Title: Womandla Health: Development and Rationale of a Behavioral Intervention to Support
HIV Treatment Adherence Among Postpartum Women in South Africa
Version: 1 Date: 06 Oct 2023
Reviewer's report:
I enjoyed reading this manuscript describing the qualitative work undertaken to inform a new
intervention to support women living with HIV during the transition from pregnancy to post-
partum. I appreciate the care taken by the authors to understand women’s perspectives and
incorporate them into the design of the Womandla Health intervention. The rationale and
theoretical framework for the study were well described. At the same time, I do have some
suggestions for the authors that I think will strengthen the manuscript.
Major comments
1. The previously published results of the PAM study should be presented in the introduction,
not in the results, as these are not findings from the current investigation. The title, abstract, and
introduction of the study should be updated accordingly to indicate that your prior work (not
the current study) explored the importance of transitions during pre- and post-natal period. It
should be clear from the title, abstract, and intro that the current investigation uses qual data
from the last timepoint of longitudinal interviews to inform intervention development. I would
remove aim 1 of the study that is described in the intro, since this describes your prior work,
not the current investigation.
2. I would remove figure 1 because it’s not pertinent to the findings of the current investigation.
I think figure 2 can be updated to reflect the intervention content only, not the design of the
study that will be used to test the intervention in the future. In its current form, figure 2 is more
appropriate for a protocol paper. Instead, it would be really helpful to see a visual representation
of the content and timeline of the individual and group sessions of the Womandla Health
intervention, as well as how the proposed content interacts with the important transitions found
in your prior work. Here it would be good to bring the prior findings into the visual to put the
recommended intervention components into context.
3. When the authors describe the Womandla Health intervention (last paragraph of this section),
they mention that the intervention addresses community factors including family and partner
support. The number of women who reported this to be a top area of importance actually
seemed relatively low (based on table 2), so this wasn’t discussed in the results section in detail.
However, it seems important to describe these perspectives (i.e., what was said on this topic), if
this content area is ultimately included in the intervention.
4. The discussion can be greatly improved by discussing the proposed intervention components
and how it relates to other existing programs for this population. What is similar and different
about the Womandla Health program compared to other programs? Here is the place to explicate
that and reiterate the novelty of the proposed intervention.
Minor comments
1. There are a few small changes in the introduction that would help with readability.
a. In the first sentence, indicate that the 30% refers to women in SA
b. The last sentence of the first paragraph was unclear-- why is now (as opposed to any other
time) a critical time in the SA HIV epidemic to increase treatment adherence?
c. In the second paragraph, the authors describe the challenge related to suboptimal HIV
care engagement postpartum and specifically discuss the effect on women’s ability to adjust
to lifelong treatment. It seems like an important place to also mention the ongoing risk for
vertical transmission during the postpartum period (e.g., via breastfeeding) if there is suboptimal
adherence
2. It was unclear whether topic j (medication adherence) referred only to ART or included other
medications as well. If it only included ART, how was this different from topic a (education
about HIV, PMTCT, and ART)?
3. In the section on Mutlicomponent Intervention, what did the authors mean by “a typical
manualized individual-level intervention would not fully address the varying issues arising in
women’s lives”? Manualized treatments can have varying degrees of flexibility. Please explain
your perspective and rationale a bit more.