Reviewer’s report
Title: 
'PrEP'ing for a PrEP Demonstration Project: Understanding PrEP
Knowledge and Attitudes among Cisgender Women
Version: 
1 
Date: 
26 Feb 2021
Reviewer's report:
'PrEP'ing for a PrEP Demonstration Project: Understanding PrEP Knowledge
and
Attitudes among Cisgender Women
The manuscript examines the experiences of cisgender women who accessing
HIV prevention and the individual and systems level facilitators and barriers and
their associated PrEP knowledge, attitudes and barriers to uptake in the US. This
is an interesting study given its context within a larger demonstration study.
However, there is a concern that the dissemination of this results may be late
given the age of the data and several more recent studies that have been
published with very similar conclusions reported in this study. 
Moreover, several issues in the methodological approach and the interpretation
of the findings raises a concern that the authors' interpretation may not be
entirely supported by the data presented. 
The following are specific issues that the authors may want to address.
Lines 70-73- 
The statement on lines 70-73 assumes that at risk women are a homogeneous
group. The reality however is the factors that put women are risk differ from one
individual to another. These different risk factors will apply to different
categories of women, even though one particular factor maybe more dominant
for a single woman
Line 108-109 
The data was collected about 6 years ago and in a rapidly evolving context of
PrEP use and implementation, there is some concern that the data is quite old. It
would be useful to acknowledge more recent literature and how that impacts the
findings reported in the manuscript. An important question for authors here is
how much has changed since the data was collected?
Lines 111-112
The sample size is really small to allow any meaningful interpretation of how
findings will apply to different categories of women, especially those who are
not represented in the sample. Because of the small participant pool, in-depth
interviews would have been more appropriate. Moreover, how many of these 22
participants were recruited by telephone, email, testing sites, etc.?
Lines 114-116
Please describe the informed consent process
Line 124
Was this information on HIV status self-reported? Was it verified?
Line 142-143
Intro suggests WoC were the focus, why include white non-hispanic women?
Otherwise, please make clear all women regardless of race or ethnicity were
included
What was the sampling technique used? what is the rationale for the wide age
difference? Were FGDs organized by homogeneous characteristics?
Include a table of participants' characteristics
Line 146
What is the PrEP status of each of the participants? Were there some who had
previously used PrEP or were they all PrEP naive? Disclosing this information is
important to help situate some of the findings in context. For example, some
results/discussions suggest that some participants discussed fears about side
effects and barriers to accessing PrEP but it is not clear if these are actually users
or potential users.
Line 153-154
What is the proportion of participants with some prior knowledge of PrEP? How
did this impact the findings reported?
Line 157-161
Please separate verbatim quotes into new paragraphs.
Line 162-164
It is not clear how the statement on line 164 is to be interpreted as medical
mistrust
Line 179
Please clarify if WLWH and HIV-negative women were mixed in the same
FGD? This was otherwise previously suggested.
What were the rules regarding HIV status disclosure if women with different
status were mixed in the same group?
Were there concerns about confidentiality?
Line 188
The basis for the statements on lines 187-188 is unclear. Perhaps, this is one
example of authors' interpretation that is not supported by the data. If the women
have never heard much less use PrEP, how can they speak to its side effects?
Line 222
Please include age of participants quotes are attributed to
Line 248
The criteria for determining that participants were at risk is not described and
should be discussed in the methods. One is assuming that if exposure or
participation in heterosexual intercourse was a criterion for risk of exposure, then
all sexually active women (and men) are exposed to some risk.
Line 271
The authors interpretation of medical mistrust is not investigated or supported by
data.
Line 329-330
This statements included on lines 329 -330 is the main challenge with assessing
the contribution of this study to literature. The small sample size, even for a
qualitative study and the lack of detailed description of the sampling technique
are fatal flaws in the study design.
Secondly, the data was collected about 6 years ago and since then, several
studies with more rigorous methodology have been conducted and published
(see: https://pubmed.ncbi.nlm.nih.gov/?
term=PrEP+use+among+women+in+the+united+states). How do these more
recent data impact the results presented here.
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
No
Is the presentation of the work clear?
Yes
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
No