PONE-D-21-32836Global overview of suicidal behavior and associated risk factors among people living with human immunodeficiency virus: a scoping reviewPLOS ONE

Dear Dr. Ko

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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

Reviewer #3: Partly

Reviewer #4: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: N/A

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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: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: No

Reviewer #4: No

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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: This systematic review reviewing global literature to document suicidal behavior and risk factors among people living with HIV from Jan 1 1988 to July 8 2021. The purpose is to help prevent suicidal risk among PLHIV. It is an original literature review. With such a wide ranging study, it can be difficult to find consistent findings or learning points especially with various confounding factors in various studies which are difficult to adjust for. A number of risk factors and suicidal behavioral patterns were observed among these papers. The selection of publications to review was extensive which could lead various inconsistent conclusions in addition to few consistent ones including psychiatric conditions, low social support, discrimination. As per authors, previous primary research had shown poor social support, HIV stigma, mental disorders and associated co-morbidities as risk factors.

Clearly, the authors have worked hard and gone through a lot of papers for this manuscript. It was quite interesting and informative to read. I have a few comments/ questions about it that I believe could help make it more suitable for publication. This includes minor grammatical errors to major questions.

1) Authors have mentioned several times (e.g.- Line 32, line 204 and also in conclusion) that suicide rates have increased from the pre HAART era to Post HAART recently. This seemed unlikely to me and looked into citations you have made. Citation 5 says suicide decreased to 0. And in citation 63, it says suicide proportion has increased as aids related cause of death has decreased. Citation 4 mentions "Suicide rates decreased significantly with the introduction of HAART". Please correct me with evidence that completed suicides have increased since HAART was brought in.

If you are stating that suicidal rates have in fact increased in this time, could you mention why that is? Which risk factors have worsened? when you say suicide rates have increased, do you mean suicides are causing higher proportion of deaths because people are living longer due to HAART and not dying due to AIDS as much? If so, that needs clarifying.

2) Line 28- 800k died every year - in which years or is that an average since 1988? Please clarify

3) Line 50-53: Review sentence grammar

4) Line 47: Relation between 3 suicide behaviors- It would be interesting if you could specify certain risk factors that are more associated with either one of these 3 suicidal behaviors separately or other different relationships between the 3. Just a suggestion.

5) Line 165- Pre* HAART not Per*

6) Line 225- Some risk factors are confusing such as 'religion', 'gender', 'age'. Could you specify what the papers say about how these factors affect risk? Which ages, genders, etc?

7) Discussion- Line 253-255- "Suicide prevalence highest in Americas/ Europe from 1997 to 2020" but then you list countries that has Australia, Thailand, South Africa as top prevalence in the next few lines.

8) Discussion- Line 259-Line 261: You mentioned reasons as liberal laws on doctor-assistant suicide, gun control or economic/ social pressures: Any citations for that?

9) Discussion- Line 268- Line 270- "85% of suicides occur in Africa and middle/low income countries": Citation?

10) You could mention higher risk of suicide in people with HIV compared to general population to emphasize suicidal risks in PLHIV (as seen in citations you have provided)

11) Discussion- Line 274- In Asian region, most common suicide behavior is completed suicide. So increased completed suicides compared to other regions (that goes against previous report that suicidal behaviors highest in Americas/ Europe) or completed suicides are higher than suicidal ideation/ attempts (That's not possible)

12) Discussion- Line 278 - "Most common death factor?"; "Depression and its common cause." Please correct that whole sentence to be clear grammatically.

13) In Discussion- It would help to mention something the reader should take from this study that could help clinically such as importance of social supports, etc in HIV treatment

14) Conclusion- "We found that Americas, Europe and Asia have the highest rates of suicidal behavior" - Compared to what? Africa and Australia? Better if conclusion is more specific. Please change the wording to explain what you mean.

15) How did your results compare to what we knew from previous research studies- Confirmed some? Expanded any additional information we didn't know before? Add them in conclusion as important findings from this study.

16) The figures and tables are well done. Would help to have a table with consistent/ inconsistent risk factors

17) There are several limitations you can add at the end.

1) Different types of studies can have different qualities of study. Not evaluating which studies are better in terms of sample size, biases, etc. is a limitation.

2) Given different time periods, cultures etc, in regional studies review, it is difficult to make generalized conclusions for global factors and patterns. Recent studies more valuable than pre-HAART studies.

3) Different scales/ measurement tools were used which also affects consistency in studies.

18) Many grammatical errors and spelling errors noted in the manuscript. It would be helpful to review it once more.

Reviewer #2: some of the sentences are repetitive specially definitions of different suicidal behaviors including ideations, and attempts and can be revised. Good description of consistent and inconsistent risk factors.

Reviewer #3: The submitted manuscript discusses an important topic of suicide in patients with HIV. However in its current form, the article suffers from some deficiencies which need to be addressed. A lot of focus has been placed on tabular display of data rather than the written sections. The introduction section especially has been presented in a very matter of fact fashion and does not evoke much curiosity in the reader. The authors need to cite more articles to drive home the point that suicide in patients with HIV is a matter of public health concern. It would be helpful to tie in Hypersexual behaviors, sexual addiction and other psychiatric disorders to HIV.

I refer the authors to the following article which discussed hypersexuality and sexual addiction to risk of getting STDs. Kindly review and cite the article as appropriate.

https://www.researchgate.net/profile/Ashish-Sarangi-2/publication/320741412_Hypersexual_Disorder-A_Case_Report_and_Analysis_A_R_T_I_C_L_E_I_N_F_O/links/59f916ea0f7e9b553ec0c8ec/Hypersexual-Disorder-A-Case-Report-and-Analysis-A-R-T-I-C-L-E-I-N-F-O.pdf

Although not the primary aim, it would be helpful to include a few lines in the discussion section making suggestions on how to screen patients at risk of suicide and refer for appropriate interventions.

It will also be helpful to discuss the main methods used for suicide if this data is available for example hanging e.t.c

Please condense the tables as there is too much data in the tables for meaningful review.

I will be happy to accept a revised manuscript for consideration as I believe it has potential.

Reviewer #4: Thank you for the opportunity to review the article.

The review is an excellent and balanced overview that includes 193 observational studies, a large sample size from 49 countries, both clinic and hospital data from multiple databases, encompasses diverse populations, 23 years of data( 2/3 of papers were recent), gives an interesting perspective on historical pre HAART suicide rate compared to post HAART suicide rate in HIV patient that ironically showed an increasing trend of suicidal behavior post-HAART therapy which is essential to be addressed and is often overlooked. Furthermore, they have highlighted risk factors of suicidal ideation and complete suicide in detail in different countries(included physical, psychological, social, demographic risk factors), also used standard scales as their guide, talked about methods of committing suicide in different countries, information on prevalence, association with certain coexisting conditions like substance disorder, mental illness, etc. They have registered in INPLASY, has Prisma flow diagrams, appropriate methodology for review and bias, did JBI for ROB assessment, and have good review article tables and flow charts.

However, I have few suggestions that could be added to the article.

In my opinion, a key feature that could be included in the article is, using all patient sample data from various articles divided into baseline characteristics such as age, sex, ethnicity, family history data, cultural and social aspects, important comorbid conditions like substance use disorder, stigma, mental illness, and side effects of any HAART therapy causing suicidal ideation. Then, Subsequently analyzed the total patient sample to derive any associations and protective factors. Please elaborate more on the third point mentioned in the discussion part and, if able to, try to describe any methods that can tackle this situation of suicide in post HAART HIV patients with a positive angle. Language is unclear at certain parts of the papers, making it difficult to follow. Therefore, I advise the authors to revise with Minor phrasing and grammatical issues to improve the flow and readability of the text.

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Reviewer #1: No

Reviewer #2: Yes: Meenal Pathak

Reviewer #3: No

Reviewer #4: Yes: Wasey Ali Yadullahi Mir

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Global overview of suicidal behavior and associated risk factors among people living with human immunodeficiency virus: A scoping review

PONE-D-21-32836R1

Dear Dr. Ko,

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

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Saeed Ahmed, MD

Academic Editor

PLOS ONE

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

Reviewer #3: All comments have been addressed

Reviewer #4: All comments have been addressed

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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

Reviewer #3: Yes

Reviewer #4: Yes

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

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

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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: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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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

Reviewer #3: Yes

Reviewer #4: Yes

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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: Authors seem to have incorporated the comments and feedback in their update. It is an important topic, and the data is analyzed extensively.

Reviewer #3: The reviewer comments have been adequately addressed. Happy to accept for publication as it will be a good addition.

Reviewer #4: (No Response)

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