Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Major Comments:

1)Individuals affected by HIV may experience depression, post-traumatic stress disorder, and in aging populations, Alzheimer's disease-related dementias (ADRD). These outcomes are unlikely to be effectively detected by the self-rated health strategy. The resulting health overview is likely to be grossly misleading. The self-rated health strategy resembles Activities of Daily Living (ADL), which is part of detailed psychiatric evaluations utilized for PLWH. 

2) Study size is small: 26 participants. 

3) Study design is flawed: Only virally suppressed PLWH are included.

4) Interpretation of interviews is flawed: Highly subjective concerning PLWH's self-health assessment. 

Overall, the manuscript gives the impression that the authors had a preconceived bias in their interview strategy. 

Minor Comments:

1) Describe Abbreviation at first instance: Most abbreviations are described. Some are missing, e.g., SRH in the abstract. Abbreviations are redescribed in the manuscript, but not consistently at first instance. Proofreading the manuscript is required. 

 

Author Response

REVIEWER 1

Major comments

Comment 1: Individuals affected by HIV may experience depression, post-traumatic stress disorder, and in aging populations, Alzheimer's disease-related dementias (ADRD). These outcomes are unlikely to be effectively detected by the self-rated health strategy. The resulting health overview is likely to be grossly misleading. The self-rated health strategy resembles Activities of Daily Living (ADL), which is part of detailed psychiatric evaluations utilized for PLWH. 

 

Response: The study focused on perceptions/insights of the participants on what they considered as determinants. It did not involve any psychiatric evaluations as these were not in the interest of the current study.

Comment 2: Study size is small: 26 participants

Response: We appreciate the reviewer for pointing out this important observation. Although a sample size of 26 might seem limited, it was guided by reaching saturation rather than achieving statistical power. We achieved data saturation by the 20th interview, and later interviews served to further validate the themes that emerged.

We have strengthened the rigour of our study by implementing member checking and analyst triangulation. We acknowledge that a larger sample size could enhance the transferability of our findings, and this limitation has been thoroughly documented in the limitations section of our report.

Comment 3: Study design is flawed: Only virally suppressed PLWH are included.

 

Response: Thank you for your observation concerning our study's concentration on individuals with virally suppressed HIV. The primary aim of this research was to understand perceived determinants of Excellent Self-rated Health Among HIV Virally Suppressed adults. Introducing non-suppressed individuals could create confounding variables, such as disparities in treatment effectiveness and disease advancement. The discussion is revised to explicitly address this limitation and emphasise the need for broader sampling in future research

 

Comment 4: Interpretation of interviews is flawed: Highly subjective concerning PLWH's self-health assessment. 

 

Response: Thank you for your analysis and interpretation. While self-reported health assessments possess an inherent subjectivity, they provide valuable insights into participants' experiences, which are crucial for qualitative research. The primary aim was not to quantitatively assess health status, but rather to comprehend the determinants of SRH among HIV virally suppressed adults. The issue of subjectivity is addressed in limitation section.

 

Minor Comments:

Comment: Describe Abbreviation at first instance: Most abbreviations are described. Some are missing, e.g., SRH in the abstract. Abbreviations are redescribed in the manuscript, but not consistently at first instance. Proofreading the manuscript is required. 

 

Response: This has been addressed as advised.

 

Reviewer 2 Report

Comments and Suggestions for Authors

The authors are aiming to understand the determinants of SRH of PLWH in South Africa using a qualitative design. But the introduction says that Several  studies have assessed SRH already. In what way the present study is novel or adds new knowledge. Is this the first study to assess SRH among PLWH in the study setting?

A detailed review of literature with respect to SRH and related concepts and the research gaps needs to  be presented for this study, other wise the paper could turn to be a repetition .

What the author means by “contextual evidence”  for informing holistic approaches to promote and sustain  well-being in PLWH, beyond viral suppression. In what way the SRH is different from other constructs like self-esteem , self efficacy, agency, empowerment, quality of life?No theoretical discussion have been provided to add meaning the concept of SRH and the  justification looks very weak .

 

The authors mention cluster sampling which is for  quantitative designs usually. Sampling strategy needs to be clarified.

Random numbers were used for selecting participant? But what is the line list of participant and from how much how may were selected? For qualitative study exploring new concepts, maximum variation or theoretical sampling will be done. Why random sampling?

 

Author’s say data saturation was achieved in 26^th sample but they also say that data was collected from 26 random sample?  There is confusion and misunderstanding of the entire sampling process.

 

No mention about study tools, pilot testing etc? the items which should be met as per COREQ criteria is missing in the manuscript. This needs to be done otherwise manuscript method looks poor.

 

Provide  a tree of codes sub- themes and themes and then write the results. The presentation of result looks selective. Result  should be substantiated with the additional quotes ( in appendix) and there should be more contextualisation based on gender , socio economic status etc. Authors must use framework matrix to juxtapose quotes based on gender , SE status

The discussion,  as I told must bring in more theoretical insights  and place the findings based on a framework. Just present SRH without its relation to other key constructs like ( self esteem, self acceptance, self efficacy, quality of life ) etc would not add value to the study. 

COREQ checklist must be added and all the items must be quoted within the text of the manuscript.

Author Response

Comment 1: The authors are aiming to understand the determinants of SRH of PLWH in South Africa using a qualitative design. But the introduction says that Several studies have assessed SRH already. In what way is the present study novel or adds new knowledge? Is this the first study to assess SRH among PLWH in the study setting?

Response: Thank you for your comment. This has been addressed in the introduction. 

 

Comment 2: A detailed review of literature with respect to SRH and related concepts and the research gaps needs to be presented for this study, other wise the paper could turn to be a repetition.

Response: A paucity of qualitative literature in the proximal and identical population on Excellent SRH has been one of the motivating factors for the study. This is addressed in the introduction.

 

Comment 3: What the author means by “contextual evidence”  for informing holistic approaches to promote and sustain  well-being in PLWH, beyond viral suppression. In what way the SRH is different from other constructs like self-esteem , self efficacy, agency, empowerment, quality of life? No theoretical discussion have been provided to add meaning the concept of SRH and the  justification looks very weak.

Response: The understanding of the authors is that SRH addresses issues pertaining health perceptions whilst others predominantly address the psychological domains. A sentence has been added in the introduction to address the reviewers comment

 

Comment 4: The authors mention cluster sampling which is for  quantitative designs usually. Sampling strategy needs to be clarified.

Response: This has been addressed under methods as recommended

 

Comment 5: Random numbers were used for selecting participant? But what is the line list of participant and from how much how may were selected? For qualitative study exploring new concepts, maximum variation or theoretical sampling will be done. Why random sampling?

 Response: Thank you for noting the error. The methods and selection section has been reconstructed.

 

Comment 6: Author’s say data saturation was achieved in 26^th sample but they also say that data was collected from 26 random sample?  There is confusion and misunderstanding of the entire sampling process.

No mention about study tools, pilot testing etc? the items which should be met as per COREQ criteria is missing in the manuscript. This needs to be done otherwise manuscript method looks poor.

Response: The methodology section has been reviewed and compliance to COREQ criteria confirmed.

 

Comment 7: Provide  a tree of codes sub- themes and themes and then write the results. The presentation of result looks selective. Result  should be substantiated with the additional quotes (in appendix) and there should be more contextualisation based on gender , socio economic status etc. Authors must use framework matrix to juxtapose quotes based on gender , SE status

Response: The study has five themes that emerged and no subthemes are presented. The study had a predominantly female participant population with similar backgrounds and characteristics. This has been highlighted under strengths and limitations. Juxtaposition had been tricky to conduct.

Comment 8: The discussion,  as I told must bring in more theoretical insights  and place the findings based on a framework. Just present SRH without its relation to other key constructs like ( self esteem, self acceptance, self efficacy, quality of life ) etc would not add value to the study. 

The COREQ checklist must be added, and all the items must be quoted within the text of the manuscript.

Response: This has been addressed in the document. The COREQ guide has been applied.

Reviewer 3 Report

Comments and Suggestions for Authors

General concept comments

The running head should be corrected replacing the year of publication 2023 with 2025.

Specific comments

Authors and afiliations

Review whether the number 3 should appear after author Rachel Crokett's last name or whether her email address should be added to the end of affiliation 4 instead of the end of affiliation 3.

Review author affiliations; all should have the country name.

Title

The reviewer suggests to be included in the title the country name South Africa after the Eastern Cape Province,

Abstract

Line 32. The abbreviation SRH must be defined. Acronyms/Abbreviations/Initialisms should be defined the first time they appear in each of three sections: the abstract; the main text; the first figure or table.

Introduction

Line 41. The abbreviation PLWH must be defined. Acronyms/Abbreviations/Initialisms should be defined the first time they appear in each of three sections: the abstract; the main text; the first figure or table.

Line 42. The abbreviation ART must be defined. Acronyms/Abbreviations/Initialisms should be defined the first time they appear in each of three sections: the abstract; the main text; the first figure or table.

Lines 50 and 51. PLWH and ART must be defined on lines 41 and 42, there is no need to repeat the definition.

Materials and methods

Line 119. The authors state that they used Nvivo version 15, however, in the Abstract (line 16) they state that they used Nvivo version 13. Please, rectify this contradiction.

Conclusions

Line 303. The authors are encouraged to replace PLHIV with the acronym they have been using in the text, PLWH.

References

Line 330. Remove space after 90-90-90

Line 331. Add space after 6 June 2025

Lines 347, 350, 366, and 368. The citations for references 9, 11, 19, and 20 are incomplete. Authors should add information for each publication.

Author Response

Comment 1: The running head should be corrected, replacing the year of publication 2023 with 2025.

Response: Thank you for the comment. This has been addressed as recommended

 

Comment 2: Authors and affiliations Review whether the number 3 should appear after author Rachel Crokett's last name or whether her email address should be added to the end of affiliation 4 instead of the end of affiliation 3.

Review author affiliations; all should have the country name.

Response: This has been corrected

Comment 3: Title: The reviewer suggests to be included in the title the country name South Africa after the Eastern Cape Province,

Response: South Africa has been added to the title

 

Comment 4:

Abstract

• Line 32.The abbreviation SRH must be defined. Acronyms/Abbreviations/Initialisms should be defined the first time they appear in each of three sections: the abstract; the main text; the first figure or table.

Response: This has been addressed throughout the document

Comment 5:

Introduction

• Line 41. The abbreviation PLWHmust be defined. Acronyms/Abbreviations/Initialisms should be defined the first time they appear in each of three sections: the abstract; the main text; the first figure or table.

 

Response: This has been addressed throughout the document

 

• Line 42. The abbreviation ARTmust be defined. Acronyms/Abbreviations/Initialisms should be defined the first time they appear in each of three sections: the abstract; the main text; the first figure or table.

 

Response: This has been addressed throughout the document

 

• Lines 50 and 51. PLWH and ART must be defined on lines 41 and 42, there is no need to repeat the definition.

 

Response: This has been addressed throughout the document

 

Comment 6:

Materials and methods

• Line 119. The authors state that they used Nvivo version 15, however, in the Abstract (line 16) they state that they used Nvivo version 13. Please, rectify this contradiction.

 

Response: Thank you for the comment. The error has been corrected.

 

Comment 7: Conclusions

• Line 303. The authors are encouraged to replace PLHIV with the acronym they have been using in the text, PLWH.

 

Response: All “PLHIV” has been replaced with ‘PLWH’ per reviewer’s recommendations

 

Comments 8: References

• Line 330. Remove space after 90-90-90

 

Response: space removed

 

• Line 331. Add space after 6 June 2025

 

Response: space added

 

• Lines 347, 350, 366, and 368. The citations for references 9, 11, 19, and 20 are incomplete. Authors should add information for each publication.

Response: The references have been corrected

Reviewer 4 Report

Comments and Suggestions for Authors

The article is very important because of the subject matter covered. It would have been better if certain issues had been included or clarified.

1. In lines 60-61 we read about numerous studies. It would be good to recall them.

2. On lines 95-96, we read about the participants in the studies. It should be explained why women predominated.

3. In lines 109-110 we read about studies that lasted on average 30 minutes. Is it possible to conduct in-depth research in such a time.

4. A table with the research participants and some information about the research participants would be useful.

5. From line 150 onwards we read about detailed research topics.

It should be clearly explained to what extent the quoted statements are distinctive and why there are so few of them.

6. Since there are five main themes in the research, they should be clearly and sequentially addressed, discussed point by point, in the discussion.

7. The conclusions should clearly indicate the perspective of further research.

Author Response

Comment 1:  In lines 60-61 we read about numerous studies. It would be good to recall them.

Response: The sentence has been reconfigured

 

Comment 2: On lines 95-96, we read about the participants in the studies. It should be explained why women predominated.

Response: The comment has been addressed by adding more information. Though the study targeted both sexes, females were predominant because of general low health seeking behaviours of males.

Comment 3: In lines 109-110 we read about studies that lasted on average 30 minutes. Is it possible to conduct in-depth research in such a time.

Response: The sentence has been reconstructed

Comment 4 : A table with the research participants and some information about the research participants would be useful.

Response: A table on socio-demographic characteristics has been inserted.

Comment 5: From line 150 onwards we read about detailed research topics.

It should be clearly explained to what extent the quoted statements are distinctive and why there are so few of them.

Response: This has been addressed as recommended

Comment 6:  Since there are five main themes in the research, they should be clearly and sequentially addressed, discussed point by point, in the discussion.

Response: The section has been reconfigured to address the comments of the reviewer. More literature references has been inserted.

Comment 7: The conclusions should clearly indicate the perspective of further research.

Response: This has been addressed in line with the reviewer’s recommendations.

 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

1) All SRH, besides pain discounting, are incredibly positive. There are no negative health-related inputs in the interviews. Either the cohort of 26 individuals is incredibly unique, or the study design has a flaw that has not been outlined. It almost reads like an advertisement, and that is incredibly concerning. 

2) There is a mention of mental health at various points in the manuscript, but the sample questions did not even remotely ask the participants about their mental well-being or validate cognitive performance. Were the participants asked if they had experienced any signs of depression? A quick cognitive check could be to ask who the President/Prime Minister is, what the date is today, did you brush your teeth today, and have breakfast? 

There was no need for a complete psychiatric evaluation. However, the interview questions are generating a misleadingly positive health status for this small cohort. 

Minor Comments:

1) I still see abbreviations not being defined at the first instance they occur in the manuscript, but at random locations. Please do an additional round of careful proofreading. (e.g. ART line 43, pg 1)

Author Response

Comments as attached.

Author Response File: Author Response.pdf