Reviewer ’s report  
Title: Perceptions and decision -making with regard to pregna ncy among HIV positive women in 
rural Maputo Province, Mozambique - a qualitative  study  
 
Version: 1 Date: 12 Feb 2017  
 
Reviewer: Jean Anderson  
 
Reviewer's report:  
This is a very interesting qualitative study which adds to the literature around women's 
experience and decision -making about pregnancy in the setting of HIV and has implications  both 
for further studies and for potential interventions.  
 
i have a few concerns:  
 
Background:  
 
1. the term "biomedical norms" is used repeatedly throughout the paper. this is not a specific 
term that is understandable by most readers and, in fact, what a re biomedical norms in one 
setting may not be norms in another. i would recommend changing this terminology to make 
it clear that these are recommendations specific to the Mozambican setting. it would be 
helpful to note where these "norms" come from -in sou nds as if these are formal 
recommendations from the Ministry of Health or official Mozambican National Plan. should 
make clear exactly what are the Mozambican guidelines for initiation of ART -is there are 
CD4 cutoff? are all women who express a desire to c onceive given ART, regardless of CD4?  
2. relevant to the "norms" referenced ab one, how are these disseminated to providers? how 
would women who have HIV know about them, especially before they become pregnant?  
3. Are Hiv testing and ART free? this is ver y relevant to issues surrounding adherence and 
financial obstacles  
4. concerning Primary prevention of HIV, the statement is made that this involves HIV 
counseling and testing before pregnancy. however, primary prevention should be more that 
this-what meas ures are encouraged/counseled when HIV testing is negative?  
5. may want to briefly mention what traditional contraceptive measures are preferred \ 
6. the statement is made the FP serves as the entrance point for ART decision -making. not clear 
what this mean s.  authors also noted that if tested HIV - positive, there was referral to ART 
clinics.  
 
Methods: well described  
 
Results: overall i found this section well written and with many interesting observations  
1. clarify: "most participants had a HIV test prior to the last pregnancy" "however, the 
majority...knew their HIV+ status at the first antenatal visit". does this mean that majority who 
did not already know their status were testing at the 1st antenatal v isit? 
2. should clarify whether ART free and whether (as is implied) HIV -infected individuals can get 
only one month of ART at a time, which may significantly impact adherence for those who 
live at some distance from ART distribution site.  
3. similarly, th e issue of hunger, which is  noted as barrier to adherence, should be elaborated 
upon, either in this section or perhaps more appropriately in the discussion  
Discussion/conclusions: does a good job of summarizing findings but i believe the authors miss 
an opportunity to put forward specific recommendations, other than more health education, 
which is too generic. there were many findings that could generate specific suggestions for 
interventions at the individual or community level that are both respectful o f cultural values but 
promote healthier behaviors in terms of ART adherence and prevention of unintended 
pregnancy.  
 
Are the methods appropriate and 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 adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
Yes 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an a dditional statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
Not relevant to this manuscript  
Quality of written English  
Please indicate the quality of language in the manuscript:  
Acceptable  
Declaration of competing interes ts 
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