Virological non-suppression among adult males attending HIV care services in the fishing communities in Bulisa district, Uganda

Ignatius Senteza; Barbara Castelnuovo; David Mukunya; Fredrick Makumbi

doi:10.1371/journal.pone.0293057

. 2023 Oct 19;18(10):e0293057. doi: 10.1371/journal.pone.0293057

Virological non-suppression among adult males attending HIV care services in the fishing communities in Bulisa district, Uganda

Ignatius Senteza ^1,^*, Barbara Castelnuovo ^2,^#, David Mukunya ^3,^#, Fredrick Makumbi ^1,^#

Editor: Joel Msafiri Francis⁴

PMCID: PMC10586650 PMID: 37856568

Abstract

Background

Virological non-suppression is a critical factor in driving HIV transmission rates, yet there is limited data available on the determinants of this phenomenon, particularly in fishing communities where the incidence of HIV is disproportionately high. We aimed to determine the prevalence and determinants of virological non-suppression among adult males (≥15 years) attending HIV care services in the fishing communities of Bulisa district.

Methods

We conducted a cross-sectional study among all adult males (≥15 years) living with HIV who were resident within the fishing communities, and in care for atleast 6 months at the six health facilities offering HIV services in the fishing communities in Bulisa district. To obtain data on patient and health facility characteristics, we reviewed patients’ records and conducted face-to-face interviews with the participants. We conducted descriptive and regression analyses using modified Poisson regression, accounting for data correlation of observation at the facility level to obtain prevalence ratios (PR) with 95% confidence intervals in Stata version 14.0.

Results

413 participants were studied and 379 (91.8%) were interviewed. The participant’s average age (SD) was 40 (10.7) years and 70.5% (267/379) were engaged in the fishing business. The prevalence of virological non-suppression was 88/413–21.3% (95% CI: 18%-26%). Factors associated with higher odds of virological non-suppression included: Age 26–50 years (adj.PR = 1.53, 95%CI: 1.11–2.08) and 15–25 years (adj.PR = 2.99, 95%CI: 1.27–7.05) compared to age above 50 years; unemployment (adj.PR = 1.28, 95%CI: 1.10–1.49); hazardous use of alcohol (adj.PR = 1.34, 95%CI: 1.10–1.62); non-mobility between fish landing sites (adj.PR = 1.37, 95%CI: 1.003–1.87); distant HIV treatment services (adj.PR = 1.37, 95%CI: 1.11–1.69) and TB diagnosis (adj.PR = 1.87, 95%CI: 1.33–2.64).

Conclusion

Virological non-suppression among people living with HIV in fishing communities along the shores of Lake Albert is alarmingly high, exceeding the UNAIDS threshold of 10% by two-fold. Several key determinants were identified, including hazardous alcohol use, unemployment, and access barriers to HIV treatment services.

Introduction

The World Health Organization (WHO) identifies key populations as groups that are particularly vulnerable to contracting Human Immunodeficiency Virus (HIV) [1]. In Africa, fishing communities represent a significant proportion of these at-risk populations [2, 3] due to the high prevalence of HIV within these communities [4]. Specifically, along the shores of Lake Victoria (the biggest lake in Uganda), the prevalence of HIV is as high as 19.7% [5] which is three times higher than the general population’s prevalence of (6.2%) [6].

The fishing business is often characterized by male dominance, high-risk sexual behaviours [6], frequent alcohol consumption [7] and mobility between different fishing sites [8]. These factors contribute to the potential transmission of HIV, highlighting the need for more effective methods of prevention. One such approach is recognizing the importance of undetectable viral loads in achieving untransmittable HIV status [9–12]. To better understand the factors that contribute to virological suppression among individuals with HIV, it is important to contextualize these determinants. By gaining a better understanding of the factors that contribute to virological suppression among individuals with HIV, we may be able to reduce the incidence of HIV in fishing communities [13, 14].

Bulisa district, located along the shores of Lake Albert, has a significant portion of its population (14.2%) engaged in the fishing business [15]. While the prevalence of HIV among these fishing communities is not known, it is likely to be higher than that of the general population due to the high rates of HIV observed in fishing communities [5]. However, the overall prevalence of HIV in Bulisa district, based on 2020 program data in DHIS-2, was lower at 5.1% [16] as compared to the national prevalence of 6.2% reported in the UPHIA report of 2017 [6].

A study carried out in Uganda using national programme data in 2017 found that the prevalence of virological non-suppression among males with HIV was 13%. However, in Bulisa district during the same time, the prevalence of virological non-suppression amongst all adult males for the same period was much higher, at 20% [17]. This is particularly concerning, as it exceeds the UNAIDS virological non-suppression threshold of 5% by 2030 [18] and twice as high as the UNAIDS threshold of 10% that was supposed to be achieved by 2020 [19].

While there are program data available on virological non-suppression amongst PLHIV at district level in Uganda, little is known about the burden of virological non-suppression specifically among the male-dominated fishing communities. Furthermore, the association of virological non-suppression and key characteristics prevalent in fishing communities such as risky sexual behaviours [20], hazardous alcohol consumption [21] and high mobility [8] is not well understood. Although certain factors have been linked to virological non-suppression in various population groups, these may not apply to fishing communities.

This study aimed to determine the prevalence of virological non-suppression and the associated factors among adult males (15+) living with HIV in the fishing communities of Bulisa district.

Methodology

Study setting

The study was conducted in the fishing communities situated along the shores of Lake Albert in Bulisa district, which is approximately 288.5km west of Kampala, the capital city of Uganda [15]. The estimated population according to the National Population and Housing Census 2014 is 113,161 [22]. According to district reports, around 2000 (1.76%) individuals are living with HIV in these communities, with males constituting 45% of the population [16]. Notably, a majority of those with HIV (approximately two-thirds) reside in fishing communities [16]. Fishing activities typically occur at fish landing sites where boats dock, and the trading of fish takes place.

Fishermen often move between fish landing sites, depending on seasonal changes, to increase their chances of catching fish. There are seven public health facilities in the district, but only six are easily accessible to ten or more fishing communities. These facilities routinely assess the virological status of adult patients under HIV care six months after initiating ART treatment and every 12 months thereafter [23].

Patients who have virological non-suppression are typically provided with three intensive adherence counselling sessions before undergoing a repeat viral load test. The management of patients living with HIV is based on several differentiated service delivery models which depend on their degree of stability. For instance, patients who are virologically suppressed, are in WHO clinical stage I or II, have no active TB disease or have completed the intensive phase of TB treatment are considered stable [23]. Stable patients have access to different treatment modalities, including the fast-track drug refill model where patients who do not have any complaints can receive drugs without seeing a clinician. Additionally, there’s the community drug refill model where a patient can obtain their medication from the community. Lastly, the client-led ART delivery model is available, whereby patients form small groups and take turns to collect and deliver their drugs. Patients who are deemed unstable are typically enrolled on the facility-based improvement modality which involves closer monitoring and management of individuals with serious illnesses and advanced HIV disease is considered [23]. In Bulisa district, approximately 47% of adult males living with HIV are enrolled on to the fast-track refill model while 41% are on the facility-based management model. A smaller number of patents, approximately 6%, are enrolled on the client-led ART delivery model, and 6% are equally distributed between facility-based groups and community drug distribution models [16].

Study design

To determine the prevalence of virological non-suppression and factors associated with it among adult males (aged 15 years and above) living with HIV in the fishing communities of Bulisa district, we conducted a cross-sectional study involving patient records and interviews.

Participants selection

Our study involved all adult males (aged 15 years and above) living with HIV and residents of the fishing communities in Bulisa district. The participants were required to have received ART treatment for at least 6 months between January 2019 and January 2020. We screened patient records from the ART registers and/ or the electronic medical records system to obtain participants’ demographics, duration on ART and place of residence. Those who met the inclusion criteria were documented on a master list using their treatment numbers and facility code.

To assess the contribution of the health facility to virological non-suppression, we conducted face-to-face interviews with the HIV clinic nurse/ clinical officer in charge at each of the six health facilities serving patients living with HIV in the fishing communities. The selection was done purposively.

Data collection and management

To obtain data for our study, we used a combination of patients’ files and primary data collection through face-to-face interviews of patients and HIV clinic charges using questionnaires and data abstraction tools. The patients’ questionnaire was structured and designed based on characteristics common among residents of fishing communities and factors previously associated with virological non-suppression from other population segments [17, 21, 24–33].

The Health worker’s questionnaire was structured and designed based on factors identified in previous qualitative and quantitative studies that focused on the quality of health care [34–41]. Data collection was carried out by trained research assistants and questionnaires were translated into Lugungu (the native language).

To minimize non-responsiveness, we ensured the completeness of the data collection tools and followed up on missed opportunities using phone calls and physical follow-ups.

Our outcome of interest was virological non-suppression, which we defined as a viral load of less than 1000 copies/ml. Only up-to-date viral load results were considered and we defined an up-to-date viral load result as a result obtained within 12 months from the time of taking off the blood sample at the time of data collection. The independent variables included characteristics salient among residents of fishing communities and those previously associated with virological non-suppression from other studies. These included: hazardous use of alcohol which was assessed using the 12 points AUDIT C tool where a score ≥4 indicated hazardous use of alcohol [42], mobility based on the frequency of movement between fishing landing sites, sexual behaviour assessed based on the number of sexual partners and condom use within 12 months. Occupation was categorised as unemployed, involved in the fishing business or other jobs [8, 20, 21, 43]. Other jobs included farming, transport and general trade, while the fishing business included active fishing and trading in fish.

Patient-related characteristics previously associated with virological non-suppression included age measured in complete years (15–25, 26–50, >50 years); marital status (single, divorced, married, cohabiting and widowed); ART regimen; line of treatment (first, second, third line); ART side effects and how they disrupted work, frequency of ART regimen (once and twice daily); adherence based on pill count by the attending clinician categorized as good (>95%), fair (80–95%), poor (<80%); fulfilment of clinical appointments; disclosure of HIV status (one option from a list of provided options); belongingness to a treatment support group; duration on ART measured in months; daily average income measured in Ugandan shillings (I USD = UGX 3500) categorised according to income level and TB diagnosis with 12 months [17, 21, 24–33]. Health facility characteristics included: the level of the health facility (HC II, HC III, HC IV and hospital levels with the HCII level being the lowest point of care and the hospital being the highest point of care within the district; perceived length of appointment intervals (long, short, neither long or short) and the perception whether HIV services were extended closer to the workplace/home; perceived quality of health education and the quality counselling. These characteristics were selected based on previous studies [34–41]. All data were captured using entry screens designed with EPInfo software and then exported into Microsoft Excel.

Data analysis

Data were analysed using Stata version 14.0 and summarized using frequencies and proportions. At the exploratory stage, we realised that 34 (<10%) participants with the outcome of interest were missing data from face-to-face interviews. These included those who had transferred out, died, were lost to follow up or were displaced due to floods along Lake Albert. Descriptive analyses were performed and results were reported using frequencies and proportions.

Age (years) was normally distributed, and therefore, mean (SD) was used as a measure of central tendency. However, the duration on ART (months) was skewed, and thus, median (IQR) was used as the measure of central tendency. The prevalence of virological non-suppression was the proportion of participants with an up-to-date viral load who had virological non-suppression.

During regression analysis, participants with missing data were excluded and a complete case analysis was considered. We used bivariable analysis to obtain the strength of association between each independent variable with virological non-suppression. Poisson regression was used to generate crude prevalence ratios (CPR) with 95% confidence intervals and p-values. Multicollinearity was assessed using variance inflation factor (VIF = 1/ (1-R2)) where R is the correlation coefficient. A VIF greater than or equal to 10 indicated serious multicollinearity [44–46]. Preference of factors used at the multivariable analysis level was based on: biological plausibility; p-value less than 0.25 at bivariable analysis [47] and uniqueness of the factor (s) to the fishing community. These criteria were used to ensure that the most relevant and significant factors were included in the analysis.

At the multivariable analysis level, backward elimination modelling was conducted using modified Poisson regression accounting for data correlation of observation at facility level to obtain adjusted prevalence ratio (adj.PR) as measures of association, with corresponding 95% confidence intervals and p values. Health workers’ responses from face-to-face interviews were analysed using frequencies, and results were summarized using tables.

Ethical consideration

We sought approval from the Research and Ethics Committee of Makerere University—School of Public Health to carry out the research. Written informed consent was obtained from all study participants, and assent was obtained from guardians of participants aged 15 to 18 years.

Results

Fig 1 shows the description of the data that were used in the study.

Out of the 829 adult males receiving HIV care in Bulisa district between January 2019 and January 2020, 462 (55.7%) fulfilled the eligibility criteria, and 413 (89.4%) of eligible participants had an up-to-date viral load.

Out of 829 participants line listed, 462 fulfilled the inclusion criteria of whom 413 had an up-to-date viral load test result. 367 were excluded because they were non-residents in the fishing communities or had been enrolled on ART for less than 6 months and were not due for viral load monitoring according to the guidelines for viral load monitoring in Uganda. The response rate for the face-to-face interviews was 379/413 (91.8%). The 34 (8.2%) participants who were not interviewed had either died, were lost from care, transferred out or displaced due to floods.

The average (SD) duration on ART (months) was comparable between participants who were interviewed [41.7 (29.9)] and those who were not interviewed [40.3(30.4)], p-value = 0.794. However, those interviewed and not interviewed differed in their mean (SD) age (years), 40 (10.7) versus 35.9 (9.3), p = 0.011.

Demographic, individual and health facility-related characteristics of the participants

Table 1 shows the demographic, individual and health facility-related characteristics of the participants.

Table 1. Demographic, individual and health facility-related characteristics of participants n = 413.

Characteristics	Frequency (n)	Percentage (%)
Age category
15 to 25	19	5.0
26 to 50	291	76.8
> 50 years	69	18.2
Marital status
Single	70	18.5
Divorced	52	13.7
Married	113	29.8
Cohabiting	133	35.1
Widowed	11	2.9
Occupation
Others jobs	90	23.8
Engaged in fishing business	267	70.5
Not employed	22	5.8
Average income
Less than UGX 10,000	226	59.6
Between 10,000–20,000	133	35.1
More than UGX 20,000	20	5.3
Up-to-date viral load
Suppression	325	78.7
Non-suppression	88	21.3
Ever changed regimen from baseline
No	107	26.0
yes	306	74.0
Line of the current regimen
First	371	89.8
Second/ third	42	10.2
Duration on ART
Less than 24 months	141	34.1
24–50 months	129	31.2
Greater than 50 months	143	34.6
Documented adherence level
Good	312	75.5
Fair	60	14.5
Poor	41	10.0
Number of sexual partners in the previous 12 months
None	21	5.6
One	174	46.3
More than one	181	48.1
Partner HIV status
Don’t know	105	30.9
Negative	90	26.5
Positive	145	42.7
Condom use
Never	157	44.2
Once in a while	165	46.5
Every time	33	9.3
Missed taking ART in the last 12 months
No	150	40.0
yes	228	60.0
HIV disclosure
No one	31	8.2
Any other family member	131	34.7
Workmate/ friend/neighbour	37	9.8
Wife	179	47.4
Hazardous use of alcohol
Non-hazardous use	261	63.2
Hazardous use	152	36.8
Frequency of moving between fish landing sites in a year
Never	156	41.5
Once or twice	149	39.6
More than twice	71	18.9
ARVs and stability at work
No disruption	271	71.9
Disrupts work	106	28.1
Permanent resident of Bulisa
No	82	21.7
Yes	296	78.2
Participant’s facility level for treatment
Health Centre II level	24	5.81
Health Centre III level	254	61.50
Health Centre IV level	101	24.46
Hospital level	34	8.23
Belonging to a treatment support group
No	255	67.8
Yes	121	32.2
Assessment of Confidentiality at the health facility
No Confidentiality	98	26.0
Some confidentiality	93	24.7
Maximum confidentiality	186	49.3
Quality of health education talks
Do not happen at all	19	5.0
Less interactive and rushed	67	17.7
Interactive	293	77.3
Perceived length of clinic appointments
Long	49	12.9
Neither long nor Short	240	63.3
Short	90	23.8
Viral load turnaround time
Did not know	34	9.0
1 to 2 months	207	55.8
More than 2 months	20	5.4
Less than 1 month	110	29.7
HIV services extended near work/home
Yes	210	55.6
No	168	44.4
Current ART regimen
TDF/3TC/EFV	57	15.4
TDF/3TC/DTG	281	74.1
TDF/3TC/ATV/r	16	4.2
AZT/3TC/NVP	9	2.4
Other second-line regimens	13	3.4
Other first-line regimens	3	0.8
Diagnosed with TB within 12 months
No	356	93.9
Yes	23	6.1

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The mean (SD) age was 40 (10.7) years and the median (IQR) duration on ART was 37 (17–57) months. The proportion of participants with virological non-suppression was 21.3%. Three-quarters of the participants were taking TDF/3TC/DTG as their current ART regimen and more than two-thirds were engaged in the fishing business. Only 5%of participants reported earning more than UGX 20,000 (about 6 US dollars) per day on average.

About one-third of the participants reported having had 2 to 3 sexual partners in the previous 12 months. One-third reported never knowing their partner’s HIV status. Half of the participants had partners who were living with HIV. About one-third were engaged in hazardous alcohol use and one-half of them moved between fish landing sites at least once in the past 12 months. More than three-quarters of the participants were permanent residents of Bulisa district and about two-thirds sought their treatment from mid-level health facilities (either HC III or HC IV).

The prevalence of virological non-suppression amongst adult males (≥15 years) living with HIV in the fishing communities of Bulisa was 22.2% (95% CI: 18% -26%).

Factors associated with virological non-suppression

Table 2 summarises the results from the bivariable and multivariable analyses.

Table 2. Bivariable and multivariable analysis for determining the factors associated with virological non-suppression amongst adult males living with HIV in the fishing communities of Bulisa district.

Factor	Virological suppression status		Bivariable analysis n = 379		Multivariable analysis n = 372
Factor	Suppressed n (%)	Non-suppressed n (%)	Crude PR (95%CI)	P-value	Adjusted PR (95%CI)	P-value
Age category
Greater than 50 years	60(86.96)	9(13.04)
26 to 50	223(76.63)	68(23.37)	1.79(0.89–3.59)	0.100	1.63(1.14–2.32)	0.007
15 to 25	12(63.16)	7(36.84)	2.82(1.05–7.58)	0.039	3.26(1.42–7.48)	0.005
Occupation
Others jobs	72(80)	18(20)
Fishing/trading in fish	207(77.5)	60(22.47)	1.1(0.66–1.92)	0.665	1.09(0.84–1.41)	0.699
Not employed	16(72.73)	6(27.27)	1.3(0.54–3.44)	0.511	1.31(1.15–1.50)	<0.001
Daily average income
> UGX 20,000	18(90.0)	2(10.0)
< UGX 10,000	167(73.89)	59(26.11)	2.6(0.64–10.68)	0.182
UGX 10,000–20,000	110(82.71)	23(17.29)	1.73(0.41–7.33)	0.457
Belonging to a treatment group
Yes	95(78.51)	26(21.49)
No	198(77.65)	57(22.35)	1.04(0.65–1.65)	0.868
HIV disclosure
No one	23(74.19)	8(25.81)
Other family members other than the wife	95(72.52)	36(27.48)	1.06(0.49–2.30)	0.872
Workmate/ friend/neighbour	35(94.59)	2(5.41)	0.21(0.04–0.99)	0.048
Wife	141(78.77)	38(21.23)	0.82(0.38–1.76)	0.616
Hazardous use of alcohol
Non-hazardous use	179(78.85)	48(21.15)
Hazardous use	116(76.32)	36(23.68)	1.12(0.73–1.73)	0.607	1.32(1.14–1.54)	<0.001
Frequency of moving between fish landing sites
More than twice a year	56(78.87)	15(21.13)
Once or twice a year	116(77.85)	33(22.15)	1.04(0.57–1.93)	0.880	1.12(0.88–1.44)	0.344
Never	122(78.21)	34(21.79)	1.03(0.56–1.89)	0.920	1.27(1.03–1.56)	0.020
ARV disruption towards work
No disruption	218(80.44)	53(19.56)
Disrupts work	75(70.75)	31(29.25)	1.5(0.96–2.33)	0.075
Missed taking ART in the last 12 months
No	126(84)	24(16)
Yes	169(74.12)	59(25.88)	1.6(1.0–2.6)	0.047
Number of sexual partners in previous 12 months
None	17(81)	4(19)
Only one	132(75.9)	42(24.1)	1.27(0.45 3.53)	0.651	1.50(0.62–3.64)	0.374
More than one	144(79.6)	37(20.4)	1.07(0.38–3.01)	0.893	1.03(0.45–2.36)	0.946
Marital status
Single	51(72.86)	19(27.14)
Divorced	41(78.85)	11(21.15)	0.78(0.37–1.64)	0.511
Married	89(78.76)	24(21.24)	0.78(0.43–1.43)	0.424
Cohabiting	106(79.7)	27(20.3)	0.75(0.41–1.35)	0.332
Widowed	8(72.73)	3(27.27)	1.00(0.30–3.4)	0.994
Line of the current regimen
First	284(83.78)	55(16.22)
Second/ third	11(27.50)	29(72.50)	4.5(2.85–7)	<0.001
Participant’s facility of treatment
Health Centre II level	16(66.7)	8(33.3)
Health centre III	207(81.5)	47(18.5)	0.56(0.26–1.17)	0.124	0.62 (0.57–0.68)	<0.001
Health centre IV	78(77.23)	23(22.77)	0.68(0.3–1.53)	0.353	1.03(0.91–1.16)	0.659
Hospital level	24(70.59)	10(29.41)	0.88(0.35–2.23)	0.792	1.20(1.03–1.40)	0.019
Diagnosed with TB in last 12 months
No	281(78.93)	75(21.07)
Yes	14(60.87)	9(39.13)	1.86(1.13–2.63)	<0.001	1.98(1.39–2.82)	<0.001
HIV services extended close to workplace/ home
Yes	170(81)	40(19)
No	125(74.4)	43(25.6)	1.34(0.87 2.07)	0.179	1.38(1.07–1.77)	0.012

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At bivariable analysis. Age between 15 to 25 years was associated with a higher prevalence of virological non-suppression (CPR = 2.82, 95% CI = 1.05–7.58) compared to participants greater than 50 years. The prevalence of virological non-suppression amongst participants who disclosed their HIV status to either workmate, friend, or neighbour was 0.21 times (CPR = 0.21, 95% CI = 0.04–0.99) compared to the prevalence of virological non-suppression amongst participants who never disclosed their HIV status. The prevalence of virological non-suppression amongst participants diagnosed with TB within 12 months before the study was 1.86 times (CPR = 1.85, 95% CI = 1.13–2.63) compared to the prevalence of virological non-suppression among participants who were never diagnosed with TB. Other results are summarised in Table 2.

At multivariable analysis. Results for factors salient among patients living with HIV in the fishing communities are described below. Other results are summarised in Table 2.

The prevalence of virological non-suppression among unemployed participants was 1.31 times (adj.PR = 1.31, 95%CI: 1.15–1.50) the prevalence of virological non-suppression amongst participants that were engaged in other jobs other than fishing. The prevalence of virological non-suppression amongst adult males who engaged in hazardous use of alcohol was 1.32 times (adj.PR = 1.32, 95%CI: 1.13–1.54) the prevalence of virological non-suppression amongst participants who never engaged in hazardous use of alcohol. The prevalence of virological non-suppression amongst participants who solely operated at one fishing landing site was 1.27 times (adj.PR = 1.27, 95%CI: 1.03–1.56) compared to the prevalence of virological non-suppression amongst participants who moved more than twice annually between fishing landing sites. The prevalence of virological non-suppression amongst participants who reported that HIV treatment services were not close to their workplaces was 1.38 times (adj.PR = 1.38, 95%CI: 1.07–1.77) the prevalence of virological non-suppression amongst participants that reported that HIV treatment services were extended closer to their workplaces. The prevalence of virological non-suppression amongst participants diagnosed with TB within 12 months before the study was 1.98 times (adj.PR = 1.98, 95%CI: 1.39–2.82) compared to the prevalence of virological non-suppression amongst participants that were not diagnosed with TB within the same period.

The role of health facilities towards virological non-suppression amongst adult males living with HIV in the fishing communities of Bulisa district

Table 3 shows the results from face-to-face interviews among health workers that focused on the preparedness of the health facilities to serve people living with HIV and the quality of care offered to them.

Table 3. Preparedness of health workers to serve people living with HIV and quality of services offered to people living with HIV.

Variable	Freq of response	Type of response	Response per Health Facility
Variable	Freq of response	Type of response	Butiaba	Bugoigo	Biiso	Bulisa Hosp	Bulisa HC	Kigwera
whether there are days the HIV clinic remains unattended to by clinicians	6	Yes		X
	6	No	X		X	X	X	X
Whether there is a schedule for health education talks	6	Yes	X	X			X	X
Whether there is a schedule for health education talks	6	No			X	X
Availability of peer leaders residing within fishing communities at the HIV clinic	6	Yes	X	X			X	X
	6	No			X	X
whether peer leaders have been trained in supporting fellow positive patients	4	Yes	X	X			X	X
presence of staff designated to provide adherence counselling	6	Yes	X		X	X	X	X
	6	No		X
whether staff providing counselling have been trained in counselling skills	5	Yes			X		X	X
	5	No	X			X
Whether the facility staff has received training in the latest HIV guidelines	6	Yes	X	X	X	X	X	X
Frequency of refresher sessions in HIV management	6	Annually			X
		Bi-annually		X
		Quarterly	X			X
		monthly					X	X
Whether some patients have missed having their viral loads done timely	6	Yes	X	X	X	X	X
	6	No						X
Reasons for missing timely assessment of viral load	6	Missing appointments	X		X	X	X
		Missing results		X
		Stockouts			X
whether there are communication channels for patients to consult	6	Yes	X	X	X	X	X	X
whether there are mechanisms to extend services nearer to patients	6	Yes	X	X	X	X	X	X
Mechanisms used to extend services close to the patients	13	CCLADS	X		X		X
		CDDPs	X		X	X	X	X
		Home refills	X	X		X	X	X
Average waiting time	6	< 30 minutes				X
		30–60 minutes			X			X
		1–2 hours	X	X			X
Frequency of assessing feedback about service delivery from patients	6	Quarterly			X
		Never		X			X
		Monthly	X			X		X
Availability of a quality improvement team to improve service delivery among patients	6	Yes	X	X	X	X	X	X
The method used to assess adherence	8	Health worker judgment	X		X		X
		Daily physical counts		X		X	X	X
		Missing appointments			X

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At five out of six health facilities, patients were routinely attended to by a clinician except for Bugoigo HC III where an experienced HIV peer leader occasionally attended to patients. Four out of six facilities offered scheduled health education talks for patients and had peers resident within the fishing communities trained to support fellow patients. Five of the six facilities had staff designated to provide adherence counselling however only three had received training in counselling skills. The main method for assessing adherence at all facilities was daily physical counting of pill balances. All facilities received training in the national HIV treatment and prevention guidelines. Patients at five out of six facilities were served through community drug distribution points (CDDPs) and home refills, whereas three facilities also used CCLADs (community client-led ART delivery). Only one facility had a waiting time of no more than 30 minutes. Five of the six health facilities assessed feedback from patients quarterly. All facilities had quality improvement committees aimed at improving the quality of care among patients.

Discussion and conclusion

Our study aimed to evaluate the prevalence of virological non-suppression and the associated factors among adult males living with HIV in the fishing communities of Bulisa district. Our findings revealed that the prevalence of virological non-suppression was remarkably high (21.3%), which was twice the UNAIDS threshold of 10%. Furthermore, we noted that this figure was considerably higher than the prevalence of non-suppression observed in other fisherfolk settings (9%) [48] as well as among the general male population living with HIV in Uganda (13%) [17]. These results suggest that adult males living with HIV in fishing communities could be contributing significantly to the burden of virological non-suppression. This finding may have significant implications for HIV control and prevention programs in these communities, as targeted strategies could be developed to address the identified risk factors and improve virological suppression rates among HIV-positive individuals living in fishing communities.

According to the study’s findings, there is a higher likelihood of virological non-suppression among individuals with hazardous alcohol use. Alcohol dependence has been previously associated with poor adherence to ART [21] which in turn leads to an increased risk for virological non-suppression [17]. Therefore, addressing the challenge of hazardous alcohol use could be an effective strategy to improve virological outcomes among people living with HIV.

Results from this study further revealed that individuals under the age of 50 had a higher likelihood of experiencing virological non-suppression. There was also a correlation demonstrated in the study, indicating that the odds of non-suppression increased with decreasing age. Previous studies that focused on the relationship between age and adherence, a major predictor of virological non-suppression, suggested that older individuals may exhibit better adherence to antiretroviral medication [49, 50]. Better adherence with increasing age could potentially explain the lower likelihood of virological non-suppression. Therefore, interventions to improve medication adherence among younger individuals may be necessary to enhance their virological outcomes and achieve better overall health.

This study found that being unemployed was associated with higher odds of experiencing virological non-suppression. These findings are consistent with previous studies that have also identified a link between unemployment and poorer health outcomes like non-adherence to ART and virological non-suppression [51, 52]. Therefore, interventions targeting employment and income generation may be necessary to improve access to health care and treatment adherence, hence the reduced risk of virological non-suppression.

According to this study, remaining stationed at a single fishing site for an entire year as compared to migrating between fishing landing sites in search of better yield from fishing was found to have a slight association with virological non-suppression. This finding contrasts with previous studies which linked extensive migration with virological non-suppression [53]. In fishing communities, people tend to move between fish landing sites based on fluctuations in fish quantities [8]. Individuals who did not change fishing landing sites may have been among the unemployed, who were found to have higher odds of virological non-suppression. Profiling of adult males at fish landing sites in line with their mobility patterns could help in redirecting efforts to address the challenge of virological non suppression.

This study found that a lack of nearby HIV treatment services was associated with higher odds of virological non-suppression. This finding highlights the importance of providing convenient access to treatment services among fishing communities where mobility between work sites certainly poses a challenge to treatment access. On the positive side, all six health facilities in the fishing communities had mechanisms in place to extend HIV treatment services closer to patients that included CDDPs, CCLADs and direct drug delivery [23]. In contrast, some studies conducted in non-fishing settings did not find any association between the geospatial patterns of treatment sites, differentiation of treatment, and virological non-suppression [54, 55]. Extending services closer to patients could help in reducing the long time spent at some facilities which manifested as a long waiting time of more than 30 minutes at some facilities. Such long waiting times are likely to discourage patients from seeking regular care from the facilities, resulting in poor adherence and poor treatment outcomes like virological non-suppression. Therefore, it’s important to consider the working culture of the patients when designing HIV treatment programs to optimise health outcomes.

This study revealed that having a history of TB disease within the past 12 months was associated with greater chances of virological non-suppression, consistent with an earlier nationwide study among PLHIV in Uganda [17]. This may be due to the immunosuppressive effects of TB on the body [56], which impedes individuals from achieving viral suppression. This finding highlights the importance of screening for TB and providing appropriate treatment to improve the overall health outcomes of people living with HIV.

This study also found that seeking HIV care at the hospital level was associated with greater odds of virological non-suppression. Conversely, receiving treatment from mid-level (HC III and IV) facilities was associated with lower odds of virological non-suppression compared to the lowest-level health facility. This suggests that the referral system in the district may be effective, as patients with advanced HIV disease with a higher likelihood of virological non-suppression are referred from lower levels to facilities with greater resources to provide comprehensive care. These findings highlight the importance of providing appropriate levels of care for patients based on their clinical needs and the role of efficient referral systems in optimizing health outcomes for people living with HIV.

Contrary to other studies, we did not find any association between sexual behaviour [53] and virologically non-suppression.

Results from the health worker interviews showed that the majority of facilities had trained health workers attending to patients. Training could reduce the impact of virological non-suppression as it necessitates informed decisions and builds the confidence of health workers. Previous studies also indicated that health worker training has an impact on patient outcomes [57].

A strength of our study was the use of interviews to supplement the information obtained from secondary data, which enabled the exploration of unique determinants of virological non-suppression not routinely captured among HIV-positive patients seeking care. Additionally, adjusting for the clustering of variables by health facility level during multivariable analysis allowed us to account for data correlation of observation at facility level.

However, some limitations also need to be noted. Some questions required participants to recall key events, which could have introduced an element of recall bias [58]. Social desirability bias could have influenced some participants to respond to questions assessing sensitive topics, such as sexual behaviour, with reservations. Missingness of some secondary data may have led to selection bias. For example, interviewed participants were older than the non-interviewed participants which could have biased the final results since age was identified as a key predictor of virological suppression [59]. Furthermore, the failure to collect information on the models of care used in the health facilities may have resulted in the missing of valuable information that could inform treatment differentiation policies for people living with HIV in fishing communities. Whereas the study assessed disclosure and partner HIV status, it missed out on assessing these with focus on participants that had multiple partners.

In conclusion, our study found that the prevalence of virological non-suppression among people living with HIV along the shores of Lake Albert is alarmingly high, at twice the UNAIDS threshold of 10%. Key determinants of virological non-suppression in fishing communities include hazardous use of alcohol, unemployment, age younger than 50 years, and distant HIV treatment services. We, therefore, recommend that the responsible authorities establish HIV medicine refill points at fish landing sites to extend access to HIV treatment services. Additionally, targeted interventions should be developed to address hazardous alcohol use and unemployment. By implementing these recommendations, we can work towards reducing the prevalence of virological non-suppression and improving health outcomes for people living with HIV along the shores of Lake Albert and in fishing communities elsewhere.

Supporting information

S1 File. Research fund scholarship.

(PDF)

Click here for additional data file.^{(1.9MB, pdf)}

S2 File. Location of Bulisa district in Uganda.

(PDF)

Click here for additional data file.^{(152.6KB, pdf)}

S3 File. Coded sheet.

(XLSX)

Click here for additional data file.^{(171.3KB, xlsx)}

S4 File. Code definitions.

(PDF)

Click here for additional data file.^{(239.2KB, pdf)}

S5 File. Consent and ascent forms—English version.

(PDF)

Click here for additional data file.^{(89.2KB, pdf)}

S6 File. Consent and ascent form translated version.

(PDF)

Click here for additional data file.^{(133.6KB, pdf)}

S7 File. Patient questionnaire–English version.

(PDF)

Click here for additional data file.^{(161.5KB, pdf)}

S8 File. Patients questionnaire translated version.

(PDF)

Click here for additional data file.^{(109.7KB, pdf)}

S9 File. Data abstraction tool.

(PDF)

Click here for additional data file.^{(92.2KB, pdf)}

S10 File. Health workers questionnaire.

(PDF)

Click here for additional data file.^{(99.9KB, pdf)}

S11 File. Ethical approval.

(PDF)

Click here for additional data file.^{(1.4MB, pdf)}

S12 File. Stata output for the final model.

(TXT)

Click here for additional data file.^{(3.5KB, txt)}

S13 File

(DOCX)

Click here for additional data file.^{(23.3KB, docx)}

Acknowledgments

The authors of the research manuscript express their gratitude to several parties for their contributions to the study. Specifically, they acknowledge the School of Public Health at Makerere University for providing the platform to conduct the study, the capacity-building department at the Infectious Diseases Institute for their mentorship throughout the research process, the people of Bulisa district for their support during data collection and cooperation throughout the study, and the author’s family members for their moral, social, and financial support during the development of the manuscript.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Funding Statement

SI was partly funded by the Gilead foundation. BC was partly funded by the Fogarty International Centre, National Institute of Health (grant# 2D43TW009771-06 “HIV and co-infections in Uganda"). Other funds were mobilised from personal savings. The management of people living with HIV was partly supported by the President's Emergency Plan for AIDS Relief through the United States Centres for Disease Control (CDC) and Prevention and the terms of a cooperative agreement number NU2GGH001294-03-05". There was no additional external funding received for this study. The funders had no role in study design, data collection and analysis, the decision to publish, or the preparation of the manuscript.

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BC was partly funded by the Fogarty International Centre, National Institute of Health (grant# 2D43TW009771-06 “HIV and co-infections in Uganda")

The management of people living with HIV was partly supported by the Presidents Emergency Plan for AIDS Relief through the United States Centers for Disease Control (CDC) and Prevention and the terms of cooperative agreement number NU2GGH001294-03-05"

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BC was partly funded by the Fogarty International Centre, National Institute of Health (grant# 2D43TW009771-06 “HIV and co-infections in Uganda")

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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: Partly

Reviewer #2: Yes

**********

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

Reviewer #1: No

Reviewer #2: I Don't Know

**********

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

**********

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: No

Reviewer #2: Yes

**********

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: Summary: This manuscript summarizes findings of an interesting analysis of predictors of viral non-suppression among men in fishing communities in Uganda, a high-risk population.

Major comments:

1. The outcome of interest of viral non-suppression should be defined. It is not clear what viral load threshold is being used in this outcome determination (i.e. not detected, 50 copies/mL, 1,000 copies/mL).

2. The multivariable model includes 15 predictors, many of which are multi-level categorical variables. Given that only 84 participants had non-suppression, there may be a risk of having overfit the model with too many predictors. The authors should provide justification for this or reconsider the variables that are included in the final model.

3. Would consider reframing conclusions to be more generalizable to a regional or global audience, rather than specific implications for the district health office for the area in which the study took place.

Minor comments:

1. The authors should use person-centered language in describing HIV status. Specifically, rather than referring to HIV positive adults, the authors should use the term “people with HIV.”

2. Methods – Study design: Further detail on the participant and healthworker interview regarding the health facilities would be helpful. Specifically, were interviews standardized by questionnaire, or were they open-ended and then coded using qualitative methodology? These methods and the factors explored should be more clearly explained.

3. Methods – Data collection: Not all factors explored in the regression analyses are explained in the methods section. Authors should note if adherence data are based on self-report, clinician assessment, or pill count. It would be also important to understand at what time point the predictors of interest of clinic and ART regimen are related to. For example, if ART regimen is listed as second-line, is that because a second-line regimen was prescribed at the visit when an elevated viral load was acted on, or was the viral load collected while on a second-line regimen? The same would be true for clinic, given that patients with virologic failure may be referred to higher level health centers.

4. Methods – Data analysis: It seems that a complete case analysis strategy was employed, rather than imputing missing data. If that is correct, this should be stated.

5. Results – When referring to 829 men in HIV care in Bulisa district, is this fully inclusive of all patients at all health facilities in the district, or only a subset? It would also be helpful to understand why 367 were excluded (which inclusion criteria were not met?).

6. Discussion – The authors note that longer duration between appointments was beneficial, but these data are not clearly located in the results table. Does this refer to the predictor labeled “clinical appointments and work”? The wording of the response options could be confused with referring to the length of the clinical visit itself, rather than the time interval between visits.

7. Discussion – The authors recommend the establishment of savings groups in fishing communities to improve treatment adherence. However, this isn’t discussed elsewhere in this analysis/manuscript.

8. Figure 1 – It would be helpful to be consistent with inclusion of percentages and numbers of participants.

9. Results – The authors should explain why age and regimen change were not included in the multivariable model.

10. The manuscript should be carefully reviewed and edited to correct typos, sentence structure errors, and spelling errors throughout.

Reviewer #2: Review of “Virological non-suppression among adult males attending HIV care services in the fishing communities in Bulisa district, Uganda”

Summary of review

Thank you for the opportunity to review this paper that outlined HIV virologic non-suppression and covariates. This is an important piece of work that adds to understanding one of the more vulnerable groups in Uganda. Overall, the manuscript was well-written. I have some specific points of clarification mainly in the Methods Section. Additionally, the Discussion section could be further expanded to better put the current findings into the broader research context.

Additional questions and suggestions are offered by manuscript section:

Overall

1. Please use people first language, for example instead of writing HIV positive, please change to people with HIV or men with HIV.

Introduction

1. It would be helpful for readers if you separated the one big Introduction paragraph into several smaller paragraphs.

2. The authors state that the HIV prevalence in the Bulisa district is 5.1%, but this is lower than the 2020 country-wide prevalence of 5.4% according to UNAIDS, please double-check the data and sources. It would be helpful to include years and sources in the text when feasible given that in this one sentence there appears to be comparisons among three different sources. It would also be helpful for the reader if you compared the Bulisa district HIV prevalence to the overall country-wide HIV prevalence for context.

“In a study carried out in Uganda using national programme data in 2017, the prevalence of nonsuppression among males was 13% [15]. However, in Bulisa district, with 14.2% of the population engaged in fishing business [16] and HIV prevalence of 5.1% [17], the

prevalence of virological non-suppression amongst all adult males for the same period was much higher at 20%.”

Methods

1. Under “study setting”, when describing the different management pathways for different patients, I would use the formal terminology – such as, “differentiated care models”.

2. Under “study setting”, please define facility based improved management.

3. Under “study design”, the first sentence is likely missing a word, “We conducted a cross-sectional *** utilising patients records and interviews to determine the prevalence of virological non-suppression and factors associated with virological nonsuppression among adult males, resident in the fishing communities of Bulisa district.”

4. Under “study design” please clarify whether interviews were also done with MWH participants.

5. Under “participant selection”, the following sentence is likely missing a word, “One health worker per facility was purposively selected for the face to *** interviews.”

6. Under “data collection and management”, please dscribe in more detail how adherence was categorized – was this self-report, a questionnaire, etc.?

7. Under “data analysis”, what was the definition of virologic non-suppression? What was the virologic threshold? What was the definition of “up to date” viral load – what was the viral load timing cut-off point for study inclusion?

8. Under “ethical considerations”, please also include if Uganda National Council of Science and Technology approval was obtained.

9. Under “data analysis”, please explain the rationale for when the authors chose to use means vs. medians. I would also outline that proportions and frequencies were described.

10. It would be helpful for the reader for a more detailed explanation of what the authors mean by landing sites – are these sites still in the same fishing villages – are they farther away? What are the implications of moving between different landing sites?

11. Please describe in greater details the questionnaire procedures with study staff. How were staff chosen to interview? How was the questionnaire designed?

Results

1. Please clarify over what amount of time participants reported number of sexual partners.

2. Under “Factors associated with virological non-suppression”, it would be more clear when comparing VL suppression in relation to income, if you compared the lower wage participants as baseline to the higher wage participants (so that your PR is >1 – similar to the other variables you have discussed). I would recommend this for any PR that is reported as <1 in the results.

Discussion

1. Paragraph 2, the authors state that men earning more money were less likely to have virological suppression. This appears to be the opposite of the data presented.

3. I would recommend developing the first five or so paragraphs discussing the pertinent covariates of non-virologic suppression. For each point that you bring up, please expand the comparison to the literature and the implications for your specific research site.

4. An additional limitation could be the lack of back translation from the local language to English if this was not done.

Figures/Tables

1. Figure 1 has typos, please edit – ex: “Dint meet eligibility criteria 367”

**********

6. 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 #1: No

Reviewer #2: No

**********

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PLoS One. 2023 Oct 19;18(10):e0293057. doi: 10.1371/journal.pone.0293057.r002

Author response to Decision Letter 0

15 Feb 2023

Journal Requirements:

>>>>>>This has been included under the methodology section.

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.

>>>>>>> This has been rectified.

4. Thank you for stating in your Funding Statement: "SI was partly funded by the Gilead foundation

BC was partly funded by the Fogarty International Centre, National Institute of Health (grant# 2D43TW009771-06 “HIV and co-infections in Uganda")

>>>>>> Funding statement amended

5. Thank you for stating the following financial disclosure: "SI was partly funded by the Gilead foundation

BC was partly funded by the Fogarty International Centre, National Institute of Health (grant# 2D43TW009771-06 “HIV and co-infections in Uganda")

>>>>>>>>>>>This has been rectified in the cover letter.

Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf.

>>>>>>>> This has been included in the cover letter.

>>>>>>> These have been included.

Reviewer #1: Summary: This manuscript summarizes findings of an interesting analysis of predictors of viral non-suppression among men in fishing communities in Uganda, a high-risk population.

Major comments: Comment well appreciated.

>>>>>>>Major edits were done following this comment. 88 participants had virological non-suppression. To avoid the risk of overfitting the model as guided, the 1 in 10 to rule was used and only 9 independent variables were used. (8.8 rounded off to 9). Several variables in the previous model were dropped and some were replaced in the final model.

>>>>>> Conclusions and recommendations have been reframed as guided.

Minor comments:

1. The authors should use person-centered language in describing HIV status. Specifically, rather than referring to HIV positive adults, the authors should use the term “people with HIV.”

>>>>>>> This was addressed throughout the whole document.

>>>>>>> Exploration on the factors considered was done.

>>>>>>> Elaboration on the interviewing process included.

>>>>>> All factors explored in the regression analysis have been explained in the methodology section A viral load within a period of 12 months from the time of sample collection was compiled for this study. The relationship of this viral load with the duration on second line regimen was compiled for this study. So, it is hard to tell whether a high viral load was related to deciding to switch to second line or it applied to a patient who had been on second line for atleast 6 month.

This is one of the indicators that were replaced while reducing the number of variables at multivariable analysis

4. Methods – Data analysis: It seems that a complete case analysis strategy was employed, rather than imputing missing data. If that is correct, this should be stated.

>>>>>> Case based analysis was used

>>>>> Inclusion criteria was included in the consort diagram.

>>>>>> Clinical appointments were assessed as long or short according to the participants perception.

Time interval between visits is much better as suggested for consideration under discussion.

>>>>>>> Saving groups had been suggested as a way to boost the income of participants since average income had an association with virological non-suppression. However, the guidance on the wording is noted for consideration.

8. Figure 1 – It would be helpful to be consistent with inclusion of percentages and numbers of participants. >>>>> All percentages have been included in the table

9. Results – The authors should explain why age and regimen change were not included in the multivariable model.

>>>>> Age has been included in the revised model as one of the universal confounders.

>>>>> At Multivariable analysis, inclusion of variables was mainly determined by the uniqueness in relation to fishing communities. Variables with a p-value less than 0.25 were included and eliminated until a better model was obtained. Regimen change was one of them. Multicollinearity is also another reason why it was eliminated.

10. The manuscript should be carefully reviewed and edited to correct typos, sentence structure errors, and spelling errors throughout.

Reviewer #2: Review of “Virological non-suppression among adult males attending HIV care services in the fishing communities in Bulisa district, Uganda”

Summary of review

Additional questions and suggestions are offered by manuscript section:

Overall

1. Please use people first language, for example instead of writing HIV positive, please change to people with HIV or men with HIV.

This was addressed throughout the whole document.

Introduction

1. It would be helpful for readers if you separated the one big Introduction paragraph into several smaller paragraphs. >>>>>> This was done

>>>>>> This was rectified

“In a study carried out in Uganda using national programme data in 2017, the prevalence of non-suppression among males was 13% [15]. However, in Bulisa district, with 14.2% of the population engaged in fishing business [16] and HIV prevalence of 5.1% [17], the prevalence of virological non-suppression amongst all adult males for the same period was much higher at 20%.”

>>>>> This was rectified

Methods

1. Under “study setting”, when describing the different management pathways for different patients, I would use the formal terminology – such as, “differentiated care models”. >>>> Adopted as guided

2. Under “study setting”, please define facility based improved management. >>>> This was defined

>>>>> This was rectified

4. Under “study design” please clarify whether interviews were also done with MWH participants.

>>>> MWH not clear to me. But interview section was rectified

5. Under “participant selection”, the following sentence is likely missing a word, “One health worker per facility was purposively selected for the face to *** interviews.” >>>> This was rectified

6. Under “data collection and management”, please dscribe in more detail how adherence was categorized – was this self-report, a questionnaire, etc.? >>>> Categorization of adherence was included

8. Under “ethical considerations”, please also include if Uganda National Council of Science and Technology approval was obtained. >>>>> This study was done as part of the fulfilments required for the awards of Master’s degree in Public health at Makerere University.

The university/ IRB has the responsibility to submit a list of student’s researches to UNCST. My letter for approval is attached here.

9. Under “data analysis”, please explain the rationale for when the authors chose to use means vs. medians. I would also outline that proportions and frequencies were described.

>>>>> Mean (SD) was used as a measure of central tendency for age since this had a normal distribution. Duration on ART had a skewed distribution hence median (IQR) was used as the measure of central tendency.

The phrase “landing sites” has been edited to “fish landing sites”

11. Please describe in greater details the questionnaire procedures with study staff. How were staff chosen to interview? How was the questionnaire designed?

>>>This has been addressed under study design and participants selection.

Results

1. Please clarify over what amount of time participants reported number of sexual partners. >>>> This has been addressed

>>>> This was considered for all other variables that has PR < 1 included at multivariable analysis.

Discussion

1. Paragraph 2, the authors state that men earning more money were less likely to have virological suppression. This appears to be the opposite of the data presented.

>>>> Average income is one of the variables that were dropped when cutting down the number of variables from 15 to 9 at multivariable analysis. Justification for cutting down the variables was considered to avoid the risk of over fitting the model following the guidance from reviewer one but also from the reviewed literature.

2. Consider “social desirability bias” to explain this concept – “Information bias could have also resulted from desirability by some participants responding to some questions like those assessing sexual behavior with reservations.” >>> Indeed, social desirability explains the responses to sexual behavior questions better as guided. This has been considered in the manuscript.

4. An additional limitation could be the lack of back translation from the local language to English if this was not done.

>>>>> This has been considered.

Figures/Tables

1. Figure 1 has typos, please edit – ex: “Dint meet eligibility criteria 367” >>>> Typos have been revised in the entire document

6. 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.

No objection

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file.^{(1.3MB, docx)}

PLoS One. doi: 10.1371/journal.pone.0293057.r003

Decision Letter 1

Joel Msafiri Francis

11 Apr 2023

PONE-D-21-31809R1Virological non-suppression among adult males attending HIV care services in the fishing communities in Bulisa district, Uganda.PLOS ONE

Dear Dr. Senteza,

Please submit your revised manuscript by May 26 2023 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'.

We look forward to receiving your revised manuscript.

Kind regards,

Joel Msafiri Francis, MD, MS, PhD

Academic Editor

PLOS ONE

Journal Requirements:

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.

[Note: HTML markup is below. Please do not edit.]

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

**********

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

Reviewer #2: Yes

**********

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

Reviewer #2: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #2: Summary of review

The authors have done a commendable job incorporating the previous recommendations. I have additional recommendations to further strengthen the manuscript outlined below.

Overall

1. There continue to be typos and English grammar problems throughout the manuscript.

2. Please use precise writing throughout your manuscript – several examples of imprecision are outlined below in the Intro paragraph, “which district”, “prevalence of what”?

3. I’m struggling to understand how the health center survey fits in with the virologic suppression analysis. A starting point would be to describe the clinic/hospital level of each health center you surveyed. Is there a way to tie in the six health centers into the multivariable analysis of viral suppression?

Introduction

1. Page 3, Para 2 - This sentence is grammatically incorrect – please revise, “This mix of potential drivers of HIV transmission rises the need to contextualize more efficient methods of HIV prevention.

2. Page 3, Para 2 – “Basing on the assertion that undetectable viral load translates into no transmission of HIV (undetectable = untransmittable) [9-12], understanding the determinants of virological suppression could help in reducing the incidence of HIV in fishing communities [13, 14].” Change basing to based.

3. Overall, Paragraph 3 is confusing. I am not understanding the comparisons or what we are always discussing due to imprecise language.

4. Page 3, Para 3 – What are you comparing – what is this higher than? “The prevalence of HIV amongst the residents of the fishing communities is not known but is likely to be higher given the observed prevalence of HIV in the fishing communities along Lake Victoria[5].”

5. Page 3, Para 3 – clarify which district, “However, the general prevalence of HIV in the district based on 2020 program data in DHIS-2 was lower at 5.1% [16] as compared to the national prevalence of 6.2% reported in the UPHIA report of 2017 [6].”

6. Page 3, Para 3 – These percentages of non-suppression are among men with HIV (MWH) correct? As written, you state that this percentage is among all adult men. “In a study carried out in Uganda using national programme data in 2017, the prevalence of non-suppression among males was 13%. However, in Bulisa district, the prevalence of virological non-suppression amongst all adult males for the same period was much higher at 20% [17].”

7. This doesn’t make sense – you’re comparing the same thing, “Whereas there is the availability of program data about virological non-suppression for the districts with fishing communities in Uganda, little is known about the burden of virological non-suppression among the male-dominated fishing communities.

Methods

1. Page 4, last sentence of “Study Setting” – what is the difference between facility-based management and facility-based improved management model, “40% on facility-based management, 6% on client-led ART delivery and 3% on the facility based improved management model.”

2. Under “Participant selection”, Is the “in charge” a person? Can you provide more detail (ie the nurse in charge)? “The HIV clinic in charge at each of the six health facilities serving patients living with HIV in the fishing communities was purposively selected for the face-to-face interviews to assess the contribution of the health facility to virological non-suppression.”

3. Page 6, “Data Collection Management”, I think you might mean 12 months from this study? As written it sounds like you mean the viral load was run up to 12 months after that blood vial’s collection. “An up-to-date viral load result was defined as a viral load result within 12 months from the time of taking off the blood sample”

4. Page 7, was pill count adherence based on participant report or did research staff count participant pills?

Results

1. Page 10, It would be helpful to clarify the corresponding age with each group. “However, they differed in their mean (SD) age (years), 40 (10.7) versus 35.9 (9.3), p=0.011.”

2. Page 10, It makes more sense to compare the proportion of participants with viral non-suppression to those who did not did not participate in the study instead of comparing VL nonsuppression among participants with any eligible participant.

3. Page 10, under “Demogrpahics” please define “mid-level health facility”.

4. Page 10, under “Demographics”, “About one-third reported having had 2 to 3 sexual partners in the previous 12 months and one-third never knew their partner’s HIV status.” Is partner knowledge status in reference to all partners? Any one partner? Please clarify.

5. Page 13-14, under “Bivariable and multivariable analysis, you only discuss Bivariable analysis. I would potentially shorten the bivariable results and give more space to highlight the big takeaways from the multivariable analysis.

Discussion

1. I suggest separating the discussion into cohesive paragraphs. I suggest reading other Discussion sections from high-impact journals for reference. A typical discussion paragraph will take a finding from your study that’s interesting to you, and put it in the context of broader research. You’ll typically try to compare this finding to research in similar settings or populations. Typically, you’ll want to describe the other studies a bit as your reader won’t necessarily have time to look at your references. You’ll then try to formulate a take-away, such as a suggestion or interpretation for how your study finding fits into the larger data. You don’t need to address every finding from your results section – only the findings you think are interesting. You begin to do this later in the discussion section.

2. I would try to better tie in the health center survey to the virologic nonsuppression outcome. As it stands these seem like two completely separate projects. Better framing in the discussion could help this issue.

Figures/Tables

1. Table 1. Under “number of sexual partners in previous 12 mo”, I suggest changing “only one” to “one”.

2. Table 1. Under “Quality of clinical appointments and work”, what is the difference between “long enough” and “they are just fine”? These two fields do not seem exclusionary.

3. Table 2. I am confused by the column headings: “No – suppressed” and Yes-non-suppressed”. I would remove the No/Yes and simply write suppressed vs. non-suppressed.

4. Table 2. It looks like you are trying to bold any p-values <0.05. If this is the case, you should also bold TB diagnosed in past 12 mo.

5. Table 3 took me a few minutes to comprehend. It might be visually easier to digest the information you’re trying to describe by having the six health centers at column headers, and then simply checkmark which health centers respond yes to each question.

**********

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: No

**********

PLoS One. 2023 Oct 19;18(10):e0293057. doi: 10.1371/journal.pone.0293057.r004

Author response to Decision Letter 1

29 Jun 2023

We appreciate the support provided by the reviewers in making our work better. We are really grateful.

All comments suggested were of great importance and we believe we have presented a better version of the manuscript.

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file.^{(22.4KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0293057.r005

Decision Letter 2

Joel Msafiri Francis

19 Jul 2023

PONE-D-21-31809R2Virological non-suppression among adult males attending HIV care services in the fishing communities in Bulisa district, Uganda.PLOS ONE

Dear Dr. Senteza,

Please submit your revised manuscript by Sep 02 2023 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'.

We look forward to receiving your revised manuscript.

Kind regards,

Joel Msafiri Francis, MD, MS, PhD

Academic Editor

PLOS ONE

Journal Requirements:

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: (No Response)

**********

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

Reviewer #2: Yes

**********

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

Reviewer #2: I Don't Know

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #2: Yes

**********

6. Review Comments to the Author

Reviewer #2: Overall

The authors have done a commendable job incorporating the previous recommendations. I have additional recommendations to further strengthen the manuscript outlined below.

Introduction

1. Page 3, Paragraph 1: A prevalence is not a rate – please revise.

2. Page 4, Paragraph 1, Line 1: Clarify type of non-suppression (virologic) as done later in the sentence.

Methods

1. Study setting: I recommend including the number of people living in this district/setting – this would put the number of people living with HIV into context.

2. Page 7, Data collection and management: Please cite references for the sentences, The patients’ questionnaire was structured and designed based on characteristics common among residents of fishing communities and factors previously associated with virological non-suppression from other population segments” and “The Health worker’s questionnaire was structured and designed based on factors identified

in previous qualitative and quantitative studies that focused on the quality of health care.”

3. Page 7, punctuation errors in the phrase: “adherence based on pill count by the attending clinician categorized as good (>95%), fair (80-95%) poor (<80%), fulfilment of clinical appointments;”should be, “adherence based on pill count by the attending clinician categorized as good (>95%), fair (80-95%), poor (<80%); fulfilment of clinical appointments;”

4. Page 10, The following sentence does not make sense, “Out of the 462 participants who fulfilled the eligibility criteria, 367 were excluded because they were non-residents”. Residing in the district is an eligibility criteria and above the authors state 462 participants met criteria.

5. Page 11, the authors compare participants interviewed vs. those who did were not interviewed for several categories, but they compare participants interviewed to all participants for viral load. I recommend they consistently compare those interviewed vs. those who did not interview.

6. How did the authors ask about HIV disclosure? Could participants state disclosure to multiple categories or were they to only choose one? Please clarify in the manuscript.

7. How did the authors partner HIV status in regards to people with multiple partners? Please clarify in the manuscript.

8. Under quality of clinical appointments and work, please clarify the difference between, “long enough” and “they are just fine”. Please clarify in the manuscript.

9. Under viral load turn around time, please clarify “can’t tell”. Does this mean the participant didn’t know or didn’t want to report this in the study?

Results

1. Please define CPR at first use.

2. It is difficult to think about prevalence ratios < 1. I recommend reversing your reference labels to have results where your prevalence ratios are all > 1.

3. Please revise this sentence as it is difficult to follow, “The prevalence of virological non-suppression amongst participants who received care from the only hospital in the district was 1.22 times (adj.PR=1.22, 95%CI: 1.08-1.37) and 0.61 (adj.PR=0.61, 95%CI: 0.57-0.66) amongst participants that sought treatment at health centre III levels compared to the prevalence of virological non-suppression amongst participants who received care at health centre II level.”

4. Overall you could cut down significantly on the word count of the Results section. Since this data is in the Tables, you should only write out the most important findings you wish to highlight.

5. Why wasn’t ARV regimen change or ARV line of therapy in the multivariable analysis since these seemed to significantly associated with virologic nonsuppression?

6. It appears that there are 9 variables in the multivariable model. Are the authors concerned about overfitting the model? Especially since participants without viral suppression were 84 (in regards to the 1/10 regression rule).

7. The data regarding the health facility factors does not seem relevant in this analysis since the authors do not tie this into the viral nonsuppression in any way. I would recommend removing this and potentially it could be a short report.

Discussion

1. In regards to limitations, the authors state, “An additional limitation could be the lack of back translation from the local language to English which could have led to a loss of meaning in the translation of some data.” If the authors and people doing the analysis understood and were fluent in the local language, then there is no need for English translation.

Figures/Tables

1. Table 3. Please remove the “No” row for each question. This is confusing. The “Yes” row alone is sufficient.

**********

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: No

**********

PLoS One. 2023 Oct 19;18(10):e0293057. doi: 10.1371/journal.pone.0293057.r006

Author response to Decision Letter 2

3 Oct 2023

These have been included in the attachment labelled response to reviewers.

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file.^{(20.4KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0293057.r007

Decision Letter 3

Joel Msafiri Francis

5 Oct 2023

Virological non-suppression among adult males attending HIV care services in the fishing communities in Bulisa district, Uganda.

PONE-D-21-31809R3

Dear Dr. Senteza,

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.

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Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0293057.r008

Acceptance letter

Joel Msafiri Francis

10 Oct 2023

PONE-D-21-31809R3

Virological non-suppression among adult males attending HIV care services in the fishing communities in Bulisa district, Uganda.

Dear Dr. Senteza:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. 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.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 File. Research fund scholarship.

(PDF)

Click here for additional data file.^{(1.9MB, pdf)}

S2 File. Location of Bulisa district in Uganda.

(PDF)

Click here for additional data file.^{(152.6KB, pdf)}

S3 File. Coded sheet.

(XLSX)

Click here for additional data file.^{(171.3KB, xlsx)}

S4 File. Code definitions.

(PDF)

Click here for additional data file.^{(239.2KB, pdf)}

S5 File. Consent and ascent forms—English version.

(PDF)

Click here for additional data file.^{(89.2KB, pdf)}

S6 File. Consent and ascent form translated version.

(PDF)

Click here for additional data file.^{(133.6KB, pdf)}

S7 File. Patient questionnaire–English version.

(PDF)

Click here for additional data file.^{(161.5KB, pdf)}

S8 File. Patients questionnaire translated version.

(PDF)

Click here for additional data file.^{(109.7KB, pdf)}

S9 File. Data abstraction tool.

(PDF)

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S10 File. Health workers questionnaire.

(PDF)

Click here for additional data file.^{(99.9KB, pdf)}

S11 File. Ethical approval.

(PDF)

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S12 File. Stata output for the final model.

(TXT)

Click here for additional data file.^{(3.5KB, txt)}

S13 File

(DOCX)

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Submitted filename: Review of virological non-suppression among adult males attending HIV cares services in Uganda.docx

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Data Availability Statement

All relevant data are within the paper and its Supporting Information files.

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PERMALINK

Virological non-suppression among adult males attending HIV care services in the fishing communities in Bulisa district, Uganda

Ignatius Senteza

Barbara Castelnuovo

David Mukunya

Fredrick Makumbi

Roles

Abstract

Background

Methods

Results

Conclusion

Introduction

Methodology

Study setting

Study design

Participants selection

Data collection and management

Data analysis

Ethical consideration

Results

Fig 1. A consort flow diagram showing data that were used.

Demographic, individual and health facility-related characteristics of the participants

Table 1. Demographic, individual and health facility-related characteristics of participants n = 413.

Factors associated with virological non-suppression

Table 2. Bivariable and multivariable analysis for determining the factors associated with virological non-suppression amongst adult males living with HIV in the fishing communities of Bulisa district.

The role of health facilities towards virological non-suppression amongst adult males living with HIV in the fishing communities of Bulisa district

Table 3. Preparedness of health workers to serve people living with HIV and quality of services offered to people living with HIV.

Discussion and conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

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Acceptance letter

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Associated Data

Supplementary Materials

Data Availability Statement

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