Hypergammaglobulinemia in treated and untreated people with HIV

Isabel Vigmo; Staffan Nilsson; Aylin Yilmaz; Magnus Gisslén; Josefina Robertson; Johanna Karlsson

doi:10.1371/journal.pone.0349405

Peer Review History

Original SubmissionAugust 13, 2025
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While the authors have coined up a clinically relevant topic for the article, several revisions are needed to enhance clarity, methodological rigor, and consistency. Below are comments for the authors’ consideration. MAJOR COMMENTS 1. The manuscript alternates between describing the study as retrospective and prospective. Please clarify the study's exact design and use consistent terminology in the Abstract, Methods, and Results sections. If this is a retrospective analysis of prospectively collected cohort data, state this clearly. In lines 97–98, clarify whether some participants contributed multiple samples and how this was addressed in the analysis. If repeated measures were used, consider mixed effects or Generalized Estimating Equations (GEE) models, or select one sample per participant with sensitivity analyses. Additionally, in line 99, replace “One hundred sixty-six” with numerals. 2. The definition and ascertainment of primary HIV infection (PHI) require more detail. While PHI is defined as within 12 months of infection by the authors, the criteria used to determine this are not described. Specify whether the diagnosis was based on documented seroconversion, RNA+/Ab status, p24 antigen detection, or patient history, and address the possibility of late presenters being misclassified as PHI. Additionally, if authors could consider adding all category definitions in the article to a dedicated “Definitions” subsection. 3. Given that the data span from 1985 to 2023 and measurements were performed on different assay platforms, describe any calibration or harmonization procedures and assess whether platform or sampling era confounded the results. Sensitivity analyses restricted to uniform assay periods would strengthen the findings. 4. The authors state that the control group includes both PrEP and non‑PrEP individuals. It would be great if authors consider presenting subgroup analyses or adjusting for PrEP status in all control comparisons to avoid bias in defining what we may call “normal” reference ranges. 5. The statistical analysis involves numerous pairwise tests without adjustment for multiple comparisons. Apply false discovery rate or family‑wise error control and report effect sizes (e.g., median differences with 95% CIs) alongside p‑values. Clarify the handling of non‑normal data and log‑transformed variables. 6. Missing data for key biomarkers are noted in Table 1 and 2 captions. Authors could take time to state explicitly how missing values were handled, for instance, excluded, imputed, and assess whether the missingness was random. 7. In Table 2, summing the figures in column (n) gives a total of 892, which exceeds the stated sample size. Please clarify the actual study sample size and explain any discrepancies. 8. Figure 3 is mentioned in line 244 but is not included in the manuscript. Ensure all referenced figures are present, correctly numbered, and match their in‑text citations, and also the numbering must be sequentially ordered for both Tables and Figures in the article. 9. Some discussion statements, particularly those around lines 341-353, are not fully supported by the presented data. Revise to ensure interpretations are directly linked to results and acknowledge limitations in small subgroups. 10. Lines 41-43: The interpretation of inflammatory biomarker data could be expanded further. The statement “About one‑third of ART‑suppressed participants have elevated neopterin and β2‑microglobulin.” If authors could quantify the overlap with elevated IgG and explore predictors of persistent hypergammaglobulinemia using adjusted models, this could help with clarity on the data presentation in the article. 11. The Methods section and data analysis descriptions are not sufficiently detailed. Please expand these to clearly explain the analytical approach, including any statistical tests, adjustments, and handling of repeated measures. 12. The Swedish epidemic cohort reflects a male predominance, and the authors appropriately noted this. However, the finding that women had significantly higher IgG levels is interesting. Could this be explored further? Was this difference consistent across all CD4 strata and treatment groups? A brief comment on this would add depth. 13. Given the numerous factors influencing IgG levels (sex, treatment status, CD4 count, and inflammatory markers), a multivariate regression analysis would be highly valuable. This would help determine the independent predictors of IgG levels (and persistent hypergammaglobulinemia on ART) while controlling for other variables. The current univariate analyses are informative but could be significantly strengthened by a multivariate model. 14. Lines 314-322: The discussion on clinical implications is somewhat speculative. The suggestion that IgG could be a surrogate marker for B-cell dysfunction is interesting. Could the authors be more specific? For instance, in which clinical scenarios might measuring IgG be most useful (monitoring patients with incomplete immune reconstitution despite ART)? Also, please clarify the statement on lines 301-302; low albumin was only found in the OIM group, so it cannot be a general marker of HIV-related inflammation but rather of acute concomitant illness. MINOR COMMENTS 1. Under the Abstract section, define all abbreviations at first use, for instance “human immunodeficiency virus (HIV)” and “immunoglobulin G (IgG)”. Apply this consistently for all abbreviations throughout the manuscript, including in tables and figures. 2. Line 133: "guidelines existing at the time of inclusion". Please specify the core principle, for instance, if authors considered a combination of at least two drugs from different classes. Additionally, what would be of value if guidelines could be cited. 3. Figure 2: The figure is helpful. Consider adding the p-values for the significant comparisons (HIV+ untreated and ART) directly to the figure or its legend for clarity. 4. Figure 3: The axis labels for Figure 3D should be "S-β2-microglobulin (mg/L)". 5. Line 275: "in 45 % and 37 %". This is fine, but for consistency, you could use the "%" symbol throughout (e.g., 45%). 6. Line 311: "mean age of 42 years". Could this be a typo in the results (Table 1) report? Please, authors, report the "median" instead. 7. Correct unit errors, for instance, (“ml/L” to “mg/L) for β2‑microglobulin, unless perhaps there were some conversions applied and typographical inconsistencies, for instance, “IgG -levels” to “IgG levels” (line 288) and standardize HIV‑1 vs HIV usage. 8. Ensure all tables and figures have self‑contained legends that define abbreviations, state reference limits, and specify comparison frameworks. Add 95% CIs to medians in tables where possible. 9. Where qualitative terms like “weak correlation” are used, include numeric rho and p‑values in text or figure captions. 10. When comparing results to other countries, provide possible explanations for differences (e.g., ART coverage, prophylaxis use, cohort characteristics) rather than stating comparability without context. 11. Check that all data in the text match the values in tables and figures and review the manuscript for typographical and formatting errors. 12. If applicable, include an accession or URL for the Swedish National Data Service in the Data Availability statement. Reviewer #2: Title: Hypergammaglobulinemia in treated and untreated people with HIV This paper by Vigmo et. al. is well-written and covers an important and under-investigated area of chronic HIV infection. The cohort is large and well-characterized, with a long follow-up period that includes both pre- and post-ART periods. The findings are clinically relevant and demonstrate persistent B-cell dysregulation (hypergammaglobulinemia) and immune activation even in virologically suppressed individuals. However, several points require clarification or expansion to strengthen the conclusions. Major Comments 1. In lines 99-101, the authors mention that 166 participants provided samples twice and were thus included in both treated and untreated groups. This creates a significant issue of non-independence between the ART and the various untreated CD4 strata groups. The statistical comparisons between these groups are potentially confounded by this repeated sampling. The authors must clearly address this as a key limitation in the discussion. The statistical analysis should be clarified; were comparisons between groups treated as independent? If so, this is a methodological weakness. Consider using statistical methods that account for paired/repeated measures for these specific comparisons or focusing more on cross-group trends rather than direct pairwise tests between these non-independent groups. 2. In the methods section, Lines 98-101, Laboratory methods (lines 144-145), two different methods were used for IgG (nephelometry and immunoturbidimetry). Was there any harmonization or validation between these two methods across the long study period? This should be briefly mentioned to assure readers that measurements are comparable over time. 3. A major potential confounder for hypergammaglobulinemia is co-infection with Hepatitis C virus (HCV), which is common in PWH and a known cause of high IgG concentration. The authors did state this as a limitation (lines 327-329), but they do not provide any data. Ideally, the prevalence of HCV co-infection (and other chronic infections like Hepatitis B, Syphilis, and Epstein-Barr virus) should be reported for the key groups, especially the high IgG groups and the ART group. If data is available, a sensitivity analysis excluding HCV+ (or for any other chronic infectious disease) individuals would greatly strengthen the conclusion that the hypergammaglobulinemia is HIV-driven. If no data is available, this must be stated as a significant limitation. Minor Comments 1. In line 167. The authors mention that ‘Partial correlation was performed when deemed appropriate.’ This is too vague. He authors need to specify what variables were adjusted for in the partial correlations (e.g., in Fig 3, were correlations adjusted for age, sex?). 2. In the results section, Table 1, the female percentage in the ‘With PrEP’ control group is 0% (0/45). This is a significant demographic difference from the ‘Without PrEP’ group (42.3% female) and the PWH groups. This should be noted in the text, since sex is later shown to have an influence on IgG levels. ****** -->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. https://doi.org/10.1371/journal.pone.0349405.r001
Revision 1
22 Nov 2025 Author Response Response to reviewers “Hypergammaglobulinemia in treated and untreated people with HIV” First, we wish to thank the two reviewers for their interest in our work and their constructive comments on the paper. We have revised the manuscript accordingly, and we address each comment below. Reviewer 1 Major comments Q1: The manuscript alternates between describing the study as retrospective and prospective. Please clarify the study's exact design and use consistent terminology in the Abstract, Methods, and Results sections. If this is a retrospective analysis of prospectively collected cohort data, state this clearly. In lines 97–98, clarify whether some participants contributed multiple samples and how this was addressed in the analysis. If repeated measures were used, consider mixed effects or Generalized Estimating Equations (GEE) models, or select one sample per participant with sensitivity analyses. Additionally, in line 99, replace “One hundred sixty-six” with numerals. A1: Thank You for this valuable comment. We have clarified that the study is a cross-sectional analysis of prospectively collected data, and the term “retrospective” has been removed throughout the manuscript. For the group comparisons in Table 2, no participant contributed more than one sample; each sample represents a unique subject, either in the ART group or one of the untreated groups, thus all samples are independent. This has been clarified in the Definitions section (lines 121-123) and in the captions of Table 1 and 2 (lines 189-192 and 219-222). Prompted by this remark, we also revised Figure 2, dividing the HIV-positive samples into ART-treated and untreated groups. Finally, “one hundred sixty-six” has been replaced with numerals. Q2: The definition and ascertainment of primary HIV infection (PHI) require more detail. While PHI is defined as within 12 months of infection by the authors, the criteria used to determine this are not described. Specify whether the diagnosis was based on documented seroconversion, RNA+/Ab status, p24 antigen detection, or patient history, and address the possibility of late presenters being misclassified as PHI. Additionally, if authors could consider adding all category definitions in the article to a dedicated “Definitions” subsection. A2: The diagnosis of primary HIV infection (PHI) was based on a combination of clinical symptoms and laboratory confirmation through seroconversion, nucleic acid testing or ELISA results. This information has been added to the Definitions section (lines 110-112). The combined use of clinical and laboratory data minimizes the risk of misclassification of infection stage. Further, definitions for all study categories have now been consolidated under a dedicated “Definitions” subsection, as suggested. Q3: Given that the data span from 1985 to 2023 and measurements were performed on different assay platforms, describe any calibration or harmonization procedures and assess whether platform or sampling era confounded the results. Sensitivity analyses restricted to uniform assay periods would strengthen the findings. A3: Thank You for raising this important point regarding the change in analytical methods for IgG measurement during the study period. When the analytical instrument was replaced, a comprehensive validation was performed, including verification of the reference interval. The laboratory has also participated continuously in two external quality assurance programs (Equalis and INSTAND). According to available validation and external quality control data, the transition from nephelometry to immunoturbidimetry did not result in any clinically relevant differences in IgG concentrations. This information has been added to the Laboratory methods section (lines 143-145). Q4: The authors state that the control group includes both PrEP and non PrEP individuals. It would be great if authors consider presenting subgroup analyses or adjusting for PrEP status in all control comparisons to avoid bias in defining what we may call “normal” reference ranges. A4: While HIV-negative controls using PrEP showed higher concentrations of β2-microglobulin and neopterin when compared to HIV-negative controls not using PrEP, there was no significant difference in IgG levels between these groups. This has now been stated in the Results section (lines 204-206). The observed biomarker differences between PrEP and non-PrEP controls have been described previously (Robertson et al, references 28 and 30) and this has now been addressed in the Results (lines 262-265) as well as in the Discussion (lines 351-355. We have also performed a subgroup analysis comparing HIV-negative controls with and without PrEP in all control comparisons and the overall results remained unchanged (lines 206-207). Q5: The statistical analysis involves numerous pairwise tests without adjustment for multiple comparisons. Apply false discovery rate or family wise error control and report effect sizes (e.g., median differences with 95% CIs) alongside p values. Clarify the handling of non normal data and log transformed variables. A5: In table 2, 32 pairwise tests were performed. Using Holm-Bonferroni, which is still conservative due to correlated tests, to correct for multiple inference does not change the status of any of the nominally significant tests. We agree that effect sizes are generally important, however, in this context we believe including them would make the table less readable. For this reason, we decided not to include these data. Regarding data distribution, non-normally distributed variables were log-transformed prior to analysis, as stated in the Statistical methods section (lines 165-175). Q6: Missing data for key biomarkers are noted in Table 1 and 2 captions. Authors could take time to state explicitly how missing values were handled, for instance, excluded, imputed, and assess whether the missingness was random. A6: Thank You for this comment. Regarding the missing data for inflammatory biomarkers (neopterin, β2-microglobulin, albumin), these were missing by random, e.g., when the remaining blood volumes were insufficient for the required assays. Hence, no systematic error was identified. Missing data were excluded pairwise in the statistical analyses. This information has been added to the captions of Table 1 and Table 2 (lines 193-194 and 224-225, respectively). Q7: In Table 2, summing the figures in column (n) gives a total of 892, which exceeds the stated sample size. Please clarify the actual study sample size and explain any discrepancies. A7: Thank You for noting this. The HIV-negative control group (n = 71) was subdivided into participants using PrEP (n = 45) and not using PrEP (n = 26). Thus, the total number of samples (n = 821) is correct. To clarify this, we have right-aligned the participant number for the HIV-negative subgroups (with and without PrEP) in Table 1 and Table 2. In addition, information on the total sample size has been added to the table legends (lines 189-192 and 219-222). Q8: Figure 3 is mentioned in line 244 but is not included in the manuscript. Ensure all referenced figures are present, correctly numbered, and match their in text citations, and also the numbering must be sequentially ordered for both Tables and Figures in the article. A8: Figure 3 was submitted along with the manuscript, but seems to be missing in the file presented to Reviewer 1. Q9: Some discussion statements, particularly those around lines 341-353, are not fully supported by the presented data. Revise to ensure interpretations are directly linked to results and acknowledge limitations in small subgroups. A9: Thank You for this comment. It appears there may have been a line displacement, as lines 341-353 contained the supporting figure captions rather than discussion text. We would appreciate clarification regarding which specific part(s) of the discussion Reviewer 1 is referring to, so that we can address the concern appropriately. Q10: Lines 41-43: The interpretation of inflammatory biomarker data could be expanded further. The statement “About one third of ART suppressed participants have elevated neopterin and β2 microglobulin.” If authors could quantify the overlap with elevated IgG and explore predictors of persistent hypergammaglobulinemia using adjusted models, this could help with clarity on the data presentation in the article. A10: We assume that the Reviewer is referring to lines 228-230 in the previous manuscript version. Instead of quantifying the overlap, we would like to refer to Figure 3, which appears to be missing from the manuscript provided to Reviewer 1. Here, correlation coefficients were explored for IgG regarding HIV-RNA, CD4+, neopterin, beta-2-microglobulin, albumin, and age in untreated and ART-suppressed HIV-positive participants. Q11: The Methods section and data analysis descriptions are not sufficiently detailed. Please expand these to clearly explain the analytical approach, including any statistical tests, adjustments, and handling of repeated measures. A11: Thank You for this valuable comment. The statistical section has been rewritten. Q12: The Swedish epidemic cohort reflects a male predominance, and the authors appropriately noted this. However, the finding that women had significantly higher IgG levels is interesting. Could this be explored further? Was this difference consistent across all CD4 strata and treatment groups? A brief comment on this would add depth. A12: We agree with the Reviewer that the gender differences in IgG levels warrant further discussion. We have therefore expanded the analysis of IgG levels in men and women within the untreated groups, and this is commented on in the Results section (lines 241-246). Gender differences in IgG levels in the general population as well as among HIV-negative controls have been addressed in the Discussion section (lines 329-336). Additionally, Figure 2 has been modified to present HIV-positive samples divided into ART-treated and untreated groups. Q13: Given the numerous factors influencing IgG levels (sex, treatment status, CD4 count, and inflammatory markers), a multivariate regression analysis would be highly valuable. This would help determine the independent predictors of IgG levels (and persistent hypergammaglobulinemia on ART) while controlling for other variables. The current univariate analyses are informative but could be significantly strengthened by a multivariate model. A13: We have performed a multivariable analysis, but did not include neopterin and β2-microglobulin, since we do not consider them as causal determinants to IgG, but rather correlated parallel outcomes to IgG that misleadingly attenuate the impact of the other predictors when included. The results from the multivariable analyses are reported in the Results section (lines 207-211). Q14: Lines 314-322: The discussion on clinical implications is somewhat speculative. The suggestion that IgG could be a surrogate marker for B-cell dysfunction is interesting. Could the authors be more specific? For instance, in which clinical scenarios might measuring IgG be most useful (monitoring patients with incomplete immune reconstitution despite ART)? Also, please clarify the statement on lines 301-302; low albumin was only found in the OIM group, so it cannot be a general marker of HIV-related inflammation but rather of acute concomitant illness. A14: We have revised the final sentence to make the interpretation of persistent hypergammaglobulinemia of ART-suppressed participants less speculative (lines 385-387). We also agree that the observed hypoalbuminemia in the OIM study group is likely related to the concomitant infection or malignancy, rather than to HIV-infection itself. This has been clarified in the Discussion section (lines 355-357). Minor comments Q1: Under the Abstract section, define all abbreviations at first use, for instance “human immunodeficiency virus (HIV)” and “immunoglobulin G (IgG)”. Apply this consistently for all abbreviations throughout the manuscript, including in tables and figures A1: All abbreviations have now been defined in the manuscripts as well as in the figure and table legends. Q2: Line 133: "guidelines existing at the time of inclusion". Please specify the core principle, for instance, if authors considered a combination of at least two drugs from different classes. Additionally, what would be of value if guidelines could be cited. A2: We have added citations for past and present Swedish treatment guidelines (lines 114-118). Q3: Figure 2: The figure is helpful. Consider adding the p-values for the significant comparisons (HIV+ untreated and ART) directly to the figure or its legend for clarity. A3: P values have been added. Further, we have chosen to divide the HIV-positive group into treated and untreated participants, since 166 participants provided two samples and hence were included in both groups. Q4: Figure 3: The axis labels for Figure 3D should be "S-β2-microglobulin (mg/L)". A4: Hyphens have been added consistently in tables and figures. Q5: Line 275: "in 45 % and 37 %". This is fine, but for consistency, you could use the "%" symbol throughout (e.g., 45%). A5: The gaps between numbers and percentage signs have been removed. Q6: Line 311: "mean age of 42 years". Could this be a typo in the results (Table 1) report? Please, authors, report the "median" instead. A6: “Mean” has been changed to “median”. Moreover, we have reported the median age for untreated and treated participants, respectively. Q7: Correct unit errors, for instance, (“ml/L” to “mg/L) for β2 microglobulin, unless perhaps there were some conversions applied and typographical inconsistencies, for instance, “IgG -levels” to “IgG levels” (line 288) and standardize HIV 1 vs HIV usage. A7: These inconsistencies have been corrected. Q8: Ensure all tables and figures have self contained legends that define abbreviations, state reference limits, and specify comparison frameworks. Add 95% CIs to medians in tables where possible. A8: The legends for all tables and figures have been reviewed to ensure they are self-contained, with definitions of abbreviations and clear descriptions of comparisons frameworks. Reference intervals have been added to the legends of Table 2, Fig 2, Fig 3 and S2 Fig. We chose not to add 95 % CI, as we believe presenting median (IQR) values provide a clearer and more accessible summary of the data. Q9: Where qualitative terms like “weak correlation” are used, include numeric rho and p values in text or figure captions. A9: Numeric rho and P values are shown in Figure 3, which unfortunately seems to be missing for Reviewer 1. Q10: When comparing results to other countries, provide possible explanations for differences (e.g., ART coverage, prophylaxis use, cohort characteristics) rather than stating comparability without context. A10: No comparisons between countries have been made in the manuscript. Q11: Check that all data in the text match the values in tables and figures and review the manuscript for typographical and formatting errors. A11: The manuscript has been reviewed for typographical and formatting errors. Q12: If applicable, include an accession or URL for the Swedish National Data Service in the Data Availability statement. A12: The anonymized dataset for the present study has been uploaded to the Swedish National Data Service with restricted access due to participant confidentiality. The DOI is stated in the Data availability statement, line 391. Reviewer 2 Major comments Q1: In lines 99-101, the authors mention that 166 participants provided samples twice and were thus included in both treated and untreated groups. This creates a significant issue of non-independence between the ART and the various untreated CD4 strata groups. The statistical comparisons between these groups are potentially confounded by this repeated sampling. The authors must clearly address this as a key limitation in the discussion. The statistical analysis should be clarified; were comparisons between groups treated as independent? If so, this is a methodological weakness. Consider using statistical methods th Attachments Attachment Submitted filename: Respons to Reviewers.docx https://doi.org/10.1371/journal.pone.0349405.r002
17 Feb 2026 Decision Letter - Sepiso K. Masenga, Editor -->PONE-D-25-36523R1-->-->Hypergammaglobulinemia in treated and untreated people with HIV-->-->PLOS One Dear Dr. Vigmo, 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 kindly respond to reviewer 3 and resubmit a revised version. ============================== Please submit your revised manuscript by Apr 03 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. Please include the following items when submitting your revised manuscript:--> 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 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. 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There is no requirement to cite these works unless the editor has indicated otherwise. 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. 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 #3: 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 #3: Yes ****** -->3. Has the statistical analysis been performed appropriately and rigorously? --> Reviewer #1: Yes Reviewer #3: 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 #1: Yes Reviewer #3: Yes ****** -->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 #3: 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 #1: The authors have done a great job addressing all the concerns which were raised. Great work on this manuscript. Reviewer #3: Peer Review Report Manuscript Title: Hypergammaglobulinemia in treated and untreated people with HIV I thank the editorial team for the opportunity to review this revised manuscript. I commend the authors for their thoughtful engagement with the previous review comments; the amendments have certainly strengthened the paper. However, to ensure the highest level of clarity and rigor, I have a few remaining points that require the authors' attention before the manuscript can be considered for acceptance. Specific Comments: 1. Clarity of Statistical Reporting (Major Point): In Figure 3, the presentation of the correlation coefficients requires revision for consistency and clarity. Specifically, the notation for the correlation coefficients (rp) should be standardized to use a decimal point, not a comma. For instance: - In Fig 3C, please clarify whether the values are `rp = 0.076, p = 0.102` and `rp = 0.074, p = 0.263`. - Similarly, in Fig 3E, the value should be presented as `rp = -0.277, p < 0.001`. Ensuring this standardized formatting is crucial for unambiguous data interpretation. 2. Discussion of Demographic Limitations (Major Point): The authors have appropriately addressed several reviewer comments and have noted the male predominance within the Swedish epidemic cohort. However, a critical demographic imbalance persists between the control groups that warrants explicit acknowledgment as a study limitation. - The ‘With PrEP’ control group is exclusively male (0% female, 0/45), which stands in stark contrast to the 'Without PrEP' control group (42.3% female) and the cohorts of people with HIV (PWH). - This significant difference introduces a potential source of demographic bias that could influence the comparative analyses of immunoglobulin levels. I strongly recommend that the authors explicitly add a statement to the Discussion or Limitations section acknowledging this imbalance. A cautionary note on how this might affect the generalizability or interpretation of the findings related to the PrEP-naïve control group would significantly strengthen the manuscript's scientific rigor and transparency. ****** -->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 #3: Yes: David Chisompola ******** [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. --> Attachments Attachment Submitted filename: Review comments.docx https://doi.org/10.1371/journal.pone.0349405.r003
Revision 2
18 Mar 2026 Author Response Response to Reviewer 3: Q1: Clarity of Statistical Reporting (Major Point): In Figure 3, the presentation of the correlation coefficients requires revision for consistency and clarity. Specifically, the notation for the correlation coefficients (rp) should be standardized to use a decimal point, not a comma. For instance: In Fig 3C, please clarify whether the values are `rp = 0.076, p = 0.102` and `rp = 0.074, p = 0.263`. Similarly, in Fig 3E, the value should be presented as `rp = -0.277, p < 0.001`. Ensuring this standardized formatting is crucial for unambiguous data interpretation. A1: Thank you for pointing this out. The comma has been corrected to a decimal point in the revised Figure 3. Q2: Discussion of Demographic Limitations (Major Point): The authors have appropriately addressed several reviewer comments and have noted the male predominance within the Swedish epidemic cohort. However, a critical demographic imbalance persists between the control groups that warrants explicit acknowledgment as a study limitation. - The ‘With PrEP’ control group is exclusively male (0% female, 0/45), which stands in stark contrast to the 'Without PrEP' control group (42.3% female) and the cohorts of people with HIV (PWH). - This significant difference introduces a potential source of demographic bias that could influence the comparative analyses of immunoglobulin levels. I strongly recommend that the authors explicitly add a statement to the Discussion or Limitations section acknowledging this imbalance. A cautionary note on how this might affect the generalizability or interpretation of the findings related to the PrEP-naïve control group would significantly strengthen the manuscript's scientific rigor and transparency. A2: We agree that the gender imbalance in the HIV-negative control group on PrEP represents a potential limitation of the study. To further address this, we have added statements in the Discussion section (lines 332-334 and 380-382), acknowledging this imbalance and its potential influence on the generalizability of the findings. Attachments Attachment Submitted filename: Response to reviewer - resubmission 2.docx https://doi.org/10.1371/journal.pone.0349405.r004
30 Apr 2026 Decision Letter - Mattia Trunfio, Editor <p>Hypergammaglobulinemia in treated and untreated people with HIV PONE-D-25-36523R2 Dear Dr. Vigmo, 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, Mattia Trunfio, M.D., Ph.D Academic Editor PLOS One Additional Editor Comments (optional): Interesting work! 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 #3: 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 #3: Yes ****** -->3. Has the statistical analysis been performed appropriately and rigorously? --> Reviewer #1: Yes Reviewer #3: 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 #1: Yes Reviewer #3: Yes ****** -->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 #3: 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 #1: Great work that has been presented by the authors. The reviewers concerns were addressed. One more vital concern to address; the attached uploaded supplementary file "S1 Table", is not clear what it represents: 1. It has no tag/title 2. The first column, equally the title is not defined. If authors could kindly attend to this matter. Best regards. Reviewer #3: I thank the authors for the thoughtful and comprehensive responses to the reviewers’ comments. The revisions have substantially strengthened the manuscript in terms of clarity, rigor, and overall presentation. The authors have adequately addressed the concerns raised, and the manuscript has improved considerably as a result. I recommend acceptance of the manuscript for publication. ****** -->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 #3: No ******** Attachments Attachment Submitted filename: Comment.docx https://doi.org/10.1371/journal.pone.0349405.r005
Formally Accepted
Acceptance Letter - Mattia Trunfio, Editor PONE-D-25-36523R2 PLOS One Dear Dr. Vigmo, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, 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. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@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. Mattia Trunfio Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0349405.r006

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