Title: Adaptive Leadership in Clinical Encounters with Women Living with HIV
Version: 4 Date: 16 Apr 2022
Reviewer's report:
This is a well-written and thoughtful piece. I recommend it for publication but have some
suggestions to strengthen it further in places.
Minor edits:
i) line 97. Diagnoses?
ii) line 141. 'are' rather than 'as'?
iii) line 161. Add 'the' before 'study'?
iv) line 437. Truncated sentence?
More substantive edits:
a) Please avoid use of the letters 'WLWH' throughout. This feels dehumanising. Letters are
fine for institutions (eg WHO) or things (eg ATM) but should never be used for people.
See UNAIDS terminology guideline 2015, page 4. https://www.unaids.org/sites/default/files/
media_asset/2015_terminology_guidelines_en.pdf)
b) line 104 onwards. The word 'risk' suggest a certain level of agency - and then possible blame
- which those concerned often don't have. I suggest the use of eg 'vulnerable to' instead of 'at
risk of'.
c) line 151. Please see the UNAIDS terminology guideline, 2015, which explains that 'HIV-
infected' should not be used either (op.cit.)
d) line 198. I see from your limitations section that women living with HIV were not involved
in the study design. It is good to see your recommendation for their full involvement in future
studies. This will further enrich the quality of your research and findings.
e) line 313. It would be good to discuss further and/or reference the value of peer support in your
discussion section. See eg PWN-USA and the Well Project for various relevant references. See
also eg https://www.thewellproject.org/hiv-information/how-be-advocate-yourself-and-others
f) line 400 onwards (discussion section). Further challenges facing women
living with HIV can include eg intimate partner violence, sexual and
reproductive health issues (eg contraception, voluntary abortion, ante-natal
care, infant feeding options (https://us02web.zoom.us/rec/share/vNMQdXuTqssgsWJrMk-
eNbxb27dhlNPeAHGlJhffUtuzfT6M1i5L0tW35I72_neO.xTSRLP7UD3w45cxP ), HPV,
access to PAP smears, cervical cancer, menopause and related issues...) it would be good to
have a fuller picture of these diverse issues and if/how women are supported to access holistic,
integrated healthcare in eg easily accessible one-stop shops.  It would be good also to refer a
little to wider literature already  in the HIV field. See for example the WHO Guideline on SRHR
of women living with HIV 2017 (https://www.who.int/publications/i/item/9789241549998);
and the 2 resulting Canadian Women's toolkits (one for clinicians and one for women living
with HIV) which were adapted from and built on this, including violence/trauma-aware care
(https://cep.health/clinical-products/hiv/). Trauma-aware care is especially important if women
are experiencing trauma from their HIV diagnosis and/or IPV, or alcohol/drug use, sexual
violence and/or adverse childhood experiences.  It would be good somehow in your discussion
section to refer to these materials, since they are closely related to what you are describing, in the
context of HIV, women, doctor/patient relationships, SRHR and quality of care issues. Also eg
Peyre et al (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5037933/) refers to the importance
of the first clinic visit to long-term ARV use in France.