A Scoping Review of How High-Income Country HIV Guidelines Define, Assess, and Address Oral ART Adherence

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This manuscript addresses a critical yet under-explored issue: how clinical guidelines define, measure, and address adherence to antiretroviral therapy (ART). The use of a scoping review methodology based on JBI and PRISMA-ScR standards is appropriate for mapping conceptual and operational heterogeneity across guidelines.

The manuscript demonstrates commendable breadth and rigor in its search and inclusion strategy, and the descriptive findings are both timely and informative. However, to meet the standard of analytical contribution required for publication, major methodological clarifications, analytical enhancements, and conceptual refinements are necessary. Below are detailed considerations grouped thematically:

1. Title: The current title is overly broad. The phrase “How HIV Clinical Guidelines Address Adherence…” lacks precision. I recommend a more specific and academically rigorous title, such as:
   “A Scoping Review of How High-Income Country HIV Guidelines Define, Assess, and Address ART Adherence”
2. Abstract:

The abstract overemphasizes the number of guidelines included and underplays the conceptual contribution of the findings.

There is insufficient clarity regarding the analytical framework used for content synthesis (e.g., how categories were generated inductively vs. deductively).

The lack of definitions and thresholds is stated, but its practical implications are not highlighted.

3. INTRODUCTION – CONCEPTUAL FOUNDATION

• The literature review is underdeveloped. While several sources are cited to justify the relevance of ART adherence, the justification for analyzing guidelines (vs. empirical studies or RCTs) is not clearly articulated.
• The distinction between adherence as a clinical outcome vs. an implementation issue is blurred. It would benefit the reader if the authors explicitly positioned their work within the implementation science or health systems guidance literature, which would deepen the theoretical framework.
• The authors mention variability in adherence thresholds and definitions but do not present a conceptual typology or synthesis of how adherence has historically been defined (e.g., behavioral, pharmacological, virological adherence).

4. METHODS – CLARITY, REPRODUCIBILITY, AND TRANSPARENCY

A- Eligibility Criteria and Scope

• While the authors restrict inclusion to English and French guidelines, the rationale is weak and insufficiently problematized. This introduces a Eurocentric and Anglophone bias, especially considering that important OECD countries (e.g., Spain, Germany, Japan) produce guidelines in their own languages.

Please, Explicitly address the bias introduced by excluding non-English/French documents and consider listing excluded countries/guidelines with reasons.

B- Grey Literature Search

• The grey literature strategy is insufficiently detailed. There is no justification for limiting search to specific repositories, nor is there a list of specific government/institutional websites accessed.

Please, provide a transparent appendix listing:
(1) grey literature databases searched;
(2) government websites reviewed per country;
(3) keyword strategies used for Google-based searches.

C- Data Charting and Coding

• The use of NVivo is appropriate, but the coding strategy lacks transparency. There is no clear description of how codes were created (inductively, deductively, or hybrid).
• Categories like “education,” “mental health,” “provider training,” etc. appear without a coding tree or explanation of how they were defined and differentiated.

 

5. RESULTS – STRUCTURE AND SYNTHESIS

While the findings are rich, they are presented in a fragmented and overly enumerative format, which undermines analytical clarity.

Specific issues:

• Figure S2 and Table S3 are referenced but not critically used in the narrative. These should be synthesized within the main text rather than relegated to supplementary material.
• Overreliance on frequency counts (e.g., “7 guidelines recommend x…”) risks obscuring nuance and interrelationship between categories.

Recommendations:

• Introduce cross-tabulations or visual maps showing overlap between types of interventions and subpopulations addressed.
• Create summary matrices to show how guidelines vary across key domains (definition, threshold, measurement method, frequency, population-specific interventions).

Author Response

Please see the attachment providing a point-by-point response to each comment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

General Comments:
This is a well-written and clearly structured scoping review addressing a pertinent issue in HIV care: adherence to oral antiretroviral therapy (ART). The manuscript is easy to follow and highlights important gaps in current clinical guidance and opportunities for future research. The rationale for the review is strong, and the reporting is consistent with current methodological standards for scoping reviews. However, a few areas would benefit from clarification or refinement, as outlined below.

Abstract:

• Please clarify in the abstract that the focus of the review is specifically on oral ART adherence, to distinguish from long-acting or injectable regimens which may fall under broader ART adherence topics.

Materials and Methods:

• Rephrase the sentence “this study conducted a scoping review” to the more appropriate first-person academic voice: “We conducted a scoping review.”
• Please provide a justification for the selected timeframe (2017–2023). Was this based on guideline relevance, changes in treatment landscape, or another rationale?
• Consider discussing why a scoping review was chosen over an umbrella review, particularly given that the research question appears to involve synthesizing information from existing guidelines. What motivated the specific focus on guidelines as the source of evidence?

Results – Figure 2:

• In Figure 2, the term “outcomes” may be misleading. Based on the methods section, these appear to be guideline-reported domains rather than clinical outcomes per se. Consider revising the figure title and accompanying legend (and other parts of the manuscript) to clarify this distinction. Alternatively, if these are scoping review "outcomes" this should be clarified in the methods.

Conclusion:
Overall, this is a timely and relevant review that is methodologically sound. Addressing the minor issues noted above will further strengthen the clarity and interpretability of the manuscript.

Author Response

Please see the attachment, which provides a point-by-point response to each comment.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The manuscript is well crafted, and as a reviewer, it refreshes me on my clinical time, where I could see individuals living with HIV. This is a novel topic as it addresses one of the key targets to end AIDS as a public health threat. The abstract is well-structured, aligning objectives, methods, and results effectively, though a minor revision is suggested to include the term “threshold” in the keywords. While the introduction is slightly brief, it successfully outlines the rationale for the scoping review. Minor terminology improvements are suggested, such as individual living with HIV, viral load suppression.

The methods section is robust and ethically sound. However, the review was limited to guidelines that might not be updated with the latest evidence on adherence. In the results section, although the findings are extensive and well-described, two key areas need attention: a deeper discussion on adherence thresholds, particularly the commonly referenced 95% benchmark, and the underexplored role of healthcare providers in influencing adherence, especially under the health system barriers section.

This is a good paper for publication and requires very minor revision. Overall, the paper is acceptable for publication.

Comments for author File: Comments.pdf

Author Response

Please see the attachment, which provides a point-by-point response to each comment.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

All of the reviewer’s suggestions were fully addressed, with well-founded justifications provided for each point — including cases where limitations prevented complete implementation (such as the exact listing of government websites accessed).