PONE-D-24-31521"I think they are infected because of their ignorance and lack of responsibility": a mixed-methods study on HIV-related stigma in the healthcare system in Kazakhstan.PLOS ONE

Dear Dr. Iskakova,

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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Academic Editor

PLOS ONE

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2. Thank you for stating the following in the Acknowledgments Section of your manuscript: 

We express our sincere gratitude to all individuals and organizations whose contributions were essential to this research. Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health under Award Number D43TW010046. The content is solely the responsibility of the authors and does not necessarily represent the official views of   the National Institutes of Health. We also deeply appreciate the study participants for their time and valuable input in completing the surveys. Special thanks to Sir Kanat Tosekbaev from the Department of Public Health of Almaty for his assistance in recruiting healthcare workers for the study. We are thankful to Asfendiyarov Kazakh National Medical University and the New York State International Training and Research Program (D43 TW010046) for providing epidemiology and biostatistics training to our research team members. 

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3. We note that this data set consists of interview transcripts. Can you please confirm that all participants gave consent for interview transcript to be published?

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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: Yes

Reviewer #2: I Don't Know

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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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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: Dear Authors,

Thank you for the opportunity to review your manuscript for publication. I appreciate the effort and dedication that went into this work. Please find the following comments for attention.

_____________________________________________________________________________________________________

General comments:

• Insert page numbers throughout the manuscript

_____________________________________________________________________________________________________

Abstract:

• (Line 32 under Methods) change “bivariate associations” into bivariate analysis to refer to the statistical analysis of the relationship between two variables.

• (Line 33 under methods) it would be better to say “models were performed” instead of “models were used” for a more precise and formal tone.

• (Line 40-42 under results) This statistical reporting “(AOR=0.25; 95%CI=0.09,0.67; p=0.006)”, must be formatted in full at first appearance to improve clarity as follows (AOR [Adjusted Odds Ratio] =0.25; 95%CI [95% Confidence Interval] =0.09, 0.6; p=0.006).

_____________________________________________________________________________________________________

Introduction:

• (Line 60) Reformat and restate the following “…. estimates (2020)……” by simply removing parentheses as follows “…..estimates in 2020…”.

• (Line 62 -64) I recommend that the authors report on the achievement of the 2020 90-90-90 targets alongside the progress toward the new, ambitious 95-95-95 targets in the Kazakhstan context for viral suppression, set by UNAIDS for 2025.

• (Line 67-68) The following sentence must be cited, and I strongly recommend the citations of recent statistics “Notably, the number of new HIV infections in Kazakhstan increased by 68 39% in the years of 2010-2019.”

• (Line 74-76) This sentence warrants citation “The term ‘stigma’ is associated with “exclusion”, “rejection”, or “blame” of one due to holding a particular condition which is a subject for social judgment.”

• (Line 77-79) Citation is quired for this statement: “Stigma associated with HIV/AIDS can also be self-internalized by PLHIV, meaning that the general negative reactions to HIV from others may result in “internalized” stigmatization among PLHIV.”

• (Line 74-84) The multifaceted concept of stigma has been conceptualized, but this has primarily focused on self-stigma and enacted stigma. However, public stigma and perceived stigma, which may also be relevant in the context of this study, have been largely overlooked.

• (Line 82) Address the typo “feelings wile enacted stigma” write while for clarity

• (Line 83-84) This assertion needs citation “Fear of disclosure and shame caused by HIV-related stigma may keep PLHIV from getting the care needed in time.”

• (Line 87) Rephrase the term caregivers “For example, caregivers may” to healthcare providers.

• (Line 89) specify the context (country or region) in which this study was conducted “Previous research conducted in Europe…”

• (line 93-94) Authors ought to clarify what they mean with “regular procedure” given that this phrase carries significant ethical implications particularly with regards to patient confidentiality and ethical responsibility of Healthcare Providers. This point must be elaborated.

• (Line 107) Revise this grammatical error “exploratory study is aimed to….” to “This exploratory study aims to assess….”

_____________________________________________________________________________________________________

Methods:

• (Line 109) This section should be written as “Material and Methods”

• (Line 116 -118) Under the subheading of “Population and Sampling”, it is essential to include the sample size formula along with its corresponding parameters defined to demonstrate how the total sample size of 380 was determined. This should clearly indicate whether the figure represents a minimum or maximum sample size. This transparency will enhance the understanding of the sampling process and ensure the validity of the research findings.

• (Line 120 – 124) Upon my review of this paragraph, it appears that the study utilizes a sequential mixed methods design; however, it does not specify which type of sequential design has been employed. It is important to note that there are two types of sequential mixed methods designs: exploratory and explanatory. Authors should first define the appropriate design relevant to the study and clarify its application within the research context.

• (Line 126) the following subheading should be well-formatted “Fig 1. Data collection steps”

• (Line 127 under data collection) This statement is very vague and therefore warrants clarification “The data collection process of this study is described elsewhere”

• (Line 140) Describe the structure of the self-administered survey questionnaire that was employed.

• (Line 150-151 under measures) Authors must state exactly where readers should look for the relevant information regarding re-validation process of the questionnaires.

• (Line 148 -183) The article should clearly describe the preexisting scales incorporated into the study for measuring key variables if the questionnaire was not originally developed by authors. It must report the documented reliability coefficients from previous studies and state the internal consistency coefficient obtained in the current study. Additionally, each measure’s items should be outlined by specifying that responses were rated on a Likert scale, including the number of points used for the ratings.

• (Line 184 -191) It is beneficial to include a figure that illustrates semi-structured interview guide questions.

• (Line 199) This statement must be cited “previous research findings.”

• (Line 200 -201) “We identified these responses as missing following 201 the questionnaire guide, which led to a decreased sample size to 272 complete responses” Authors should specify their approach to managing missing data, detailing the criteria or thresholds used to determine which incomplete questionnaires were excluded from the analysis. For example, questionnaires with more than 50% of missing data for each participant were excluded from the analysis.

• (Line 213-214) “Qualitative data analysis results were presented using quotations from participants and translated to English by the investigator who is fluent in all three languages.” Authors should clearly explain the translation process, detailing both back-and-forward translation methods to ensure conceptual equivalence. Additionally, they should discuss how the pilot study contributed to refining certain questions for improved clarity and context.

_____________________________________________________________________________________________________

Results:

• (Line 228) Revise this phrase to “…was the most common…” instead of “the commonest..”

• (Line 230) Rephrase “…is homogeneous female dominated.” to “..is predominantly female”

• (Line 238) Remove colon by combining the sentence smoothly “study: 83% (n=380)”

• (Line 257) “[AOR=0.25, 95%CI (0.09,0.67), p=0.006)” Authors should be consistent between the use of parentheses and square bracket.

• (Line 277) Rephrase “medical manipulations” to “medical care or treatment”.

• (Line 278) The preferred and non-stigmatising term to refer to this key population is “patients/people living with HIV” instead of “HIV-positive patients”

_____________________________________________________________________________________________________

Discussion:

• (Line 364) Results figures should be included exclusively in the results section and not in the discussion. (“with 87% (n = 380)”)

• (Line 368) Rephrase “HIV-positive patients” to PLHIV and please address this phrasing throughout the manuscript.

• (Line 371-372) Cite those studies immediately “Numerous studies have explored HIV-related stigma in healthcare, primarily focusing on the experiences of PLHIV.”

• (Line 406 -407) This line must be cited “…largely due to widespread homophobia in the country.”

• (Line 412) It is now LGBTQIA+ population and this acronym should be written in full at the first appearance.

• (Line 419) Correct the grammatical error “although there's been….” to “there has been…”

• (Line 432) Rephrase “other high HIV prevalence regions…” to “other regions with high HIV prevalence”

• (Line 434) Correct grammar “future research use larger,…” to “future research to use larger….”

• (Line 441-442) Authors must report reliability coefficients scores of all measures used to confirm reliability and the process of translation including forward-and back-translation (From English to Kazakh and Russian and from target languages back to the source language) should be also outlined for confirming content validity (Conceptual Equivalence).

Conclusions:

• (Line 446) This is now new “mid-level medical staff” whereas I initially believed the study was aimed at healthcare providers or professionals in general, without any specific focus on their level of training.

• (Line 448) Rephrase to remain consistent with “HIV care” instead of “AIDS care”

• (Line 453) Rephrase to “combat HIV related stigma” for consistency.

_____________________________________________________________________________________________________

References:

• (Line 482) “STIGMA INDEX OF PEOPLE LIVING WITH HIV, 2.0. CAAPL- Central” revise formatting pertaining to the font size accordingly.

Thank you!!

Reviewer #2: Overall

Quantitative data were collected in 2019 (five years ago). It is likely that the HIV epidemic has changed. For example, most countries are nearing epidemic control. Is it possible that the findings are dated? If so, this could be included as a limitation.

Overall, our study reinforces existing research – What exactly is the additional value of this study?

Some stigma studies have recommended a socio-ecological model approach to addressing stigma focusing on the various levels (individual, family/relationship, community, societal). It is unlikely that just focusing on some health-care workers will solve HIV-related stigma. It is likely that in keeping with the socio-ecological model, interventions need to address multiple levels and address intersectional stigma – probably a discussion point. See for example: Ferris France N, Byrne E, Nyamwanza O, Munatsi V, Willis N, Conroy R, et al. Wakakosha "You are Worth it": reported impact of a community-based, peer-led HIV self-stigma intervention to improve self-worth and wellbeing among young people living with HIV in Zimbabwe. Front Public Health. 2023;11:1235150. Epub 20230728. doi: 10.3389/fpubh.2023.1235150

Abstract

Methods section should say when study was conducted.

Internalized stigma – Terminology is shifting to ‘internal stigma’.

Throughout, would put point (full stop after references i.e. [1,2].

Despite advances made in the clinical management of HIV, 24 % [24%]

do not have an access [do not have access]?

Methods

Interviews were conducted until data saturation was achieved. Was the sample of 10 predetermined or guided by the need to achieve theme saturation? It is unlikely that theme saturation could have been achieved with just 10 interviews.

The questionnaires were self-administered to provide more privacy to the respondents. Were these paper-based or electronic e.g. ACASI, CASI?

they can comfortably participate in the interviews [could]?

The questionnaire has several sections that include [had…included]

non-clinical-administrative stuff [staff]

people who agree with at least [agreed]

number of healthcare staff who answered at least of these statements [least ?? of]

who have some level of stigmatizing opinion about PLHIV and those who do not have it [who had…who did not]

Sample items on this scale include [included]

those who do not [did not]

those who have not answered [had not]

Line 159-160 and Table 2 knowledge on HIV transmission [of]?

For the qualitative data collection, a semi-structured interview guide was used consisting of 20 open-ended questions and guided probes with clarifications used throughout interviews. Please include as supplementary file.

reaching the word count of 15325 words – could leave out?

bilingual nature of the interviews and its [their]

Each interview was coded by a primary analyst and verified by a secondary analyst. Include initials if they are authors.

before the participation [before participating]

As shown in Table 3, the qualitative interview participants were women – There is nothing in Table 3 that shows they were women.

Separately, Table 3 could leave out the “Speciality” column as this likely identifies the participants e.g. One could guess who the young Endocrinologist is?

Analysis of the qualitative analysis??

The majority of the participants…See also Many interviewees mentioned, Most respondents – could include actual numbers. Also, these are only 10 participants who can’t be many even if all?

proposed on more [proposed more]?

These concerns have led [led]

drug addiction as a disease [condition]?

deep south USA [US]

during focus group discussions (FGDs) – It does not look like these are described anywhere else? Methods describe only qualitative interviews conducted remotely using social media platforms such as WhatsApp, Zoom and telephone calls

LGBT – provide full form first mentioned Terminology has shifted to LGBTQI+

It's important, it’s plausible [It is], there's been [there has]

Could present study strengths before limitations

future research use larger [uses]

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Reviewer #1: No

Reviewer #2: No

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PONE-D-24-31521R1"I think they are infected because of their ignorance and lack of responsibility": a mixed-methods study on HIV-related stigma in the healthcare system in Kazakhstan.PLOS ONE

Dear Dr. Iskakova,

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 Mar 08 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,

Joseph KB Matovu, Ph.D.

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.

Additional Editor Comments:

This is an important study about stigma among primary healthcare workers. Although the data were collected some 4-5 years, I believe that the study findings are still relevant to the HIV response globally. I have a few comments in addition to those raised by the reviewers:

1. The authors indicate that for the qualitative component, they interviewed 10 participants were chosen "... from the main sample" for in-depth interviews. It is not clear how and when the 10 participants were selected. Were the 10 participants also interviewed quantitatively? If yes, did the selection happen immediately after the quantitative interview had been completed? If they were interviewed after the quantitative interview, were they informed that they would be invited for a follow-on qualitative interview? In general, the authors should explain: a) how and when the selection of the 10 participants was made, and b) why the selection was restricted to only 10 participants.

2. The authors use the term "participants" to refer to those who participated in the quantitative and qualitative interviews. This can be confusing. I suggest that they use 'respondents' for the quantitative interviews, and 'participants' for the qualitative interviews.

3. It wasn't clear to me if the 10 participants were key informants or in-depth interview participants. While the rest of the paper refers to "in-depth interviews" - on page 11, the authors refer to these participants as "informants". So, were they interviewed as key informants or in-depth interview participants?

4. The estimated sample size was 380 but the authors report that they interviewed 448 respondents. No explanation is given for this sort of protocol deviation. Did they seek an amendment to increase the sample size from 380 to 448? Why and how did they end up interviewing more than the estimated sample size? What was the rationale for this? The authors should provide a clear explanation/justification for going over their estimated sample size by up to 68 respondents.

5. Regarding the HIV stigma measurements, can the authors reference any standard tool that they used to collect data? I would like to imagine that stigma validated tools exist and there are standard questions that are used to measure stigmatizing attitudes about HIV, including those used in demographic and health surveys, stigma index, etc. Where did the authors obtain their questions to measure the stigmatizing opinions about HIV?

6. To what extent are the HIV stigma measurements consistent with other measures of HIV stigma in other settings/countries?

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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 #1: All comments have been addressed

Reviewer #2: (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 #1: Yes

Reviewer #2: (No Response)

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

Reviewer #1: Yes

Reviewer #2: (No Response)

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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 #1: Yes

Reviewer #2: (No Response)

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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 #1: Yes

Reviewer #2: (No Response)

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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 #1: Discussion:

Comment 1:

(Line 394-395) “For instance, a study conducted among healthcare providers in the Deep South US found comparable percentages of stigma, with 89% of respondents at urban healthcare centers and 91% at rural clinics demonstrating at least one stigmatizing attitude [25].”

Specify the context in which the study was conducted. Change “Deep South US” to “among healthcare staff in Alabama and Mississippi of the United States (US)”.

Comment 2:

(Line 387) Rephrase “stigmatizing opinions about PLHIV” to Stigmatizing attitudes towards PLHIV.

Comment 3:

Throughout the discussion section, it would be clearer and more reader-friendly if the either authors first state the key results or findings of the current study before delving into a comparison with previous studies. Presenting the results upfront ensures the readers understand the main contributions of the study before they evaluate how these findings relate to existing literature. This approach helps to avoids confusion and strengthens the narrative flow of the discussion without missing the bigger picture. Paragraph from line 417 to 426 is an exception to the above comment.

Comment 4:

In the discussion paragraphs (from line 419 to 449), the authors addressed discriminatory and stigmatizing incidents against key populations, including MSM, LGBTQIA+, and sex workers. It is imperative to clarify whether these vulnerable groups are also part of the PLHIV community, experiencing compounded stigmatization and discrimination, particularly in primary healthcare settings when seeking HIV care. Otherwise, the stigma discussed may not be directly related to HIV as the primary focal point of the current study.

Reviewer #2: Most of my comments have been addressed. I only have a few more, outlined below.

• Stigma towards individuals engaged in same-sex behavior or drug use appeared to be stronger than towards PLHIV overall. Unsure how respondents were able to make the distinction. What if those in same-sex behavior or drug use were also LHIV? Just wondering if the issue of double-stigma emerged or should be explored in future studies – that is both same-sex behavior or drug use and LHIV. See for example: the “double stigma and double trouble” reported by https://doi.org/10.1371/journal.pgph.0002442

• …around 82% of PLHIV in the country are aware of their status, 68% are on ART, and only around 78% have suppressed viral loads [5].

These figures are confusing as one would expect a cascade - with first figure being highest, second being higher and third being lower than second.

• Although Kazakhstan has made progress, it has not yet achieved the 90-90-90 targets.

Include a citation of the 90-90-90 targets and also the more ambitious 95-95-95 goals by 2025.

• Although some healthcare providers in resource-limited settings may prefer to visibly mark the files PLHIV for perceived safety reasons, this practice can lead to breaches of patient confidentiality and reinforce stigma [15]. Include [of]: Although some healthcare providers in resource-limited settings may prefer to visibly mark the files of PLHIV for perceived safety reasons…

• were restricted to small sample size studies and/or focusing – change to [focused]

• leading to stigmatization of PLHIV using a mixed methods approach. Elsewhere, spelling includes hyphen: mixed-methods

• There are 65 PHCs in Almaty located evenly among 8 districts. 65/8 may not be evenly distributed?

• Several primary healthcare clinics (n=8) were recruited for the quantitative component based on a simple random sampling technique. Could say: Eight primary healthcare clinics were recruited for…

• where they can comfortably – change to [could] comfortably

• The primary study outcome was based "Stigmatizing opinions about PLHIV," measured using a 4-point Likert scale with response options ranging from “Strongly Disagree” to “Strongly Agree”.The – Is its based [on]? Also check space between sentences.

• For the qualitative data collection, a semi-structured interview guide was used consisting of 20 open-ended questions and guided probes with clarifications used throughout interviews (see S1 File) – include reference to the supplement file as suggested.

• which were also utilized to explain variations – see additional spaces

• Written informed consent forms were obtained from the respondents before participating in both quantitative and qualitative arms of the study - Written informed consent was obtained from the respondents before participating in both quantitative and qualitative arms of the study.

• Such gender distribution among the respondents is not surprising since the majority of healthcare workers in the country is predominantly female dominated – delete dominated: is predominantly female.

• 14%(n=63) – check space

• Fig 2 demonstrates descriptive statistics of HIV related stigma [HIV-related]

• around a half of the respondents were aware about the undetectable viral load [around half…were aware of…]

• with non-traditional sexual orientations or PWNSO (Fig 4) – give full form of PWNSO here.

• In other words, only one quarter… [For example, only a quarter…]

• one’s HIV status without a consent [one’s HIV status without consent]

• In our study, we observed differential treatment of PLHIV based on [perceived infection mode].

• According to one source, the local media often portrays s lesbian [delete extra “s” after portrays

• Nonetheless, [to our knowledge], this is the first study to address HIV-related stigma in healthcare using both quantitative and qualitative methods in Kazakhstan.

• Effective strategies to combat HIV related stigma [HIV-related]

• Acknowledgement [Acknowledgements]

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Reviewer #1: No

Reviewer #2: No

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PONE-D-24-31521R2"I think they are infected because of their ignorance and lack of responsibility": a mixed-methods study on HIV-related stigma in the healthcare system in Kazakhstan.PLOS ONE

Dear Dr. Iskakova,

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 19 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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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.

Additional Editor Comments:

1. The explanation about collecting data from more respondents than the estimated sample size needs to be further tightened. Yes, the researchers' argument that a big sample size improves the accuracy of the estimates and the study power. However, this does not justify interviewing more people than the estimated sample size. A note should be included in the "Discussion" section to state the implications of shooting over and above the estimated sample size and how this might be avoided in future studies.

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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 #1: All comments have been addressed

Reviewer #2: (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 #1: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: No

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Reviewer #1: Yes

Reviewer #2: 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 #1: Line 44: Rephrase “HIV-positive” to patients living with HIV, to avoid using stigmatizing statements that refer to PLHIV.

Line 130: “Mixed methods” is an approach, then 134 “sequential explanatory” is a research design. This should be clearly articulated.

Line 329 -330: Italicize the verbatim account of a Midwife for consistency.

A sample of 10 participants who participated in the qualitative phase were selected purposefully from those who had already completed a quantitative survey? Or they were not at all part of the first phase. If they were not part of the first phase a rational is needed to elucidate why a different sample was invited. However, if they were part, authors must explain in detail how they were recruited and selected for the second phase.

I have never seen the section that integrate quantitative results with qualitative findings, provided that this study was designed sequentially whereby qualitative findings had to explain quantitative results. Without such integration, this defeats the purpose of sequential explanatory design, as the essence of mixed methods is about combining insights. Therefore, some form of integration is essential.

Reviewer #2: I have a few edits:

For the qualitative phase, 10 participants were selected from the survey sample for the in-depth interviews. [delete the - For the qualitative phase, 10 participants were selected from the survey sample for in-depth interviews.]

• The paper-based questionnaires were self-administered to provide more privacy to the respondents. [Paper-based questionnaires were self-administered to provide more privacy to the respondents.]

• and disagree with the fourth statement [disagreed]

• then depending on new finding [findings]

• demonstrated protective effect [demonstrated a protective effect]

• while those have not seen [while those had…]

• The qualitative interview participants frequently expressed concerns about the transmission of HIV when they think of …[thought of]

• be careful in choosing sexual partners with females [be careful in choosing female sexual partners]

• They reported feeling of “discomfort” and “disgust” [They reported feelings…]

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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

**********

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"I think they are infected because of their ignorance and lack of responsibility": a mixed-methods study on HIV-related stigma in the healthcare system in Kazakhstan.

PONE-D-24-31521R3

Dear Dr. Iskakova,

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.

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Kind regards,

Joseph KB Matovu, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments: