Reviewer ’s report  
 
Title: Awareness, attitudes and perceptions regarding  HIV and PMTCT amongst pregnant 
women  in Guin ea-Bissau - a qualitative study  
 
Version: 1 Date: 18 Dec 2016  
 
Reviewer: Abigail Hatcher  
 
Reviewer's report:  
 
This manuscript examines an important topic, namely how pregnant patients in Guinea -Bissau 
accessed or were inhibited from a ccessing PMTCT services. There are, however, a number of 
issues that need to be addressed to prepare the manuscript for publication.  
 
 
 
Introduction  
 
1. In the Introduction, the fourth paragraph (lines 118 to 123) seems to suggest that the most 
recent national data around PMTCT was from 2008. If this is the case, it's important to 
state the paucity of data which makes it challenging to assess PMTCT over  the past 
decade. If there is in fact data available that is more recent, it's essential to cite it.  
 
 
 
Methods  
 
2. These data were collected more than five years ago, which is not a problem if the authors 
explain why they are still relevant despite major shi fts in PMTCT policy over this time 
period.  
 
 
3. In line 143, briefly remind the reader what the WHO guidelines stated at the time 
regarding eligibility for access ART during pregnancy.  
 
 
 
Results  
 
4. In line 258, it would be important to add a quote or summariz e participant stories to back 
up the finding that discrimination and abandonment were major concerns.  
 
 
5. In line 271, please introduce the quote from Interview 14.  
 
6. In line 287, the quote should read "talk to the patient with as few other people around a s 
possible." Since these are translations into English, the grammar should be correct.  
 
 
7. In line 314, note whether the lack of post -test counseling aligns with or contradicts 
national guidelines at the time of the interviews. I find it concerning that hea lth workers 
blame women for their "lack of knowledge" when it is clearly a health systems gap which 
is leading to an inability of patients to access crucial information. Whenever possible, it 
would be wise for the authors to be critical of this judgmental health worker view, rather 
than accepting this dynamic as the patients' fault.  
 
 
8. In line 320, the authors point out a very interesting association of testing with having a 
"good character". Please provide an illustrative quote or story.  
 
 
9. In lines 340 -342, several interesting considerations about partner and family dynamics 
are highlighted and these are deserving of an illustrative quote or story.  
 
 
10. I would encourage the authors to consider removing the final Results section on supply -
side barriers beca use it does not add much new richness to the argument. Alternately, it 
can be left in but requires considerable development with additional lines of reasoning 
and quotes. My sense is that the other sections of Results are stronger and add plenty to 
the man uscript without this final section.  
 
 
 
Discussion  
 
11. In line 418, I would say "perceived stigma at a household and community level".  
 
 
12. In line 422, the authors say "Despite counseling and testing preceding the time point of 
most interviews…" But the data seem to point to a distinct lack of pre - and post -test 
counseling procedures. The Discussion needs to focus on what actually occurs in these 
settings, which seems to differ to international guidelines around how HIV testing and 
counseling should actually h appen.  
 
 
13. In lines 423 -424, it does not seem appropriate to say "insufficient awareness" and "lack 
of HIV knowledge" given that these gaps in understanding are purely the result of an 
inattentive health system. No patient should be expected to educate th emselves on a 
medical procedure, but should rather be provided with detailed information and ongoing 
counseling opportunities throughout their engagement with the health system. Please 
rephrase accordingly.  
14. In lines 437 and 438, please add citations.  
 
 
15. The paragraph in lines 454 would benefit from the addition of insights of ethnographic 
work on how traditional beliefs create meaning in difficult circumstances (Merten et al. 
2010).  
 
 
16. Please rewrite lines 480 -481 and 483 -484 as these seem to be sente nce fragments.  
 
 
 
Figures  
 
17. Fig 2 would benefit from some grouping of the themes into various ecological levels: 
personal, household, institutional, community.  
 
 
 
 
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 con trols 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 manuscript or would you recom mend an  
additional statistical review?  
If an additional statistical review is recommended, please specify 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 interests  
Please complete a declaration of competing interests, considering the following que stions:  
 
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 o r 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 y ou 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 competing in terests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
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