-->PONE-D-24-30309-->-->Mixed Feelings: Unintended Consequences of HIV Outreach Care in Zimbabwe-->-->PLOS ONE

Dear Dr. Gluskinos,

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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We look forward to receiving your revised manuscript.

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Richard Makurumidze

Academic Editor

PLOS ONE

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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?

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Reviewer #1: Partly

Reviewer #2: Partly

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

Reviewer #1: N/A

Reviewer #2: No

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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: No

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: The paper need additional proofreading, that includes removing more emotional language, e.g. " Closer to home, no longer secret, and dramatically reducing the physical barriers to care and the long-lasting stigma that resulted from treating only the gravely ill... ", as well as making sure all necessary statements are cited.

The gap in literature, and contribution of the paper is not clear. This should be very clearly specified in the introduction. In addition, the research question is also stated clearly enough

More information is needed on the composition/description of the respondents, how many were health care providers, community leaders, patients, etc.

The interviews with 60 participants could have interesting findings, but the current version is not making the argument sufficiently. For example, important information on the method is still missing, and a broader thematic analysis of the interviews could provide more in depth insights.

Reviewer #2: In the research article “Mixed Feelings: Unintended Consequences of HIV Outreach Care in Zimbabwe” by Noa Gluskinos et al., the authors explore both positive and negative impacts of HIV outreach care in Zimbabwe, particularly regarding stigma. Using qualitative data from 60 interviews conducted between January 13 and March 1, 2019, the study reveals how outreach efforts can inadvertently reinforce stigmatization.

Incorporating the suggestions below would, in my view, greatly enhance the impact of the manuscript. Thank you for considering these recommendations.

1. The manuscript currently lacks demographic information about the study participants (e.g., sex, age, education background), which may influence experiences and perceptions of stigma. Presenting this data is crucial, as certain demographic characteristics may play a significant role in how stigmatization manifests and is perceived. Including a demographic summary would allow readers to better understand the context of these findings and any potential influences on stigma-related experiences.

2. While the authors utilized QDA Miner for descriptive qualitative analysis, I recommend adding quantitative analysis where applicable to strengthen the study’s rigor. The addition of figures or charts to present key themes, frequencies, or demographic breakdowns would enhance the clarity and accessibility of the findings. Visual aids could also provide a clearer picture of how widespread certain themes are across the full set of 60 interviews, offering a more balanced and comprehensive view.

3. Out of the 60 interviews conducted, only 9 are discussed in the results section. It would be beneficial if the authors could clarify the relevance of these 9 interviews in relation to the entire dataset. A brief explanation of whether these examples are representative, typical, or outlier cases would improve transparency and provide readers with a sense of how these findings apply to the broader study population.

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Zimbabwe ART PLOSOne Review.docx

-->PONE-D-24-30309R1-->-->Mixed Feelings: Unintended Consequences of HIV Outreach Care in Zimbabwe-->-->PLOS ONE

Dear Dr. Gluskinos,

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 Jun 04 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,

Richard Makurumidze (MBChB, MPH, PhD)

Academic Editor

PLOS ONE

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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 #2: All comments have been addressed

Reviewer #3: (No Response)

**********

-->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

Reviewer #3: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: N/A

**********

-->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

Reviewer #3: No

**********

-->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

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 #2: a. The authors present the distribution of all age intervals of the interviewed participants, which is acceptable. However, presenting the participants' ages as a median with a range would enhance clarity and improve reader comprehension.

b. The authors organize the analyzed framework into 24 codes, which are further summarized into seven categories. However, no statistical comparison is provided among these codes and categories. Additionally, it is unclear to what extent these codes and categories contribute to the study’s conclusion.

Reviewer #3: Overall Comments

1. This is a potentially interesting paper.

2. Authors should be guided by journal guidelines available: https://journals.plos.org/plosone/s/submission-guidelines

3. It provides a lot of detail in the introduction and by the time one gets to the results (perhaps the critical section), one is tired and does not get the key takeaways. For example, introduction is overlong. Introduction should put the study into context. Should state the research question. Should have a clear statement on aims/objectives-why study was conducted and what it aimed to show. Cite a few other studies to put yours into perspective but this section should not be a review of literature. Introduction should be about 1-1.5 pages long.

4. Also some of the detail in the Methods could be left out.

5. As part of this study, we conducted 60 semi-structured interviews with community leaders, healthcare providers, patients, and community members in the areas served by the mission hospital and its outreach clinics.

I am assuming “this study” is referring to the CBART study? What was the purpose of conducting the 60 interviews? Was it as part of process evaluation?

6. Need to be careful with language e.g., infected people, internalized stigma, positive people, HIV positive man

7. It appears that the analysis identified 24 codes (Fig 1) and seven categories, themes I assume. However, results present 3 broad themes – knowledge of ART, persistence of HIV stigma, mixed feelings about outreach care.

It is unclear how the main themes came down from seven to three. It may be that the three themes need to have sub-themes?

8. Also, did the seven categories necessarily emerge (as per line 309)? If researchers were using a Framework approach, these seven items appear to be issues they would set out to explore from the outset.

9. Related to 3, researchers need to include the interview guide as a supplemental file and refer to it as (S1 File) in text.

10. Figure 2. It is unclear what the percentages represent especially as it shows seven categories from 24 codes in figure 1. One would think that the 24 codes were later categorized into seven themes.

Specific Comments

Abstract

Should be structured into the following sub-headings (and not exceed 300 words):

Background – Should briefly contextualize the study (4-5 sentences)

Methods – Should briefly describe the study including period it was conducted and how data were processed and analyzed.

Results – Could constitute the bulk of the abstract including total number of participants, any key demographic details and then go on to present a fair summary of the results.

Currently, just about a sentence - our study reveals that stigma and complex social relations significantly affect the practices and experiences of outreach ART care of both patients and health providers.

Conclusions – Ok as is - The study’s results highlight the need to understand the consequences of the decentralization of HIV care, as well as the barriers and facilitators associated with outreach ART care, to improve the quality of care and provide true accessibility to HIV care for all.

Introduction

Line 83 - decentralization of HIV care (explain what you mean by this).

Lines 84- 90 highlighted section should be moved to the Discussion.

Line 122- The number of centers providing ART increased progressively, from five in June 2004 to 48 in September 2005, covering 32 of 60 districts – There are a total of 68 districts in Zimbabwe. What happened to the other 8?

Line 138 – Define internal stigma (please note that terminology has moved from internalized to internal stigma) – see Heniff L et al. Reported impact of creativity in the Wakakosha ('You're Worth It') internal stigma intervention for young people living with HIV in Harare, Zimbabwe. PLOS Glob Public Health. 2024 Nov 5;4(11):e0003909. doi: 10.1371/journal.pgph.0003909.

Lines 179-188 could be left out.

Methods

Participants were selected using a purposeful snowball sample – repeating lines 244-245.

Results

Line 402 - People did not understand the disease – Is “disease” referring to AIDS or HIV, a condition – could be an issue of translation here.

Discussion

Line 662 - In Zimbabwe, the implementation of ART started in 2004 when the Zimbabwean government joined the "3 by 5" initiative, launched in 2003 by UNAIDS and WHO (65, 66).

Repetitive – this has been mentioned in the Introduction.

Lines 665-670 – should come earlier in Introduction – describing decentralization.

Lines 692-704 need references.

Line 703- For many, despite access to ART, the battle against AIDS has yet to be won. Unsure what this means as ART stops/delays progression to AIDS.

Minor additional comments

Antiretroviral therapy should be written consistently throughout, currently Anti-Retroviral Therapy/ antiretroviral therapy

Acknowledgments

Check journal requirements but I think all listed by name should have provided consent.

References

References need updating. See for example recent papers on stigma/Stigma in Zimbabwe:

• Ferris France, N. et al. (2025). Interventions to reduce self-stigma among people living with HIV: A systematic review.Stigma and Health. Advance online publication. https://doi.org/10.1037/sah0000600

• Rich C et al. Exploring the beliefs, experiences and impacts of HIV-related self-stigma amongst adolescents and young adults living with HIV in Harare, Zimbabwe: A qualitative study. PLoS One. 2022 May 18;17(5):e0268498. doi: 10.1371/journal.pone.0268498.

• Ferris France N 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 Jul 28;11:1235150. doi: 10.3389/fpubh.2023.1235150.

• Heniff L et al. Reported impact of creativity in the Wakakosha ('You're Worth It') internal stigma intervention for young people living with HIV in Harare, Zimbabwe. PLOS Glob Public Health. 2024 Nov 5;4(11):e0003909. doi: 10.1371/journal.pgph.0003909.

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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.

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Reviewer #2: Yes:  Siriwat Akapirat

Reviewer #3: No

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Attachments

Attachment

Submitted filename: renamed_81aa5_with line numbers.docx

-->PONE-D-24-30309R2-->-->Mixed Feelings: Unintended Consequences of HIV Outreach Care in Zimbabwe-->-->PLOS ONE

Dear Dr. Gluskinos,

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 26 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,

Lara Vojnov

Academic Editor

PLOS ONE

Journal Requirements:

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.

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.

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

Reviewer #3: (No Response)

**********

-->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

Reviewer #3: Yes

**********

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

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 #2: Yes

Reviewer #3: No

**********

-->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

Reviewer #3: 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 #2: a. Line 65–66: The sentence “However, the study shows that but that they also had unintended negative consequences” contains a minor error. Please revise to “However, the study shows that …”

b. Line 274–276: The phrase “community health workers, community leaders and community health workers” appears to duplicate “community health workers.” Kindly check whether this repetition was unintended.

c. Age of participants: Table 1 presents an age range of 20–80, while the text (line 314) describes participants’ ages as ranging from 18 to the mid-70s. Please clarify this discrepancy.

Reviewer #3: All comments have been addressed. The manuscript needs proofreading especially as 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. See for example:

Line 64 - The study reveals that s treatment

Check this - However, the study shows that but that they also had unintended negative consequences.

…physical and social barriers to access ART (full stop missing)

Line 102…increase the physical and social barriers to access ART . (check spacing at end of sentence.

Line 106 – Could delete the heading ‘Background’.

Line 228 - the patience (patients)?

Fig 1 heading says Ditribution (Distribution)?

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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 #2: Yes:  Siriwat Akapirat

Reviewer #3: No

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[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. Please note that Supporting Information files do not need this step.-->

Mixed Feelings: Unintended Consequences of HIV Outreach Care in Zimbabwe

PONE-D-24-30309R3

Dear Dr. Gluskinos,

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,

Lara Vojnov

Academic Editor

PLOS One