified in a risk score developed by our study team. We have provided additional detail on lines 132-134 articulating that the risk score details statistically significant predictors of incident HIV-1 infection among GBMSM and TGW in coastal Kenya and thus may help local health care providers assess HIV-1 acquisition risk. We have included detailed eligibility criteria in ‘S1 Table’ and referenced this on lines 134-135. Beyond age, no other demographics (e.g., race, ethnicity, religion, or socioeconomic status) informed recruitment, nor were clients required to be local residents, with all clients identified via the mobilisers peer networks. • We also clarify from lines 210-212 that “All mobiliser were invited to participate in the focus group discussions and all newly diagnosed peers were invited to participated in in-depth interviews that only those willing to participate were included in the sample.” We have also noted from lines 239-241 that 18 newly diagnosed clients participated in in-depth interviews in the parent study, three of whom were not mobilised. 2. Was paying the mobilisers and the clients a stipend not a way of inducement? How did the study protocol guard against possible connivance between mobilisers and clients who could pretend as gay or transgender in order to receive the financial incentive? • Thank you for this important comment. While we understand a stipend may risk inducement or connivance, the study team followed local guidelines in line with the standard rates established by the research institute so as to not leave the participants financially worse off as a consequence for taking part in the study, which may impact recruitment and retention based on socioeconomic status. This justification has been added to the text on lines 150-152. Moreover, as conservative attitudes towards LGTBQIA+ people prevail in coastal Kenya, the study team’s experience suggested that the risk of connivance of clients pretending to be GBMSM or transgender to receive the stipend to be low. Further, clients were part of mobilisers’ networks, so the mobilisers generally had already made an assessment of whether the client would be gay or transgender before introducing them to the study. 3. In figure 1, in the chart for partner notification services under the "disclosure" section, there is an apparent contradictory message – "You don't need to disclose your HIV status". Please clarify. • Thank you for this comment and for flagging a necessary clarification. Figure 1 provides information on the different modules covered in the training materials and does not detail the peer mobilization processes. The item on Peer Notification Services (PNS) details the PNS protocol from the perspective of someone newly diagnosed with HIV. We have clarified in the caption of the figure on lines 184-187 that the item on ‘disclosure’ refers “to the fact that an individual newly diagnosed with HIV does not need to disclose their HIV status to a partner as part of the PNS process, for example, if they would choose the partner to be notified by a health provider.” Review #2 comments I believe the topic of OST is very relevant in the field of HIV given that is relatively new in most parts of the world. I think the paper reflects very well the implementation of the program and its evaluation. 1. While I understand the relevance of including AHI as an important element, I believe there were probably other broader issues that could have been more relevant, such as the importance of testing overall. Can you maybe clarify why the team chose AHI? • Thank you for this clarifying comment, we appreciate the importance of further clarifying why AHI testing was included. We provided in the introduction from lines 62-69 additional context on why testing for AHI is important as part of a comprehensive set of HIV testing services. This included some restructuring of the paragraph to streamline the narrative and providing a reflection from lines 72-79 on why targeted AHI testing may be an efficient strategy in under-resourced settings and the importance of recognizing AHI symptoms at the time of PrEP initiation as PrEP initiation should be delayed if AHI is suspected. • We further reflect on why we included AHI testing in the methods section from lines 121-122 stating that AHI testing is “a relevant component of the promotion of HIV testing throughout the entire life course of HIV infection.” 2. Even though the importance of peer mobilization is acknowledged, I think there's room for a stronger statement about how crucial the peers have been in the implementation of new methods for testing, prevention and treatment within the HIV world. • Thank you for this constructive feedback. We discuss the importance of peer mobilization in the introduction and have revised the statement from line 82-85, including additional references, to emphasize that peer mobilisation represents “an effective and proven community-led approach to engage people living with and disproportionately affected by HIV” to underscore the crucial role that peers have played in the successful implementation of new HIV tools. • We also include an explicit statement in the opening of the discussion from lines 375-377 that this study “reflects the crucial role that peer mobilisers have been shown to play in the implementation of new methods for testing, prevention, and treatment of HIV.” • We finally included a statement in the conclusion from lines 449-450 that intensive engagement with mobilisers can meaningfully support peer mobilisation and that “Such an approach can facilitate the crucial role that peer mobilisers have been shown to play in the implementation of new methods for testing, prevention, and treatment of HIV.” Attachments Attachment Submitted filename: HIV and AHI Education Pilot Study_Rebuttal Letter_01JUL2025.docx https://doi.org/10.1371/journal.pone.0322255.r002
11 Nov 2025 Decision Letter - Juan Pablo Gutierrez, Editor “They recognize me as a doctor”: a peer mobilisation training programme to promote oral HIV self-testing and referral for acute HIV infection screening among gay and bisexual men and transgender women in coastal Kenya, an exploratory study PONE-D-25-14122R1 Dear Dr. Palmer, After reviewing the latest version and confirming that you have addressed previous reviewers' comments, 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. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Juan Pablo Gutierrez Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0322255.r003
Formally Accepted
Acceptance Letter - Juan Pablo Gutierrez, Editor PONE-D-25-14122R1 PLOS ONE Dear Dr. Palmer, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Juan Pablo Gutierrez Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0322255.r004

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