Title: Trends and factors associated with HIV testing among women aged 15–49 years in Belize:
An analysis using the Multiple Indicator Cluster Survey 2006, 2011, and 2015–2016
Version: 1 Date: 02 Dec 2022
Reviewer's report:
This manuscript examines the factors associated with HIV testing in women of reproductive age
in Belize and trends in HIV testing in 2006, 2011, and 2015-2016. As the authors note, Belize has
one of the highest HIV prevalence rates in Central America and women account for nearly half
of new diagnoses. Understanding the factors associated with testing can inform populations in
need of additional resources or interventions to improve testing. This manuscript provides initial
insight into the factors associated with testing among women of reproductive age in Belize. The
manuscript is well organized, has a clear study objective and uses an appropriate data source
to address the objectives. However, the statistical modeling and use of pooled, unweighted
results introduces critical limitations that need to be addressed or stronger justification provided.
In addition, points made in the abstract conclusion and discussion reference certain policy
interventions; however, the timing and scope of those interventions are not well characterized.
Information on these interventions is essential to informing if methods are appropriate and how
to interpret findings. More specifically, the main aspects that need to be addressed include:
• A clear description of the policy/program interventions that have been implemented that are
intended to reach women of reproductive age in Belize is needed, including timing, frame
the analysis, justify methods choices, and interpret findings. Without this information on
the policies/program intervention, results cannot be appropriately interpreted as we cannot
understand why there were increases in testing and who the interventions were aiming to
reach. For example, when was voluntary testing and counseling at all healthcare institutions
implemented in Belize? This should be specified and considered in how the methods are
structured. If implemented during this survey time frame, should not pool results. Further, is
this the same or different then the ‘reproductive healthcare services provided by the Ministry of
Health’ – the timeframes and populations reached with these services needs to be specified and
may result in necessary changes to the methods.
• Use of unweighted pooled results does not seem appropriate and was not evident as a common
practice for this data source in the literature. This is particularly problematic for the logistic
regression model 1. Strongly recommend removal of unweighted, pooled descriptive results
and model 1 unless can strongly justify the appropriateness and added value of these results.
Could continue to include models 2-4 and leverage alternate methods using the individual,
weighted estimates to assess trends, such as average annual changes to enable standardized
comparisons given the variance in timing between surveys to garner similar types of results.
Variance-weighted least squares regression could be used to estimate the average of absolute
annual change which allows to test the statistical significance of the observed trends. If do
continue to include, need to be extremely clear in results and tables which are weighted and
unweighted – not just in footnotes or in the methods. By reporting unweighted and weighted
results in same section without clear, distinctive language, results are hard to follow. Group
pooled, unweighted results, then weighted results.
• Embedded throughout both the policy interventions and methods is that there is no independent
variable on pregnancy history. It appears based on available documentation for MICS that an
‘ever pregnant’ variable is available, or could be deduced from the survey, it should be included
in the analysis. Controlling for pregnancy history would provide critical information on factors
associated with testing.
Additional recommendations and comments for consideration:
- Abstract, results: Comparisons should be noted when describing ‘more’ or ‘less’ likely results.
Further, there modeling results vary by model yet are presented as consistent; should be revised
to more accurately portray changes overtime.
- Background, 1st paragraph: It is unclear why the prevalence rates differ between the 2nd and
3rd sentences – 1.9% and 1.2% (calculated based on 4,500 / 387,879). Rounding may explain
part of the difference but not fully. Please revise to clarify for consistency.
- Background, 2nd paragraph: HIV testing is necessary/required, not just ‘primary’ – recommend
revising to clarify.
- Background, 4th paragraph: Delete ‘and’ before ‘inconvenience’, add ‘and’ before ‘negative’.
- Background, 4th paragraph, last sentence: Please clarify how heterosexual intercourse without
a condom is the ‘primary’ route of HIV transmission, but accounts for only 1/3rd of new HIV
infections. Is there a substantial percentage with unknown risk?
- Methods, study design: Please add a reference/source for the survey. Then if space is a
limitation could streamline the description of the data source.
- Methods, sampling, 2nd sentence: Editing needed to clarify # of zones with which survey years.
The following may work: In the 2006 survey, 6 administrative zones were identified, and in the
2011 and 2015/2016 surveys, 7 zones were identified.
- Methods, Outcome variable: Revise “access” to “assess”.
o Please confirm the variable had 100% response rate, no missing?
- Methods, HIV knowledge and attitude: Please clarify justification for categorizations of
knowledge of HIV and attitudes. Should also using consistent wording; e.g., either positive or
accepting.
- Methods: Did you test for collinearity between independent variables?
- Results, first paragraph: Based on relative and absolute increases, it’s the 35-49 age group that
has the highest increase; the 25-34 age group has the highest testing percentage, but not increase.
- Results: Cronbach’s alpha should be described in methods
- Results, logistic regression, 2nd paragraph, 1st sentence:  I think a ‘respectively’ is needed at
end of sentence to clarify each comparison is separate and no interaction terms were included
in the multivariable model. However, if models were stratified interaction terms were included,
then need to clarify here and describe in methods.
- Discussion, 7th paragraph, 2nd and 3rd sentences: Should these sentences be combined?
Revision and clarification needed.
- Discussion, 7th paragraph, last sentence: This seems to fit better with the discussion on rurality
two paragraphs later.