A Systematic Review Exploring the Psychosocial Factors Affecting Adolescent Access to HIV Treatment Services

Reviewer’s comments

Manuscript changes/amendments

Reviewer 1

Thank you for the opportunity to review this paper. I think, starting this current verision, that the paper is not yet powerfull and suitable for publication. The review is based on 18 empirical paper and I think that increasing the design and reseach demand it could be much more interesting and suitable for publication.

Thanks for this comment. The number of studies included in a systematic review depends on the research topic, as well as the amount of supportive evidence available. Thus, we are unable to increase the design and research demand (or increase the number of papers included). Given that three international multidisciplinary databases in addition to one local (South African) database were used, we believe that the databases used were of a sufficient type and number to ensure the inclusion of articles adhering to the inclusion criteria of this systematic review. In addition, the development of the search strategy (SPIDER) was in line with current guidelines for systematically reviewing both quantitative and qualitative research together (see Cooke et al. (2012) and Methley et al. (2014)). Lastly, the search strings, designed to increase both their specificity and sensitivity, were appraised by a senior librarian and research supervisor at the University of the Witwatersrand. Therefore, as the authors of this systematic review, we believe that the design of this study cannot be altered as it is sufficiently rigorous to address the proposed research question.

Reviewer’s comments

Manuscript changes/amendments

Reviewer 2

Major comments

Overall this appeared to be a very well done systematic review within the limits of the available studies, which unfortunately were significant.

As the authors noted, generalizable conclusions are difficult to make from this data given that few studies used the same quantitative measures. Perhaps the greatest contribution of this review is in identifying gaps in current knowledge which should be further investigated. The authors were still able to identify common themes which I believe are helpful to the practitioner.

Thank you for this comment. We agree there were some limits to the available studies and it proved quite a challenge to generate a thematic overview from the set of studies which used quite disparate methodologies. We agree however that the themes identified do have some important implications for practice.

Minor comments

The Prisma flow diagram is incorrect, it shows a box with n=66 splitting into a box of n=18 and a box of n=1013. The box below that one also has incorrect splitting.

Thank you for pointing out this error. We have corrected the splitting on the diagram.

Lines 253/254: The sentence regarding most participants being female except the three cited studies which were all female is confusing.

Thank you for this point. We have refined the sentence and removed the following unnecessary/confusing wording: “Kidman and Violari [65] only included female participants in their study.“ This was removed as it caused confusion. The finding we intended to discuss was that “Most participants across the studies were female – except for the study conducted by Brittain et al. [59].” (Line 570-571).

Reviewer’s comments

Manuscript changes/amendments

Reviewer 3

As there are so many reports available related to proposed studies and few I am mentioning for better understanding?

https://pubmed.ncbi.nlm.nih.gov/35841462/

https://pubmed.ncbi.nlm.nih.gov/34852889/

10.1371/journal.pone.0165936

We hope we have understood this comment correctly. Although there are reports available related to our study, they are not systematic reviews. To our knowledge, there are no reviews which specifically explore the psychosocialfactors affecting adolescent access to HIV treatment services in South Africa.

[1]    Line no. 23 “studies ought to have been published between 1 January 23 2000 and 31 July 2020” if possible data can be included upto 2022

Thank you for this suggestion. The dates we selected for inclusion of studies relate to the deadlines for the first author’s research report/dissertation in 2020, on which this paper is based. The time frame (20-year period) was also chosen to include relevant developments within the HIV field at the time. As noted in the manuscript, all included articles were published between 2015 and 2020. We have considered this suggestion carefully but are of the opinion that by extending the time frame to 2022, additional database searches would have to occur as well as the analysis of relevant articles – i.e. the search and analysis would have to be conducted again and it would not be a simple task to add in papers from the additional two years. Given the tight time constraints for re-submission to the journal as well as the time required for PROSPERO to approve a protocol amendment, we have elected not to include papers from 2021 and 2022.

[2]    Study needs to elaborate few more aspects like TB-HIV co-infection, MDR/XDR in HIV

Thanks for this comment. Although some of the included studies noted that the “physical health of ALHIV was impacted by… symptomatic pulmonary TB” (line 1401–1402), none of the studies provided information on aspects like TB-HIV co-infection, MDR/XDR in HIV. This may be a shortcoming in current HIV research initiatives adopting a mental health lens. Given that this study was a systematic review of current literature exploring the psychosocial factors affecting adolescent access to HIV treatment services in South Africa, we are of the opinion that commentary on TB-HIV co-infection, MDR/XDR in HIV is not well suited for this manuscript which adopted a psychosocial approach to healthcare.

[3]    Age group, gender and inclusion and exclusion criteria for the study should be very clear

Thanks for this comment. Given that South African HIV statistics understand adolescence as being constituted of two distinct age groups (10 – 14 years and 15 – 19 years) which do not represent the stratification of age according to the three stages of adolescence, as per the WHO, South African researchers are at odds when defining their proposed ‘adolescent age bands’. This creates inconsistencies across adolescent research initiatives. Likewise, many research initiatives focusing on ‘adolescents’ often include either ‘children’ (defined as those under the age of 18) or young adults (up to the age of 24) in their sample. There is little-to-no HIV research which specifically samples adolescents (10-19 years old). This is further complicated by older children/younger adolescents needing to attend paediatric healthcare facilities whereas older adolescents attend adult-oriented healthcare facilities.

RE gender, all papers which sampled

“HIV-positive adolescents (≥ 10 years old and ≤ 19 years old) residing in South Africa” (line 150–151) regardless of their gender, were included in this systematic review.

Given that HIV has a unique psychosocial impact across the gender spectrum, this study did not have a preference in terms of selecting papers which only sampled males or females. This study sough to explore the psychosocial factors affecting adolescent access to HIV treatment services in South Africa.

[4]    Overall extensive English, grammer editing needed

We respectfully disagree with this comment. Our response is reinforced by reviewer 1 and reviewer 2 noting that “English language and style are fine/minor spell check required”. Likewise, the Grammarly application was used to ensure that the language and grammar used was sufficiently appropriate. Both authors are first language English speakers.

[5]    Add 1-2 graphical abstract for better understanding.

Thanks for this suggestion. We have added in a table of themes and sub-themes which hopefully addresses the reviewer’s comment.

[6]    Impact of societal condition, dietary behaviour for HIV patients needs to mention. Recent steps taken by Government at national as well as international level for controlling the disease also needs to highlight

Thank you for this comment. The National Strategic Plan is mentioned in the section describing the ‘setting’ (line 82– 94). However, as the impact of societal condition, dietary behaviour for HIV patients was not apparent in the included studies, we have not included a discussion on this.