-->PONE-D-25-21420-->-->Evaluating the effect of community-based programs on viral load among HIV-positive orphaned and vulnerable children on antiretroviral treatment: findings from the ACHIEVE project in Tanzania-->-->PLOS One

Dear Dr. Exavery,

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 Jan 28 2026 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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We look forward to receiving your revised manuscript.

Kind regards,

Sarah Nanzigu, Ph.D.,MSc.,MBchB

Academic Editor

PLOS One

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

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2. We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match.

When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section.

3. Thank you for stating the following financial disclosure:

This paper is based on data from the ACHIEVE project in Tanzania, 2020 - 2026. The project is supported by PEPFAR through the USAID.

At this time, please address the following queries:

a) Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

b) State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

c) If any authors received a salary from any of your funders, please state which authors and which funders.

d) If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

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

This study is part of the ACHIEVE project, funded by PEPFAR through USAID. A version of this manuscript, based on Group 1 respondents, was presented as a poster (WEPEC296) at AIDS 2024, the 25th International AIDS Conference, held in Munich, Germany, from July 22-26, 2024. Further details about the presentation can be found at: https://programme.aids2024.org/Abstract/Abstract/?abstractid=3356. Also, another abstract based on Group 2 respondents was presented as a poster (TUPE040) at the HIVR4P 2024, the 5th HIV Research for Prevention Conference that took place in Lima, Peru, October 6-10, 2024.

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

This paper is based on data from the ACHIEVE project in Tanzania, 2020 - 2026. The project is supported by PEPFAR through the USAID.

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

5. Thank you for stating the following in the Competing Interests section:

I have read the journal's policy and the authors of this manuscript have the following competing interests: One author, Amon Exavery, was awarded a travel scholarship by the International AIDS Society (IAS) to attend and present an abstract based on Group 2 respondents at the HIVR4P 2024, the 5th HIV Research for Prevention Conference, held in Lima, Peru, October 6–10, 2024. The rest of the authors declared that no competing interests exist.

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7. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Additional Editor Comments:

The manuscript needs serious attention to eliminate inconsistencies and improve clarity. Some of the inconsistencies have been presented under comments from reviewer 1.

In addition, kind attend to the following:

1. Reconcile names of community program in the your letter to the editor ( currently stated as 'WORTH Yetu economic strengthening') with the name presented in your manuscript title (ACHIEVE).

2. Your study title and abstract seem to represent just a subset of the entire study. The first two study objectives presented in the main body (lines 111- 118) are not captured in your title and abstract. Moreover, the evaluation of 'the impact of ACHIEVE' as an objective is so marginalized that a reader would consider it a secondary objective. I would encourage authors to rethink their study report and line it with their original study aims.

3. Just to emphasize a comment by reviewer 1, of the need for authors to clearly state the inclusion/ exclusion criteria, the report seems to mix up 'period on ART' and 'duration under ACHIEVE'. While lines 158-160 states that CLHIV who had been on ART for at least six months and had at least two clinically confirmed viral load test results spaced at least six months apart between July 2021 and July 2023', the table of baseline characteristics on page 12 emphasizes on duration on the ACHIEVE project', and goes ahead to include participants' duration less than 6 months. A reader would wonder if this group was eligible for the study. The authors therefore need to clearly state the inclusion/ exclusion criteria, and consistently apply the relevant variables in the analysis.

4. The tables of results are overcrowded with a lot information. Authors should consider limiting themselves to data most relevant to their report. Just to cite examples: Is it of much relevant to your report that caregiver's age be categorized into 5 groups and then family size into 3 groups?

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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: Yes

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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: Yes

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-->4. 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: 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: This manuscript is technically sound and result of their findings supports the conclusion. The presented data, the methodology and the details of the analysis shows that they used standard data analysis software and were able to different variables and possible factors that could affect the outcome. However, I observe that the authors needs few major revisions on some of the Tables as I have highlighted in the manuscript to aid the readers to appreaciate the result of their findings in a more simplified and clear fashion without much ambiguity.

I have made comments on the body of the work as they would find in the attached document.

Reviewer #2: Thank you for the opportunity to review this interesting article on community base programming and the influence of three categories of interventions on viral load among children receiving ARVs.

While the article is potentially of interest to a subset of readers who are programming with certain pediatric populations in mind, the interventions that were the focus of this report are not especially innovative, and the specifics of these interventions is unclear. Even if one is to pursue similar programming based on these findings, it would be nearly impossible to reproduce the activities leading to the reported impact.

Importantly, there is very little discussion of sustainability, cost-effectiveness, government ownership and the current context of HIV programming (including community-level investments) as of this review in late 2025.

In fact, for those following the future of programming and related budgets in Tanzania and other countries in the region, the manuscript comes off as disjointed from reality and largely naive to the latest driving programmatic political factors that will ultimately determine the success of such programs, and their relevance.

Indeed, the funding agency that is behind these investments no longer exists, and the upcoming five years will look nothing like the previous 20. If one is to look for similar studies over the last decade, s/he will find several, including from Tanzania.*** While the Konga community-based intervention model seems to be implemented by the National Council of People Living with HIV (NACOPHA), the relationship of current work with he many years preceding would offer important context. To imporve the value of this manuscript. the report needs to include much more information placing this study in current context.

With a re-write to update the paper in accordance with current context and placing these interventions in context (and providing more information on how the activities are executed so that they can be replicated), the Editor may consider accepting the article. Of note, much of the existing literature focuses on adolescents and youth, and CLHIV data is sparse.

A rooted paper informing the future of practical community programming among this young and highly vulnerable population would be welcome.

---

***

Ferrand RA et al. 2017. Community-based caregiver support to reduce virological failure in children and adolescents with HIV (ZENITH): Randomised controlled trial. Lancet Child Adolesc Health.

Chikwari CD et al. 2018. Community health worker support for older children and adolescents with HIV: Process evaluation of the ZENITH trial. Implementation Science.

Willis N et al. 2019. Effectiveness of Community Adolescent Treatment Supporters (CATS) on linkage, retention, and adherence among adolescents with HIV: Randomised trial. BMC Public Health.

Mavhu W et al. 2020. Differentiated peer-led service delivery for adolescents with HIV (Zvandiri): Cluster randomised trial. Lancet Global Health.

Ndhlovu CE et al. 2021. Peer-support intervention to improve ART outcomes among adolescents and young adults with virologic failure: Randomised controlled trial. AIDS Research & Therapy.

Simms V et al. 2022. Peer-led Problem Discussion Therapy for adolescents living with HIV: Cluster-randomised trial. PLOS Medicine.

Dhlamini N et al. 2019. Peer-led HIV care continuum outcomes in the Zvandiri programme. Global Health: Science & Practice.

Mageda K et al. 2023. Effectiveness of a community-based Konga model to improve viral suppression in children with HIV: Cluster-randomised clinical trial. BMC Public Health.

Mongi J et al. 2023. Community-based differentiated service delivery for paediatric HIV in Tanzania: Improved viral suppression and retention. HIV Pediatrics Conference Proceedings.

Msomi N et al. 2023. Determinants of viral load suppression among orphaned and vulnerable children receiving community-based caseworker support. Frontiers in Public Health.

Kahema L et al. 2022. Determinants of viral load non-suppression among HIV-positive children and adolescents in community treatment settings in Tanzania. Bulletin of the National Research Centre.

Grimwood A et al. 2012. Community adherence support and treatment outcomes among children on ART: Multicentre cohort study. Journal of the International AIDS Society.

Machiha A et al. 2024/2025. Integrated community-based HIV and SRH services for youth (CHIEDZA): Cluster randomised trial. Nature Medicine.

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Reviewer #1: Yes: Nnenna Assumpta EZEOKAFOR

Reviewer #2: No

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NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

Attachments

Attachment

Submitted filename: PONE-D-25-21420_reviewer.pdf

-->PONE-D-25-21420R1-->-->Evaluating the effects of community-based programs on viral rebound and viral suppression among HIV-positive orphaned and vulnerable children receiving antiretroviral treatment: findings from the ACHIEVE project in Tanzania-->-->PLOS One

Dear Dr. Exavery,

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 May 10 2026 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 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.

As the corresponding author, your ORCID iD is verified in the submission system and will appear in the published article. PLOS supports the use of ORCID, and we encourage all coauthors to register for an ORCID iD and use it as well. Please encourage your coauthors to verify their ORCID iD within the submission system before final acceptance, as unverified ORCID iDs will not appear in the published article. Only the individual author can complete the verification step; PLOS staff cannot verify ORCID iDs on behalf of authors.

We look forward to receiving your revised manuscript.

Kind regards,

Tacilta Nhampossa

Academic Editor

PLOS One

Journal Requirements:

1, If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

2. 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.

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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: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

-->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

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: 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 #1: Yes

Reviewer #2: Yes

Reviewer #3: 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 #1: Yes

Reviewer #2: Yes

Reviewer #3: 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 #1: The authors have adequately addressed the comments raised in the previous round of review; however, there are a few minor revisions I ave observed that should be corrected before publication. I have highlighted the comments in the attached document

Reviewer #2: This reviewer appreciates the thoughtful responses to all elements in the initial review. Thank you for the opportunity to provide feedback.

Reviewer #3: One main comment about the title (line 5 of the PDF version: Use of the term "HIV-positive": this terminology is not appropriate per UNAIDS guidance. Replace with “living with HIV”.

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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.

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: No

Reviewer #3: No

**********

[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.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

-->

Attachments

Attachment

Submitted filename: PONE-D-25-21420R1.pdf

Attachment

Submitted filename: PONE-D-25-21420_R1_240326.pdf

Evaluating the effects of community-based programs on viral rebound and viral suppression among HIV-positive orphaned and vulnerable children receiving antiretroviral treatment: findings from the ACHIEVE project in Tanzania

PONE-D-25-21420R2

Dear Dr. Exavery,

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,

Tacilta Nhampossa

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 #1: All comments have been addressed

**********

-->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

**********

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

Reviewer #1: 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 #1: 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 #1: 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 #1: I appreaciate the opportunity to review this piece of work. The authors have done a great job in developing the manuscript and contributing to the body of knoweldege that can help guide future programming especially among the CLHIV with opportunity for further research for strategies for scaling impact in the long term. They have also been able to address all comments in the second round of the review.

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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.

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

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