Syndemic interactions between HIV/AIDS, mental health conditions, and non-communicable diseases in sub-Saharan Africa: A scoping review of contributing factors

Arvin B. Karbasi; Chukwuemeka Iloegbu; Christina Ruan; Nana Osei-Tutu; Kahini Patel; Leah Frerichs; John Patena; Dorice Vieira; Deborah Adenikinju; Lydia Samuels; Joyce Gyamfi; Emmanuel Peprah

doi:10.1371/journal.pone.0328515

Peer Review History

Original SubmissionMarch 12, 2025
22 May 2025 Decision Letter - Saima Hirani, Editor PONE-D-25-11960Syndemic Interactions between HIV/AIDS, Mental Health Conditions, and Non-Communicable Diseases in sub-Saharan Africa: A Scoping Review of Contributing FactorsPLOS ONE Dear Dr. Karbasi, 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. Overall, a well-written manuscript with a strong rationale and clear methodology. There are a few areas that require clarity and further details: Is there any target population for this review- any specific age, gender etc.? Please clarify. It would be nice to add the names of African countries to the inclusion criteria. In figure 2, please recheck the calculation- studies screened (2913) - studies excluded (2706) = 207. The total shown in the figure is 188. Scoping reviews do not typically assess the quality of the studies. Usually systematic reviews appraise studies as one of the core components of their methodology. Figure 6 shows the quality assessment of 13 studies. How about other studies’ findings (for quality)? It would be nice to add a discussion around age distribution in the current evidence. Highlighting any gaps would be useful for future research. Please submit your revised manuscript by Jul 06 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. 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Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 5. 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: Please find the Reviewers' comments below. [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? 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 ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: N/A ****** 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 ****** 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 ****** 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: Line 492- 493: Will the figures be expanded in the final print? The legends in the current format are not legible Line 501: It was nice that the author used the phrase ‘synthesize current evidence’ as another study conducted by Moyo-Chilufya et al. 2023 considered NCD and mental disorders among PLHIV in Africa (ref: https://pmc.ncbi.nlm.nih.gov/articles/PMC10570719/). Line 574: ‘As the population ages and the prevalence of NCDs rises’, kindly provide a reference for the statement. Reviewer #2: In this scoping review, the authors explored existing evidence on the relationship between HIV, mental health issues, and non-communicable co-morbidities such as hypertension and diabetes. The review is interesting and well-written. This is not usually the case for me as a reviewer, but I have almost no substantive comments for the authors. The review is contextualised appropriately, the methods are described adequately, the results seem reliable and interesting, and the discussion is reasonable without being overly ambitious. Well done! My only suggestion would be to include a discussion of the lack of children or adolescents living with HIV in these studies. All the studies included in the review enrolled people above 18 years of age, and many were much older. Children and young people living with HIV tend to be neglected in research, especially mental health research. For a starting point for discussion of this, see the section on “insights in absence” in DOI: 10.1093/braincomms/fcad231 which also found that children and young people were absent in research on depression/inflammation. I appreciate that many of the non-communicable diseases that were of interest to the authors are more prevalent in older adults – though this is not always the case (e.g. Type 1 diabetes or chronic respiratory issues can be of substantial impact in young people), so it’s still important to highlight the lack of evidence in children with HIV. ****** 6. 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: 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". If this link does not appear, there are no attachment files.] 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. https://doi.org/10.1371/journal.pone.0328515.r001
Revision 1
12 Jun 2025 Author Response We would like to express our sincere gratitude to the reviewers and the editorial team for their careful and thorough review of our manuscript. We greatly appreciate the time, effort, and expertise that went into evaluating our work. In the sections below, we provide detailed, point-by-point responses to each of the editorial and reviewer comments. We have carefully considered all feedback and have revised the manuscript accordingly to address the concerns and suggestions raised. We are especially thankful for the opportunity to revise and resubmit our manuscript. The constructive critiques we received have been instrumental in enhancing the clarity, rigor, and overall quality of the paper. We believe that the manuscript is now substantially improved and hope that the revisions meet your expectations. Comments from the Editor Editor Comment 1 1. Is there any target population for this review-any specific age, gender, etc.? Please clarify. It would be nice to add the names of African Countries to the inclusion criteria. Author Response to Comment 1: Thank you for your thoughtful suggestions. In designing our selection criteria, we intentionally did not impose any specific age or gender restrictions during the selection process, as our aim was to ensure the review was as inclusive and representative of the current literature as possible. By including studies across all age groups and genders, we aimed to ensure that our analysis reflects the diverse and multifaceted nature of syndemic interactions. We specifically sought to examine contributing factors relevant to both male and female individuals to reflect the broader landscape of syndemic interactions. While all included studies enrolled participants aged 18 and older—with the exception of Carpenter et al.—we did not apply an upper or lower age limit in our inclusion criteria. As noted in Section 2.1 (Inclusion/Exclusion Criteria), we have incorporated a note indicating no restrictions were placed on age or gender. Interestingly, the absence of studies involving children and adolescents highlights a clear gap in the current literature. We have now addressed this point explicitly in the lack of syndemic literature section, emphasizing the need for future research focused on younger populations, who appear to be underrepresented in syndemics research despite the potential relevance of several non-communicable conditions in this group. Regarding your second point, given the large number of countries represented in the included studies (approximately 46), we opted to avoid listing them all in the main text to reduce visual clutter. Instead, we have provided the full list of countries in S1 Appendix SS for reference. Editor Comment 2 2. In Figure 2, please recheck the calculation—the studies screened (2913) – studies excluded (2706) = 207. The total shown in the figure is 188. Author Response to Comment 2: Thank you for carefully reviewing the figure and bringing this discrepancy to our attention. We have rechecked the calculations and identified the source of the error. The figure has been revised accordingly to accurately reflect the correct number of studies. The updated version is now included in the revised manuscript. Editor Comment 3 3. Scoping reviews do not typically assess the quality of the studies. Usually, systematic reviews appraise studies as one of the core components of their methodology. Figure 6 shows the quality assessment of 13 studies. How about other studies’ findings (for quality)? Author Response to Comment 3: Thank you for the observation. You are correct that formal quality or risk of bias (RoB) assessments are not typically required for scoping reviews, as the primary goal is to map the breadth of evidence rather than evaluate the strength of individual findings. In our case, we conducted a targeted quality assessment of the 13 studies most directly aligned (i.e., qualitative, mixed methods, and cross-sectional) with our objective to provide insight into the methodological rigor of this subset. While we did review all included studies qualitatively for relevance and basic methodological soundness, we did not apply a formal RoB tool to the remaining studies (4), consistent with scoping review methodology. We have clarified this in the manuscript in section 3.6 Quality assessment and specified the quality assessment presented in Figure 6. Comments from Reviewers Reviewer 1 Comment 1 1. Line 492-493: Will the figures be expanded in the final print? The legends in the current format are not legible. Author Response to Comment 1: Thank you for this helpful observation. We agree that clarity is essential for effective communication of the data. In response, we have revised the figure by enlarging the legend to improve legibility and ensure that all elements are clearly visible. The updated figure has been included in the revised manuscript. Reviewer 1 Comment 2 2. Line 501: it was nice that the author used the phrase ‘synthesize current evidence’ as another study conducted by Moyo-Chilufya et al. 2023 considered NCD and mental disorders among PLHIV in Africa. Author Response to Comment 2: Thank you for your kind words and for highlighting the relevance of the phrase in connection with the work by Moyo-Chilufya et al. (2023). We appreciate your recognition and are encouraged by the alignment of our approach with existing research in this important area. Reviewer 1 Comment 3 3. Line 574: ‘As the population ages and the prevalence of NCDs rises’, kindly provide a reference for this statement. Author Response to Comment 3: Thank you for catching this important detail. We have now added appropriate references to support this statement, drawing from recent literature that highlights the global trends in aging populations and the increasing burden of NCDs. These citations have been included in the revised manuscript to strengthen the contextual foundation of this point. Reviewer 2 Comment 1 1. In this scoping review, the authors explored existing evidence on the relationship between HIV, mental health issues, and non-communicable co-morbidities such as hypertension and diabetes, The review is interesting and well-written. This not usually the case for me as a reviewer, but I have almost not substantive comments for the authors. The review is contextualized appropriately, the methods are described adequately, the results seem reliable and interesting, and the discussion is reasonable without being overly ambitious. Well done! My only suggestion would be to include a discussion of the lack of children or adolescents living with HIV in these studies. All the studies included in the review enrolled people above 18 years of age, and many were much older. Children and young people living with HIV tend to be neglected in research, especially mental health research. For a starting point for discussion of this, see the section on “insights in absence” in DOI:10.1093/braincomms/fcad231 which also found that children and young people were absent in research on depression/inflammation. I appreciate that many of the non-communicable diseases that were of interest to the authors are more prevalent in older adults – though this is not always the case (e.g. Type I diabetes and chronic respiratory issues can be of substantial impact in young people), so it’s still important to highlight the lack of evidence in children with HIV. Author Response to Comment 1: Thank you very much for your generous feedback and for highlighting an important gap in the literature. We greatly appreciate your thoughtful suggestion regarding the exclusion of children and adolescents living with HIV in the studies reviewed. In response we have expanded Section 4.1, to explicitly address this issue by discussing the lack of syndemic research involving younger populations living with HIV in Africa. We have also cited the article you recommended (DOI:10.1093/braincomms/fcad231) to underscore the broader concern of underrepresentation of children and adolescents in mental health and syndemic research. We agree that this is a critical area for future investigation, particularly given the unique challenges faced by younger individuals with chronic conditions such as HIV and NCDs. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0328515.r002
20 Jun 2025 Decision Letter - Saima Hirani, Editor PONE-D-25-11960R1Syndemic Interactions between HIV/AIDS, Mental Health Conditions, and Non-Communicable Diseases in sub-Saharan Africa: A Scoping Review of Contributing FactorsPLOS ONE Dear Dr. Karbasi, Thank you for submitting your revised manuscript to PLOS ONE. We appreciate the time and effort you have put into addressing the reviewers' comments. After reviewing the updated submission, we noted that while many of the comments have been addressed thoughtfully, there are still a few points that require further attention before we can proceed. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Kindly review Figure 2 (the PRISMA flow diagram) carefully to ensure that the number of studies is accurately represented throughout the chart. Please submit your revised manuscript by Aug 04 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. 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, Saima Hirani, PhD 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. [Note: HTML markup is below. Please do not edit.] [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". If this link does not appear, there are no attachment files.] 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. https://doi.org/10.1371/journal.pone.0328515.r003
Revision 2
23 Jun 2025 Author Response We have corrected PRISMA Flow Diagram to account for the correct number of studies and appreciate the editor for bringing this to our attention. Attachments Attachment Submitted filename: Response to Reviewers 2.docx https://doi.org/10.1371/journal.pone.0328515.r004
3 Jul 2025 Decision Letter - Saima Hirani, Editor Syndemic Interactions between HIV/AIDS, Mental Health Conditions, and Non-Communicable Diseases in sub-Saharan Africa: A Scoping Review of Contributing Factors PONE-D-25-11960R2 Dear Dr. Karbasi, 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. If you have any questions relating to publication charges, please contact our Author Billing department directly at authorbilling@plos.org. 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, Saima Hirani, PhD Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0328515.r005
Formally Accepted
Acceptance Letter - Saima Hirani, Editor PONE-D-25-11960R2 PLOS ONE Dear Dr. Karbasi, 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. Saima Hirani Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0328515.r006

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