Bone mineral density among virologically suppressed Asians older than 50 years old living with and without HIV: A cross-sectional study

Lalita Wattanachanya; Sarat Sunthornyothin; Tanakorn Apornpong; Hay Mar Su Lwin; Stephen Kerr; Sivaporn Gatechompol; Win Min Han; Thanathip Wichiansan; Sarawut Siwamongsatham; Pairoj Chattranukulchai; Tawatchai Chaiwatanarat; Anchalee Avihingsanon; HIV-NAT 207/006 study team

doi:10.1371/journal.pone.0277231

Peer Review History

Original SubmissionApril 4, 2022
1 Aug 2022 Decision Letter - Julie AE Nelson, Editor PONE-D-22-09858Bone mineral density among virologically suppressed Asians older than 50 years old living with and without HIV: a cross-sectional studyPLOS ONE Dear Dr. Avihingsanon, 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. Each of the two reviewers has made specific recommendations for something to add so please address this in your revised version. Please submit your revised manuscript by Sep 15 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. 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To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ 5. One of the noted authors is a group or consortium HIV-NAT 207/006 study team. In addition to naming the author group, please list the individual authors and affiliations within this group in the acknowledgments section of your manuscript. Please also indicate clearly a lead author for this group along with a contact email address. 6. We note that you have included the phrase “data not shown” in your manuscript. Unfortunately, this does not meet our data sharing requirements. PLOS does not permit references to inaccessible data. We require that authors provide all relevant data within the paper, Supporting Information files, or in an acceptable, public repository. Please add a citation to support this phrase or upload the data that corresponds with these findings to a stable repository (such as Figshare or Dryad) and provide and URLs, DOIs, or accession numbers that may be used to access these data. Or, if the data are not a core part of the research being presented in your study, we ask that you remove the phrase that refers to these data. 7. 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. [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: No 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: The present manuscript is sound, however, It appears that a critical piece of data is missing. The adjusted BMD values adjust for age, BMD, and other traditional osteoporotic risk factors. The statistical analysis seemed appropriate and was rationalized. All data underlying the findings in their manuscript were made fully available. Moreover, the manuscript is presented in an intelligible fashion and written in standard English. Reviewer #2: Introduction: Well written overview of the current literature, as well as justification for the research conducted. Methods: Study population: further information should be detailed on how the cohort and sample selected for this specific AMH study were derived. Sample size (462 of which 256 were Women living with HIV (WLWHIV) ) appears adequate to make conclusions although the wide age range ( 12-50 years of age) result in small numbers in certain age groups. Statistical Analyses appear appropriate. Results: The findings indicate the expected relationship between younger age and higher AMH levels. Of Interest, and in support of their hypothesis, the authors found that among the women over 35 years of age, the AMH levels were associated with HIV status and shortened telomere length in PBMCs, with WLWHIV having lower AMH levels compared to women of similar age range who were not HIV infected. These findings support earlier studies that suggested WLWHIV and provide a potential laboratory marker, AMH, to help provide guidance for WLWHIV with regards to fertility, and child spacing decisions. Some limitations to the findings include that the WLWHIV had increased risk of other risk factors that could also impact on telomere length and ovarian function such as smoking, and drug use. Conclusions: well thought out and not overreaching. In summary, an interesting and useful manuscript in terms of better understanding of the role of AMH over time and hypotheses generating in terms of differences seen among WLWHIV and women without HIV in terms of ovarian aging and reproductive health. ****** 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. Attachments Attachment Submitted filename: PONE-D-22-09858_Rec.pdf https://doi.org/10.1371/journal.pone.0277231.r001
Revision 1
30 Sep 2022 Author Response Reviewers' comments: Reviewer #1: 1. Improve mechanics, table organization, spacing as well as formatting of tables in the document. RESPONSE: Thank you for the suggestion. We have managed to make sure that all the tables are well formatted and easy to read. 2. A few lines, for example, Line 57 appear to need citations. RESPONSE: Thank you for pointing out this this. We have carefully rechecked to ensure that all the sentences had proper citations, including the sentence in line 58-59. Reference 3, 4, and 50 were added into the References section. 3. The reproductive history in Table 1 is unclear. Is menstruation exhausted referring to the number of women that have reached menopause? RESPONSE: Thank you for. Yes, “menstruation exhausted” referred to the number of women that have reached menopause. We have added “n (%)” after each category of reproductive history in Table 1. 4. Empty boxes in tables 3 and 4 RESPONSE: All variables with p-values ≤ 0.20 from the univariate analyses were included in the multivariable regression model. Therefore, all the empty boxes in Table 3 and Table 4 were left blank because these variables that were not significant in the univariate models were not included in the multivariate analyses. The detailed methodology regarding the adjusted models was provided in the Statistical analysis section of, line 132-133. 5. What units are being presented in table 6? RESPONSE: We have added the units of P1NP, CTX and 25(OH)D in Table 6. 6. Were any of the women in the study on hormonal replacement therapy? RESPONSE: All the women in the study were not on hormonal replacement therapy. 7. In the abstract it is written, “After adjusting for age, BMI, 45 and other traditional osteoporotic risk factors, BMD of virologically suppressed older PWH did not differ from participants without HIV”, however, no data is shown highlighting adjusted BMD. A similar statement is made in the discussion, lines 259-260, which states, “after adjusting for clinical risk factors listed above, there was no difference in BMD at any sites between PWH and people living without HIV”, however, adjusted BMD values are not in the manuscript. All that is shown in table 2, which has the unadjusted BMD values, which are lower in people with HIV compared to people without HIV. RESPONSE: Analysis of the comparison of adjusted BMD between HIV+ and HIV- participants of both sexes (shown below) indicated that the BMD values after adjustment were comparable between HIV- and HIV+ of both sexes. Comparison of adjusted BMD between HIV+ and HIV- participants of both sexes Site HIV status Absolute BMD (g/cm2) Adjusted model* P-valueⱡ Mean difference 95% CI Men (n=297) Lumbar spine uninfected 0.96 (0.14) ref - infected 0.94 (0.16) -0.002 (-0.04, 0.04) 0.93 Total hip uninfected 0.91 (0.13) ref - infected 0.86 (0.13) -0.03 (-0.06, 0.003) 0.076 Femoral neck uninfected 0.74 (0.12) ref - infected 0.71 (0.11) -0.02 (-0.04, 0.01) 0.26 Women (n=184) Lumbar spine uninfected 0.88 (0.18) ref - infected 0.85 (0.16) -0.04 (-0.08, 0.01) 0.12 Total hip uninfected 0.81 (0.17) ref - infected 0.79 (0.13) -0.01 (-0.05, 0.03) 0.56 Femoral neck uninfected 0.66 (0.21) ref - infected 0.64 (0.12) -0.02 (-0.06, 0.02) 0.32 Adjusted for age, BMI, and smoking status in men and for age, BMI, and menstruation status in women; ⱡ P-values were estimated by linear regression models • We have demonstrated in Table 3 and Table 4 that HIV status was not correlated with BMD in both men and women in the multivariate analyses. So, we did not include the table above in our manuscript. However, we have provided p-value “P>0.1” in the abstract as the followings: “After adjusting for age, BMI, 45 and other traditional osteoporotic risk factors, BMD of virologically suppressed older PWH did not differ from participants without HIV (P>0.1)”. • In Discussion section, we have also added the table references “(Table 3 and Table 4)” in line 271-273 as the following: “…after adjusting for clinical risk factors listed above, there was no difference in BMD at any sites between PWH and people living without HIV (Table 3 and Table 4).” 8. Elevated circulating levels of bone turnover markers such as P1NP and CTX can be indicative of dysregulated bone turnover, which can also drive increased fracture risk. It is worth discussing what this could mean for long-term bone quality for people living with HIV. For instance, it has been shown that there is reduced bone microarchitecture in people with HIV despite comparable BMD relative to HIV age-matched sex-matched HIV negative persons, therefore even if there are no significant BMD differences there are other factors outside of BMD that may drive fracture risk. RESPONSE: We have expanded our discussion on page 21 in Discussion section, line 335-337, as the followings: “Fifth, index of bone microarchitectural quality, such as trabecular bone score, was not assessed in our study. It has been shown that PWH had worse bone microarchitecture than age- and sex-matched HIV negative persons [50]. Future studies evaluating the bone quality together with BMD may improves fracture prediction in older PWH with virological suppression. Finally, this study is a cross-sectional design, while a longitudinal study would have provided more information on the BMD changes over time and the fracture incidence, as well as the factors that influence bone loss and fracture.” Reviewer #2: 1. Ideally, a longitudinal design would have been used. The authors should comment on the rationale for only presenting cross sectional data for this cohort which is in long term follow up. RESPONSE: Thank you for your suggestion. Currently, the longitudinal study of these participants is undergoing to follow-up on measuring the changes in BMD and the fracture incidence, as well as identifying the factors that influence bone loss and fracture. • In the current study, we report the outcome of BMD, calciotropic hormones, vitamin D status, and bone turnover markers at the patients’ baseline visit compared to HIV-uninfected controls. • We have expanded our discussion on page 22 in Discussion section, line 339-341. 2. The reason that 38% of those on TDF ART were on a half dose should be further detailed. RESPONSE: All treatment regimens and doses were based on the physician’s decision since this is an observational study, and the reason behind it may probably due to the reduced creatinine clearance or low body weight of patients. We have added more detail in Results section (line 160-162) as the following: “Among these, 35% used TDF at half dose. Of note, since this is an observational study, all ART regimens and doses were based on the physician’s decision and local guidelines, and the reason behind it may probably because of reduced creatinine clearance or low body weight of patients.” Attachments Attachment Submitted filename: Response to Reviewers.docx* https://doi.org/10.1371/journal.pone.0277231.r002
24 Oct 2022 Decision Letter - Julie AE Nelson, Editor Bone mineral density among virologically suppressed Asians older than 50 years old living with and without HIV: a cross-sectional study PONE-D-22-09858R1 Dear Dr. Avihingsanon, 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, Julie AE Nelson, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): 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 #1: All comments have been addressed 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 #1: Yes Reviewer #2: (No Response) ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: (No Response) ****** 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 #1: Yes 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 #1: Yes Reviewer #2: (No Response) ****** 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 #1: In addition to fully addressing all of the reviewers' comments, the authors improved the readability of the manuscript and provided further justification for the formatting. 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 #1: No Reviewer #2: No ******** https://doi.org/10.1371/journal.pone.0277231.r003
Formally Accepted
28 Oct 2022 Acceptance Letter - Julie AE Nelson, Editor PONE-D-22-09858R1 Bone mineral density among virologically suppressed Asians older than 50 years old living with and without HIV: A cross-sectional study Dear Dr. Avihingsanon: 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 Dr. Julie AE Nelson Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0277231.r004

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