PONE-D-24-57343Development and delivery of an online HIV pre-exposure prophylaxis (PrEP) training for community pharmacists to prepare for the implementation of a pharmacy-led PrEP service in Malaysia.PLOS ONE

Dear Dr. Zaki,

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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Ali Ahmed, PhD

Academic Editor

PLOS ONE

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Additional Editor Comments:

I have only concern of sample diversity as most of participants are chinese, given the diversity of Malaysia. Does this impact the implications of your findings?

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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: Yes

Reviewer #3: Partly

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

Reviewer #1: I Don't Know

Reviewer #2: Yes

Reviewer #3: 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: Yes

Reviewer #3: 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: No

Reviewer #2: Yes

Reviewer #3: 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: Consider revising the title - Development and delivery of an online HIV pre-exposure prophylaxis (PrEP) training for community pharmacists to prepare for the implementation of a pharmacy-led PrEP service in Malaysia. This title could be made more explicit e.g., Development and Evaluation of an Online PrEP Training Program for Community Pharmacists to Enhance Pharmacy-Led HIV Prevention Services in Malaysia

Abstract- The phrases "stigmatized key populations" and "non-traditional differentiated service delivery models, like pharmacies" are slightly repetitive when describing the rationale. Simplify for conciseness. While informative, the committee, platform, and timeline description could be condensed. Focus on the core aspects, such as the training content, evaluation tools, and key methodological steps. While the results highlight the improvement in knowledge scores, the discussion of gaps in knowledge and variability among participants is not explored sufficiently. Briefly mention specific gaps to better contextualize the need for enhanced training methods. Link participant demographics to their potential impact on training outcomes. While the conclusion mentions the need for modern methodologies, it does not connect how these would address the identified gaps.

Introduction- While the introduction thoroughly describes the HIV epidemic in Malaysia, key affected populations, and existing service delivery gaps, it is overly detailed, with some points repeated unnecessarily, e.g., barriers to public healthcare facilities and the potential of pharmacy-based models. The transition between some paragraphs feels abrupt, particularly when discussing global recommendations, local implementation, and the rationale for pharmacy-led models. The introduction outlines the problem well but doesn't sufficiently emphasize how the study addresses these gaps.

The Materials and Methods section provides detailed descriptions of the study's design, processes, and tools, which is commendable. The EPIS framework adds rigor and aligns the study within a recognized implementation science framework, strengthening the study's credibility. However, the section is densely packed with information, making it challenging to follow. Key components like "Development of the training program," "Delivery," and "Data analysis" could be more distinct. Breaking the section into clearly labeled subsections, e.g., Training Program Development, Study Design, Participant Recruitment, Training Delivery, Evaluation, and Data Analysis, would improve readability. Certain details, e.g., repeated mentions of module content and pre/post-test descriptions, are unnecessarily repeated. While the stakeholder consultation is mentioned, its contributions to the training program development are not elaborated upon. The author should highlight specific insights or recommendations from stakeholders that informed the program design to strengthen the relevance of the consultation. There is insufficient explanation of why particular tools, e.g., Edpuzzle and Google Forms, were chosen. The section uses long paragraphs that make key details hard to locate.

Results -The results section contains substantial data organized around demographic characteristics, pre- and post-training knowledge scores, feedback on the training program, and participant suggestions for improvement. Demographic information is detailed but repetitive, with percentages mentioned in both text and table form. Summarize key demographic trends in the text and refer readers to the table for further details. Table 3 presents data participant-by-participant, which may not be necessary for interpretation. Condense Table 3 to highlight summary statistics (mean, SD, minimum, maximum, p-value) without individual scores. The narrative describing pre- and post-training knowledge scores is overly general and does not critically engage with the data. For example, the statement “the online training appears insufficient” is unsupported by nuanced analysis. Provide a more detailed interpretation of the data. The feedback is summarized well but lacks a deeper synthesis or connection to broader findings. Authors need to analyze feedback to identify recurring themes, e.g., clarity of clinical content, need for quizzes, the pacing of modules, etc, and link these themes to observed knowledge gaps.

Discussion section—While improving knowledge scores is significant, the discussion could delve deeper into how these scores translate into practical application or readiness to provide PrEP services. The discussion briefly mentions areas where the training fell short, e.g., indications, side effects, and contraindications, but it does not explore why these gaps persist or propose specific ways to address them in future iterations. While participant feedback is mentioned, the discussion does not thoroughly analyze or contextualize it. For example, the perceived disconnect between participants’ satisfaction and actual knowledge gains could be explored in more depth. The discussion does not sufficiently address potential barriers to implementing the training program on a larger scale, such as resource constraints, internet accessibility, or variations in pharmacists' baseline knowledge. While the study's relevance to public health goals is noted, e.g., achieving zero new HIV infections in Malaysia by 2030, the practical steps needed to integrate pharmacists into the national PrEP service framework are not discussed. Although the ERIC taxonomy is cited, its application in this context is not detailed. Explaining how ERIC strategies could specifically enhance pharmacist training would strengthen the argument.

Conclusions—The conclusions summarize the study's key findings, emphasizing the novelty and effectiveness of the online PrEP training program in increasing pharmacists' knowledge. However, there is an overgeneralization. For example, while the training program improved knowledge, the conclusions imply broader success without fully addressing the uneven knowledge gains among participants or the remaining critical knowledge gaps. Recommendations for incorporating advanced learning methodologies are mentioned but lack specificity. For example, how case-based or simulation-based learning could be practically integrated is not explored. The conclusions do not discuss potential logistical or systemic challenges, e.g., funding, time constraints, or accessibility issues that might hinder nationwide program implementation. There is little mention of how increased pharmacist knowledge translates into actual improvements in PrEP service delivery or uptake in Malaysia. While knowledge improvement is highlighted, confidence and skill in counseling and service provision are not sufficiently addressed, even though they are critical for successful PrEP delivery.

Reviewer #2: Congratulations to the authors for the well written manuscript. The manuscript highlights a salient issue on the development and delivery of online PrEP training for new cadres such as pharmacy providers in the context of task shifting services. Two issues for consideration:

1. The title of the manuscript gives prominence to the development and delivery of the online training. However, the primary substance of the manuscript is on PrEP knowledge gains from undertaking the training. Would the authors consider reframing their title to address the primary focus of their manuscript.

2. The limitations of the study are well described but no strengths are included. It would be good to read why the authors think this research adds to the field and why their study is a strong one.

Reviewer #3: OVERALL: This manuscript focuses on development and assessment of an online, self-paced PrEP training program for community pharmacist for PrEP delivery in Malaysia. This is the first known assessment of such a training program in Malaysia and adds to the sparse literature on how pharmacy providers could be trained to deliver PrEP services in Malaysia and other global settings. While addressing an important topic, some further details on how the training was developed and what went into development of the assessment tools would be helpful. Additionally, it isn’t clear why the authors choose to only describe the online component of this training program and not the in-person training that followed—which seemed to utilize many of the training strategies the authors suggest for enhancement of the online training module. I think presenting both training components together would enhance this paper and present a wholistic package of how pharmacy providers might be trained on PrEP delivery. Further, both the Introduction and Discussion of the paper could be revised for clarity and focus.

MAJOR:

• (Abstract, Results): It isn’t clear how to interpret the “knowledge score”. How was this constructed and scored; what types of questions were included in this assessment?

• (Abstract, Results): It is not totally clear what you mean from the following sentence: “While training significantly improved knowledge scores, it did not produce consistent knowledge gains for all participants or address some critical PrEP knowledge gaps”. Can you be more specific on the gaps of interest? And how many participants didn’t have knowledge gains?

• (Abstract, Conclusions): Might temper conclusions because not proving in this abstract that pharmacy PrEP delivery increases PrEP access.

• (Introduction): The introduction could be abbreviated for focus and clarity.

• (Methods): How was the content of the open-ended questions analyzed? Which subsequently led to key themes on the most useful aspects of the training and areas for improvement presented in the Results?

• (Discussion, paragraph 2): Still not clear where your suggested threshold of 80% knowledge comes from. Seems arbitrary to suggest such threshold if different knowledge assessments using different tools.

• (Methods): Details on how pharmacists were trained on HIV testing required for PrEP delivery missing. Especially since this might require in-person practice that is difficult to delivery remotely.

• (Discussion): Unclear what you would measure the effect of training on? If using as an ERIC implementation strategy, wouldn’t the ultimate outcome be PrEP uptake at the pharmacy versus knowledge among providers? And you did see a positive change in knowledge among providers post-training, so unclear why you are suggesting that the training wasn’t effective at knowledge gain?

• (Discussion): You note that modern learning methodologies (e.g., case-based, team-based) could improve knowledge outcomes among pharmacy providers – in the methods, might be worth mentioning why you didn’t incorporate any of these approaches when you developed this online training.

• (Discussion): IF the online training was just part one of provider training, followed by the in-person training – why is the in-person training not included in this manuscript to complete the discussion of how you might train pharmacy providers for PrEP delivery?

• (Discussion & limitations): These sections of the paper are long and could be abbreviated for focus and clarity.

MINOR:

• (Formatting): Formatting of the current manuscript is a little confusing – the distinction between sections and subsections is not clear. Additional subsections (e.g., data collection, analysis) in the methods could enhance clarity.

• (Methods): The April 2023 stakeholder meeting is mentioned without details on what types of stakeholders attended this meeting and what was discussed. Adding a brief description of this would be helpful.

• (Methods, Delivery of the online self-paced PrEP training program): Would suggest moving several details here (e.g., who attended the training, duration of engagement) to the Results section.

• (Results, Table 3): Not sure inclusion of this table in the main paper is necessary – would suggest including as an appendix, if want to keep.

• (Results, Table 4): Would consider adding a column that is the % change from pre- to pos-training assessment. Could include overall score across question at bottom of this table (i.e., info in Table 3).

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Reviewer #1: No

Reviewer #2: Yes:  Daniel Were

Reviewer #3: No

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PONE-D-24-57343R1Development and evaluation of an online HIV pre-exposure prophylaxis (PrEP) training program for community pharmacists to implement pharmacy-led PrEP services in Malaysia.PLOS ONE

Dear Dr. Zaki,

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 05 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,

Ali Ahmed, 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.

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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 #4: (No Response)

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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 #4: Yes

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

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 #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 #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 #4: My comments are:

Line 106: Can you explain what you mean by strategic task shifting?

What modifications were made while adapting the physician-targeted training program for pharmacists?

Line 402: The word ‘cisgender’ may need explanation.

Can more details about the in-person workshop be provided?

Lines 486 to 489. A sentence is repeated.

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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 #4: Yes:  Pathiyil Ravi Shankar

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[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.

Development and evaluation of an online HIV pre-exposure prophylaxis (PrEP) training program for community pharmacists to implement pharmacy-led PrEP services in Malaysia.

PONE-D-24-57343R2

Dear Dr. Rafdzah,

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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Ali Ahmed, PhD

Academic Editor

PLOS ONE