Title: Knowledge and Perceptions About Dolutegravir and Dolutegravir Counselling: A
Qualitative Study among women living with HIV
Version: 3 Date: 15 Apr 2023
Reviewer's report:
This is an interesting study that evaluates the perspectives of women living with HIV and
healthcare providers in Malawi regarding the DTG switch campaign. My comments for the
manuscript are below.
Methods
Under the topic study participants, some information on provider participants should be
included. Additional information on how they were trained may follow this under the topic
“Counseling”. I would suggest a third subheading “recruitment of participants”.
It is unclear how the participants were recruited and more detailed information is needed on
how the patient- and provider-participants were purposively selected. How many patients were
approached in the S4 study and how many non-S4 women were approached? How many
rejected? Same questions apply for the provider-participants. In other words, how was the
decision made to include a specific participant?
Please specify the Department of HIV & AIDS and Viral Hepatitis. Is it a department of a
hospital or an institution of the MoH?
Results
The targeted number for patient-participants was 20 but 18 were interviewed. Please give
information why the target was not met.
“Most of the women had only been on EFV-based ART for almost 4 years”(Please provide the
number)
What was the time period between counselling and IDI for each participant?
Table 2 does not add much to the study; the information is already in the text.
Discussion
The authors report “Our findings showed that women in both groups were well versed on DTG’s
potential side effects and felt well counselled on the benefits of switching.” However, in the
results section, almost all the women were reported to have the perception that DTG was not
meant for women of childbearing age, rather it was meant for men and older women. It is clearly
stated in the DTG counseling information script that DTG has no contraindication. So there
seems to be some misinformation there.
The authors reported that the counsellors were trained as a part of the UNC-Project Malawi,
which is a collaboration between the University of North Carolina at Chapel Hill (UNC)-
where several authors of the manuscript are affiliated with, and the Malawi MoH.  However,
many provider-participants reported that they did not have enough information to give clear
answers to women’s questions. In the discussion, the authors stated that “some were trained
more systematically, while others were just briefed about DTG”. Since this was a structured
project, one would expect that the trainings would also be structured and the description in the
methods section gives an impression that they were. I would suggest the authors to discuss the
reasons for this in more detail.
Counselling was done by nurses, doctors or officers. This also may have an influence on a
patient’s decision as a doctor would be much more knowledgeable than a nurse or an officer and
would have a stronger effect on decision making. I would suggest adding this to the discussion.
The timing between counselling and IDIs is important for recall bias but it is not mentioned in
the results and the discussion. This may be a major limitation of the study.