Prevalence and factors associated with psychological distress among key populations in Togo, 2017.

OBJECTIVES: Mental health is a largely neglected issue among in Sub-Saharan Africa, especially among key populations at risk for HIV. The aim of this study was to estimate the prevalence of psychological distress (PD) and to assess the factors associated among males who have sex with males (MSM), female sex workers (FSW) and drug users (DU) in Togo in 2017. STUDY
DESIGN: A cross-sectional bio-behavioral study was conducted in August and September 2017 using a respondent-driven sampling (RDS) method, in eight cities in Togo.
METHODS: A standardized questionnaire was used to record sociodemographic characteristics and sexual behaviors. The Alcohol Use Disorders Identification Test (AUDIT) and a subset of questions from the Tobacco Questions for Survey were used to assess alcohol and tobacco consumption respectively. PD was assessed with the Kessler Psychological Distress Scale. A blood sample was taken to test for HIV. Descriptive statistics, univariable and multivariable ordinal regression models were used for analysis.
RESULTS: A total of 2044 key populations including 449 DU, 952 FSW and 643 MSM with a median age of 25 years, interquartile range (IQR) [21-32] were recruited. The overall prevalence of mild PD among the three populations was 19.9% (95%CI = [18.3-21.8]) and was 19.2% (95%CI = [17.5-20.9]) for severe/moderate PD. HIV prevalence was 13.7% (95%CI = [12.2-15.2]). High age (≥ 25 years) [aOR = 1.24 (95% CI: 1.02-1.50)], being HIV positive [aOR = 1.80 (95% CI: 1.31-2.48)] and hazardous alcohol consumption [aOR = 1.52 (95% CI: 1.22-1.87)] were risk factors for PD. Secondary [aOR = 0.52 (95% CI: 0.42-0.64)] or higher [aOR = 0.46 (95% CI: 0.32-0.64)] education levels were protective factors associated with PD. FSW [OR = 0.55 (95% CI: 0.43-0.68)] and MSM [OR = 0.33 (95% CI: 0.24-0.44)] were less likely to report PD compared with DU. CONCLUSION AND RECOMMENDATIONS: This is the first study conducted among a large, nationally representative sample of key populations in Togo. The prevalence of PD is high among these populations in Togo and was associated to HIV infection. The present study indicates that mental health care must be integrated within health programs in Togo with a special focus to key populations through interventions such as social support groups.

Introduction

Mental health disorders represent a growing public health challenge worldwide. According to the World Health Organization (WHO), mental health is a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community [1]. Between 1990 and 2010, the burden of mental health disorders, such as depression and other common mental disorders, alcohol-use/substance-use disorders, and psychoses, increased by 37.6% [2,3]. Overall, mental health disorders are key contributors to nearly 10 to 14% of the global burden of disease, including death and disability [3,4]. Several factors have been associated with mental health, including gender, marital status, education, tobacco use, partner control/abuse [5,6].

Some population subgroups, such as those at higher risk of HIV are particularly burdened with mental health issues. According to the UNAIDS, gay men and other men who have sex with men (MSM), female sex workers (FSW) and their clients, transgender people, people who inject drugs and prisoners and other incarcerated people are the main key population groups [7]. In a study conducted in the Netherlands in 1999, mental health disorders were more prevalent among homosexually active people compared with their heterosexually active counterparts [8]. In addition, Luo et al. in a meta-analysis, reported that the pooled lifetime prevalence of suicidal ideation among MSM was 34.9% [9]. Similarly, using the Center for Epidemiological Studies Short Depression Scale, FSW in the Dominican Republic were more frequently screened positive for depression compared with HIV negative women who were not FSW (70.2% vs 52.2%) [10]. Moreover, poor mental health has been identified as a key contributor to the HIV epidemic among key populations. Indeed, MSM who are mentally depressed engage in unprotected sex and substance abuse [11-13]. Several studies have demonstrated a significant association between depressive symptoms and HIV and other sexually transmitted infections (STI) among MSM [14-16]. Poor mental health is a major concern in sub-Saharan Africa which bears the heaviest burden of HIV/AIDS [17]. As an integral part of overall well-being, mental health is not on the front line in terms of priority for health practitioners and it has been a largely neglected issue among marginalized populations in the developing world [17,18].

The high rates of HIV/AIDS among MSM and other key populations have pushed preventive interventions to focus on the risks associated with HIV/AIDS transmission and this situation has led to mental health neglect [19]. In Togo, HIV prevalence among key populations ranges from 11% to 13% compared to 2.1% in the general population [20,21]. Although issues related to key populations have been extensively studied in Togo, to our knowledge, no data are available on mental health problems among these populations. The aim of this study was to assess the prevalence of and factors associated with PD among MSM, FSW and DU in Togo in 2017.

Methods

Study design and sampling

This study was a bio-behavioral cross-sectional study conducted from August to September 2017 in eight cities in Togo. Prior to the study, locations (associations and hot spots) specific to each group of key population were identified during preliminary visits with the help of leaders from these communities. DU and FSW were recruited in drug-dealing/consumption locations and brothels (licensed or not), respectively. MSM were recruited using a Respondent Driven Sampling (RDS) method. MSM community leaders were the first “seeds”. A total of 28 seeds were identified at first based on their roles in their community and on their representativeness. Each seed from the first wave selected had to represent at least one sub-group: the actives (the ones who penetrate during sex), the passives (the penetrated), bisexuals, gays, etc. Each participant was then given three coupons with a unique identification code to recruit three other seeds in their network until the required sample size for each group was reached. Inclusion criteria for the three groups were being 18 years or older, living/working/studying in Togo for a minimum of 3 months at the time of the study, and being in possession of a recruitment coupon. In addition to these criteria, criteria specific to MSM were having had anal sex with a man in the previous 12 months, for FSW having had sex in exchange for money as a compensation in the previous 12 months and for DU, consuming heroin, cocaine or hashish at the time of the study.

Ethics approval and consent to participate

This study was approved by the “Comité de Bioéthique pour la Recherche en Santé” (Bioethics Committee for Health Research) from the Togo Ministry of Health (CBRS No. 18/2017/CBRS of June 22nd 2017). Potential participants were informed about the study purpose and procedures, potential risks and protections, and compensation. Informed consent was documented with signed consent forms prior to participation.

Data collection

After eligibility screening and written informed consent, a structured and standardized questionnaire was administered by trained study staff during a face-to-face interview. The Kessler PD Scale (K10) [22] was used to measure PD. The K10 is a 10-item screening tool which has been used in several countries and it has been validated in a low-income, African setting with strong validity and reliability [23,24].

Alcohol and tobacco consumption were also assessed using validated tools: the Alcohol Use Disorders Identification Test (AUDIT) [25] and a subset of the Tobacco Questions for Surveys [26] respectively. To collect information on socio-demographic characteristics, risky sexual behaviors, STIs, HIV prevention methods, HIV testing history, access to health care services, and HIV knowledge, items from the Family Health International (FHI) 360 validated guide for bio-behavioral surveys [27] were included in the questionnaire. The same questionnaires were used across the three populations with slight adaptations depending on the population.

Laboratory testing

Two HIV rapid tests were performed using SD Biolane Duo VIH/Syphilis rapid test kits. For each participant, a 4 mL blood sample was collected and a third test, ImmunoComb II VIH1-2 Comfirm (Orgenics Ltd, Israël) was used for confirmation. All biological test analyses were completed in the principal HIV laboratory research unit, the Molecular Biology Laboratory (CBMI) at the University of Lomé.

Scores and operational definitions

Psychological distress

The K10 has been examined and validated among several populations and aims at measuring anxiety and depression with a 10-item questionnaire, each question pertaining to an emotional state and a five-level response scale for each response. The score obtained from the scale allows categorization of participants into four ordinal categories of PD: severe (score ≥ 30), moderate (score: 25–29), mild (score: 20–24) and none (score < 20) [28]. In our study, due to the small number of participants falling in the severe category, we collapsed the Kessler PD scores into three categories as: severe/moderate (score ≥25), mild (score: 20–24) and none (score <20).

Alcohol consumption

To assess alcohol consumption, the AUDIT-C was used. The AUDIT-C is a screening tool used to identify persons who are hazardous drinkers or have active alcohol use disorders (including alcohol abuse or dependence). The AUDIT-C is a modified version of the 10 question AUDIT instrument and it proved to be as effective as the AUDIT [29]. As with the 10-item AUDIT, higher scores indicate more problematic alcohol use. The AUDIT-C is scored on a scale of 0–12. Each question has 5 answer choices and can obtain a score from 0 to 4. A score ≥5 for men and ≥4 for women indicates hazardous drinking, while a score of 0 indicates a non-drinker; moderate alcohol use lies in-between [25,30,31].

Statistical analysis

We used a Partial Proportional Odds (PPO) model to assess factors associated to PD. Descriptive statistics were performed and results were presented with frequency tabulations and percentages. Prevalence rates were estimated with their 95% confidence interval. For model building, characteristics that had a p-value <0.20 in univariable analysis were considered for the full multivariable models, which were subsequently finalized using a stepwise, backward elimination approach (p-value <0.05). Predictor variables were selected as those found to be relevant according to the literature review. All computations were conducted using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA).

Results

Sociodemographic and clinical characteristics

A total of 2044 key populations including 449 DU, 952 FSW and 643 MSM with a median age of 25 years, interquartile range (IQR) [21–32 years] were included. More than two-thirds (68.5%) of participants had at least a secondary education level and 15.7% were married or living with a partner. The HIV prevalence was 13.7% (95%CI = [12.2–15.2]) across the three key populations with the highest prevalence among MSM (21.6%; 95%CI = [18.5–25.0]). Other sociodemographic and clinical characteristics are summarized in Table 1.

Table 1

Sociodemographic and clinical characteristics of key populations, Togo 2017.

	DU (n = 449)	FSW (n = 952)	MSM (n = 643)	Total (= 2044)
Age (years), median [IQR]	29 [23–37]	26 [22–32]	23 [20–26]	25 [21–32]
Marital status, n (%)
Married/Living with a partner	148 (33.0)	133 (14.0)	40 (6.2)	321 (15.7)
Not married	301 (67.0)	819 (86.0)	603 (93.8)	1723 (84.3)
Education level, n (%)
Primary school	160 (35.6)	429 (45.1)	54 (8.4)	643 (31.5)
Secondary school	268 (59.7)	476 (50.0)	358 (55.7)	1102 (53.9)
College/University	21 (4.7)	47 (4.9)	231 (35.9)	299 (14.6)
Religion, n (%)
Other/ Non-believer	97 (21.6)	110 (11.5)	65 (10.1)	272 (13.2)
Christian	282 (62.8)	747 (78.5)	525 (81.7)	1554 (76.0)
Muslim	70 (15.6)	95 (10.0)	53 (8.2)	220 (10.8)
Alcohol consumption, n (%)
Non-drinker	66 (14.7)	323 (33.9)	326 (50.7)	715 (34.9)
Moderate drinking	79 (17.6)	197 (20.7)	130 (20.2)	406 (19.9)
Hazardous consumption	304 (67.7)	432 (45.4)	187 (29.1)	923 (45.2)
Tobacco consumption, n (%)
Non-smoker	89 (19.8)	825 (86.7)	546 (84.9)	1460 (71.4)
Smoker	360 (80.2)	127 (13.3)	97 (15.1)	584 (28.6)
HIV infection, n (%)
No	433 (96.4)	827 (86.9)	504 (78.4)	1764 (86.3)
Yes	16 (3.6)	125 (13.1)	139 (21.6)	280 (13.7)

IQR: interquartile range

DU: drug user; FSW: female sex worker; MSM: men who have sex with men

Prevalence of psychological distress

The median Kessler score was 14 (IQR = [10-19]) for MSM, 18 (IQR = [13-23]) for FSW and 21 (IQR = [16-27]) for DU. About two-thirds (n = 1,244; 61.0%) of the participants did not have PD. The overall prevalence of mild PD among the three populations was 19.9% (95%CI = [18.3–21.8]) and was 19.2% (95%CI = [17.5–20.9]) for the severe/moderate PD. The prevalence of PD was statistically different in the three groups (p-value <0.001). Among DU, the prevalence of mild PD was 23.4%, 95%CI = [20-28] and 32.1%, 95%CI = [28-37] had severe/moderate PD. Severe/moderate PD was reported among one FSW in five (19.0%; 95%CI = [17-22]). The relationships between sociodemographic and clinical characteristics and PD are presented in Table 2.

Table 2

Associations between psychological distress and sociodemographic and clinical characteristics among key populations (N = 2044).

	Psychological distress
	No	Mild	Severe/Moderate	P-value
Prevalence, n (%)	1244 (60.9)	408 (19.9)	392 (19.2)
Age (years), median [IQR]	24 [21–30]	26 [21–33]	28 [22.5–34]	<0.001*
Marital status, n (%)				<0.001**
Not married	1081 (62.7)	334 (19.4)	308 (17.9)
Married/Living with a partner	163 (50.8)	74 (23.0)	84 (26.2)
Education level, n (%)				<0.001**
Primary school	292 (45.4)	164 (25.5)	187 (29.1)
Secondary school	725 (65.8)	208 (18.9)	169 (15.3)
College/University	227 (76.0)	36 (12.0)	36 (12.0)
Religion, n (%)				0.003**
Other/ Non-believer	136 (50.0)	67 (24.6)	69 (25.4)
Christian	973 (62.6)	297 (19.1)	284 (18.3)
Muslim	135 (61.9)	44 (20.2)	39 (17.9)
Alcohol consumption, n (%)				<0.001****
Non-drinker	502 (70.2)	117 (16.4)	96 (13.4)
Moderate drinking	244 (60.1)	83 (20.4)	79 (19.5)
Hazardous consumption	498 (54.0)	208 (22.5)	217 (23.5)
Tobacco consumption, n (%)				<0.001**
Non-smoker	1069 (63.3)	333 (19.7)	288 (17.0)
Smoker	175 (49.4)	75 (21.2)	104 (29.4)
HIV infection, n (%)				0.010**
No	1075 (60.9)	366 (20.8)	323 (18.3)
Yes	169 (60.4)	42 (15.0)	69 (24.6)
Key population				<0.001**
DU	200 (44.5)	105 (23.4)	144 (32.1)
FSW	548 (57.6)	223 (23.4)	181 (19.0)
MSM	496 (77.1)	80 (12.5)	67 (10.4)

a Psychological distress was measured with the Kessler Psychological Distress Scale (10). Total Kessler score <20: No Psychological distress, 20–24: Mild disorder, 25–50: Moderate/Severe disorder.

Kruskall-Wallis test

Chi-square test

IQR: interquartile range

DU: drug user; FSW: female sex worker; MSM: men who have sex with me

Factors associated with psychological distress

Results of ordinal logistic regression models among key population are presented in Table 3.

Table 3

Factors associated with psychological distress among key population in Togo (Partial proportional odds model).

(Psychological distress: 1 = Severe/Moderate, 2 = Mild, 3 = No)
	Univariable			Multivariable
	1 vs (2 and 3)	(1 and 2) vs 3	P-value	1 vs (2 and 3)	(1 and 2) vs 3	P-value
	OR (95% CI)	OR (95% CI)		aOR (95% CI)	aOR (95% CI)
Age (years)
< 25	Reference		<0.001	Reference		0.026
≥ 25	1.77 (1.48–2.11)	1.77 (1.48–2.11)		1.24 (1.02–1.50)	1.24 (1.02–1.50)
Marital status			<0.001			-
Not married	Reference			-	-
Married/Living with a partner	1.63 (1.29–2.04)	1.63 (1.29–2.04)		-	-
Education level			<0.001			<0.001
Primary school	Reference			Reference
Secondary	0.44 (0.36–0.52)	0.44 (0.36–0.52)		0.52 (0.42–0.64)	0.52 (0.42–0.64)
College/University	0.27 (0.20–0.37)	0.27 (0.20–0.37)		0.46 (0.32–0.64)	0.46 (0.32–0.64)
Religion			<0.001			-
Other/ Non-believer	Reference			-	-
Christian	0.62 (0.48–0.78)	0.62 (0.48–0.78)		-	-
Muslim	0.63 (0.44–0.88)	0.63 (0.44–0.88)		-	-
Alcohol consumption			<0.001			<0.001
Non-drinker	Reference			Reference
Moderate drinking	1.56 (1.22–2.0)	1.56 (1.22–2.0)		1.28 (0.98–1.65)	1.28 (0.98–1.65)
Hazardous consumption	2.0 (1.64–2.45)	2.0 (1.64–2.45)		1.52 (1.22–1.87)	1.52 (1.22–1.87)
Tobacco consumption			<0.001			-
Non-smoker	Reference
Smoker	1.84 (1.46–2.32)	1.48 (1.22–1.80)		-	-
HIV infection			0.004			<0.001
No	Reference			Reference
Yes	1.46 (1.08–1.96)	1.02 (0.79–1.32)		1.80 (1.31–2.48)	1.25 (0.94–1.65)
Key population			<0.001			<0.001
DU	Reference			Reference
FSW	0.56 (0.45–0.69)	0.56 (0.45–0.69)		0.55 (0.43–0.68)	0.55 (0.43–0.68)
MSM	0.23 (0.18–0.30)	0.23 (0.18–0.30)		0.33 (0.24–0.44)	0.33 (0.24–0.44)

# For nearly all variables, the left 2 columns are the same, so are the right 2 columns, because the assumption of proportional odds was met for those variables and therefore we used the same value for both columns. (Only the OR for tobacco smoker and HIV infection were different.)

In univariable analysis, age, marital status, education level, religion, alcohol consumption, tobacco consumption, HIV infection status and the group of key population were associated with PD (Table 3).

In multivariable analysis, after adjustment on the other variables, respondents who were 25 years old and older, were more likely to have severe/moderate or mild PD than respondents who were younger (p = 0.026). HIV positive serological status was a risk factor for PD (aOR = 1.80; 95%CI [1.31–2.48]). The odds of PD were higher among hazardous drinkers (aOR = 1.52; 95%CI = [1.22–1.87]) compared to non-drinkers. Those with secondary school level or with college/university level were less likely to have severe/moderate or mild PD compared to those who stopped in primary school (p<0.001). Compared to DU, FSW (aOR = 0.55; 95%CI = [0.43–0.68]) and MSM (aOR = 0.33; 95%CI = [0.24–0.44]) were less likely to have severe/moderate or mild PD.

Discussion

Among MSM, FSW, and DU in Togo, the overall prevalence of mild and severe/moderate psychological distress was 19.9% and 19.2% respectively. DU had higher level of psychological distress compared with FSW and MSM (p<0.001). Also, among the three populations, participants with HIV infection were more likely to experience psychological distress than their non-infected counterparts. Factors associated with psychological distress other than HIV infection were greater age, lower education level and hazardous alcohol consumption.

We did not have national data or data among key populations in Togo to which we could compare our findings. Other studies using K-10 were conducted in Africa. In the general population in South Africa (n = 25850), 23.9% of study participants reported psychological distress (K-10≥20) [34]. Hazardous alcohol drinking (OR = 1.79) as well as HIV positive status (OR = 4.76) were associated with psychological distress as observed in our study. In another cross-sectional study among 180 patients conducted in drug rehabilitation centers in Nepal which used K-6 as psychological distress measurement tool, the prevalence of high psychological distress was 51.1% [35]. Factors associated with psychological distress were age, education level, severity of drug abuse. Among Latino and African American MSM living in the USA, 22% had moderate/severe psychological distress using the K-10 scale [36]. This prevalence is similar to the overall moderate/severe psychological distress prevalence in our study among the three key populations (19.0%). However, this estimate was higher than that reported among MSM in our study (10.4%). There is a gap between the percentages of PD in other countries and in our study mainly because of the age differences. Indeed, the population considered in our study is relatively young (median age = 25 years) unlike in other studies [35,36]. Also, different tools have been used in the other studies to measure PD as the Patient Health Questionnaire (PHQ) [19], the Center for Epidemiologic Studies Depression Scale (CES-D) [40] and K-6 [35].

Several studies in developed countries have reported that alcohol or drug consumption are closely associated with psychological distress. This is consistent with our study regarding alcohol consumption. Binge drinking or cocaine consumption were associated with psychological distress among Latino and African American in the USA [36].

Among 280 HIV infected patients in our study, 39.6% had psychological distress (K-10 scale>20). In a Nigerian study among 117 people living with HIV/AIDS recruited in a teaching hospital, 47.9% participants had psychological distress (K-10 scale>20) [37] and alcohol use was associated with PD. Similar results were reported in Ethiopia where an association between PD and alcohol use disorder was reported (OR = 1.90) [38].

A limited number of studies among key populations used the Kessler scale. However mental health was explored in these populations with tools such as the PHQ and the CES-D. A study in India among MSM (n = 1176) measured the prevalence of depression with PHQ-2 tool. Having had an STI in the six months preceding the study, being HIV positive, not having used a condom during sexual intercourse were associated with depression [19]. In the USA, a cross-sectional survey was conducted among Lesbian, Gay male, and Bisexual (LGB) older adults, aged 50 and older (n = 2439). This study investigated depression among LGB with the CES-D tool and the findings revealed that lifestyle, financial barriers, obesity were factors which accounted for poor general health, and depression among LGB older adults [39]. Another study conducted in the USA among black MSM (n = 197) used the CES-D to measure depression. This study has also reported a link between alcohol consumption and depressive symptoms [40].

Little is known about mental health among key populations in sub-Saharan Africa, and to our knowledge this study is the first one which has assessed psychological distress among these groups using an international validated tool (K-10). This tool has been validated in the African context in South Africa in general population [34]. In addition, we used data from a nationally representative study (n = 2044) including three main groups of key populations, allowing for the generalization of our findings. Finally, our study provided useful information on factors associated with PD among key populations in order to design specific interventions within these populations.

Our study has some limitations. First, we worked on three populations, but it is possible that an FSW may be a DU or an MSM may also be a DU. However, to classify the population, we took into account only the entry point. Since our study was based on self-reporting, social desirability bias cannot be ruled out. This bias could have underestimated the prevalence rates of PD. Also, as we conducted a cross-sectional study, causality between the factors identified and PD could not be addressed. Other factors such as an employment status were not included although they could potentially affect psychological distress, as reported in a study conducted among MSM in South Africa [34]. Finally, there was no medical evaluation in the present study.

Conclusion and recommendations

This is the first study conducted among a large, nationally representative sample of key populations in Togo. The prevalence of PD is high among Key Population in Togo and was associated to HIV infection. Mental health care such as social support groups must be integrated within health and prevention programs dedicated to key populations in Togo in order to promote a holistic perspective of their health. In order to confirm the high prevalence of PD, studies in the general population or comparative studies are needed. Also, since PD a multifactorial process, it would be useful to couple a qualitative study with a quantitative study.

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13 Jan 2020

PONE-D-19-29894

Prevalence and factors associated with psychological distress among key populations in Togo, 2017.

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Reviewer #2: Yes

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Reviewer #1: Thanks for the opportunity to read and learn about your interesting work. May I offer the following suggestions.

General:

It is important to be clear about the direction of associations in key places like the Abstract and in the first paragraph of Discussion. I think most of what you say in the Results section of the Abstract is okay *except* regarding education. I recommend you end the list of factors with "hazardous alcohol consumption (aOR and 95% CI are listed here) were associated with PD." Then start a new sentence saying something like "People with secondary (aOR and 95% CI here) or higher (aOR and CI) education levels were LESS likely to report PD." Then in the first paragraph of Discussion section (page 11), you should specify GREATER age and LOWER education level.

Where you refer to bivariate and multivariate methods, my understanding is these should be labeled Univariable and Multivariable (ending with -able instead of -ate). See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3679183/ for discussion.

There are several places where you splice two sentences together with the word "and." Probably better to separate to 2 sentences, or use a semicolon instead of the "and." e.g., near bottom of page 2 after citations (11-13).

Specific:

Page 1 Abstract, last line in Methods section, should "model" have an -s on it ? Also, not sure if you can use abbreviation PD without introducing it, even though it appears later in the sentence in the name of the scale.

Regarding Results section of Abstract, see note below about so many zeros after decimal points. for median and IQR, delete the ".0" because you are using only integer values. For the percentages, some of the ".0" are actually not correct. 19.0% should be 19.2% (392/2044). Although I did not calculate the CI's, those too are not correct and you will have to calculate those yourself (where it says 18.0-22.0 and 17.0-21.0).

page 2, 2nd paragraph. I would change the 1st 2 sentences around a bit: "Some population subgroups, such as those at higher risk of HIV, are particularly burdened with mental health issues. According to UNAIDS (etc …)"

page 2, 8th line from bottom, insert "the" so it says "key contributor to the HIV epidemic"

page 3 line 7, add "of" so it says "prevalence of and factors associated with"

Need just a little more info on what "passives, actives" refers to - is it sexual position ?

Last paragraph on Kessler PD Scale - some of this text is repeated on the next page; delete one or the other.

Page 4 -- should be only one L in syphilis. Then 2 lines down, delete s on "tests"

next paragraph is where Kessler PD repeat occurs. Also in that paragraph, change "allows to categorize" to "allows categorization of."

page 5: along with "latent" mention that PO model is used for *ordinal* outcome variables.

With backward elimination approach, what was the criterion for elimination ? e.g., P<0.05, 0.01 ?

page 6: first sentence regarding Kessler scores, leave off all the zeros after decimal for median and IQR scores, since these Kessler score values are always integers. On the other hand, in the next sentence some of the zeros after decimal point in the percentages are not correct. 20.0% is correct, but 61.0% should be 60.9%, and 19.0% should be 19.2%. You will need to recalculate your 95% CI's in this sentence and the rest of this paragraph - these should not all be ending with ".0%"

I don't think you need Figure 1. Instead, just add the key population groups as another variable at the bottom of Table 2.

In Table 2, you need to make the same corrections to percentages (first row only) as in the text, namely change 61.0 to 60.9 and 19.0 to 19.2. On age, delete the ".0"s since all these numbers are integers only. Throughout the rest of Table 2, I think the ROW totals should add to 100% rather than the column totals. That helps the reader quickly approximate the odds ratios you will be presenting in Table 3.

Page 9: Change 1st sentence to: "RESULTS OF ordinal logistic regression models (etc...)" (add s to "models")

Line 2, here I would say univariable analysis instead of univariate. (and note you said "bivariate" in the abstract, which I think should also say "univariable")

Line 3, delete the word "factors" so it just says "were associated with …"

Next paragraph, change multivariate to multivariable.

Add an s so it says odds in "The odd of psychological" and then change "was" to "were"

Table 3: change column headers to Univariable and Multivariable. I think you should explain in a footnote that for nearly all variables, the left 2 columns are the same, and the right 2 columns are the same, because the assumption of proportional odds was met for those variables and therefore you used the same value for both columns. (only the tobacco smoker and HIV infection OR's are different.)

page 11, it is confusing to use "respectively" when there are 2 different lists. I suggest "Among MSM, FSW, and DU in Togo, the overall prevalence of mild and severe/moderate psychological distress was 20.0% and 19.2% respectively."

2nd paragraph, Could you say more about whether and why these percentages reporting PD in other countries are higher or lower than in your study ? In the sentence where you cite the 23.9% in South Africa, you could say "compared to 39.2% in our study."

Best wishes with the manuscript and your research.

Reviewer #2: Review for article titled: Prevalence and Factors Associated with Psychological Distress among Key Populations in Togo, 2017

Overall, the paper reads well, congratulations!

I have minor comments that I think need to be addressed:

Abstract

1. The write up has several grammatical errors that should be worked on.

2. Use of abbreviations should come after you have spelled the long form earlier. In the abstract, the author has used the abbreviation PD for the first time before it is written in full.

3. In reporting factors associated with PD, the author could choose to report such factors in groups; that is those that increase the risk and those that reduce the risk.

4. The conclusion sounds more like a recommendation. I advise that you give concluding statements based on your findings. You may want to title the section as Conclusion and Recommendation and include a sentence on recommendations.

Introduction:

1. When making reference of previous studies, there is no need to report estimates and their 95% confidence intervals.

2. A statement, .... “poor mental status has been identified as a key contributor to HIV epidemic among key populations,” requires a citation.

Results:

1. The statement, “the prevalence of psychological distress was statistically different in the three groups” lacks supporting statistical evidence to substantiate it.

2. Table 2:

a. All percentages should be row percentages to make sense of the relationships between variables

b. The p-value reported for the relationship between age and psychological distress need to be described whether it is a p-for trend or not. If it is not a p-value for trend, then there is also a need to mentions which comparison is being made.

Discussion:

1. When referencing previous studies, there is no need to report the estimates and their 95% confidence intervals.

2. Grammatically, use “a” and “an” as appropriately. FSW should be preceded by “an” and not “a”…similarly, it is “an MSM” and not “a MSM”

3. In the limitations of your study, you have pointed out some potential bias that could have been introduced in your study. However, you did not show or describe the potential impact of the introduced bias to your results.

4. One of the limitations you have mentioned is the cross-sectional nature of your study pointing that, you cannot elicit causality from this design. Does this mean the findings are of no use? Can you mention how can we make use of your findings despite the lack of causality?

5. The last paragraph of your discussion presents recommendations. I advise it be moved to an appropriate section.

Conclusion:

1. Your conclusion presents recommendations. I would advise you change the title of the section to Conclusion and Recommendation and then include concluding remarks as well as recommendations.

**********

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Reviewer #2: No

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Submitted filename: Review_Factors associated with PD among KPs in Togo.docx

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7 Feb 2020

Response to reviewers

Reviewer #1: Thanks for the opportunity to read and learn about your interesting work. May I offer the following suggestions.

Authors: We thank the reviewer for this encouraging comment.

1. It is important to be clear about the direction of associations in key places like the Abstract and in the first paragraph of Discussion. I think most of what you say in the Results section of the Abstract is okay *except* regarding education. I recommend you end the list of factors with "hazardous alcohol consumption (aOR and 95% CI are listed here) were associated with PD." Then start a new sentence saying something like "People with secondary (aOR and 95% CI here) or higher (aOR and CI) education levels were LESS likely to report PD."

Then in the first paragraph of Discussion section (page 11), you should specify GREATER age and LOWER education level.

Authors: We thank the reviewer for these comments which have been taken into consideration in the abstract and discussion sections.

HIV prevalence was 13.7% (95%CI = [12.2-15.2]). High age (25 years and over) [aOR = 1.24 (95% CI: 1.02–1.50)], being HIV positive [aOR = 1.80 (95% CI: 1.31–2.48)] and hazardous alcohol consumption [aOR = 1.52 (95% CI: 1.22–1.87)] were risks factors associated with PD. People with secondary [aOR = 0.52 (95% CI: 0.42-0.64)] or higher [aOR = 0.46 (95% CI: 0.32-0.64)] education levels were protective factors associated with PD.

Discussion (page 10)

Factors associated with psychological distress other than HIV infection were greater age, lower education level and hazardous alcohol consumption.

2. Where you refer to bivariate and multivariate methods, my understanding is these should be labeled Univariable and Multivariable (ending with -able instead of -ate). See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3679183/ for discussion.

Authors: We thank the reviewer for these comments. All the words have been relabeled (bivariate relabeled univariable and multivariate relabeled multivariable).

Descriptive statistics, univariable and multivariable ordinal regression models were used for analysis.

For model building, characteristics that had a p-value <0.20 in univariable analysis were considered for the full multivariable models, which were subsequently finalized using a stepwise, backward elimination approach (p-value <0.05).

In univariable analysis, age, marital status, education level, religion, alcohol consumption, tobacco consumption, HIV infection status and the group of key population were associated with PD (Table 3).

In multivariable analysis, after adjustment on the other variables, respondents who were 25 years old and older, were more likely to have severe/moderate or mild PD than respondents who were younger (p=0.026).

3. There are several places where you splice two sentences together with the word "and." Probably better to separate to 2 sentences, or use a semicolon instead of the "and." e.g., near bottom of page 2 after citations (11-13).

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

4. Specific:

Page 1 Abstract, last line in Methods section, should "model" have an -s on it ? Also, not sure if you can use abbreviation PD without introducing it, even though it appears later in the sentence in the name of the scale.

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Methods

Psychological distress (PD) was assessed with the Kessler Psychological Distress Scale. A blood sample was taken to test for HIV. Descriptive statistics, univariable and multivariable ordinal regression models were used for analysis.

5. Regarding Results section of Abstract, see note below about so many zeros after decimal points. for median and IQR, delete the ".0" because you are using only integer values. For the percentages, some of the ".0" are actually not correct. 19.0% should be 19.2% (392/2044). Although I did not calculate the CI's, those too are not correct and you will have to calculate those yourself (where it says 18.0-22.0 and 17.0-21.0).

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Results

The overall prevalence of mild PD among the three populations was 19.9% (95%CI= [18.3-21.8]) and was 19.2% (95%CI= [17.5-20.9]) for severe/moderate PD. HIV prevalence was 13.7% (95%CI = [12.2-15.2]).

6. page 2, 2nd paragraph. I would change the 1st 2 sentences around a bit: "Some population subgroups, such as those at higher risk of HIV, are particularly burdened with mental health issues. According to UNAIDS (etc …)"

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Some population subgroups, such as those at higher risk of HIV, are particularly burdened with mental health issues. According to the UNAIDS, gay men and other men who have sex with men (MSM), female sex workers (FSW) and their clients, transgender people, people who inject drugs and prisoners and other incarcerated people are the main key population groups (7).

7. page 2, 8th line from bottom, insert "the" so it says "key contributor to the HIV epidemic"

page 3 line 7, add "of" so it says "prevalence of and factors associated with"

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Moreover, poor mental health has been identified as a key contributor to the HIV epidemic among key populations.

The aim of this study was to assess the prevalence of and factors associated with PD among MSM, FSW and DU in Togo in 2017.

8. Need just a little more info on what "passives, actives" refers to - is it sexual position?

Authors: We thank the reviewer for these comments. These two notions refer to sexual positions: the active designates the one who penetrates and the passive, the penetrated.

9. Last paragraph on Kessler PD Scale - some of this text is repeated on the next page; delete one or the other.

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

10. Page 4 -- should be only one L in syphilis. Then 2 lines down, delete s on "tests"

next paragraph is where Kessler PD repeat occurs. Also in that paragraph, change "allows to categorize" to "allows categorization of."

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Two HIV rapid tests were performed using SD Biolane Duo VIH/Syphilis rapid test kits. For each participant, a 4 mL blood sample was collected and a third test, ImmunoComb II VIH1-2 Comfirm (Orgenics Ltd, Israël) was used for confirmation. All biological test analyses were completed in the principal HIV laboratory research unit, the Molecular Biology Laboratory (CBMI) at the University of Lomé.

Scores and operational definitions

Psychological Distress

The score obtained from the scale allows categorization of participants into four categories of PD: severe (score ≥ 30), moderate (score: 25-29), mild (score: 20-24) and none (score < 20) (28).

11. page 5: along with "latent" mention that PO model is used for *ordinal* outcome variables.

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

We considered Partial Proportional Odds model for the dependent variable Psychological Distress (PD).

• The Proportional Odds (PO) model is appropriate when the response categories are based on one or more latent response variable.

12. With backward elimination approach, what was the criterion for elimination? e.g., P<0.05, 0.01?

Authors: We thank the reviewer for these comments. The criterion for elimination was p<0.05 for the multivariable model.

For model building, characteristics that had a p-value <0.20 in univariable analysis were considered for the full multivariable models, which were subsequently finalized using a stepwise, backward elimination approach (p-value <0.05).

13. page 6: first sentence regarding Kessler scores, leave off all the zeros after decimal for median and IQR scores, since these Kessler score values are always integers. On the other hand, in the next sentence some of the zeros after decimal point in the percentages are not correct. 20.0% is correct, but 61.0% should be 60.9%, and 19.0% should be 19.2%. You will need to recalculate your 95% CI's in this sentence and the rest of this paragraph - these should not all be ending with ".0%".

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Prevalence of psychological distress

The median Kessler score was 14 (IQR = [10-19]) for MSM, 18 (IQR = [13-23]) for FSW and 21 (IQR= [16-27]) for DU. About two-thirds (n=1,244; 61.0%) of the participants did not have psychological distress. The overall prevalence of mild psychological distress among the three populations was 19.9% (95%CI= [18.3-21.8]) and was 19.2% (95%CI= [17.5-20.9]) for the severe/moderate psychological distress. The prevalence of psychological distress was statistically different in the three groups (p-value <0.001). Among DU, the prevalence of mild psychological distress was 23.4%, 95%CI = [20-28] and 32.1%, 95%CI = [28-37] had severe/moderate psychological distress. Severe/moderate psychological distress was reported among one FSW in five (19.0%; 95%CI = [17-22]). The relationships between sociodemographic and clinical characteristics and psychological distress are presented in Table 2.

14. I don't think you need Figure 1. Instead, just add the key population groups as another variable at the bottom of Table 2.

In Table 2, you need to make the same corrections to percentages (first row only) as in the text, namely change 61.0 to 60.9 and 19.0 to 19.2. On age, delete the ".0"s since all these numbers are integers only. Throughout the rest of Table 2, I think the ROW totals should add to 100% rather than the column totals. That helps the reader quickly approximate the odds ratios you will be presenting in Table 3.

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Table 2: Associations between psychological distressa and sociodemographic and clinical characteristics among key populations (N=2044)

Psychological distress

No Mild Severe/Moderate

P-value

Prevalence, n (%) 1244 (60.9) 408 (19.9) 392 (19.2)

Age (years), median [IQR] 24 [21-30] 26 [21-33] 28 [22.5-34] <0.001*

Marital status, n (%) <0.001**

Not married 1081 (62.7) 334 (19.4) 308 (17.9)

Married/Living with a partner 163 (50.8) 74 (23.0) 84 (26.2)

Education level, n (%) <0.001**

Primary school 292 (45.4) 164 (25.5) 187 (29.1)

Secondary school 725 (65.8) 208 (18.9) 169 (15.3)

College/University 227 (76.0) 36 (12.0) 36 (12.0)

Religion, n (%) 0.003**

Other/ Non-believer 136 (50.0) 67 (24.6) 69 (25.4)

Christian 973 (62.6) 297 (19.1) 284 (18.3)

Muslim 135 (61.9) 44 (20.2) 39 (17.9)

Alcohol consumption, n (%) <0.001**

Non-drinker 502 (70.2) 117 (16.4) 96 (13.4)

Moderate drinking 244 (60.1) 83 (20.4) 79 (19.5)

Hazardous consumption 498 (54.0) 208 (22.5) 217 (23.5)

Tobacco consumption, n (%) <0.001**

Non-smoker 1069 (63.3) 333 (19.7) 288 (17.0)

Smoker 175 (49.4) 75 (21.2) 104 (29.4)

HIV infection, n (%) 0.010**

No 1075 (86.4) 366 (89.7) 323 (82.4)

Yes 169 (13.6) 42 (10.3) 69 (17.6)

Key population <0.001**

DU 200 (44.5) 105 (23.4) 144 (32.1)

FSW 548 (57.6) 223 (23.4) 181 (19.0)

MSM 496 (77.1) 80 (12.5) 67 (10.4)

* Kruskall-Wallis test; ** Chi-square test;

15. Page 9: Change 1st sentence to: "RESULTS OF ordinal logistic regression models (etc...)" (add s to "models")

Line 2, here I would say univariable analysis instead of univariate. (and note you said "bivariate" in the abstract, which I think should also say "univariable")

Line 3, delete the word "factors" so it just says "were associated with …". Next paragraph, change multivariate to multivariable. Add an s so it says odds in "The odd of psychological" and then change "was" to "were"

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Factors associated with Psychological Distress

Results of ordinal logistic regression models among key population are presented in table 3.

In univariable analysis, age, marital status, education level, religion, alcohol consumption, tobacco consumption, HIV infection status and the group of key population were associated with psychological distress (Table 3).

In multivariable analysis, after adjustment on the other variables, respondents who were 25 years old and older, were more likely to have severe/moderate or mild psychological distress than respondents who were younger (p=0.026). Those with secondary school level or with college/university level were less likely to have severe/moderate or mild psychological distress compared to those who stopped in primary school (p<0.001). The odds of psychological distress were higher among hazardous drinkers (aOR=1.52; 95%CI= [1.22-1.87]) compared to non-drinkers. HIV serological status was a factor associated with psychological distress (aOR= 1.80; 95%CI [1.31-2.48]). Compared to DU, FSW (aOR= 0.55; 95%CI = [0.43-0.68]) and MSM (aOR= 0.33; 95%CI = [0.24-0.44]) were less likely to have severe/moderate or mild psychological distress.

16. Table 3: change column headers to Univariable and Multivariable. I think you should explain in a footnote that for nearly all variables, the left 2 columns are the same, and the right 2 columns are the same, because the assumption of proportional odds was met for those variables and therefore you used the same value for both columns. (only the tobacco smoker and HIV infection OR's are different.)

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Table 3: Factors associated with psychological distress among key population in Togo (Partial proportional Odds model) #.

(Psychological distress: 1 = Severe/Moderate, 2 = Mild, 3 = No)

Univariable Multivariable

1 vs (2 and 3) (1 and 2) vs 3 P-value 1 vs (2 and 3) (1 and 2) vs 3 P-value

OR (95 % CI) OR (95 % CI) aOR (95 % CI) aOR (95 % CI)

Age (years)

< 25 Reference <0.001 Reference 0.026

≥ 25 1.77 (1.48-2.11) 1.77 (1.48-2.11) 1.24 (1.02-1.50) 1.24 (1.02-1.50)

Marital status <0.001 -

Not married Reference - -

Married/Living with a partner 1.63 (1.29-2.04) 1.63 (1.29-2.04) - -

Education level <0.001 <0.001

Primary school Reference Reference

Secondary 0.44 (0.36-0.52) 0.44 (0.36-0.52) 0.52 (0.42-0.64) 0.52 (0.42-0.64)

College/University 0.27 (0.20-0.37) 0.27 (0.20-0.37) 0.46 (0.32-0.64) 0.46 (0.32-0.64)

Religion <0.001 -

Other/ Non-believer Reference - -

Christian 0.62 (0.48-0.78) 0.62 (0.48-0.78) - -

Muslim 0.63 (0.44-0.88) 0.63 (0.44-0.88) - -

Alcohol consumption <0.001 <0.001

Non-drinker Reference Reference

Moderate drinking 1.56 (1.22-2.0) 1.56 (1.22-2.0) 1.28 (0.98-1.65) 1.28 (0.98-1.65)

Hazardous consumption 2.0 (1.64-2.45) 2.0 (1.64-2.45) 1.52 (1.22-1.87) 1.52 (1.22-1.87)

Tobacco consumption <0.001 -

Non-smoker Reference

Smoker 1.84 (1.46-2.32) 1.48 (1.22-1.80) - -

HIV infection 0.004 <0.001

No Reference Reference

Yes 1.46 (1.08-1.96) 1.02 (0.79-1.32) 1.80 (1.31-2.48) 1.25 (0.94-1.65)

Key population <0.001 <0.001

DU Reference Reference

FSW 0.56 (0.45-0.69) 0.56 (0.45-0.69) 0.55 (0.43-0.68) 0.55 (0.43-0.68)

MSM 0.23 (0.18-0.30) 0.23 (0.18-0.30) 0.33 (0.24-0.44) 0.33 (0.24-0.44)

aOR: adjusted Odds ratio; OR: Odds ratio

# For nearly all variables, the left 2 columns are the same, so are the right 2 columns, because the assumption of proportional odds was met for those variables and therefore we used the same value for both columns. (only the tobacco smoker and HIV infection OR's are different)

17. page 11, it is confusing to use "respectively" when there are 2 different lists. I suggest "Among MSM, FSW, and DU in Togo, the overall prevalence of mild and severe/moderate psychological distress was 20.0% and 19.2% respectively."

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Discussion

Among MSM, FSW, and DU in Togo, the overall prevalence of mild and severe/moderate psychological distress was 19.9% and 19.2% respectively.

18. 2nd paragraph, could you say more about whether and why these percentages reporting PD in other countries are higher or lower than in your study? In the sentence where you cite the 23.9% in South Africa, you could say "compared to 39.2% in our study."

Authors: We thank the reviewer for these comments. There is a gap between the percentages of PD in other countries and in our study mainly because of the age differences. Indeed, the population considered in our study is relatively young (median age = 25 years) unlike in other studies.

Zaller N, Yang C, Operario D, Latkin C, McKirnan D, O’Donnell L, et al. Alcohol and cocaine use among Latino and African American MSM in 6 US cities. Journal of substance abuse treatment. 2017;80:26.

Gyawali B, Choulagai BP, Paneru DP, Ahmad M, Leppin A, Kallestrup P. Prevalence and correlates of psychological distress symptoms among patients with substance use disorders in drug rehabilitation centers in urban Nepal: a cross-sectional study. BMC psychiatry. 2016;16(1):314.

Best wishes with the manuscript and your research.

Authors: We thank the reviewer for this encouraging comment and for all the inputs to enhance the quality of the paper.

Reviewer #2: Review for article titled: Prevalence and Factors Associated with Psychological Distress among Key Populations in Togo, 2017. Overall, the paper reads well, congratulations!

I have minor comments that I think need to be addressed:

Authors: We thank the reviewer for this encouraging comment.

Abstract

1. The write up has several grammatical errors that should be worked on.

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

2. Use of abbreviations should come after you have spelled the long form earlier. In the abstract, the author has used the abbreviation PD for the first time before it is written in full.

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Abstract

Objectives

Mental health is a largely neglected issue among in Sub-Saharan Africa, especially among key populations. The aim of this study was to estimate the prevalence of psychological distress (PD) and to assess the factors associated among males who have sex with males (MSM), female sex workers (FSW) and drug users (DU) in Togo in 2017.

3. In reporting factors associated with PD, the author could choose to report such factors in groups; that is those that increase the risk and those that reduce the risk.

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Abstract

Results

High age (25 years and over) [aOR = 1.24 (95% CI: 1.02–1.50)], being HIV positive [aOR = 1.80 (95% CI: 1.31–2.48)] and hazardous alcohol consumption [aOR = 1.52 (95% CI: 1.22–1.87)] were risks factors associated with PD. People with secondary [aOR = 0.52 (95% CI: 0.42-0.64)] or higher [aOR = 0.46 (95% CI: 0.32-0.64)] education levels were protective factors associated with PD.

Results

Factors associated with Psychological Distress

In multivariable analysis, after adjustment on the other variables, respondents who were 25 years old and older, were more likely to have severe/moderate or mild PD than respondents who were younger (p=0.026). HIV serological status was a risk factor associated with PD (aOR= 1.80; 95%CI [1.31-2.48]). The odds of PD were higher among hazardous drinkers (aOR=1.52; 95%CI= [1.22-1.87]) compared to non-drinkers. Those with secondary school level or with college/university level were less likely to have severe/moderate or mild PD compared to those who stopped in primary school (p<0.001).

4. The conclusion sounds more like a recommendation. I advise that you give concluding statements based on your findings. You may want to title the section as Conclusion and Recommendation and include a sentence on recommendations.

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Conclusion and Recommendations

This is the first study conducted among a large, nationally representative sample of Key Population in Togo. The prevalence of PD is high among Key Population in Togo and was associated to HIV infection. The present study indicates that mental health care must be integrated within health programs in Togo with a special focus to key populations through interventions such as social support groups.

Introduction:

1. When making reference of previous studies, there is no need to report estimates and their 95% confidence intervals.

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

2. A statement, .... “poor mental status has been identified as a key contributor to HIV epidemic among key populations,” requires a citation.

Authors: We thank the reviewer for the comment. The statement above and the sentence which follows it in the text, have the same citation (11–13).

Moreover, poor mental health has been identified as a key contributor to the HIV epidemic among key populations. Indeed, MSM who are mentally depressed engage in unprotected sex and substance abuse (11–13). Several studies have demonstrated a significant association between depressive symptoms and HIV and other sexually transmitted infections (STI) among MSM (14–16).

Results:

1. The statement, “the prevalence of psychological distress was statistically different in the three groups” lacks supporting statistical evidence to substantiate it.

Authors: We thank the reviewer for the comment. We have put the p-value of the chi-square test below figure 1 but have put it now in the text since we removed the figure 1.

The prevalence of PD was statistically different in the three groups (p-value <0.001).

2. Table 2:

a. All percentages should be row percentages to make sense of the relationships between variables

b. The p-value reported for the relationship between age and psychological distress need to be described whether it is a p-for trend or not. If it is not a p-value for trend, then there is also a need to mentions which comparison is being made.

Authors: We thank the reviewer for these comments. All percentages have been changed into row percentages in Table 2. The p-value reported for the relationship between age and psychological distress is for a Kruskall-Wallis test.

Discussion:

1. When referencing previous studies, there is no need to report the estimates and their 95% confidence intervals.

Authors: We thank the reviewer for these comments which have been taken into consideration in the revised document.

2. Grammatically, use “a” and “an” as appropriately. FSW should be preceded by “an” and not “a” …similarly, it is “an MSM” and not “a MSM”

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Our study has some limitations. First, we worked on three populations, but it is possible that an FSW may be an DU or an MSM may also be an DU.

3. In the limitations of your study, you have pointed out some potential bias that could have been introduced in your study. However, you did not show or describe the potential impact of the introduced bias to your results.

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Since our study was based on self-reporting, memory bias and social desirability bias cannot be ruled out. These bias might have had an effect on the prevalence rates of PD. Also, as we conducted a cross-sectional study, causality between the factors identified and psychological distress could not be addressed.

4. One of the limitations you have mentioned is the cross-sectional nature of your study pointing that, you cannot elicit causality from this design. Does this mean the findings are of no use? Can you mention how can we make use of your findings despite the lack of causality?

Authors: We thank the reviewer for these comments. A cross sectional studies cannot prove causality.

Like any cross-sectional study, our study cannot conclude a causality between the factors identified and psychological distress. However our results are useful to the extent that, acting on the associated factors will reduce the risk of the event occurring.

5. The last paragraph of your discussion presents recommendations. I advise it be moved to an appropriate section.

Authors: We thank the reviewer for these comments which have been taken into consideration in the document. The paragraph has been moved to the conclusion.

Conclusion:

1. Your conclusion presents recommendations. I would advise you change the title of the section to Conclusion and Recommendation and then include concluding remarks as well as recommendations.

Authors: We thank the reviewer for these comments. In the revised version of the manuscript, we changed the title of the section to Conclusion and recommendations.

Conclusion and Recommendations

This is the first study conducted among a large, nationally representative sample of key populations in Togo. The prevalence of PD is high among Key Population in Togo and was associated to HIV infection. Mental health care such as social support groups must be integrated within health and prevention programs dedicated to key populations in Togo in order to promote a holistic perspective of their health. In order to confirm the high prevalence of PD, studies in the general population or comparative studies are needed. Also, since PD a multifactorial process, it would be useful to couple a qualitative study with a quantitative study.

Submitted filename: Response_to_Reviewers.docx

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26 Mar 2020

PONE-D-19-29894R1

Prevalence and factors associated with psychological distress among key populations in Togo, 2017.

PLOS ONE

Dear MPH TCHANKONI,

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Additional Editor Comments (if provided):

Thank you for addressing all the previous comments. Please kindly address the few additional comments from the reviewers.

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Reviewers' comments:

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Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

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Reviewer #1: Thank you for addressing my comments. There are still a few small mistakes, and some comments that are addressed in your response to me but I am not sure if they are addressed in the manuscript.

Abstract line 37: add "at risk for HIV" after "key populations."

line 56 delete s on "risks" so it will say "risk factors"

line 57: delete "People with" (the people themselves are not the protective factors)

line 304: change "these bias" to "these biases"

A few items that you answered to me but I still think need to be addressed in the manuscript itself (thanks for numbering the comments, that is a good idea). :

Comment 8: change "passives, actives" to "passive or active sexual position"

Comment 11: the ordinal nature of the outcome variable is what actually matters to the proportional odds model. You could have multiple latent variables involved that led to a multi-categorical outcome variable (e.g., anxious extroverts, anxious introverts, non-anxious extroverts, non-anxious introverts) that was not ordinal, and in that case the proportional odds model would not be correct.

Comment 18: The information that you provided to me regarding age differences is helpful, but I think that info should be provided a little more specifically in the manuscript in line 266.

Two additional item related to comment 11:

11.1: Did you actually report anything based on the Partial Proportional Odds model (PPO) as opposed to the Proportional Odds model (PO) ? If not I suggest you delete the description of PPO in methods in lines 173-178.

11.2: add the word "ordinal" in line 155 so it says "four ordinal categories"

Congrats on the great work!

Reviewer #2: Credits to the authors for addressing all the comments. I have minor additional comments for consideration before publication in the attached document. Thanks for making an effort to contribute to science as we work to end the HIV pandemic.

**********

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Reviewer #2: No

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Submitted filename: Reviewers Additional Comments.docx

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27 Mar 2020

Response to reviewers

Reviewer #1: Thank you for addressing my comments. There are still a few small mistakes, and some comments that are addressed in your response to me but I am not sure if they are addressed in the manuscript.

Authors: We thank the reviewer for this encouraging comment.

1. Abstract line 37: add "at risk for HIV" after "key populations."

line 56 delete s on "risks" so it will say "risk factors"

line 57: delete "People with" (the people themselves are not the protective factors)

line 304: change "these bias" to "these biases"

Authors: We thank the reviewer for these comments which have been taken into consideration in the abstract and discussion sections. We have reworded the sentence before the one referring to biases and therefore “bias” is in the singular.

Abstract

Objectives

line 37: Mental health is a largely neglected issue among in Sub-Saharan Africa, especially among key populations at risk for HIV.

line 56 and 57: (…) and hazardous alcohol consumption [aOR = 1.52 (95% CI: 1.22–1.87)] were risk factors for PD. Secondary [aOR = 0.52 (95% CI: 0.42-0.64)] or higher [aOR = 0.46 (95% CI: 0.32-0.64)] education levels were protective factors associated with PD.

Discussion

line 304: Since our study was based on self-reporting, social desirability bias cannot be ruled out. This bias could have underestimated the prevalence rates of PD.

2. Comment 8: change "passives, actives" to "passive or active sexual position"

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Each seed from the first wave selected had to represent at least one sub-group: the actives (the ones who penetrate), the passives (the penetrated), bisexuals, gays, etc.

3. Comment 11: the ordinal nature of the outcome variable is what actually matters to the proportional odds model. You could have multiple latent variables involved that led to a multi-categorical outcome variable (e.g., anxious extroverts, anxious introverts, non-anxious extroverts, non-anxious introverts) that was not ordinal, and in that case the proportional odds model would not be correct.

Authors: We thank the reviewer for these comments which have been taken into consideration in the document and the sentence has been removed from the section.

Statistical analysis

We considered Partial Proportional Odds model for the dependent variable PD. Descriptive statistics were performed and results were presented with frequency tabulations and percentages. Prevalence rates were estimated with their 95% confidence interval. For model building, characteristics that had a p-value <0.20 in univariable analysis were considered for the full multivariable models, which were subsequently finalized using a stepwise, backward elimination approach (p-value <0.05). Predictor variables were selected as those found to be relevant according to the literature review. All computations were conducted using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA).

4. Comment 18: The information that you provided to me regarding age differences is helpful, but I think that info should be provided a little more specifically in the manuscript in line 266.

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Discussion

(…) This prevalence is similar to the overall moderate/severe psychological distress prevalence in our study among the three key populations (19.0%). However, this estimate was higher than that reported among MSM in our study (10.4%). There is a gap between the percentages of PD in other countries and in our study mainly because of the age differences. Indeed, the population considered in our study is relatively young (median age = 25 years) unlike in other studies (35,36). Also, different tools have been used in the other studies to measure PD as the Patient Health Questionnaire (PHQ) (19), the Center for Epidemiologic Studies Depression Scale (CES-D) (40) and K-6 (35).

5. 11.1: Did you actually report anything based on the Partial Proportional Odds model (PPO) as opposed to the Proportional Odds model (PO)? If not I suggest you delete the description of PPO in methods in lines 173-178.

Authors: We thank the reviewer for these comments which have been taken into consideration in the document and the description has been removed from the section.

Statistical analysis

We considered Partial Proportional Odds model for the dependent variable PD. Descriptive statistics were performed and results were presented with frequency tabulations and percentages. Prevalence rates were estimated with their 95% confidence interval. For model building, characteristics that had a p-value <0.20 in univariable analysis were considered for the full multivariable models, which were subsequently finalized using a stepwise, backward elimination approach (p-value <0.05). Predictor variables were selected as those found to be relevant according to the literature review. All computations were conducted using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA).

6. 11.2: add the word "ordinal" in line 155 so it says "four ordinal categories"

Psychological Distress

The K10 has been examined and validated among several populations and aims at measuring anxiety and depression with a 10-item questionnaire, each question pertaining to an emotional state and a five-level response scale for each response. The score obtained from the scale allows categorization of participants into four ordinal categories of PD: severe (score ≥ 30), moderate (score: 25-29), mild (score: 20-24) and none (score < 20) (28).

Congrats on the great work!

Authors: We thank the reviewer for this encouraging comment and for all the inputs to enhance the quality of the paper.

Reviewer #2: Credits to the authors for addressing all the comments. Thanks for making an effort to contribute to science as we work to end the HIV pandemic.

Authors: We thank the reviewer for this encouraging comment.

1. Abstract: In the sub-section results line 56/57, the statement, “….were risks factors associated with PD.”, should be changed to “…were risk factors for PD” or “….were factors associated with PD.”

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Abstract

Results

Line 56/57: (…) were risk factors for PD. Secondary [aOR = 0.52 (95% CI: 0.42-0.64)] or higher [aOR = 0.46 (95% CI: 0.32-0.64)] education levels were protective factors associated with PD.

2. Results section:

Line 231: the statement, “HIV serological status was a risk factor associated with PD…” should read, “HIV positive serological status was a risk factor for PD…” Having it as just HIV serological status is ambiguous.

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Main document

Results

In multivariable analysis, after adjustment on the other variables, respondents who were 25 years old and older, were more likely to have severe/moderate or mild PD than respondents who were younger (p=0.026). HIV positive serological status was a risk factor for PD (aOR= 1.80; 95%CI [1.31-2.48]).

3. Line 302: “…. FSW may be an DU or an MSM may also be an DU.” Should change to “…. FSW may be a DU or an MSM may also be a DU”

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

Discussion

(…) Our study has some limitations. First, we worked on three populations, but it is possible that an FSW may be a DU or an MSM may also be a DU. However, to classify the population, we took into account only the entry point.

4. Line 304/305: “These bias might have had an effect on the prevalence rates of PD.” This statement first needs to be qualified; will the biases overestimate or underestimate the prevalence? To answer this question, you will need to dissect each bias separately. Consider revision appropriately.

Authors: We thank the reviewer for these comments which have been taken into consideration in the document.

However, to classify the population, we took into account only the entry point. Since our study was based on self-reporting, social desirability bias cannot be ruled out. This bias could have underestimated the prevalence rates of PD.

31 Mar 2020

Prevalence and factors associated with psychological distress among key populations in Togo, 2017.

PONE-D-19-29894R2

Dear Dr. TCHANKONI,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

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Academic Editor

PLOS ONE

Additional Editor Comments (optional):

I think would helpful to consider revising the description of active and passive sexual activity - I think in a sexual encounter both people are active. Would you perhaps consider using the " Top (for active)" and " Bottom (for passive)"

.

Reviewers' comments:

6 Apr 2020

PONE-D-19-29894R2

Prevalence and factors associated with psychological distress among key populations in Togo, 2017.

Dear Dr. TCHANKONI:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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