Dear Dr. Chen,

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.

==============================

ACADEMIC EDITOR:

The following changes are required for acceptance of your revised manuscript:

Use the term persons or patients with HIV instead of HIV-positive patients.

Write Health and Hospitals instead of Health + Hospitals.

Correct the sentence “Yet little can be found to address the racial differences in patient has both diagnosis HIV infection and HF'. in lines 55-56.

Place figures and captions right after the paragraph in which they are first cited and write the title in bold letters.

Explain the reasons for low HIV treatment adherence and rate of viral suppression across different racial/ethnic categories.

Consider adjusting for confounding variables or if not done, acknowledge this as study limitation.

The comments provided by Reviewer 3 are appropriate suggestions and recommendations.

This Journal Editor feels that your manuscript addresses a very important topic as persons living with HIV are living longer and experiencing a higher incidence of cardiovascular diseases, fueled by ongoing inflammation, even in the setting of consistent viral suppression. Moreover, people of lower socio-economic status are facing increased risk of cardiovascular comorbidity regardless of HIV status.

==============================

Please submit your revised manuscript by Oct 30 2025 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.

• 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'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

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: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Vladimir Berthaud

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf   and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 3 in your text; if accepted, production will need this reference to link the reader to the Table.

3. We note that there is identifying data in the Supporting Information file <file name>. Due to the inclusion of these potentially identifying data, we have removed this file from your file inventory. Prior to sharing human research participant data, authors should consult with an ethics committee to ensure data are shared in accordance with participant consent and all applicable local laws.

Data sharing should never compromise participant privacy. It is therefore not appropriate to publicly share personally identifiable data on human research participants. The following are examples of data that should not be shared:

-Name, initials, physical address

-Ages more specific than whole numbers

-Internet protocol (IP) address

-Specific dates (birth dates, death dates, examination dates, etc.)

-Contact information such as phone number or email address

-Location data

-ID numbers that seem specific (long numbers, include initials, titled “Hospital ID”) rather than random (small numbers in numerical order)

Data that are not directly identifying may also be inappropriate to share, as in combination they can become identifying. For example, data collected from a small group of participants, vulnerable populations, or private groups should not be shared if they involve indirect identifiers (such as sex, ethnicity, location, etc.) that may risk the identification of study participants.

Additional guidance on preparing raw data for publication can be found in our Data Policy (https://journals.plos.org/plosone/s/data-availability#loc-human-research-participant-data-and-other-sensitive-data) and in the following article: http://www.bmj.com/content/340/bmj.c181.long .

Please remove or anonymize all personal information (<specific identifying information in file to be removed>), ensure that the data shared are in accordance with participant consent, and re-upload a fully anonymized data set. Please note that spreadsheet columns with personal information must be removed and not hidden as all hidden columns will appear in the published file.

4. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information .

5. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

6. 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:

Reviewer #1: Minor Revision: LINE 131: Brief background of why CD4 cells are important in HIV patients.

Fig. 1 : Replace 'prevalence' with 'prevalent'.

Do the socio-economic conditions affect the diet? Diet might have direct and indirect effect on heart disease.

Reviewer #2: Minor Revision

This manuscript presents a technically sound and well-executed study examining racial disparities in HIV-positive patients with heart failure using data from the NYC 4H cohort. The research is timely, relevant, and contributes meaningfully to the understanding of how social adversity intersects with clinical outcomes in marginalized populations.

1. Technical Soundness and Data Support

The study design, a mixed retrospective and prospective cohort, is appropriate for the research question. The sample size (n=1,044) is adequate, and the inclusion of five racial groups allows for meaningful stratified analysis. The use of validated tools such as the Area Deprivation Index (ADI) and psychosocial evaluations conducted by licensed social workers adds rigor to the assessment of social adversity.

The statistical analyses are appropriately chosen and executed. Proportional hazards regression models are used to assess mortality risk, with adjustments for key confounders. The manuscript confirms that proportional hazard assumptions were tested and not violated. Chi-square and t-tests are applied correctly to compare categorical and continuous variables, respectively. Hazard ratios and confidence intervals are clearly reported, and the findings are supported by well-organized tables and figures.

The conclusions are appropriately drawn from the data. The attenuation of mortality differences after adjusting for social adversity is a compelling finding that reinforces the manuscript’s central thesis.

2. Statistical Rigor

The statistical methodology is robust. The multivariable models are well-constructed, and the stratification by race and social adversity adds depth to the analysis. The authors have transparently acknowledged limitations related to small subgroup sizes and geographic specificity, which do not undermine the core findings.

3. Data Availability

The authors have confirmed that all relevant data are included within the manuscript and its Supporting Information files. This complies with PLOS ONE’s data policy and ensures transparency and reproducibility.

4. Language and Presentation

The manuscript is written in standard English and is generally intelligible. The structure is logical, and the tone is professional. However, a few grammatical and syntactical issues should be addressed:

• Revise awkward phrasing such as “Yet little can be found to address the racial differences in patient has both diagnosis HIV infection and HF.”

A light editorial review would enhance clarity and polish.

5. Figures and Tables Formatting

While figures and tables are cited appropriately in the Results and Discussion sections, the manuscript does not fully comply with PLOS ONE’s formatting guidelines:

• Figure captions should appear directly after the paragraph in which they are first cited. Currently, they are listed separately.

• Figure titles should be in bold type to distinguish them clearly.

• No tables are embedded within figure captions, which is correct and appreciated.

Addressing these formatting issues will improve readability and ensure compliance with journal standards.

6. Ethical Compliance and Publication Integrity

The study received IRB approval (Study ID 23-12-663719(HHC)), and all data were anonymized. The ethics statement is complete and appropriate. The authors have declared no competing interests and no funding sources, and there is no indication of dual publication.

Overall Recommendation: This manuscript meets the criteria for publication in PLOS ONE. With minor editorial and formatting revisions, it will make a valuable contribution to the literature on health disparities in HIV and heart failure populations.

Reviewer #3: Major revision

The manuscript addresses an important and timely topic, exploring racial differences in HIV-positive patients with heart failure. Overall, the study has potential to make a meaningful contribution, but several areas could be strengthened. First, the rationale for focusing on racial differences should be more clearly articulated in the introduction, with a discussion of potential biological, socioeconomic, and healthcare access factors that could contribute to observed disparities. The methodology section would benefit from additional clarity regarding patient selection, inclusion and exclusion criteria, and how race was categorized and verified. Details on how heart failure was defined and classified, including ejection fraction categories and relevant biomarkers, should be included to allow reproducibility. Statistical analyses need to be more explicitly described, including any adjustments for confounding variables such as age, sex, comorbidities, and antiretroviral therapy use; consideration of interaction terms or stratified analyses might also enhance interpretation. The results section would benefit from more granular reporting, particularly regarding subgroup differences and effect sizes, rather than focusing solely on statistical significance. Discussion of potential limitations is limited; the authors should address issues such as residual confounding, single-center design, and potential selection bias, and how these factors might influence generalizability. Additionally, the discussion could more thoroughly integrate the findings with existing literature, highlighting similarities, differences, and potential mechanistic explanations. Finally, attention to clarity in tables, figures, and text—ensuring consistency in terminology and proper labeling—would improve readability. Overall, the manuscript addresses a clinically relevant topic, but these areas of improvement would enhance rigor, clarity, and interpretability.

[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?

Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: N/A

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

Reviewer #1: LINE 131: Brief background of why CD4 cells are important in HIV patients.

Fig. 1 : Replace 'prevalence' with 'prevalent'.

Do the socio-economic conditions affect the diet? Diet might have direct and indirect effect on heart disease.

Reviewer #2: This manuscript presents a technically sound and well-executed study examining racial disparities in HIV-positive patients with heart failure using data from the NYC 4H cohort. The research is timely, relevant, and contributes meaningfully to the understanding of how social adversity intersects with clinical outcomes in marginalized populations.

1. Technical Soundness and Data Support

The study design, a mixed retrospective and prospective cohort, is appropriate for the research question. The sample size (n=1,044) is adequate, and the inclusion of five racial groups allows for meaningful stratified analysis. The use of validated tools such as the Area Deprivation Index (ADI) and psychosocial evaluations conducted by licensed social workers adds rigor to the assessment of social adversity.

The statistical analyses are appropriately chosen and executed. Proportional hazards regression models are used to assess mortality risk, with adjustments for key confounders. The manuscript confirms that proportional hazard assumptions were tested and not violated. Chi-square and t-tests are applied correctly to compare categorical and continuous variables, respectively. Hazard ratios and confidence intervals are clearly reported, and the findings are supported by well-organized tables and figures.

The conclusions are appropriately drawn from the data. The attenuation of mortality differences after adjusting for social adversity is a compelling finding that reinforces the manuscript’s central thesis.

2. Statistical Rigor

The statistical methodology is robust. The multivariable models are well-constructed, and the stratification by race and social adversity adds depth to the analysis. The authors have transparently acknowledged limitations related to small subgroup sizes and geographic specificity, which do not undermine the core findings.

3. Data Availability

The authors have confirmed that all relevant data are included within the manuscript and its Supporting Information files. This complies with PLOS ONE’s data policy and ensures transparency and reproducibility.

4. Language and Presentation

The manuscript is written in standard English and is generally intelligible. The structure is logical, and the tone is professional. However, a few grammatical and syntactical issues should be addressed:

• Revise awkward phrasing such as “Yet, little can be found to address the racial differences in patient has both diagnosis HIV infection and HF.”

A light editorial review would enhance clarity and polish.

5. Figures and Tables Formatting

While figures and tables are cited appropriately in the Results and Discussion sections, the manuscript does not fully comply with PLOS ONE’s formatting guidelines:

• Figure captions should appear directly after the paragraph in which they are first cited. Currently, they are listed separately.

• Figure titles should be in bold type to distinguish them clearly.

• No tables are embedded within figure captions, which is correct and appreciated.

Addressing these formatting issues will improve readability and ensure compliance with journal standards.

6. Ethical Compliance and Publication Integrity

The study received IRB approval (Study ID 23-12-663719(HHC)), and all data were anonymized. The ethics statement is complete and appropriate. The authors have declared no competing interests and no funding sources, and there is no indication of dual publication.

Overall Recommendation: This manuscript meets the criteria for publication in PLOS ONE. With minor editorial and formatting revisions, it will make a valuable contribution to the literature on health disparities in HIV and heart failure populations.

Reviewer #3: The manuscript addresses an important and timely topic, exploring racial differences in HIV-positive patients with heart failure. Overall, the study has potential to make a meaningful contribution, but several areas could be strengthened. First, the rationale for focusing on racial differences should be more clearly articulated in the introduction, with a discussion of potential biological, socioeconomic, and healthcare access factors that could contribute to observed disparities. The methodology section would benefit from additional clarity regarding patient selection, inclusion and exclusion criteria, and how race was categorized and verified. Details on how heart failure was defined and classified, including ejection fraction categories and relevant biomarkers, should be included to allow reproducibility. Statistical analyses need to be more explicitly described, including any adjustments for confounding variables such as age, sex, comorbidities, and antiretroviral therapy use; consideration of interaction terms or stratified analyses might also enhance interpretation. The results section would benefit from more granular reporting, particularly regarding subgroup differences and effect sizes, rather than focusing solely on statistical significance. Discussion of potential limitations is limited; the authors should address issues such as residual confounding, single-center design, and potential selection bias, and how these factors might influence generalizability. Additionally, the discussion could more thoroughly integrate the findings with existing literature, highlighting similarities, differences, and potential mechanistic explanations. Finally, attention to clarity in tables, figures, and text—ensuring consistency in terminology and proper labeling—would improve readability. Overall, the manuscript addresses a clinically relevant topic, but these areas of improvement would enhance rigor, clarity, and interpretability.

**********

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: Yes: Edgar Muchinta

Reviewer #3: Yes: Chukwuka Elendu

**********

[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.]

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Dear Dr. Chen,

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 Feb 28 2026 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.

• A 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'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

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: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Ronaldo Go, MD

Academic Editor

PLOS One

Journal Requirements:

1. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

2. 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.]

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

The PLOS Data policy

Reviewer #2: Yes

Reviewer #3: Yes

**********

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

Reviewer #2: Yes

Reviewer #3: Yes

**********

Reviewer #2: Thank you for the thorough revisions. All previous concerns have been addressed, and the manuscript is now clear, rigorous, and suitable for publication, with only minor editorial polishing needed.

Reviewer #3: (No Response)

**********

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: Yes: Edgar Muchinta

Reviewer #3: Yes: Chukwuka Elendu

**********

[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.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

Racial Differences in People Living with HIV and Heart Failure: Insight from New York City Health and Hospitals HIV Heart Failure Cohort

PONE-D-25-22933R2

Dear Dr. Chen,

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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager®  and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support .

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,

Ronaldo Go, MD

Academic Editor

PLOS One

Additional Editor Comments (optional):

Reviewers' comments: