A randomized control trial of high-dose micronutrient-antioxidant supplementation in healthy persons with untreated HIV infection

Wendy L. Wobeser; Joanne E. McBane; Louise Balfour; Brian Conway; M. John Gill; Harold Huff; Donald L. P. Kilby; Dean A. Fergusson; Ranjeeta Mallick; Edward J. Mills; Katherine A. Muldoon; Anita Rachlis; Edward D. Ralph; Ron Rosenes; Joel Singer; Neera Singhal; Darrell Tan; Nancy Tremblay; Dong Vo; Sharon L. Walmsley; D. William Cameron; for the MAINTAIN Study Group

doi:10.1371/journal.pone.0270590

Peer Review History

Original SubmissionOctober 15, 2021
25 Jan 2022 Decision Letter - Maret G Traber, Editor PONE-D-21-33096A randomized control trial of high-dose micronutrient-antioxidant supplementation in healthy persons with untreated HIV infectionPLOS ONE Dear Dr. Cameron, 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. Please submit your revised manuscript by Mar 11 2022 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. 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We note that the grant information you provided in the ‘Funding Information’ and ‘Financial Disclosure’ sections do not match. When you resubmit, please ensure that you provide the correct grant numbers for the awards you received for your study in the ‘Funding Information’ section. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. Additional Editor Comments (if provided): The expert reviewers have recommended some minor changes. Please address these. [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: Yes 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: Yes 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: Yes 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: To some extent the findings are confirmatory in nature, but a large volume of work was presented which has been accumulated over a long period of time. The results carry sufficient merits to be published. Other questions are raised in my comments to authors. Reviewer #2: Overall comments: The design and methods appear to be described and performed to a high standard. Though I have some suggestions and a few questions below on a few places which I think need some clarification or more information. Specific comments: 1. (line 21) Intent-to-treat censoring 2. (line 124) It wasn't clear to me what "PLOS ONE" means here. Is this a missing reference? 3. (lines 217) Please provide a citation for the mixed-effects model. 4. (line 218) Which correlation structure was used? 5. (lines 256-273) I think some or most of this section should be included in the methods. I'm not quite sure how much; my guess is the first two paragraphs (lines 256-269). 6. (lines 256-273) I would also encourage a more complete description of the methods used for the simulations that are described in this section. This may be more appropriate to be included in the supplementary methods. 7. (lines 315-318) It seems redundant to include the p-values for both the log-rank test and PH model. 8. (lines 217, 219, 222, 227, 320, etc.) At this point in the paper, I am finding myself confused with the use of the terms "censored" and "censoring". In statistics, censoring has a specific definition, meaning the data are not available or hidden. For continuous variables, a "censored" value usually is one that falls either below or above a device's detection ability. In HIV, this is typically associated with measurements of viral load where, at least historically, assays have had a lower limit of detection (LLOD). Participants with low viral loads, their values were "censored" or hidden because the measurement was below the LLOD. I'm guessing "censored" is being used for two different purposes here and I suggest the authors read through the paper and change one of the terms to make this clearer. 9. (Figures 2-4) Ideally, these figures would include confidence bands to depict the variability in these estimates. Also, I encourage you to include them in color so they are more striking and because there are no additional fees for color figures. If there is a worry about the figures showing up in grayscale, you could switch to a palette at https://colorbrewer2.org/. ****** 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: Yes:** I. Tong Mak 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. Attachments Attachment Submitted filename: Plos one review.docx https://doi.org/10.1371/journal.pone.0270590.r001
Revision 1
11 May 2022 Author Response Review Comments to the Author Specific comments: 1. (line 21) Intent-to-treat censoring Thank you for noticing this typo – it has been corrected. 2. (line 124) It wasn't clear to me what "PLOS ONE" means here. Is this a missing reference? The actual reference has been added to the manuscript. 3. (lines 217) Please provide a citation for the mixed-effects model. We have added the required citation. 4. (line 218) Which correlation structure was used? A variance component structure was used where each patient was considered independent across all patients and visit was nested within each patient where a different variance component was each visit – this was added to the manuscript. 5. (lines 256-273) I think some or most of this section should be included in the methods. I'm not quite sure how much; my guess is the first two paragraphs (lines 256-269). Thank you for this suggestion, part of the section has been moved to methods. 6. (lines 256-273) I would also encourage a more complete description of the methods used for the simulations that are described in this section. This may be more appropriate to be included in the supplementary methods. This has been added for clarification: “Both scenarios assumed outcome rates that served as the basis for the sample size calculation for the two groups which served as the basis for the original sample size calculation was true, and simulated outcomes for those participants on study and still at risk, as well as for participants yet to be recruited in the second scenario.” 7. (lines 315-318) It seems redundant to include the p-values for both the log-rank test and PH model. We have removed the redundant p value. 8. (lines 217, 219, 222, 227, 320, etc.) At this point in the paper, I am finding myself confused with the use of the terms "censored" and "censoring". In statistics, censoring has a specific definition, meaning the data are not available or hidden. For continuous variables, a "censored" value usually is one that falls either below or above a device's detection ability. In HIV, this is typically associated with measurements of viral load where, at least historically, assays have had a lower limit of detection (LLOD). Participants with low viral loads, their values were "censored" or hidden because the measurement was below the LLOD. I'm guessing "censored" is being used for two different purposes here and I suggest the authors read through the paper and change one of the terms to make this clearer. Hope this will clarify the confussion – the data sets were “censored” and “censoring” was used in the manuscript to describe the process of excluding censored values. We tried to clarify this in the manuscript as well. 9. (Figures 2-4) Ideally, these figures would include confidence bands to depict the variability in these estimates. Also, I encourage you to include them in color so they are more striking and because there are no additional fees for color figures. If there is a worry about the figures showing up in grayscale, you could switch to a palette at https://colorbrewer2.org/. We are submitting versions in color this time. REVIEWER #2 This manuscript summarized the results from a randomized, double-blind, placebo-controlled multicenter clinical trial in Canada to assess if high doses of micronutrient plus antioxidant supplementation might provide significant beneficial effects on the HIV disease progression in asymptomatic ART-naïve HIV patients compared to similar patients receiving RDA supplementation (control). Based primarily on time-to first detection of CD4 <350 cells/ul, or ART initiation or AIDS-defined illness, no significant difference in disease progression between these two groups were found. The study represents a large volume of work accumulated for over 2 years, and the trial protocol and analyses were considered rather rigorous and thus the data seem to be of high quality, and the findings were consistent with the majority opinions/reviews in the field. The treatment group also received high dose antioxidant supplementation which renders this study more unique and the results worthy noticing. Nevertheless, the impact on key indices of oxidative stress and antioxidant capacity are missing but desirable. Other issues are listed as following. Specifics: 1. It is believed that the inclusion of multiple antioxidants and minerals in the treatment group (in addition to high doses of multivitamins) was designed to address the compelling hypothesis that oxidative stress plays an important role contributing to the pathogenesis of HIV/AIDS. However, key blood indices of oxidative stress (e.g., F2-isoprostane, 4HNE-His, TBARS etc., and/or antioxidant decreases (e.g., GSH, oxidant scavenging capacity etc.) are missing which were obtainable from the patients’ plasma/blood samples. It would be highly relevant to the theme of the study if giving RDA levels of multivitamins alone would be sufficient to improve the antioxidant/oxidative indices from the baseline comparing to giving high doses of multivitamins and antioxidants. Thank you for this suggestion. As we saw no clinicaly relevant improvement in the course of the study we we did not pursue suggested analysis. Each site may have some of the data, but collecting this at this time would be impossible. 2. The rate of CD4 T cell decline appeared to be substantially slower in the treatment (-42.7 cells/ul vs -79.7 cells/ul per 52 weeks for the control); yet statistical significance was not reached due to the stringent protocol sensitivity analysis. In a published work, it was suggested that the beneficial effects of micronutrient supplementation could only be solidified if the HIV infection was at an earlier stage. It is unclear from the study described whether such a criterion (of early HIV infection) was taken into consideration for the patient selection. Or if the patients might come from different stages of HIV infection and thus contribute to a higher degree of variability for the CD 4 T cell decline. All the participants had been diagnosed recently, with a mean diagnosis of within 2 years, however, how long the participant had been positive before diagnosis would have been n unknown variable. This clarification was added in the manuscript. https://doi.org/10.1371/journal.pone.0270590.r002
14 Jun 2022 Decision Letter - Maret G Traber, Editor A randomized control trial of high-dose micronutrient-antioxidant supplementation in healthy persons with untreated HIV infection PONE-D-21-33096R1 Dear Dr. Cameron, 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. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Maret G Traber, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0270590.r003
Formally Accepted
5 Jul 2022 Acceptance Letter - Maret G Traber, Editor PONE-D-21-33096R1 A randomized control trial of high-dose micronutrient-antioxidant supplementation in healthy persons with untreated HIV infection. Dear Dr. Cameron: I'm 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. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Professor Maret G Traber Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0270590.r004

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