Engagement and retention in HIV care in rural Southern U.S. using an All-Payer Claims Database

Jun Tao; Mofan Gu; S. Alexandra Marshall; Jure Baloh; Mike Cima; Cornelius Mabin; Nickolas D. Zaller; Dan Moore; Hannah Parent; Heather Horton; Ira B. Wilson; Amy S. Nunn; Philip A. Chan

doi:10.1371/journal.pone.0339520

Peer Review History

Original SubmissionAugust 11, 2025
1 Oct 2025 Decision Letter - Lakshminarayana Chekuri, Editor Dear Dr. Tao, 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 Nov 15 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. 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'. 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Your timely response would help this study be published and will make it accessible to interested readers across the world. I look forward to reviewing your revised manuscript. I wish you good luck with your future endeavors. [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? Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: I Don't Know ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: Overall, this manuscript provided important insights into engagement and retention in HIV care in Arkansas using All Payer Claims Databases, which represents an alternative approach to assessing engagement and retention in the developed world. The limitations are appropriately acknowledged, and the results are presented cautiously without being overstated. The manuscript is also well structured and aligns well with research and publication ethics. That said, I have a few observations that may help strengthen the study. Focus of findings: While the study set out to assess engagement and retention in care, a significant portion of the findings and discussion focusses on HIV testing. Since HIV testing would typically precede engagement and retention in care, further clarification on how these results contribute to the primary outcomes of engagement and retention would be helpful. Results section: under statistical methods, the manuscript mentions chi-square tests were used to examine meaningful differences; however, the supplementary table doesn't present the Chi-square results. Could the authors clarify whether these results are missing, presented elsewhere or were not statistically significant? in summary, this is a well prepared manuscript that addresses an important topic in HIV care. These above few observations will improve the clarity and strength of the results. Reviewer #2: This is a well written and valuable manuscript analyzing a data from the Arkansas All-payer Claims Database to characterize the HIV care cascade. Authors carefully document assumptions and criteria for extracting and coding cases. The study is important and worthy of publication. Authors are to be commended for developing a novel approach for exploring the HIV care continuum in Arkansas. There are a number of minor issues that need to be addressed: Throughout PLoS One is a global publication, and ‘rural South’ needs to be explicitly unpacked both in the title and clearly in the introduction to the U.S. rural South. Introduction Please include supporting information such as the proportion of U.S. population in ‘the South’ and how you’re defining ‘the South’. Statistics about what proportion of the U.S. population lives in the south are needed to explain why it's problematic that >50% of PLWH in the U.S. live in the south. For a global readership, when statements such as “high rates of poverty (15.4% in 2017)” line 50 are made, it would be helpful to give the U.S. median or comparison given that many countries have far higher rates of poverty than 15.4%. Line 65: ‘rapidly progressed’ - please define and provide a U.S. comparison for states where new HIV dx are associated with less rapid progression. Line 68 – ‘they must actively participate in care’ – there are PLWH who are virally suppressed and out of care; critical determinant is generally taking ART meds, not the entire chain of engagement you describe. Recommend rewording sentence to be more accurate. Please provide a sentence introducing the Ryan White program for readers who may not be familiar with it. Methods Please define how you are using rural and urban since the definition varies across countries Results Line 192 – ‘ever tested for HIV’ – does this really mean ever tested, or does it mean tested during the four years captured by your data? Please be clear. Line 197 – ‘in mostly urban’ – does this mean areas where people live are predominantly urban? Or that most people are living in urban areas. The rural/urban transition spaces of suburbs are different, and it’s not clear from your language what you mean. Line 267 – ‘our analysis only reflects testing over the four year period covered in our dataset’ Limitations You noted in lines 76-77 that approximately a third of PLWH in Arkansas receive care through the Ryan White program. A third is not ‘a small proportion’ (line 311). I recommend explicitly noting the approximately one third you’re potentially missing in the limitations (line 311), and also in the discussion (line 277-278) where you discuss the Ryan White program. ****** 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: Yes: Debbie Humphries ******** [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 https://doi.org/10.1371/journal.pone.0339520.r001
Revision 1
17 Oct 2025 Author Response Reviewer #1: Overall, this manuscript provided important insights into engagement and retention in HIV care in Arkansas using All Payer Claims Databases, which represents an alternative approach to assessing engagement and retention in the developed world. The limitations are appropriately acknowledged, and the results are presented cautiously without being overstated. The manuscript is also well structured and aligns well with research and publication ethics. That said, I have a few observations that may help strengthen the study. Focus of findings: While the study set out to assess engagement and retention in care, a significant portion of the findings and discussion focusses on HIV testing. Since HIV testing would typically precede engagement and retention in care, further clarification on how these results contribute to the primary outcomes of engagement and retention would be helpful. Response: Thank you for this comment. In the manuscript, we highlight how HIV testing is crucial for early diagnosis and linkage to care. Diagnosis is the first stage in the HIV care continuum. Results section: under statistical methods, the manuscript mentions chi-square tests were used to examine meaningful differences; however, the supplementary table doesn't present the Chi-square results. Could the authors clarify whether these results are missing, presented elsewhere or were not statistically significant? in summary, this is a well prepared manuscript that addresses an important topic in HIV care. These above few observations will improve the clarity and strength of the results. Response: Thank you for this comment. Supplement Table 1, as well as the Results section, have been revised to show results of chi-square tests and Cochran-Armitage trend test for HIV care utilization. Reviewer #2: This is a well written and valuable manuscript analyzing a data from the Arkansas All-payer Claims Database to characterize the HIV care cascade. Authors carefully document assumptions and criteria for extracting and coding cases. The study is important and worthy of publication. Authors are to be commended for developing a novel approach for exploring the HIV care continuum in Arkansas. There are a number of minor issues that need to be addressed: Throughout PLoS One is a global publication, and ‘rural South’ needs to be explicitly unpacked both in the title and clearly in the introduction to the U.S. rural South. Response: Thank you for this comment. We have updated the title and introduction to include rural Southern U.S. Introduction Please include supporting information such as the proportion of U.S. population in ‘the South’ and how you’re defining ‘the South’. Statistics about what proportion of the U.S. population lives in the south are needed to explain why it's problematic that >50% of PLWH in the U.S. live in the south. Response: Thank you for this comment. We have updated the introduction to include the suggested information. For a global readership, when statements such as “high rates of poverty (15.4% in 2017)” line 50 are made, it would be helpful to give the U.S. median or comparison given that many countries have far higher rates of poverty than 15.4%. Response: Thank you for this comment. We have updated the introduction to include this statistic. Line 65: ‘rapidly progressed’ - please define and provide a U.S. comparison for states where new HIV dx are associated with less rapid progression. Response: Thank you for this comment. We have updated the introduction to include the suggested information. Line 68 – ‘they must actively participate in care’ – there are PLWH who are virally suppressed and out of care; critical determinant is generally taking ART meds, not the entire chain of engagement you describe. Recommend rewording sentence to be more accurate. Response: Thank you for this comment. We have reworded this sentence as suggested. Please provide a sentence introducing the Ryan White program for readers who may not be familiar with it. Response: Thank you for this comment. We have updated the introduction to include a definition of RWHAP. Methods Please define how you are using rural and urban since the definition varies across countries Response: Thank you for this comment. We have included the rural and urban definitions in the Methods section. Results Line 192 – ‘ever tested for HIV’ – does this really mean ever tested, or does it mean tested during the four years captured by your data? Please be clear. Response: Thank you for this comment. We have clarified that we meant testing during the four years captured by data. Line 197 – ‘in mostly urban’ – does this mean areas where people live are predominantly urban? Or that most people are living in urban areas. The rural/urban transition spaces of suburbs are different, and it’s not clear from your language what you mean. Response: Thank you for this comment. We have revised this sentence to be more clear. Line 267 – ‘our analysis only reflects testing over the four year period covered in our dataset’ Limitations You noted in lines 76-77 that approximately a third of PLWH in Arkansas receive care through the Ryan White program. A third is not ‘a small proportion’ (line 311). I recommend explicitly noting the approximately one third you’re potentially missing in the limitations (line 311), and also in the discussion (line 277-278) where you discuss the Ryan White program. Response: Thank you for this comment. We have made the suggested revisions. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0339520.r002
8 Dec 2025 Decision Letter - Lakshminarayana Chekuri, Editor Engagement and retention in HIV care in rural Southern U.S. using an All-Payer Claims Database PONE-D-25-39217R1 Dear Dr. Tao, 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. For questions related to billing, please contact billing support . 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, Lakshminarayana Chekuri, MD, PhD Academic Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: All comments have been addressed Reviewer #2: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #1: (No Response) Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: I Don't Know ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: (No Response) Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: (No Response) Reviewer #2: Yes ****** Reviewer #1: (No Response) Reviewer #2: (No Response) ****** 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: Yes: Victoria Babirye Tumusiime Reviewer #2: Yes: Debbie Humphries ******** https://doi.org/10.1371/journal.pone.0339520.r003
Formally Accepted
Acceptance Letter - Lakshminarayana Chekuri, Editor PONE-D-25-39217R1 PLOS One Dear Dr. Tao, 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. Lakshminarayana Chekuri Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0339520.r004

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