-->PONE-D-25-68943-->-->High performance of CD4 rapid testing by lay providers in Malawi: Results from a prospective diagnostic accuracy study supporting decentralized advanced HIV disease screening-->-->PLOS One

Dear Dr. Thawani,

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Felix Bongomin, MB ChB, MSc, MMed, FECMM

Academic Editor

PLOS One

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Reviewers' comments:

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

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Reviewer #1: No

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?

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Reviewer #1: Yes

Reviewer #2: Yes

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

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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: The authors are attempting to address an important subject but they are several weaknesses with this report. To start with there are several gramma/ typographical errors that could have been taken care of before submission. Additionally, the name of the LFA being evaluated is only disclosed much later in the methodology section and is a bit surprising when it is finally mentioned as Visitect, yet through out the abstract or the introduction, there is no reference to visitect. There are some publications on visitect that should have been referenced, the authors then needed to make the case for what is different in the work that is being presented from previous evaluations.

Abstract: There is ambiguity. The name of the tool being evaluated is not mentioned, additionally, in the abstract results section, one then realised that this evaluation extends beyond CD4 LFA. The authors should consider revising the title to take care of the additional

Additional comments

Line 68 : Large proportion is ambiguous, gives impression more PLHIV are AHD than are controlled, yet this is not the case? Needs revision.

Line 74, can abbreviate PLHIV here

Line 79-81 should be referenced

Line 93, does this test have a name at all or it is just CD4 LFA?

line 97- second objective comes as a bit of a surprise, the title is silent, consider revising the title a

line 126, what quantitative NPOC device is this? It is important to name it, so readers can reference

Line 133; Tests used: This needs to been mentioned earlier, until one gets to this line does one realise that the LFA being evaluated is visitect. See earlier comment on the same. Adn no reference to other works on visitect. There are several publications on visitect performance, some reference needs to be made to these in the introductory section, then what is this study has done differently to deserve being published

Need to be clear on :

1. CD4 test LFA being evaluated? Name and manufacturer, has it been evaluated before?

2. Which test is the reference standard, is it PIMA semi quantitative or Visitect?

3. If CD4 LFA being evaluated is not visitect, clearly mention in the methodology that CD4 LFA is also being compared against visitect.

line158: Name the assay

Line 167, name the near point of care to remove ambiguity

Line 169 to 174, needs to be clear if CrAg was performed on venous blood collected for NPOC, or finger stick blood was collected. What is sample type recommended by the manufacturer. For urine lam was a fresh sample collected? How long before testing ?

Line 173 to 175- Why storage, why not test immediately. What is the sample type recommended for CD4 LFA? Refer to the SOP for visitect and clarify that using venous blood did not deviate from the recommended SOP. And is storage of samples the current practice? Initially, one gets the impression that comparison of CD4 LFA test by HDA, is comparing to qualified health staff using the exact methodology , then later one learns that different samples are used, and there is storage

179 to 181; Clarity? which specific results

Line 186 to 188, review whole sentence and revise as needed, it is difficult to read due to gramma/ typos

Line 190. Clarify, two sensitivity analysis, but I only see one analysis below?

Line 199: does this mean the sample was not adequate for accuracy evaluation ( sensitivity and Specificity), yet accuracy is the main objective for this evaluation and not reproducibility?

Line 247- predictor or predictive, and why focus on 28% simulated prevalence , why not report actual findings from this study?

Line 321 is repetition. review and remedy as needed

403- Any comment on Sample size, was it adequate for accuracy evaluation?

line 410, brief or minimal ?

References don't seem to follow the seem to follow the same format through out.

Reviewer #2: Sent earlier

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Reviewer #1: No

Reviewer #2: No

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High performance of point-of-care rapid tests for advanced HIV disease diagnosis by lay providers in Malawi: Results from a prospective diagnostic accuracy study supporting decentralized advanced HIV disease screening

PONE-D-25-68943R1

Dear Dr. Thawani,

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,

Felix Bongomin, MB ChB, Ph.D., FECMM

Academic Editor

PLOS One

Additional Editor Comments (optional):

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 #2: All comments have been addressed

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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 #2: Yes

**********

-->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 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 #2: Yes

**********

-->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 #2: Yes

**********

-->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 #2: Great job team malawi. The manuscript reads well and clearly outlines what was done and how the results were obtained and how they apply to AHD. The team has done an excelent job in responding to the comments.

Minor comments:

1. Please describe in the methods who the HDAs were,what level of education, were they HIV positive peers, what were the minimum requirements needs to be recruited as an HDA. This will help inform implementation of this intervention in other settings.

2. Line 188: add hyphen in the word re engagement.

3. Just sharing our Ugandan experience, Samples that were not run within 30 minutes of bleeding despite what the insert states. This has been high lighted well in the write up and is a significant implementation issue.

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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.

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Reviewer #2: No

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