PONE-D-24-29546Local data for local programming: Results from an HIV biobehavioral survey among people who inject drugs in Livingstone, Lusaka, and Ndola, Zambia, 2021PLOS ONE

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Additional Editor Comments:

Thank you for submitting this paper. It is great to have information on PWID from Zambia in the literarture. In addition to the feedback provided by the reviews:

1. Introduction (lines 82 - 84). The objective does not mention assessment or presentation of results around syphylis, HBV or HCV (STI and BBV), so consider noting these too.

2. Introduction. The provision and availability of needle and syringe programmes (NSP) and opioid agonist maintenance therapy (OAMT) and treatment of stimulant dependence in Zambia should be briefly described.

3. Methods (lines 92). Insert a short description about each study site for readers who may not be familiar with Zambia.

4. Findings. The findings section (notably descriptions) is a bit long in parts. Aim to focus on key findings, and reduce some descriptions of socio demographic characteristics, and refer to the table.

5,.Findings. Table 1. Insert the % for all rows, where relevant (currently only done for some).

6. Findings. Unless I missed it, I did not see the description of the type of drugs injected. This is critical to assess risk, prevention and interventions.

7. Table 3. Median duration of injecting. Check the median and p25 and p75 - I would expect the median to lie between these, but does not seem to be the case (e.g., Ndola median is 3.0 years, but IQR is 6 - 10 year).

8. Insert n for anti-HCV results and HCV PCR for sample in table and findings description.

9. Findings around awareness of OAMT - this would only apply to people with opioid dependence, but it is not clear what drugs people injected. Also, Table 3 notes " aware of any drug treatment programs" - this is too broad to reflect insights into OAMT. So if questions on OAMT were asked, please include. If not, this could be noted in the limitations.

10. Findings. Why no findings of needle reuse/ sharing? This is the most important risk factor for PWID? (Unless I missed it). This is key to include, as it is a UNAIDS GAM indicator. Please include these variables.

11. Discussion. Among PWID, the primary HIV prevention interventions are NSP and OAMT, these should be foregrounded. These interventions are more important for PWID than PrEP, yet there is much emphasis on PrEP. Similarly, the implications for policy and practice, NSP and OAMT need to be much higher priorities than PrEP, but the framing does not align with emphasis on the issues that are particular to PWID. There is mention of MAT clinics, but what about NSP? This is critical, as many African countries are resistant to NSP, but without NSP HIV prevention interventions for PWID will fail to be be effective.

12. Discussion. The low HBV and (HCV?) prevalence is encouraging, and the implication for policy could also be to continue active surveillance and testing in these high risk groups to control the epidemic, and have access to HCV treatment early, before there is an epidemic, like is happening in other countries (e.g., South Africa).

13. Conclusion. Reflection on the important gap of NSPs seems to be missing. NSPs should be framed as being the link to access HTS and then enter the treatment pathway.

We look forward to receiving your revised manuscript.

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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: N/A

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: The details from this survey are nicely presented, and provide a rich, detailed biobehavioural insights into PWID risks in Zambia. I think the manuscript can however be too descriptive in parts, and some statistical analysis would complement the data nicely.

Abstract

Lines 38-39 – don’t need to mention both HIV and HIV viral load testing.

Results – find the (1st 95) confusing, same for 2nd and 3rd – link to targets unclear. For those less familiar with HIV targets, it may be helpful to say what the targets are when they’re being discussed (and elsewhere in the paper).

Manuscript

Line 96 – the ‘prevalence of VLS’ may be better described as the proportion of people living with HIV with VLS

Lines 102-103 – not sure the data on sample size calculations are needed if they were missed by such a large margin. If the authors want to include the calculation, more details are needed on the factors limiting study size (costs/ time constraints etc).

Lines – pre-test counselling for HIV/syphilis is mentioned, was this also done for HBV/HCV, or are there no national guidelines on this?

Line 142 – Might be useful to state where the Tropical Diseases Research Centre (TDRC) laboratory is based

Results lines 196-320, Tables 2-4 – this section contains a large amount of data in well-presented tables but overall, is very descriptive with the paragraphs describing the data from each table for each location. I would like to see more comparison between the sites in this section – ie were people younger/older at one site? Were there different risk factors at each site? Was one site better at getting PWID onto ART? Some of this is mentioned in the discussion but is perhaps better placed in the results section. Some statistics to highlight differences between the sites would be informative and help to summarise the data.

Discussion – it would be useful to get some idea of how widespread injection drug use is in Zambia, and particularly in Ndola where the HIV prevalence among PWID is very high.

Reviewer #2: General comment:

Are there any prevention services available for PWID specifically in Zambia, either NSP or OAMT? The instrument asked about OAMT awareness but were there questions about uptake? Or where needles were obtained?

In comparing the results in the article with the IBBS report found online the values do not match (e.g. HIV prevalence in Lusaka is 21.9% in the article vs 21.3% in the report; the 95’s for Ndola in the article are 60.2%-100%-90.2% while in the report there are 61.9%-100%-83.7%… ). Could these discrepancies be clarified for readers who may look at the report, too?

Line 34: “progress of PWID”…is it progress of the PWID themselves or the epidemic response for and by them? It reads awkwardly as written.

Line 59: “Whereas the world’s general population has an HIV prevalence of 0.7%…”

It would be worth to specify if this refers to all ages, 15+ or any other age range. The same applies to all the values related to the general population in the article (e.g. Line 61).

Also, the value would need bounds, kindly add them, as well as all the rest of the values in the article.

Line 63: “…in which 19.6% of SSA PWID participate.”

The source from where the data come from specify that the people have participated recently.

Line 68: “… defined as HIV RNA of <1000 copies/mL during the most recent VL test”.

The source for this is: 2016 World Health Organization (WHO) Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection. Kindly update it.

Lines 96-97: “…people living with HIV in Zambia was 59.2% (19).”

The correct citation for this seems to be "Ministry of Health, Zambia. Zambia Population-based HIV Impact Assessment (ZAMPHIA) 2016: Final Report. Lusaka, Ministry of Health. February 2019".

Line 101: “…assuming an HIV prevalence of 25%”.

Why assume a prevalence of 25% if the evidence shown on the introduction showed 15.2% globally and 11.2% in SSA?

Line 236: “…healthcare because they inject drugs…”

Please specify that they have being treated unfairly or denied healthcare by healthcare practitioners.

Line 253: “…injected for a median duration of 3 years (IQR: 6-10).”

Why the IQR do not have decimal numbers? Please consolidate with the rest of the article.

Line 266: “…with HIV, 70.8% (95% CI: 56.8, 85.1) were virally suppressed”. & Line 294 “…and 58.0% (95% CI: 27.8, 88.3) of…”

Why to use the cascade here if in the abstract and introduction the reference is the 95-95-95?

Lines 273-274: “…from peer educators and/or outreach workers (47.2%), internet (11.9%), television (8.5%), radio (2.9%), and/or friends (31.9%).” & Lines 288-289 “…workers (47.1%), internet (9.1%), television (35.9%), radio (56.6%), and/or friends (37.3%).”& Lines 303-304 “…workers (31.0%), the internet (5.7%), television (5.0%), radio (6.5%), and/or friends (13.8%).”

Why not adding IC 95% on these values?

Line 277: “…Number of Hepatitis B cases…”.

Could you kindly add that Hepatitis C cases too?

Line 284: “… because they did not feel at risk whereas 22.8% (7.2, 38.2) did…”

Please add that numbers within brackets correspond to 95% CI.

Line 332: “…forced sex, and lower awareness of non-injectable alternatives present unique challenges.”

Please specify where this sentence comes from. It hasn't been introduced through the article.

Line 343: “…(13.2%), where Livingstone is located (19).” & Line 344 “…women (5.9%) and men (1.8%) of the country-wide…” & Lines 354-355-356 “…slightly higher than women (5.9%) and men (1.8%) of Zambia’s general population of the same age group but lower than the all-age prevalence in the broader Lusaka province’s general population (14.4%) (19)” & Lines 373-374: “…Copperbelt province (11.9%) (19), where Ndola is located. It was also higher than women (12.0%) and men (3.1%) in…”

Specially interesting to include IC 95% here to see if those overlap with the results found.

Line 362: “…discovering they inject drugs, and almost 8.0%…”

Is 8 percentual points, may be confusing, perhaps helpful to clarify.

Line 368: “… avoidance of healthcare,…”

Please include that it is “high frequency of” avoidance of healthcare.

Line 376: “… almost double the prevalence…”.

Is most of the double of each of the other two cities.

Lines 456-457: “…was relatively low, awareness of the benefits of opioid agonist therapy was low…”

This was not mentioned before in the article, can be specified where this come from?

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Reviewer #1: No

Reviewer #2: Yes:  Keith Sabin

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Local data for local programming: Results from an HIV biobehavioral survey among people who inject drugs in Livingstone, Lusaka, and Ndola, Zambia, 2021

PONE-D-24-29546R1

Dear Dr. Woytowich,

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,

Ibrahim Jahun, MD, MSC, 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: (No Response)

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: 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 #3: No

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: The manuscript presents a cross-sectional survey of people who inject drugs (PWIDs), aged over 16 years, on HIV indicators, syphilis, HBV and HCV and associated risk behaviours in three cities in Zambia: Livingstone, Lusaka and Ndola. The median age was 23 in Livingstone, 24 in Lusaka and 28 in Ndola. There was low female representation among PWIDs with Ndola having the highest at 30% and Lusaka lowest at 2%. The research shows significant differences in HIV prevalence of PWIDS across the three sites with the highest having a prevalence of 21.9% (Ndola) and the lowest 7.3% (Lusaka). Risk perception was low among all the three sites. Progress towards the UNAIDS 95/95/95 targets was poor among the three sites with Lusaka being the worst performing. Sypilis prevalence was highest in Ndola at 11.1% and lowest in Livingstone at 3%. Prevalence of both hepatitis B and C was low.

The authors have highlighted the study limitations that include social desirability and recall bias.

Overall, the manuscript is well written, with the various sections bringing out the relevant information. The presentation of the results by site/city has revealed important similarities and differences that could inform PWID program implementation.

The conclusions reflect the data that is presented.

The authors have not made all the data available due to ethical and legal reasons. They have described where the data can be accessed.

Reviewer #4: This recommendation I have made is based on authors response to the initial reviewers' comments. Having read the revised (clean) manuscript before reading the the reviewers comments, and authors response and tracked version, I was able to appreciate that the manuscript was clear and logical. Nothing stood out as a particular concern to me. Being from the country where this work was done, I am also able to relate with the context in which this survey was done and attest that this has been an under studied key population. Therefore, the data presented is highly relevant and highlights an important challenge for Zambia to achieving the 95-95-95 control of HIV by 2030. This challenge is certainly not unique to Zambia. Even though the manuscript highlights marked differences in the cities that were considered, the recommendations are widely applicable. The messages and recommendations contained in this manuscript may be applicable to other settings in the region and globally as it relates to PWID and HIV.

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Reviewer #3: No

Reviewer #4: No

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