High level risky sexual behavior among persons living with HIV in the urban setting of the highest HIV prevalent areas in Ethiopia: Implications for interventions.

INTRODUCTION: Data on the sexual behavior among people living with human immunodeficiency virus (PLHIV) dwelling at HIV prevalent setting located at the periphery of Ethiopia is lacking. Therefore, this study was designed to investigate sexual practice of patients following their antiretroviral therapy (ART) service and factors affecting their behavior.
MATERIALS AND METHODS: A facility based cross-sectional study design was employed to assess risky sexual practice and associated factors among HIV positive adults attending ART clinics in Gambella town, Southwest Ethiopia. Risky sexual practice is defined as a custom of getting in at least one of the following practices such as condom-unprotected sex with any partner, having two or more sexual partners and practicing casual sex in the last three months. A total of 352 randomly selected clients were interviewed by using a structured questionnaire. The multivariable logistic regression model was used to examine the association between covariates and the outcome variable.
RESULTS: Majority of the study participants were engaged at least in one of the risky sexual practices (79.8% confidence interval (CI): 75.3% - 83.9%). The multivariable analysis found that the odds of risky sexual practice were higher among individuals who use substances ('khat' users (AOR: 3.82, 95%CI:1.30-11.22), smoke cigarette (AOR:4.90, 95%CI:1.19-12.60), consume alcohol (AOR: 2.59, 95%CI:1.28-5.21)); those who never discuss about safe sex with their partner/s (AOR: 2.21, 95%CI:1.16-4.21); those who have been in attachment for longer duration (more than four years) with their partner (AOR: 3.56, 95%CI: 1.32-9.62); and groups who desire to bear children in their future life (AOR: 3.15, 95%CI:1.40-7.04) as compared to their respective comparison groups.
CONCLUSIONS: A significant number of participants were engaged at least in one of the risky sexual practices which potentially result in super infection by a new or/and drug resistant viral strain/s, and onward transmission of the virus. Thus, an HIV intervention program which focuses on the identified factors has to be implemented to mitigate risk of unsafe sexual behavior of this population group and move towards ending the HIV/Acquired Immunodeficiency Syndrome (AIDS) epidemic.

RCT Entities:   Population Interventions Outcomes

Background

HIV/AIDS remains a great public health concern worldwide. According to a recent report, globally 37.9 million people had living with HIV; from this number, about 23.3 million People were access to ART. In 2018, 1.7 million people were infected by HIV, and 770, 000 people died of AIDS-related illnesses [1, 2]. Even though HIV prevalence is reducing from time to time as global trend shows, still new HIV infections are highest among youths living in sub-Sahara Africa. Hence, about five percent of adults in the region are living with HIV [3].

In case of Ethiopia, there were an estimated 23,000 people were newly infected with HIV, 690,000 people living with HIV and there were 11,000 AIDS-related deaths in 2018 [2]. HIV epidemic in Ethiopia varies according to geographic settings. The prevalence of the disease is seven times higher in urban areas compared to the rural areas of the country. Seven out of the nine regional states and two city administrations have an HIV prevalence above one percent. Looking at HIV prevalence by region, it is highest in Gambella (4.8%), followed by Addis Ababa, Dire Dawa and Harari with 3.4%, 2.5%, and 2.4% respectively [4].

Individual-level risks for HIV acquisition and transmission is the core reason for relapsing of the HIV epidemics [5]. Moreover, adolescents and youth living with HIV are at risk of transmitting on the virus to their sexual partners and unborn child. Furthermore, they are vulnerable to potential re-infection with new HIV strain and more vulnerable to other sexually transmitted infections (STIs) compared to their HIV-negative peers [3].

Controversial findings were reported from different studies conducted on the sexual behaviors of PLHIV on ART. Some of the studies conducted in California [6], Uganda [7] and Cameron [8] have noted that a decrease in rates of risky sexual behavior among this population after initiation of ART. On the other hand, several studies from New York [9], Cote D’ivoire [10], Uganda [11], Nigeria [12], and Northwest Ethiopia [13] have shown that they are more likely to engage in risky sexual practice after initiation of ART.

Risky sexual practice/behavior in PLHIV defined in the literature as engaging in one of the following characteristics such as unprotected sex with any partner [13-17], having multiple sexual partners [14-17], casual sex [16, 17], sex under the influence of alcohol [15-17] and sexual exchange (paying or receiving goods or money for sexual intercourse) [17]. A result from cohort studies still advises safe sexual practice is necessary not only to prevent pregnancy and STIs but also to prevent HIV drug-resistant and super infection [18, 19]. A study from Southern Africa found significant associations between risky sexual behaviors (inconsistent condom use and having multiple sexual partners) and HIV infection [20]. Another study conducted in different African countries showed that a change in risky sexual behaviors can reduce HIV prevalence by up to 20% [21]. Non-use of condom by sero-concordant couples encourages the spread of resistant strains of the virus and occurrence of super infection. Super infection that may occur even while under ART in HIV-1 infection [18] was reported from different Africa countries, among heterosexual couples [22-24]. Moreover, HIV-1 super infection resulting in a triple infection in an HIV-1 infected patient who continues to practice unsafe sex is also documented in Africa [25, 26]. Deterioration of clinical status among HIV infected individuals has been reported as result of super infection [19, 22]. This underscores the need for continued preventive efforts aimed at ensuring safe sexual practices even among HIV-1 sero-concordant couples [19, 27, 28].

To date, limited studies were conducted on the sexual behavior among PLHIV and most of them are conducted at the centeral part of Ethiopia [13, 16, 17]. In contrary, data on the sexual behavior among people living with HIV in the highly prevalent marginal areas of the country is lacking. Therefore, this study was designed to investigate sexual practice of patients following their ART service and factors affecting their behavior.

Materials and methods

Study setting

The study was conducted among adults (18 years or above) living with HIV/AIDS attending ART clinics in Gambella town, Southwest Ethiopia. Gambella town is the capital city of the Gambella Regional state, which is located being 777 km away from Addis Ababa, Ethiopia. The town is administratively structured into 5 keble’s (local administrative structure) with 12,928 households and 59,468 total population. There are three governmental health facilities and 12 private clinics located in the town. Only two of the facilities are delivering ART service and a total of 2, 302 clients are actively attending their treatment follow up at ART clinics during the study period.

Study design

A facility based cross-sectional study design was employed to determine the magnitude of risky sexual practice and associated factors among HIV positive adults attending ART clinics in Gambella town, Southwest Ethiopia using quantitative data collection method.

Sample size and sampling procedure

The study populations were all HIV positive adults attending ART from June to July 2019 at ART clinics in Gambella town. The sample size was calculated by using single proportion formula, the magnitude of risky sexual practice was 38% from previously conducted research in Gondar town, Northwest Ethiopia [13], with the marginal error tolerated (d) to be 5%, and 95% confidence level giving a sample size of 362. With regards to the current study, since the source population was less than 10,000, finite population corrections formula was used to get a sample size of 313. Finally, by adding the non response rate of 15%, the total final sample size was 360. Procedurally, the sample from each health facility was proportionally allocated, and then every sixth was selected for interview by using systematic random sampling technique.

Data collection and measurement

A structured questionnaire which was adopted with modifications [5, 16] and pretested was used for data collection. The pretest was done on 30 participants attending ART clinics at neighbor town prior to the actual data collection and the questionnaire was modified when necessary. The questionnaire was first prepared in English and translated into the Amharic language, and then retranslated into English by language experts to check the consistency. The main outcome variable for the study was risky sexual practice, defined as engaged at least in one of the following practices such as condom-unprotected sex with any sexual partner, having two or more sexual partners and casual sex in the last three months prior to the date of data collection [16, 17]. The independent variables were socio-demographic characteristics which include sex, age, ethnicity, educational status, religion, marital status, occupation, monthly income, and family size; behavioral and social factors like substance use (alcohol, cigaratte and ‘khat’), desire of child, attendance of HIV prevention discussion, safer sex behavior skill training, stigma, length of followup and CD4 count; sexual practice and partner related factors like discussion about safe sex, partner HIV status and disclosure status; medical related factors such as duration of diagnosis of HIV and CD4 count. Steady partner was a partner with whom a respondent had regular sexual relationship and perceived by them as spouse or regular boy/girlfriend [17]. Casual partner means individuals with whom they had sexual intercourse once or a few times other than regular steady partners (spouse/boy/girlfriend) with or without payment [17]. ‘Khat’ use was defined consumption of ‘khat’ (chewing) during the last month prior to data collection date [29]. Alcohol consumption was defined as consuming >4 drinks in a day (or >14 drinks/week) for men and >3/day (or >7/week) for women [30]. Cigaratte smokers was defined smokers reporting one cigarette per day or an average of at least seven cigarettes per week [29].

Data processing and analysis

Data were entered using the Epidata 3.1 software, and then exported to the STATA version 15 (College Station, TX, USA) for descriptive, bivariable and multivariable analysis. The model was fitted by Hosmer and Lemeshow’s goodness-of-fit [31]. All the variables with P-value < 0.25 with risky sexual practice in univariable analysis were fitted to the final multivariable logistic regression model. Multi-Collinearity was checked using Variance Inflation Factor (VIF); values < 10 were included in the model. In the multivariable analysis, a value of P<0.05 was considered as statistically significant association. Odds ratio (OR) with 95% confidence level was used to show the strength of association between dependent and independent variables.

Ethics statement

Ethical clearance was granted by the Mettu University Institutional Review Board (IRB). Moreover, a support letter to conduct the study was obtained from Gambella regional health office. Respondents were also informed about the purpose, procedure, possible risks and benefits of participating in the study and the confidentiality of information they provide. Thus, participation in the study was voluntary, and patients had the right to stop the interview at any time. In nutshell, data were collected after informed verbal consent was obtained from each participant and name or other personal identification of the participants of the study were made anonymous. data were collected in the questionnaire.

Results

Socio-demographic characteristics

A total of 352 participants were interviewed in this study with a response rate of 97.8%, out of which, 102 (29%) of them were Aynwa by ethnicity. The mean age of the respondents was 34.1 years (SD±9.8 years). About half of them were females and two third were married. On the top of these more than half of the respondents had a monthly average income below three thousand Ethiopian Birr (Table 1).

Table 1

Socio-demographic characteristics of adults living with HIV attending ART clinics in Gambella town, Southwest Ethiopia.

Characteristics		Frequency	Percentage
Age (in years)	18–29	133	37.8
	30–39	134	38.1
	≥ 40	85	24.1
Sex	Female	180	51.1
	Male	172	48.9
Ethnic group	Anywa	102	29.0
	Amhara	79	22.4
	Nuer	66	18.8
	Oromo	65	18.5
	Other	40	11.4
Marital status	Married	230	65.3
	Single	51	14.5
	Divorced	46	13.1
	Widowed	25	7.1
Educational level	Primary education	90	25.6
	Unable to read and write	73	20.7
	Technical/vocational collage	73	20.7
	Secondary education	56	15.9
	Informal education	32	9.1
	Degree and above	28	8.0
Occupation	Self-business	107	30.4
	Government employee	95	27.0
	Daily labor	65	18.5
	House wife	57	16.2
	Other	28	8.0
Religion	Protestant	158	44.9
	Orthodox	120	34.1
	Catholic	44	12.5
	Muslim	28	8.0
	Other	2	0.6
Monthly average income (ETB)*	≤1500**	55	15.6
	1501–3000	131	37.2
	> 3000	166	47.2
Family size	≤3	144	40.9
	4–7	156	44.3
	> = 8	52	14.8

*Ethiopian Birr

** extreme poverty (less than 1.90 $ perday)

Behavioral, social and medical characteristics

In this study, one fourth of participants often use ‘khat’, 140 (39.8%) and 98 (27.8%) of them consume alcohol and smoke cigarette respectively. Regarding fertility desire 291 (82.7%) of respondents desire to bear children in the future, of which majority of the respondents, 254 (72.2%) want to have two and more children. Among the females who participated in this study, about two for every seven females had a history of pregnancy in the last twelve months and 22 (44.9%) of them had intended pregnancy.

Concerning health related services; about one fourth of them have attended support group discussion on the safe sex, 29 (8.2%) of them on their part participated in skill building training on safer sex behaviors. Regarding stigma, 35 (9.9%) and 12 (3.4%) of them experienced perceived and enacted stigma respectively. About forty-five percent of respondents have already started ART medication two years ago before data collection date. The majority of participants, 343 (97.4%) had CD4 count >350 cells/mm3 (Table 2).

Table 2

Behavioral, social and medical characteristics of adults living with HIV attending ART clinics in Gambella town, Southwest Ethiopia.

Characteristics	Frequency	Percentage
‘Khat’ use
Yes	88	25.0
No	264	75.0
Cigarette smoking
Yes	98	27.8
No	254	72.2
Alcohol consumption
Yes	140	39.8
No	212	60.2
Other substance use*
Yes	69	19.6
No	283	80.4
Desire of children in the future
Yes	291	82.7
No	61	17.3
Number of desired children
1	37	12.7
2	201	69.1
≥ 3	53	18.2
History of pregnancy in the past 12 months (females)
Yes	49	27.2
No	131	72.8
Intended pregnancy
Yes	22	44.9
No	27	55.1
Caused a pregnancy in the past 12 months (males)
Yes	22	12.8
No	150	87.2
Attending support group discussion on HIV prevention
Yes	91	25.9
No	261	74.1
Receiving any skill training on safer sex behaviors
Yes	29	8.2
No	323	91.8
Perceive stigma
Yes	35	9.9
No	317	90.1
Enact stigma
Yes	12	3.4
No	340	96.6
Length of follow up care (in months)
≤ 12	29	8.2
13–48	167	47.4
≥ 49	156	44.3
Current CD4 count
≤350	9	2.6
>350	343	97.4

*Substance indicates Shisha/hashish

Magnitude of risky sexual practices and partner related characteristics

Majority of the respondents had engaged in at least one of the risky sexual practices. Ninety-six (27.3%) had multiple partners, 66 (18.8%) with a casual partner and 58 (16.5%) with both steady and casual partners. Regarding condom use; 274 (77.8%) of them reported indicating as they inconsistently used or never used at all in all their sexual intercourse during past three months preceding the date of data collection. Different reasons were mentioned by the study participants for not using at all or inconsistently using of condom (Fig 1).

Fig 1

Reasons for not using at all or inconsistently using of condom among adults living with HIV attending ART clinics in Gambella town, Southwest, Ethiopia, 2019.

About forty-one percent of the PLHIV was reported that their sexual partner HIV sero-status was negative or unknown whereas majority, 262 (74.4%) of their sexual partners were aware about their status. Most of the participants stated that they were staying with their current partner for more than one year, and 160 (45.5%) of them were discussed about safe sex with their partner/s.

Factors associated with risky sexual practice

The multivariable analysis found that the odds of risky sexual practice were higher among individuals who use substances (‘khat’ users (AOR: 3.82, 95%CI:1.30–11.22), smoke cigarette (AOR:4.90, 95%CI:1.19–12.60), consume alcohol (AOR: 2.59, 95%CI:1.28–5.21)); those who never discuss about safe sex with their partner/s (AOR: 2.21, 95%CI:1.16–4.21); those who have been in attachment for longer duration (more than four years) with their partner (AOR: 3.56, 95%CI: 1.32–9.62); and groups who desire to bear children in their future life (AOR: 3.15, 95%CI:1.40–7.04) as compared to their respective comparison groups (Table 3).

Table 3

Bivariable and multivariable logistic regression analysis of factors associated with risky sexual practice among adults living with HIV attending ART clinics in Gambella town, Southwest Ethiopia.

Characteristics	Risky sexual practice		COR (95%CI)	P-value	AOR (95%CI)	p-value
	No	Yes
Marital status
Married	36	194	1		1
Single	13	38	0.54(0.26–1.12)	0.097	0.84(0.30–2.34)	0.735
Othersa	22	49	0.41(0.22–0.77)	0.005	0.72(0.30–1.72)	0.465
Average monthly income (in ETB)b
<1500	18	37	1		1
1500–300	25	106	2.06(1.01–4.20)	0.046	1.52(0.65–3.52)	0.322
>300	28	138	2.40(1.20–4.80)	0.014	1.23(0.53–2.88)	0.626
Discussion about safe sex with partner/s
Yes	41	119	1		1
No	30	162	1.86(1.10–3.15)	0.021	2.21(1.16–4.21)	0.016*
Length of stay with current partner/s (in months)
≤12	22	48	1		1
13–48	21	67	1.46(0.72–2.95)	0.290	1.78(0.72–4.40)	0.214
≥49	28	166	2.72(1.43–5.17)	0.002	3.56(1.32–9.62)	0.012*
‘Khat’ use
No	66	198	1		1
Yes	5	83	5.53(2.15–14.23)	0.000	3.82(1.30–11.22)	0.015*
Cigarette smoking
No	65	189	1		1
Yes	6	92	5.27(2.20–12.62)	0.000	4.90(1.91–12.60)	0.001**
Shisha/hashish use
No	64	219	1		1
Yes	7	62	2.59(1.13–5.93)	0.025	1.35(0.53–3.48)	0.529
Alcohol consumption
No	55	157	1		1
Yes	16	124	2.71(1.48–4.97)	0.001	2.59(1.28–5.21)	0.008*
Desire of children in the future
No	21	40	1		1
Yes	50	241	2.53(1.38–4.66)	0.003	3.15(1.40–7.04)	0.005*
Length of follow up on ART
≤12	11	18	1		1
13–48	31	136	2.68(1.15–6.24)	0.022	1.69(0.56–5.06)	0.349
≥49	29	127	2.68(1.14–6.27)	0.023	1.88(0.63–5.63)	0.256
Receiving any training / skill building on safe sex
Yes	9	20			1
No	62	265	1.89(0.82–4.36)	0.133	1.92(0.68–5.47)	0.219
Attending support group discussion on HIV
Yes	13	78			1
No	58	203	0.58(0.30–1.12)	0.107	0.71(0.32–1.55)	0.390

Note:1 = reference

awidowed and divorced marital status

bEthiopian birr

*p-value< 0.05

**P<0.01

Discussions

The current study explored the sexual risk behaviors among HIV-positive patients taking ART in Gambella town, Southwest Ethiopia. The study depicted that the high rates of sexual risk behavior among HIV-positive individuals on the ART have implications for the risk of contracting and /or transmitting the virus in the study area. In the curent study, the researches found that a majority of patients (77.8%) experienced inconsistent use of condom or never used it at all. From those who have negative or unknown HIV sero-status partner/s, about 77% of them had one or more sexual encounter(s) without using a condom in the last three months prior to data collection period. This highlights the dangers of continued HIV transmission despite the increasing ART rollout. Therefore, these findings call for rising awareness and motivation of using condom among HIV-positive patients. A substantial number of HIV positive clients, which accounts for (27.3%) had practiced a sexual intercourse with at least two partners. Furthermore, the findings of this study revealed that sexual practices of this vulnerable population, and underscore ways of intervening problems related to unsafe sexual practice.

This study shows that 79.8% (CI: 75.3% - 83.9%) of the respondents had at least one risky sexual practice within three months prior to the study. This finding is consistent with the result (81%) reported from Uganda (15) but it is higher than study reported (70.6%) from Southeast Nigeria [32]. It is also higher than previously reported results from Addis Ababa and Gondar, other parts of the country; where the magnitude of risky sex was 36.9%, and 38% respectively [13, 17]. The possible reason for the difference might be due to socio-demographic and geographical variation between the previous two towns compared to the current study setting. Other possible reasons could be variation in the operational definition of the risky sexual practice as the study conducted in Addis Ababa used only a single character of risky sexual practice, condom-unprotected sex with any partner. High risky sexual practice in this study highlights behavioral interventions that can reduce unsafe sexual practice among PLHIV should be reinforced.

In the current study, substance use (alcohol, ‘khat’ and tobacco) was associated with risky sexual behavior. We found out that alcohol consumption was found to be significantly associated with their high-risk sexual behavior. A similar finding was also reported from a cohort study in Switzerland [33], Northern India [34], Togo [35], Southwestern Uganda [36] and Kenya [37]. A meta‑analysis study has also identified alcohol as correlate of unprotected sexual behavior [38]. The correlation between alcohol consumption and risky sexual practice might be due to decreased self-consciousness and impaired judgments after alcohol intake which may in turn increase risky sexual practice. Odds of risky sexual practice increased by four and five folds among ‘Khat’ chewing and cigarette smoking groups respectively compared to non-users. The association between these two substances and risky sexual behavior was reported in another population. A study conducted in Malaysia reported indicating as there significant correlation between smoking and sexual activity [39]. A community based study in Ethiopia also showed that ‘Khat’ consumption is associated with HIV risk behavior [40, 41]. In Ethiopia, there are habitual practices that smoking and alcohol consumption after ‘Khat’ chewing practice [41, 42]. Using a substance in combination reduces inhibitions and increases the vulnerability of risky sex [41]. In addition to risky sexual practices, substance use is significantly contributed to poor ART adherence and poor HIV medical outcomes [43-45]. This information is critical for the development of policy and practice for HIV/AIDS care including the prioritization and planning of effective substance use screening tools and intervention methods.

A study from USA indicated that one of the most important methods to prevent HIV transmission is interpersonal communication which results in reaching on the consensus through free and frank discussion about safer sexual behavior [46]. In this study, those who did not discuss safe sex with their partner/s were 2.21 times more engaged in risky sexual practice than their counterparts. This finding is similar with previous studies conducted in other parts of the country [13, 47]. This might be due to the fact that discussion safe sex may avoid engaging in unprotected sexual acts in both sexes. Hence, avoiding open discussion on safe sex may potentially make the partners to engage in risky sex.

Similar to previous result from Eastern part of the country, this research has identified that those who have stated together for more than 4 years with a partner were more likely to be engaged in the risky sexual practice than those who stay less than one year with their partner [47]. The possible reason was that they stayed together for longer duration, and then they trust each other as a result, they might tend to be engaged in risky sexual practice. Similar to other studies [48, 49], desire to have a child is significantly associated with risky sexual practice. This might be due to social and cultural contexts put pressure on couples to bear children as a demand that couples have to fulfill in the marriage.

In this study, more than 80% of the participants have future fertility desire. Except for the use of screened fresh sperm from HIV sero-negative donors (when a woman’s male partner is HIV-infected) and adoption no conception methods are a complete risk-free of HIV transmission. However, some risk reduction methods have been used in the developed world for safer conception [50]. In resource-limited setting like Ethiopia, promotion of safer conception counseling, strong adherence to ART to reduce infectiousness of PLHIV and preventing the spread of HIV from mother to child (PMTCT) services is yet the possible ways to reduce the risk of infection.

A number of potential limitations may affect the findings of this study. First, sample size was only calculated for the prevalence of risky sexual practice and other associated factors were not considered. Secondly, sensitive of the subject may result in social desirability bias. Lastly, due to the limitation of cross-sectional study design, it is impossible to establish causal relationship and further longitudinal research is warranted to investigate the effects of the factors on the sexual behaviors among PLHIV. However, as the objective of the study was to determine the magnitude of risky sexual behavior by using a comprehensive definition and potential factors associated with it, the findings could serve as an important input to inform proper target of HIV intervention program in this population group towards ending AIDS.

Conclusions

In conclusion, the magnitude of risky sexual practice defined as engaged at least in one of the following practices: having two or more partners, causal sex and condom-unprotected sex with any partner in the last three months among HIV positive individuals who attended ART clinics in Gambella town was very high. This indicates that a considerable number of clients were potentially exposed to and/or causing super infection by a new and/or drug resistant viral strain/s, and also can infect the unborn child and their HIV sero-negative sexual partner/s. The study identified that substance use (alcohol, ‘khat’ and cigarette), lack of discussion about safe sex among sexual partners’, desire to have a child in the future, and staying together for long duration (more than four years) with a partner were important predictors of the risky sexual practice. Thus, an HIV intervention program which focuses on the identified factors has to be implemented to mitigate risk of unsafe sexual behavior in this population group and move towards ending of the HIV/AIDS epidemic.

Consent form and questionnaire (English version).

(PDF)

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Consent form and questionnaire (Amharic version).

(PDF)

Click here for additional data file.

21 Jul 2020

PONE-D-20-13455

High level of risky sexual behavior among persons living with HIV in the urban setting of the highest HIV prevalence in Ethiopia: Implications for HIV interventions

PLOS ONE

Dear Dr. Tola,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The manuscript has many typos and grammatic issues and must be copy-edited before the upcoming submission.

More than 80% of the respondents have future fertility desire. What do you recommend for balancing risky sexual behaviour and fertility desire in PLWHA including those represented in the study? Please discuss the matter further.

Can you please provide a brief review (a paragraph or so) on how the existing literature define risky sexual behaviour in PLWHA and justify the definition used in the study?

The operational definitions for many of the key variables including Khat chewing, alcohol use, smoking have not been provided. Please also make sure that the definitions on substance use take dose and frequency of use into consideration. Terms like casual partner, steady partner must also be defined.

The variables of the study are not clearly provided in the paper. As it stands, it is not possible to identify those variables that did not make it to the multivariable model. In the methods section please add a section that exhaustively describes the independent variables of the study (along with their operational definitions).

Please comment on the adequacy of the sample size for identifying predictors of risky sexual behaviour.

The rationale for considering the variables (HIV positive child living with family, family size) as predictors of risky sexual behaviour is not clear. Please justify or remove them from the analysis.

Marital status: Separated and divorced levels should be merged. As it stands the frequencies are too small for reasonable analysis.

Table 3: The variable “Length of stay with current partner/s” is confusing. What would happen if the respondent had no partner in the reference period? How did you calculate the duration among those study participants who had multiple partners?

I don’t see any report on the association between clinical variables (e.g. HIV disease staging, viral load/CD4 count) and risk sexual behaviour? Where they considered as independent predictors in the study?

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In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the methods section. Further consideration is dependent on these concerns being addressed.

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- Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. In addition, please provide further details concerning the pretesting of this tool, including the number of participants and where they were recruited from.

- Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified how verbal consent was documented and witnessed.

Additional Editor Comments (section-by-section comments):

Abstract

The background sub-section of the abstract is difficult to follow. Please revise and make it focused on the knowledge gap that lead to this undertaking.

In the methods section please provide the operational definition for “risky sexual practice”

The sentence “Finally, variables with p<0.05 was considered statistically significant” is less relevant in the abstract section.

Write abbreviations in expanded form at first use, both in the abstract and main body of the manuscurpt.

Methods

Line 105: confidence interval >> confidence level

Please provide a separate section on “data collection and measurement” and integrate the “operational definitions” sub-section with this section.

Please check for the absence of multicolinarity among the independent variables of the study

Discussion

The discussion looks more of a literature review. Please discuss the interpretation, implication and methodological limitations of the study.

Conclusion

The conclusion section must be condensed into one short paragraph.

Other comments

Multivariate >> multivariable

Bivariate >> bivariable

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: There is major flaw in the operational definition of respondents’ sexual behavior/practice which significantly affects the study finding, discussion and conclusion sections alike. Please see the attached detail review feedback.

Reviewer #2: The paper “High level of risky sexual behavior among persons living with HIV in the urban setting of the highest HIV prevalence in Ethiopia: Implications for HIV interventions” is very interesting. It is important to note that the authors were careful in writing and that the text has great potential for publication, in addition to dealing with a relevant theme in the literature. Some comments, however, are necessary to improve the quality of the manuscript.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: Review feedback.docx

Click here for additional data file.

Submitted filename: Parecer_eng.docx

Click here for additional data file.

4 Sep 2020

Dear Editor:

I appreciate the comments and suggestions of the academic editor and reviewers; their comments and suggestions were constructive and have improved our manuscript substantially. Accordingly, I have incorporated almost all of the comments and suggestions given by the academic editor and reviewers in the manuscript. Furthermore, I have responded to each of the points raised by the reviewers as follows:

Sincerely,

Tsegaye Berkessa (Corresponding author)

Academic Editor:

• The manuscript has many typos and grammatic issues and must be copy-edited before the upcoming submission.

Response: The comment was accepted and the manuscript was edited.

• More than 80% of the respondents have future fertility desire. What do you recommend for balancing risky sexual behaviour and fertility desire in PLWHA including those represented in the study? Please discuss the matter further.

Response: This comment has been well taken and corrected accordingly.

• Can you please provide a brief review (a paragraph or so) on how the existing literature define risky sexual behaviour in PLWHA and justify the definition used in the study?

Response: The comment was accepted and correction was made accordingly

• The operational definitions for many of the key variables including Khat chewing, alcohol use, smoking have not been provided. Please also make sure that the definitions on substance use take dose and frequency of use into consideration. Terms like casual partner, steady partner must also be defined.

Response: The comment was accepted and definition of terminologies was done.

• The variables of the study are not clearly provided in the paper. As it stands, it is not possible to identify those variables that did not make it to the multivariable model. In the methods section please add a section that exhaustively describes the independent variables of the study (along with their operational definitions).

Response: Correction was made accordingly

• Please comment on the adequacy of the sample size for identifying predictors of risky sexual behavior

Response: Our sample size was slightly limited compared to the number of independent variables. However, we excluded less important variables and less important variable categories was also merged. Finally, limited candidate predictors was examined to have the lower limit of events per variable (EPV) for developing the prediction model.

• The rationale for considering the variables (HIV positive child living with family, family size) as predictors of risky sexual behaviour is not clear. Please justify or remove them from the analysis.

Response: The comment has been well taken and removed from the analysis.

• Marital status: Separated and divorced levels should be merged. As it stands the frequencies are too small for reasonable analysis.

Response: This is definitely correct and we have modified accordingly.

• Table 3: The variable “Length of stay with current partner/s” is confusing. What would happen if the respondent had no partner in the reference period? How did you calculate the duration among those study participants who had multiple partners?

Response: In our study, all people living with HIV was reported they had at least one sexual partner in the last three months. Study participants were asked whether they had multiple sexual partners in the last three months. Similar to other studies for those who had a single partner on the date of data collection and separated from the other partner/s in the last three months the current partner duration was taken and for the others who had multiple partners on the date of data collection the longest stay was considered.

• I don’t see any report on the association between clinical variables (e.g. HIV disease staging, viral load/CD4 count) and risk sexual behaviour? Where they considered as independent predictors in the study?

Response: The comment was accepted and CD4 count was included in the model.

Abstract

• The background sub-section of the abstract is difficult to follow. Please revise and make it focused on the knowledge gap that lead to this undertaking.

• In the methods section please provide the operational definition for “risky sexual practice”

• The sentence “Finally, variables with p<0.05 was considered statistically significant” is less relevant in the abstract section.

• Write abbreviations in expanded form at first use, both in the abstract and main body of the manuscurpt.

Response: The comment was accepted and abstract revision was done.

Methods

• Line 105: confidence interval >> confidence level

• Please provide a separate section on “data collection and measurement” and integrate the “operational definitions” sub-section with this section.

• Please check for the absence of multicolinarity among the independent variables of the study

Response: The methods part was revised accordingly.

Discussion

• The discussion looks more of a literature review. Please discuss the interpretation, implication and methodological limitations of the study.

Response: Correction was made accordingly

Conclusion

• The conclusion section must be condensed into one short paragraph.

Response: The comment was accepted and correction was made accordingly

Other comments

• Multivariate >> multivariable

• Bivariate >> bivariable

Response: Revision was done accordingly

Reviewer 1:

• The scientific writing and English language needs editorial work.

Response: The comment was accepted and edition was made accordingly

• There is major flaw in the operational definition of respondents’ sexual behavior/practice which significantly affects the study finding, discussion and conclusion sections alike.

Response: The operational definition risky sexual practice in our study was used in several previously published reputable literature. Explained in detail in the specific feedbacks.

Specific feedbacks:

• The HIV prevalence in Ethiopia is technically “concentrated” (less than 1%) according to UNAIDS definition while the average in Africa is “generalized” 5% as indicated in the background of the manuscript (Line 50). Nonetheless, the authors characterized Ethiopia’s HIV epidemic as one of the highest in Africa which is not correct (see the Abstract and line 51 without any reference).

Response: This comment has been well taken and corrected accordingly

• This study has critical deficiency/limitation on the operational definition of “risky sexual behavior/practice” (specifically the consistent condom use …line 116) which I believe leads to remarkable challenges/gaps across the result, discussion and conclusion sections. Respondents within marital union shouldn’t necessary be categorized as “risky sexual practice” if they aren’t using condom within the union unless they are sero-discordant. However, the operational definition doesn’t qualify so. This resulted in a very higher proportion of respondents as a risky sexual practices (80%) which is not comparable with some local studies done in country (39% and 38% in Addis Ababa and Gondar respectively……line 205-206). This issue affects finding in the result (including the regression model), discussion, and ultimately the conclusion. Table-1 (Line 143) demonstrates the importance of this issue as 65% of the respondents are married. Response: The definition of “risky sexual practice” is varied from one study to another. Risky sexual practice/behavior in PLHIV defined in the literature as engaging in one of the following characteristics such as condom-unprotected sex with any sexual partner, having multiple sexual partners, casual sex, sex under the influence of alcohol and sexual exchange within the last three months (cited in the revised introduction section). Regarding condom-unprotected sex, a few studies consider as risky sexual practice only if unprotected sex with negative or unknown HIV status partner. This might be the concern of these studies were only whether the people living with HIV are adding a new infection to the pool or not. However, most of the literature was used unprotected sex with any partner including spouse/cohabiting partner (regardless of their HIV sero status) (cited in the revised manuscript). The main reason is non use of condom by sero concordant couples encourages the spread of resistant strains of the virus and occurrence of super infection. Super infection/re infection that cause detrimental clinical effects can occur even while under ART in HIV-1 infection and reported from different Africa countries among heterosexual couples. As result, still several longitudinal studies underscores the need for continued preventive efforts aimed at ensuring safe sexual practices even among HIV-1 sero-concordant couples (well cited in the revised introduction section). In addition, even though HIV-seropositive individuals deserve full reproductive rights, no conception methods are 100% risk-free of HIV transmission, other than the use of screened fresh sperm from HIV-seronegative donors (when a woman’s male partner is HIV-infected) and adoption. Hence, it is difficult to take unprotected sex among regular PLHIV partner as a safe practice. All most all of previously locally conducted studies (in Addis Aba (Dessie et al., 2011, Tadesse et al., 2019), in Gondor (Molla et al., 2017) and other several studies conducted in Africa used condom-unprotected sex with any partner as one character of unsafe sex practice (risky practice) (cited in the revised manuscript). The variation between the result (36.9% and 38% in Addis Ababa and Gondar) is not due to the difference in contextual definition of condom use among regular partner (marital union) because we used similar definition in this regard. A study conducted at Gondar defined “risky sexual practice as having one or more of the following practices during the past three months prior to date of data collection: having multiple sexual partners, casual sex, sex without or inconsistent use of condom even with regular partner, sex with the influence of substance like alcohol”. We used similar definition except for sex with the influence of substance like alcohol. If you look at the result from this study, from 38% more than 80% of them were classified as risky due to condom-unprotected sex. More than half (51.7%) of them were married and even being married was identified as one of the predictor of risky sexual practice (by 6 fold). A study conducted by Dessie and his colleagues at Addis Ababa city was defined “risky sexual practices as condom-unprotected sex with either HIV negative, HIV positive or unknown sero status partner”. In this study, about 64% of participants were married and from 36.9% risky sexual practice, majority (77.0%) of them were due to unprotected sex with spouse/regular partner (it includes marital union). Generally, higher risky sexual practice in our study compared to previous local studies (Gondar & Addis Ababa) is not due to the limitation/deficiency of our operational definition and ‘this definition’ was used by several previously published reputable literature.

• Line 157-158= It would have been good to use Viral Load levels instead of CD4 since the latter has been phased out as a treatment outcome monitoring platform for PLHIV on treatment unless this data collection was done before the change of protocol.

Response: Response: Yes exactly, data collection was done before implementation of the new protocol.

• Line 163= Says “four out of five respondent” which is 80% of respondents engaged in risky sexual practice, is this to say at least one of the operationally defined risky practices? If so it has to be clearly articulated so across the manuscript.

Response: This is definitely correct and we have modified accordingly

• Line 164-168= All risky sexual practices are less than 27% except consistent condom use (77.8%) which has exaggerated the overall finding as mentioned above.

Response: Looking at each risky sexual character multiple sexual partner is 27.3%, Casual sex is 35% (124/352 ⁓ 66 casual + 58 both casual and steady partner) and condom unprotected sex is 77.8%. However, over all risky sexual practice in the absence of condom-unprotected sex is still 43.2% (at least one risky practice; casual or had 2 or more partners). Moreover, in this study if we exclude condom-unprotected sex among HIV sere-concordant regular partners (within marital union) still the overall risky sexual practice is high (58.5%).

• Line 169=58.8% respondents’ partners’ are sero-positive, this statement is misleading unless the term “partner” is defined well and the denominator is mentioned. As it stands now, it mean more than 40% of PLHIV on treatment are in a sero-discordant relationship which is unrealistically high. The same clarity is required for partner notification on the same line (169).

Response: Yes, this line lacks clarity and can mislead and correction was made by making it clear. The left 40.2 % is not necessarily sero-discordant because it include both sero negative and unknown sero status (18.2% seronegative and 23% unknown sero status).

• Line 186= Table-3 Bivariate and Multivariate LR analysis, has core deficiency and need to be remodeled once the operational definition issue is addressed.

Response: We used similar operational definition with other several literature including the local studies as we justified in the other comment.

• Line 190-193= The remarks based on the finding is unrealistic

Response: The comment was accepted and revision was made accordingly

• Line 193-195= There is inconsistency between the finding and subsequent remark

Response: The comment was accepted and revised accordingly

• Line 201= see comment (feedback) on Line 163

Response: The comment was accepted and correction was made accordingly

• Line 205-206= The discussion pointed out important issue about the exaggerated risk level by comparing it with other studies (Addis Ababa and Gondar) and one of the authors’ possible justification is the way risk sexual practice is defined which I presume is true. This purports the need to re-consider the operational definitions of risky behavior/practices based on evidence and standard definitions.

Response: We put this remark as possible justification because a study conducted at Addis Ababa (36.9%) was narrowly defined risky sexual practice as condom-unprotected sex with any partner and other characters like multiple sexual partners and casual sex were used as independent variables (not included in the risky behavior/practice) compared to our comprehensive definition. We believe this could be one possible reason. However, this justification cannot work compared to the result from Gondar because we used almost similar comprehensive operational definition. In this regard, revision of other possible reason (justification) was done.

• Line 207-211= The discussion and final remark is not clear

Response: The comment was accepted and revision was made accordingly

• Line 212-219= The discussion lack clarity and coherence. The final remark is unrelated to issues mentioned in the preceding discussion and very stretched above and beyond the scope of the study.

Response: This comment has been well taken and corrected accordingly

Reviewer 2:

• The background section outlines the research problem and talks about the issue of HIV and the problem in Africa, but three essential are missing: i) What hypothesis do the authors intend to test? ii) How does the article contribute to the literature? iii) How is the article innovative? I suggest the authors include those answers in the final background so that the readers will better understand the purpose of the manuscript.

Response: Response: Yes, this correct and we have accepted this comment

• In line 120, the authors talk about the inclusion of variables with p <0.25. What is the reason for this value? The authors do not explain this. Are there any texts in the literature that use this value? If so, please include them in the manuscript.

Response: We followed models building strategy steps mentioned by Hosmer and Lemeshow in applied logistic regression book. First, we used univariate analysis to identify important covariates. Secondly, all the variables with p-value < 0.25 with risky sexual practice in univariate analysis were fitted to the final multivariate logistic regression model. The comment was accepted and citation of the reference was made accordingly.

• In the results section, the authors should better explain Table 1 and the implication of the relative frequency on the sample on the results. As for income, I suggest adding a note explaining the values that represent poverty and extreme poverty.

Response: This comment has been well taken and corrected accordingly.

• In line 163, the authors write “About four fifth of the respondents had engaged in risky sexual practices”, but I did not find this information in the tables. I suggest that the authors include a table with risky sexual behaviors and the proportion of the sample with each behavior. I believe the table is more important than the text for the readers to understand the actual problem. Authors can explore Figure 1 further as well.

Response: Yes exactly, table is easier to understand, but it is difficult to present all findings by using a table. We use the text to reduce the number of tables in our manuscript. Correction was made by revising the text.

• In Table 3, I suggest compiling the information about relationships in “lives with a partner or not”. You see, it is just a suggestion to turn the variables into just a binary. It is up to the authors to accept the suggestion or not.

Response: length of stay in table 3 is to show the time duration of relationship among partners. Looking at other literature; we assumed this kind of classification could indicate the time interval that can affect risky practice.

• Line 187, table note, has only one asterisk, for p <0.05. Authors should separate p <0.05 and p <0.01, as they represent different levels of significance.

Response: This is definitely correct and we have modified accordingly

Submitted filename: Response to Reviewers.pdf

Click here for additional data file.

22 Sep 2020

PONE-D-20-13455R1

High level of risky sexual behavior among persons living with HIV in the urban setting of the highest HIV prevalence in Ethiopia: Implications for HIV interventions

PLOS ONE

Dear Dr. Tola,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The manuscript still has many typos and grammatical errors. Please make sure that it is thoroughly edited by someone fluent in English. Please also correct the errors listed below.

Please acknowledge that the sample size calculation was only made for estimating prevalence of risky sexual practice and not for estimating the factors associated with the outcome of interest. This should be discussed as a limitation under the discussion section.

Line 137: It is not clear how the variable “condom use practice” is considered both as dependent and intendent variable.

The data analysis section is superficial and does not tell how the independent variables were screened for the multivariable model.

Please submit your revised manuscript by Nov 06 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Samson Gebremedhin, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (Section-by-section comments):

Abstract

Line 21: Reconsider the use of the word “edge”

Line 26: “characters” >> “practices”

Line 28: “multivariate” >> “multivariable” (please do the same throughout the document)

Line 35: “were” >> “have”

Line 44 reconsider the use of the word “eradication”

Background

Line 49 “were” >> “had”

Line 60-62: The sentence is not clear

Line 74-75: what do you mean by “sexual exchange”? its not clear.

Line 85-87: please rephrase the sentence.

Line 91: Reconsider the use of the word “edge”

Methods

Line 96: “18 years and above” >> “18 years or above”

Line 98-100: Please remove the following sentence “The town is bordered by Gambella district and Bonga village by East, Oromia Regional State by Northeast, Gambella district by Northwest and West, and Abobo district by South.”

Line 109-111: remove the header “study population” and put the sentence “The study populations were all HIV positive adults attending ART from June to July 2019 at ART clinics in Gambella town.” as the first sentence of the “sample size and sampling procedure” header.

Line 115: please remove “CI”. Please note that confidence level and confidence interval are different.

Line 126 : “if” >> “when”

Line 127: Please mention the local language

Line 130: “characters” >> “practices”

Results

Table 1: please arrange all categories of the variables in decreasing order with the exception of those variables that have natural order (monthly income, family size)

Line 174: please reconsider the use of the word “were”

Table 2: what do you mean by “Caused intended”, please also indicate sample size for the variables.

Table 3: Bivariate >> Bivariable, Multivariate >> multivariable (please also do the same throughout the document)

Table 3: it is not clear how the candidate variables were identified for the multivariable model, This must be described in the data analysis sub-section

Table 3: Shisha/hashish use3x??? what do you mean by 3X?

Discussion

275-6: The sentence is not clear.

Line 284-85: Please remove the sentence “First, alcohol consumption in this study was not verified by using Alcohol Use Disorder Identification Test (AUDIT).”. It is not a must to use this tool.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: (No Response)

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: (No Response)

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

6 Nov 2020

Dear Editor:

I appreciate the comments and suggestions of the academic editor and reviewers; their comments and suggestions were constructive and have improved our manuscript substantially. Accordingly, I have incorporated almost all of the comments and suggestions given by the academic editor and reviewers in the manuscript. Furthermore, I have responded to each of the points raised by the reviewers as follows:

Sincerely,

Tsegaye Berkessa (Corresponding author)

Academic Editor:

• The manuscript still has many typos and grammatical errors. Please make sure that it is thoroughly edited by someone fluent in English. Please also correct the errors listed below

Response: The comment was accepted and the manuscript was edited.

• Please acknowledge that the sample size calculation was only made for estimating prevalence of risky sexual practice and not for estimating the factors associated with the outcome of interest. This should be discussed as a limitation under the discussion section.

Response: This comment has been well taken and discussed in the limitation part.

• Line 137: It is not clear how the variable “condom use practice” is considered both as dependent and intendent variable.

Response: The comment was accepted and all variables that measures outcome variable were removed from the list.

• The data analysis section is superficial and does not tell how the independent variables were screened for the multivariable model.

Response: The comment was accepted and revision was made accordingly. We used model-building steps mentioned by Hosmer and Lemeshow in applied logistic regression book. All the variables with p-value < 0.25 with risky sexual practice in unavailable analysis were fitted to the final multivariable logistic regression model.

Abstract

• Line 21: Reconsider the use of the word “edge”

Response: The comment was accepted and we replaced by another word.

• Line 26: “characters” >> “practices”

Response: The comment was accepted and correction was made accordingly

• Line 28: “multivariate” >> “multivariable” (please do the same throughout the document)

Response: The comment was accepted and revision throughout the manuscript was made accordingly

• Line 35: “were” >> “have”

Response: The comment was accepted and correction was made accordingly

• Line 44 reconsider the use of the word “eradication”

Response: The comment was accepted and correction was made accordingly.

Background

• Line 49 “were” >> “had”

Response: This comment has been well taken and corrected accordingly.

• Line 60-62: The sentence is not clear

Response: The comment was accepted and the sentence was revised.

• Line 74-75: what do you mean by “sexual exchange”? its not clear.

Response: The comment was accepted and the phrase was clarified.

• Line 85-87: please rephrase the sentence.

Response: The comment was accepted and the sentence was revised.

• Line 91: Reconsider the use of the word “edge”

Response: The comment was accepted and we replaced by another word.

Methods

• Line 96: “18 years and above” >> “18 years or above”

Response: Response: Correction was made accordingly

• Line 98-100: Please remove the following sentence “The town is bordered by Gambella district and Bonga village by East, Oromia Regional State by Northeast, Gambella district by Northwest and West, and Abobo district by South.”

Response: The comment was accepted and the sentence was removed from the manuscript.

• Line 109-111: remove the header “study population” and put the sentence “The study populations were all HIV positive adults attending ART from June to July 2019 at ART clinics in Gambella town.” as the first sentence of the “sample size and sampling procedure” header.

Response: The comment was accepted and revised accordingly.

• Line 115: please remove “CI”. Please note that confidence level and confidence interval are different.

Response: This is definitely correct and we have modified accordingly.

• Line 126 : “if” >> “when”

Correction was made accordingly

• Line 127: Please mention the local language

Response: The comment was accepted and local language was mentioned.

• Line 130: “characters” >> “practices”

Response: Revision was done accordingly

Results

• Table 1: please arrange all categories of the variables in decreasing order with the exception of those variables that have natural order (monthly income, family size)

Response: The comment was accepted and revised accordingly.

• Line 174: please reconsider the use of the word “were”

Response: This comment has been well taken and corrected accordingly.

• Table 2: what do you mean by “Caused intended”, please also indicate sample size for the variables.

Response: “Caused intended” mean males who caused the pregnancy and reported that they intended to cause the pregnancy. This comment was accepted and this variable was removed from the manuscript due to sample size insufficiency, less than 10 events per variable (EPV).

• Table 3: Bivariate >> Bivariable, Multivariate >> multivariable (please also do the same throughout the document)

Response: The comment was accepted and revised accordingly.

• Table 3: it is not clear how the candidate variables were identified for the multivariable model, This must be described in the data analysis sub-section

Response: The comment was accepted and revised accordingly.

• Table 3: Shisha/hashish use3x??? what do you mean by 3X?

Response: It is editorial error. The comment was accepted and revised accordingly.

Discussion

• Line 275-6: The sentence is not clear.

Response: The comment was accepted and the sentence was revised.

• Line 284-85: Please remove the sentence “First, alcohol consumption in this study was not verified by using Alcohol Use Disorder Identification Test (AUDIT).”. It is not a must to use this tool

Response: The comment was accepted and the sentence was removed from the document.

Submitted filename: Response to Reviewers.pdf

Click here for additional data file.

9 Nov 2020

High level risky sexual behavior among persons living with HIV in the urban setting of the highest HIV Prevalent areas  in Ethiopia: Implications for interventions

PONE-D-20-13455R2

Dear Dr. Tola,

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Reviewers' comments:

13 Nov 2020

PONE-D-20-13455R2

High level risky sexual behavior among persons living with HIV in the urban setting of the highest HIV Prevalent areas  in Ethiopia: Implications for interventions

Dear Dr. Berkessa:

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on behalf of

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