Reviewer ’s report  
 
Title: Pain in amaXhosa women living with HIV/AIDS: a cross -sectional study of ambulant  
outpatients  
 
Version: 0 Date: 28 Mar 2016  
 
Reviewer: Kelly O’Brien  
 
Reviewer's report:  
 
Overall this manuscript addresses an important topic of characterizi ng pain (prevalence, severity, 
site, interference, and management) of pain among women living with HIV in a resource -limited 
setting.  This is a well written manuscript whereby authors clearly articulate the primary and 
secondary study objectives and conce pts of interest (prevalence, characteristics, management) 
related to pain. Authors provide a strong rationale for the need to explore pain from a gender and 
ethno cultural perspective in a resource -limited setting.  
 
 
  
The results are clearly presented and comprehensive.  More information on the measurement 
properties, scoring and interpretation of the questionnaires would be beneficial.  A statement 
about the limitations of the study design in relation to causation between pain and the associated 
factors wo uld be helpful as well.  Finally, authors might consider adding a section to the 
discussion related to the role of other non -pharmacological management strategies for pain.  
Below are some specific considerations the authors might consider for revision:  
 
 
 
 
1) This study did not have a comparison group; hence the concluding statement that pain 
may be more common in amaXhosa women living with HIV than other groups of people 
living with HIV is beyond the scope of the study.  Suggest authors remove this statement  
in the abstract (Line 47 -48) and conclusion section of the manuscript (Line 365) and 
simply state the important finding that this study highlights the high prevalence of pain 
among this population.  
 
 
 
2) Line 57 - Authors refer to their systematic review h owever 4 references are cited.  
Suggest authors add the reference to their systematic review as a reference in this second 
sentence in addition to the 4 studies that reported inadequate pain management.  
 
 
 
3) Line 63 - please reference the STROBE guidelines.  
4) Please justify the age cut -off of 40 years for eligibility for study inclusion.  
 
 
 
5) Did authors capture other concurrent health conditions that participants were living with 
in addition to HIV?  With increasing access to antiretroviral therapy and mor e individuals 
living longer with HIV, they may also be living with an increasing number of concurrent 
health conditions (in addition to HIV) which may also contribute to the exacerbation and 
interference of pain.  In the discussion, it would be worthwhile for authors to discuss the 
experience of pain as it relates to HIV (e.g. neuropathy, pain secondary to ddI or d4T 
medications, but also to the relationship of pain with the emergence of other health 
conditions that may contribute to increasing presence and  severity of pain such as bone 
and joint disorders, arthritic pain, etc).  This may be particularly relevant to the 
discussion given the highly prevalent sites of pain seen in the abdomen and head and 
neck which suggest pain -related sources attributed to o ther comorbidities associated with 
HIV beyond those traditionally considered in the context of HIV as they relate to HIV -
related neuropathy.  
 
 
 
6) In the Procedure section, suggest authors provide more detail for each of the interview 
administered questionna ires including their measurement properties (e.g. validity and 
reliability) with people living with HIV in resource -limited settings, their scoring and 
interpretation.   
 
 
o Suggest moving the definition of 'pain' versus 'no pain' from the results to the procedure 
section. Line 213 -215. 
 
o Suggest authors include detail of the specific variables that were extracted from the chart 
(or folder) referred to as 'most recent medica l information' - line 156.  
 
 
 
7) Discussion - while the Pain Management Index (PMI) focuses on pharmacological 
management of pain, in the discussion authors might consider discussing non -
pharmacological management strategies for pain such as physiotherapy, o ccupational 
therapy, massage therapy, complementary and alternative therapeutic approaches to pain, 
etc) and the evidence associated with these strategies in the context of HIV.   This will 
complement the authors' important take home message that considera tions for pain 
management is critical while providing more information on the different approaches to 
pain management and evidence supporting both pharmacological and non -
pharmacological interventions to reduce or prevent pain for people with HIV.  
 
 
8) Analysis section - authors provide a clear indication for the scoring and interpretation of 
the Pain Management Index.  Suggest adding similar detail on the scoring and 
interpretation for the other measures as well.   Also, five psychosocial variables were 
described in the analysis (self -efficacy, HRWQL, depression, Childhood trauma and 
PTSD - Line 171) - suggest authors also specify their approach for analysis of 
associations with employment status and education, which were part of the secondary 
objective.  
 
 
 
9) Analysis section - T-tests were conducted for parametric data, were non -parametric tests 
conducted in situations where the data were not normally distributed?  Please specify.  
 
 
 
10) Results - Line 197 to 210 - while interesting results, the associations b etween pain and 
measures of immune status, stage at diagnosis, number of years since diagnosis, number 
of months on treatment, type of antiretroviral therapy, and neuropathy status were not a 
part of the study objectives and hence go beyond the scope of th e manuscript.  Suggest 
these 2 paragraphs may be removed from the results.  Instead, perhaps authors might 
consider adding a table that summarizes the characteristics of the participants that 
includes a description of the participants and these characteris tics.  Detail on other 
concurrent health conditions that participants were living with (other than TB and 
candidiasis) would also be beneficial if these data were collected as part of the 
demographic questionnaire or chart / folder review.  
 
 
 
11) Results - In the section entitled factors associated with pain, years of schooling was 
identified as a factor associated with pain; employment status is not mentioned despite 
earlier in the manuscript (Line 194 and 195) authors indicated that both employment 
status and years of schooling were associated with pain.  Can the authors clarify?  
 
 
 
12) Results - Line 253 -255 - Authors state that there was a weak to moderate negative 
relationship between pain severity and interference and years of schooling, health related 
quality of life.  However, the relationship between pain severity and interference was 
positive with depression - greater pain severity and interference was associated with 
greater depression scores.   
 
 
 
13) In the next sentence (Line 255 -258), the statement suggests that pain scores worsened as 
years of schooling decreased.  This statement seems to suggest that schooling preceded 
the pain.  Given the cross -sectional nature of the study design the direction of the 
relationship between the factors cannot be det ermined.  Suggest revising to simply state 
that pain scores were correlated with years of schooling, HRQL scores, and depression 
scores.  
 
 
 
14) Discussion -suggest considering adding a paragraph in the discussion related to 
considerations for other non -pharm acological management strategies for pain for people 
living with HIV (see comment above).  
 
 
 
15) Limitations Section in the Discussion - Given the cross -sectional nature of the study 
design authors are unable to determine the direction of association between  pain and the 
characteristics of interest.  Authors accurately state that they were not able to determine 
whether HRQL was influenced by the presence of pain or whether low HRQL increases 
risk of pain (Line 351).  Suggest the authors expand upon this state ment to more broadly 
discuss the limitation of the cross -sectional nature of the study design in determining 
causation not only for HRQL, but also for the other factors considered in the study 
(depression, schooling, employment status, etc).  
 
 
 
 
Additional Mi nor Suggested Revisions:  
 
 
16) Please refer to data as plural throughout (e.g. Line 149 - Data were collected….)  
 
 
 
17) Line 228 and 229 - specify 92 participants and 56 participants respectively.  
 
 
 
18) Line 246 - please add the preceding statement to clarify the comparison group:  
"Compared to those without pain, women with pain……  
 
 
 
19) Tables - please add the definition of the acronyms used in the tables in the corresponding 
legends.  In Table 1 - it would be helpful to provide a description of how the severity and 
interference scores are interpreted in the legend as well.  
 
 
 
Are the methods appropriate an d well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn a dequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recom mended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an  organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial com peting interests in relation to this paper?  
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below.  If your reply is yes to any, please give details below.  
 
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