PONE-D-22-04602STI testing and subsequent clinic attendance amongst test negative asymptomatic users of an internet STI testing service; one-year retrospective studyPLOS ONE

Dear Dr. Ayinde,

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: Yes

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

Reviewer #1: Yes

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Reviewer #1: No

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Reviewer #1: 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 outlines a retrospective study of users of Internet STI testing service and sexual health clinics. The study found that there was a low subsequent clinic attendance amongst online STI test service users compared to STI clinics user.

I think the paper is well written, the methods are sound and appropriate conclusion points are drawn from the data used. However, my main concern is the follow up period used. By using one calendar year of data there is unequal follow up time for testers which is a significant limitation and is not mentioned in the limitations. Additionally, at the time of the study I believe only gay, bisexual and other men who have sex with men were recommended to test 3 monthly, all sexually active men and women aged 15-24 should be tested for chlamydia annually or on change of sexual partner (whichever is more frequent). Therefore, the people who reattend within 90 days would be a select group of people who may be at higher STI risk and the results might not be generalisable to other populations. I would suggest the explain the rationale for using a 90 day cut offs or use a longer time period for follow up in order to be representative of recommended testing guidelines.

Additionally, the references to the proportion of asymptomatic users of online testing services need to be clearly caveated that this metric will be biased because most people who are symptomatic are asked to go to a clinic and not use self-sampling. Especially as some services are only commissioned for asymptomatic people only.

Specific comments

• In some parts you mention the risk of subsequent attendance. Odds ratios do not indicate the ‘risk’ but the likelihood of something occurring.

• There are several places where acronyms are not spelt out

• Tables – there are some formatting issues; missing (95%CI), not sure why some cells are in bold.

• Limitations - have not mentioned that you analysis will not include people attending other sexual health services.

• Point to comment on, lines 260-1: “those self-identifying as being of ‘Black ethnicity’ were significantly less likely to use the online STI test service.” Some studies found that self-sampling was difficult for some communities/ethnic groups where the test being delivered to a home address with other family members who lack of privacy. Could use this references to explain this. For example the link below https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-018-5256-5

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Reviewer #1: No

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STI testing and subsequent clinic attendance amongst test negative asymptomatic users of an internet STI testing service; one-year retrospective study

PONE-D-22-04602R1

Dear Dr. Ayinde,

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,

Habakkuk Yumo, MD, MSc, PhD

Academic Editor

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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

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 #1: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

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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: No

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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

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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 #1: Thank you for addressing my previous main concern and specific comments. I am satisfied with your added explanation in the text and I think it sets out the rationale for the study in a much clearer way.

I have some further specific (minor) comments to add which I think can easier be fixed

Title

• Now you have updated the rationale for the study, you are not following people up for a year so I would say it is a retrospective cohort study

• I would also make note of the comparison aspect to the study (online testers vs clinic testers)

Abstract

• Lines 31 and 32 – compared to who?

• Lines 36 – this metric is a bit biased as you had to have previously tested to be included in the study

Table 1

• I think it will be worth rephrasing ‘Gender/Sexuality’ and updating the footnotes as they aren’t the most clear.

o Gender - It would also be useful to confirm if it is gender and not sex

o Sexuality – MSM is not a sexuality but a sexual behaviour

o The footnote for Men does not add up to the total for Male and Bisexual men appear to be included in the Male breakdown.

o My suggested change would be ‘Sex’ and Sexual orientation with All women, Heterosexual men and gay, Bisexual and MSM.

• IMD breakdown – categories are overlapping, i.e. 20% in first and second group, 40% in second and third

• Clinic attendance in the last three months – I’ve mentioned this in the abstract section but it seems a bit circular. Would this include people who tested in clinic and then tested online? Please clarify the definition further

Discussion

• Line 227 Add ‘certain’ before ‘ethnic and..’

Limitation

• People might have tested online too early in the window period of their infection and so would have been too early to tell.

Reviewer #2: Thanks for the clarifications with respect to the review comments and for the changes made in the manuscript.

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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: Sophie Grace Nash

Reviewer #2: No

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