Reviewer’s report
Title: 
Motivations to use hormonal contraceptive methods and condoms among
HIV-positive and negative women randomized to a progestin contraceptive in
Malawi: A qualitative study
Version: 
0 
Date: 
27 Nov 2020
Reviewer's report:
BMWH-D-20-00228
This is a generally well-written manuscript that allows for some additional
insight into the experiences of women in a sub Saharan African setting who are
negotiating the twin risks of HIV and unintended pregnancy where maternal
mortality is elevated. 
My comments mainly address the need for better
contextualization of the research and the findings to better bring out both the
value and limitations of the research. 
General comments:
1. The sub-study recruits from a sample of women already enrolled in a study of
2 hormonal contraceptives (HC) and who agreed to be randomized. 
Women were
recruited during the last year of the study, thus were experienced in method use
and had undergone multiple counseling sessions, it can be inferred. The paper
could do a better job of recognizing this selection pressure and limits of what can
be generalized. 
For example, the intention and motivation to use HC has been
already demonstrated, so is not really a finding per se - and conclusions cannot
make inferences about HIV negative and positive Malawian women overall. 
2. It does seem that assessing whether women understood the counseling of the
larger study was 
among the rationales for this sub-study? 
If so, please state this,
since it does not make an explicit appearance in the early part of the manuscript. 
3. There are frequent mentions in the testimonials of pregnancy reducing
immunity status of the woman. 
The authors also note this in their discussion.
However, the reader is not given the background to understand whether or not
this was a part of the educational counseling participants received - and if not,
where these notions may come from. 
Further, a brief literature review on what is
known about the impact of further pregnancy on immunity status of HIV positive
women on ART would be very helpful to put these results into context. 
Specific comments: 
Background 
Lines 120 -121: 
The ECHO study did not have a control arm without HC or
IUD, thus actual HIV risk increase with these methods is not known. 
Also, the
study was only powered to observe somewhat substantial differences across the
methods tested. 
The sentence should thus read: 
"Findings from a randomized,
multi-centre, open-label trial across 12 research sites demonstrated that the three
contraceptive methods (DMPA IM, a copper intrauterine device (IUD), and a
levonorgestrol (LNG) implant) under trial were highly effective, and that the
differences in HIV acquisition risk across the methods did not exceed 50%".
Methods
Paper describes the methods well, and it does seem to have been a carefully
designed qualitative research effort. 
Results
Line 284 - percentages unclear here. 14 of 41 women dos not equal 47% and 16
of 41 women does not equal 53% , perhaps some text was omitted by mistake
P 17 , section 3
In this section at the very least, the relationship status of the participant would
add value . 
Consider adding this for context , or adding text to make it clearer to
the reader. 
Page 18 line 440 - what kind of childbirth experiences ?….too vague to best
understand the testimonial that follows
Pp 19-20 : "Body immunity drops" has been mentioned multiple times here and
requires more attention, as indicated above, in the Intro as well as in Discussion
to unpack this
P 22: line 526 - was sexual assault/rape part of these comments/discussions? 
Line 557 - meaning of "chose methods that interfere with ARVS"? 
Discussion
The section is missing Limitations, of which there are at least 2. 
 This is a highly select sample, as noted above, thus inferences about all HIV
positive women ,for example, are unwarranted. Other conclusions may be
similarly unwarranted because of this limitation.
 Most women here are in close partnerships, which affects the findings
Line 628 - needs to be discussed in context of a highly select sample, see general
points above
Line 646 - similar to above comment: 
"….HIV positive women were highly
motivated to use contraceptive methods despite being on ART….." does not
reflect the selected sample
Line 664-666: problems with wording here/deletions
Line 671-681: discussion can be better edited, repetition here in concepts
Line 706: this conclusion seems to be premature from the evidence presented - 1
testimonial that I can find and it doesn't seem to address continuation. 
More
evidence needs to be presented. 
Line 732 in Conclusions similarly strong
statement for the evidence provided. 
Conclusions
There is a lot of richness appearing relatively late in the ms, in the Conclusions
section, regarding men and the need to explicitly work on couple communication
and ways to bring men into intervention strategies. 
I do like the direction in
which the authors are taking the results. 
However, 
I wonder if some of this
material could be added earlier on? 
See below: 
Was there any discussion about whether the women consulted with their partners
to join the study? 
It would be very helpful to add to the context here - 
Was there any couple communication revealed in the interviews/FGD about fears
of childbirth and women's desire to maintain strength and good health, that
women bring up? 
It would be valuable to know if the men are hearing any of
these comments in thinking about their reactions and about interventions going
forward? 
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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?
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