-->PONE-D-25-40652-->-->Quality of life associated with clinical and sociodemographic determinants in the postpartum period of Mexican women living with HIV. A cross-sectional study-->-->PLOS One-->--> -->-->Dear Dr. Hernández-Pineda,

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This study was supported by the Instituto Nacional de Perinatología (Mexico City) under approval number 212250-3120771.

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The authors are also deeply grateful to all the women who participated in this work, and we hope that our efforts will improve their quality of life in all respects. The authors thank to INPer (approval number 212250-3120771), as well as their colleagues, Estela Y. Godínez-Martínez, Virginia E. Santillán-Palomo, María del Pilar Meza-Rodríguez, Carmen Flores-Cisneros, Cecilia Mota-González, Rosa Georgina Rodríguez-Delgado, and Edgar Bonilla-Reyes, for their excellent technical assistance, interest in this work, and helpful discussions.

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This study was supported by the Instituto Nacional de Perinatología (Mexico City) under approval number 212250-3120771.

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Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Partly

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Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Dr. Suad Ghaben

PONE-D-25-40652

Quality of life associated with clinical and sociodemographic determinants in the postpartum period of Mexican women living with HIV.

Dear Authors

Please find my comments on your manuscript below. This research explored the Quality of Life among pregnant women diagnosed with HIV in the postpartum period. It also identified the correlation of QoL with SD factors among the target population. Your results showed an overall medium QoL, with the psychological domain scoring lowest and physical health and independence scoring highest. About half reported poor QoL, influenced by socio-demographic factors and CD4 counts.

Title:”

• Short, concise, but misleading. The sentence “Quality of life associated with clinical and sociodemographic” judges the relationship. Please correct per the recommendation provided.

• Suggestions: “Predictors of the QoL among the postpartum period of women diagnosed with HIV”

Abstract:

• Follow the PLOS ONE preferred headings of the Abstract.

• Should be revised per the corrected introduction, methods, and results.

• Write the conclusion instead of the discussion.

Introduction:

• The rationale is not clear. What is the progress of QoL? Due to what intervention? Has this intervention been considered in this study?

Methods and materials

The methods section lacks essential reporting of the sampling techniques and the ART intervention, as follows:

• The study design is not appropriately reported. With insufficient explanation of the ART intervention.

• How was sampling conducted? Is it purposive, convenient, or what?

• The inclusion criteria are not clear? Why was ART treatment included? Have you applied any measures to monitor and control the ART intervention?

• Please justify why the sampling was performed during pregnancy, and data collection was performed after delivery.

• How was the ART intervention tracked?

• Have you maintained follow-up of the women from recruitment to the actual data collection? if yes, how was the follow-up maintained?

• What are the clinical determinants that have been evaluated for association with QoL?

• Wrong selection of the statistical test. With multiple Independent variables and one dependent variable, it is advised to use multiple linear regression analysis rather than Spearman’s correlation. In this case, as the QoL is categorized in nominal variables, you should apply the Multiple Regression Model.

Results:

• Page 11: lines 203-204: “32% of our population were diagnosed with HIV during their current pregnancy, and most of the cases they believed that it was sexually transmitted Please justify the prolonged data collection period, about 18 months, considering the small sample size. This might induce balance or lack validity of the data.” Please justify that the study targets women with HIV receiving ART treatment, and the 32% of the sample were diagnosed with HIV?

• S2 file, Table. Justify collecting the QoL scores at different postpartum times of postpartum-WLWH.

Reviewer #2: The manuscript is well written in standard English and required format.

The minimum sample size calculated is 42, how the recruitment of participant is 75 was not explained.

The results/table shows n=75, with many variables showing varying sample size, indicating varying missing data that may have been cleaned before the analysis.

Table 4 (QoL in the women) may be presented as a figure (Pie or Bar Chart) instead as a table.

The discussion, and recommendation are in line with the results presented.

Also, the ethical and confidentiality considerations were stated.

Reviewer #3: Overall: Valuable insights on the QoL of women in the postpartum period, contributing to the growing body of knowledge around this subject.

Feedback

1. The introduction is written in a complicated manner; the remainder of the manuscript is more clearly written and easier to understand (compared to the introduction).

2. Line by line feedback:

3. Line 41:

a. Where would the authors propose that the QOL questionnaire be included in the healthcare system, i.e. where in the postpartum care algorithm or even the antepartum system that the QOL questionnaire be included? Is there a plan to share the findings with health authorities?

b. The authors are cautioned that this is a small sample size and generalizability of results would be limited. Is there a plan to study this area with a larger sample?

4. Lines 59- 60: The link between stigma and discrimination and chronicity of infection is unclear. Perhaps the authors could rather frame the stigma and discrimination as an additional challenge.

5. Lines 61- 67: This sentence is very difficult to follow, and the authors are advised to replace the one sentence with 2-3 linked sentences.

6. Lines 75- 79: This sentence should precede the previous 2 sentences for ease of reading.

7. Line 80- "Affects" may not be the correct word for what the reviewer understands the authors wish to convey- would "encompass" not be a better word?

8. Line 82: Review the document for TENSE- this should be “has.”

9. Lines 90- 94: Please consider simplifying the sentence extending from.

10. Line 95: Incorrect spelling ("focussing").

11. Lines 103- 107: difficult to follow, please simplify.

12. Line 116: what is meant by "this stage"?

13. Line 119: this is an unusually high LTFU- is this based on previous LTFU rates when working with this particular group of women?

14. Line 120: Please advise why 75 women were recruited if the final sample size was calculated as 42.

15. Line 126: please elaborate on how the participants’ anonymity and privacy were protected

16. Line 149: Please confirm the reference for the classification of participant perception of QoL as poor, medium and high.

17. Line 150: Please advise on the reasons for modification of the instrument and if modifications were made to all 11 questions. Further, please also advise on the total number of questions following modifications.

18. Lines 152- 153: the sentence is incomplete.

19. Line 178: Please consider discussing the reasons for late antenatal presentation discussed, especially if linked to QoL.

20. Line 193: slightly misleading statement- might be clearer if the sentence read as "reported smoking (4%) etc" as in its current phrasing it reads as 17% denied knowledge and then admitted to smoking/ alcohol etc in their partners.

21. Line 204: the word "they" is unnecessary.

22. Line 209: Is this only for the newly diagnosed women or for all participants?

23. Line 212: How were the 3 categories of adherence determined?

24. Line 212: Were these complications in the perinatal period related to the ART regimens?

25. Lines 236- 238: Is this an interpretation of the results in table 3?

26. Line 252: please review the sentence construction for the sentence beginning "There were not..."

27. Line 253: please clarify which group of postpartum women is being referred to

28. Line 307: The word "officially" implies that it is endorsed but not yet included in the targets. This 4th target, however, is still under debate and perhaps the authors should consider rephrasing this to indicate that some experts have advised a fourth target etc

29. Line 316: With 92% living in urban areas, please confirm that there is a lack of transport in these areas.

30. Line 316: Please advise how the lack of transport and security "results in discrimination, gender and social inequality and economic dependence."

31. Line 319: Please advise what is referred to by the word "which thrived." Is it adherence that is being referred to? How was this recorded in their clinical files?

32. Line 326: The authors should consider rephrasing this as 47% were aware of their partners serostatus and 26% were unaware of their status. In this 26%, some partners may be seropositive so it is advised that the authors be careful in how they present this information.

33. Line 332: Perhaps the authors would like to consider combining these sentences.

34. Line 343: The part of the sentence starting with "considering that India..." does not link well with the first part of the sentence. Please review.

35. Line 351: Please review the sentence starting with "And"- perhaps this is not meant to be a capital letter?

36. Lines 373- 385: The reviewer acknowledges the evidence presented in relation to the SARS-CoV-2 pandemic. Perhaps the authors could explore the QoL scores post 2020 and if there was improvement, to compare with other studies that might have assessed this.

37. Line 400- 403: The reviewer advises the authors to be cautious in this statement- the sample size is small and specific to one institution.

38. Line 405: consider reworking this sentence to read better.

39. Feedback on Tables included in the manuscript:

a. In Table 1:

i. Under monthly income- please confirm that the first line is meant to read "Depends on his parents." The table presents characteristics of the women on study.

ii. Please advise on the relevance of sexual debut, number of sexual partners, sexual abuse history and tattoos in the context of this study.

b. Table 2:

i. Was VL analysed in relation to duration of ART? 68% of participants have been diagnosed for more than 3 years.

ii. Please clarify why 17 women did not receive intrapartum ART- were they already on treatment? Why were 77 women eligible for intrapartum ART with 68% diagnosed with HIV infection 3 or more years prior?

iii. What does the perception of perinatal conditions refer to?

c. The heading of table 4 is incorrect as all women are included in the table, not only the women with poor QOL.

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Reviewer #1: Yes: Suad J Ghaben

Reviewer #2: Yes: Dr Tawakalit Olubukola Salam

Reviewer #3: No

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Quality of life in the postpartum period of Mexican women living with HIV: The role of clinical and sociodemographic factors

PONE-D-25-40652R1

Dear Dr. Jessica Hernández-Pineda,

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,

Marwan Salih Al-Nimer, MD, PhD

Academic Editor

PLOS One

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