Dear Dr. Okello,

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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Please address these comments including all the comments raised by reviewers 1 and 2.

Ethical statement: “Ethical approval and consent to participate. The research protocol was submitted to Lira University's Faculty of Public Health and the Lira University Research and Ethic Committee for approval (LUREC-2024-235)”.

Comment: the statement is unclear whether the study has been approved by the ethics committee or otherwise. Please be explicit about this.

Introduction:

Line 54: In Uganda, out of an estimated 1,492,742 people living with HIV, 1,255,975 are on ARVs (11). Comment: please provide percentage for ease of interpretation

Methods:

Study population: define adults

Sampling: explain how simple random sampling was carried out

Data collection: who collected the data, who conducted the interviews, which variables were collected through data abstraction, and which variables were collected through face-face interview?

Data analysis: please present the section in logical order. The initial step will be data exportation to Stata and then analysis. Also explain whether the data was initially exported from EMR in MS Excel and then imported to Stata for further analysis? How about variables collected via face-face interview, were they electronically collected, manually in MS Excel e.t.c. please be explicit to ease reproducibility.

Results:

Line 169: majority aged 0-30; however, inclusion criterion says 18yrs and above.

Table 2: label column 2. N?

Discussion:

Line 226-227 stated “In this study, we found that PLHIV receiving care in community models had higher rates of return to treatment as compared to those in the facility models.” However, results section Lines 187-188 stated that “Clients in the community care model had a lower return rate (83.9%) compared to those in the facility model (57.4%)”.

Acknowledgement:

Please acknowledge study participants.

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We look forward to receiving your revised manuscript.

Kind regards,

Jahun Ibrahim, MD, MSC, PhD

Academic Editor

PLOS ONE

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Reviewers' comments:

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: No

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: No

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1:  Dear Editor,

Thank you for the opportunity to review the manuscript "Factors Associated with Return to Treatment Following Interruption Among HIV-Positive Clients on ART in Public Health Facilities in Katakwi District, North Eastern Uganda".

The study is timely and relevant, addressing the critical issue of treatment interruption and return to HIV care, particularly in rural Uganda—a context often underrepresented in research. Its mixed-methods approach, combining structured quantitative data with contextual insights, enhances understanding of the behavioral and structural factors influencing return to treatment. By grounding the analysis in local realities such as community beliefs, proximity to health facilities, and family support, the findings offer practical value for program design. Furthermore, the use of routine data from the OpenMRS system, triangulated with paper-based records, strengthens the validity and reliability of the results.

However, there is room for improvement. Below are suggestions to help the authors to improve on the current draft and specific recommendations.

General comments

Language and grammar

The manuscript would benefit from language polishing:

• Typo: “client workers” instead of “clients” – Line 165

• Some long sentences, e.g.: “Clients coming from communities with strong beliefs against missing ART or treatment were about three times more likely...” could be re-worded, e.g. “Clients from communities with strong beliefs discouraging treatment interruption were nearly three times more likely to return to care than those from communities without such beliefs—consistent with findings from the United States and Tanzania.” It is not clear how the “strong believe” was measured or how these communities are organized into distinct groups with/without strong beliefs.

Formatting

• Please ensure that the intext citations are properly formatted, e.g., 42 and 30 in line 244 should appear as (42, 30) and not (42)(30). Also check similarly wrongly placed citations, e.g (35)(18) in line 235.

• Some sentences start without a preceding full stop, e.g. the sentence that starts with the words “Facility and home-”

Title

The title is lengthy and will benefit from a revision. For example, a shorter form could be “Determinants of Return to HIV Treatment After Interruption in Katakwi District, Uganda”

Abstract

For better flow, the sentence that starts with the words “Despite these efforts...” needs some modifications to flow better. It is unclear which efforts are referred to.

Introduction

• The introduction is comprehensive but slightly repetitive in describing global/regional return-to-treatment statistics.

• Consider clearly stating the research gap earlier in the introduction.

Methods

• Study design: Though the study follows STROBE, it claims to be mixed-method but only presents structured quantitative data.

o Recommendation: Remove “mixed-method” or clarify any qualitative component.

• Sampling and Exclusion Criteria: The rationale for excluding psychiatric patients and those admitted is not well explained.

• Measurement of outcome (Return to Treatment): Defined as >28 days, which aligns with MOH guidance —but consider justifying the cutoff with references.

• Variable Definitions: Several predictors are mentioned with yes/no responses—consider grouping by domain in a table.

• It may have been helpful to include more facilities with varying levels, since patients may not return to referral facilities since they may prefer to seek care in facilities closest to them. This can be admitted as a limitation.

• It is not clear why the two hospitals were selected as well and also, they seem to be at the same level.

• The sentence “Return to treatment was assessed using frequency counts, percentages, and a 95% confidence interval” can be dropped or re-worded since this is not have been the tool used to assess the outcome variable. Consider describing the measures used for comparison of the proportions in the bivariate analysis.

Results

• Bivariate Table (Table 2): The formatting is inconsistent. For instance, the column “Yes (n=)” is incorrectly formatted. No need to repeat “...of respondent” for the variable Gender. The table title is also long and there is not point stating that the table is about “Bivariate analysis...”

• Please be consistent with the number of decimal places for the p-values. Since the columns figures in brackets are percentages, the symbol can be included in the column headings and that it doesn’t have to be repeated.

• Highlighting of the significant values should be consistent. For example, “Mode of care”. Consider ordering categories for ordinal variables. For example, “Distance to clinic” should start with <5kms.

• Multivariate Table (Table 3): Should be better structured. Include sample size and N per group. Some p-values are misaligned.

Discussion

• Though it has a strong alignment with literature, some considerations on overstating the findings, e.g. in statements like “clients closer to facilities are less likely to return” require cautious interpretation. There may be possible confounding (e.g., stigma, facility congestion) should be hypothesized explicitly. It is surprising that clients who lived <5 kms to the clinic had the highest proportion of IIT, hence it may be challenging to explain why the significance without secondary analysis to rule out or consider stigma as a reason. Stigma alone may also not be the attributable factor since the type of facility and the services may differ depending on the type of facility. Clustering analysis may have been helpful.

• The first sentence in the discussion needs rephrasing since use of the word “only” while referring to 63.9% is countered by the second sentence where the authors indicate that the rate of return is higher than other studies. The rate seems to be within the literature quoted in the second sentence.

• In a vast rural setting, it is possible to contextualize access since some areas may be better connected than others. Hence the sentence “However, the geographical contribution to return to treatment cannot be fully contextualized within this study, as the study sites are in rural settings” may need further thought/reworking.

• It would be helpful to add more explanation on why unemployed clients or those with certain beliefs are more or less likely to return.

• In the limitations section, please remove the word “only” in line 259. In the limitation sentence “...we cannot establish a factor preceded or resulted from return to treatment,” needs substantiation since it is possible to do a competing risk analysis. Additionally, some outcomes such as viral suppression could have been considered since there is a temporal relationship with IIT.

Conclusion

• Thought practical and actionable, it could be more focused. Several recommendations are listed; grouping into themes (e.g., economic support, service delivery flexibility) would enhance clarity.

• The sentence “We noted a high return to care rate that still falls short of the UNAIDS 95% target for return to care” needs to be revised since the commonly known 95-95-95 UNAIDS targets do not reference return to care. Line 261-62

References

Some references are inconsistent, e.g. “11. Country P, Plan O. the People’s. 2020;

12. MOH. The 2019 HIV Epidemiological Surveillance Report for Uganda. file///C/Users/MARTIN%20ODOCHI/Downloads/2019-HIV-Epidemiological- Surveillance report-For print.pdf T 2019 HIV Accessed, 19/07/2021. 2019;(March 2020).”

Reviewer #2: A good write up and wonderful insight. however, to include analysis on age and sex if available regression analysis

need to also include inclusion and exclusion criteria. Can also include other form of graphic apart from tables use only.

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what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

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Determinants of Return to HIV Treatment After Interruption on ART  Among HIV Positive Clients in Katakwi District, Uganda.

PONE-D-25-25853R1

Dear Dr. Okello,

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,

Ibrahim Jahun, MD, MSC, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Yes

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

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #2: Yes

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Reviewer #2: The author has responded to all comments and the paper is well written and analysed. He is recommended

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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 #2: Yes: Ismail Lawal

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