-->PONE-D-25-55857-->-->COVID-19 pandemic-related stress and substance use behaviors among people with HIV – a mixed method analysis-->-->PLOS One

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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: Partly

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

Reviewer #1: I Don't Know

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

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

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Reviewer #1: Yes

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-->5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: This is a timely mixed-methods secondary analysis examining whether COVID-19–related stress and financial worry were associated with changes in opioid, cigarette, and alcohol use among people with HIV (PWH) with prior or current injection drug use in St. Petersburg, Russia, using data collected between May 2020 and July 2021. Key strengths include the focus on an under-studied, high-risk population outside the U.S. and the use of both survey and interview data to contextualize findings. With revisions—particularly clarifying measurement, outcome specification, statistical robustness, and interpretation—the paper could make a solid contribution.

Introduction

The introduction effectively highlights inconsistencies in prior findings. It would benefit from clearer justification of why PLWH are a particularly relevant population for studying pandemic stress and substance use, and how the Russian context may differ from other regions in shaping these experiences. Expanding on these points would better articulate the study’s contribution and research gap.

Methods, Results, and Discussion

Some details from the parent trials that are not directly analyzed here could be streamlined to avoid confusion (e.g., ART status, COVID infection history). The inclusion/exclusion table is useful, but the text should focus more tightly on variables relevant to this analysis.

The definition of “no change” combines “not changed,” “never used,” and “stopped using before the pandemic,” while “changed” includes increased, decreased, or stopped use due to the pandemic. Including never-users and pre-pandemic stoppers in the reference group may dilute or bias associations, particularly for alcohol and cigarettes, and creates inconsistencies across substances. If reanalysis is not feasible, a sensitivity analysis excluding these groups—or clearer discussion of this limitation—is recommended.

Causal language should be tightened. This is a cross-sectional analysis with stress and perceived change measured at the same time point, so directionality cannot be established. The manuscript should more clearly frame findings as associations and avoid implying causation.

Dichotomizing stress and financial worry at ≥4 on a 1–5 scale requires stronger justification or sensitivity analyses. Reporting correlations between stress and financial worry, or considering them jointly in models, would strengthen interpretation.

Interpretation of the main finding could be clearer. The outcome reflects “any change,” not direction, and most changes were decreases. Reframing conclusions accordingly would better align with the data. Language describing financial worry as “clinically meaningful” should be softened given imprecision in the estimate.

The mixed-methods approach appears more explanatory than truly convergent, as qualitative findings are used primarily for contextualization. Clarifying the design and noting reliance on English-language memos (rather than full transcript coding by the integrative analyst) as a limitation would improve transparency.

Selection bias is also possible, as only participants still engaged in follow-up completed the COVID survey. If available, describing differences between respondents and non-respondents—or acknowledging likely bias toward more stable participants—would be helpful.

Other observations

There is a time window inconsistency: the Abstract reports May 2020–March 2021, while the Methods reference interviews through July 2021. Please ensure consistent reporting.

The term “opioids” appears in qualitative narratives to include illicit opioids and methadone (and possibly diverted methadone). If possible, clarify what the opioid survey item specifically captured.

In Table 2, age is described as a mean in the text but presented as a median in the table; please make this consistent.

The four-category intervention variable combining study and arm should be clearly defined in the Methods, ideally with sample sizes per category.

Additional detail on qualitative rigor (e.g., whether saturation was assessed and how translation accuracy was ensured) would strengthen the qualitative methods.

While the Discussion appropriately emphasizes alignment with European findings, it would also be helpful to reiterate that this population—PWH with injection drug use in Russia—differs meaningfully from general population European surveys.

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Reviewer #1: No

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COVID-19 pandemic-related stress and substance use behaviors among people with HIV – a mixed method analysis

PONE-D-25-55857R1

Dear Dr Rossi,

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.

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Kind regards,

Vipula Rasanga Bataduwaarachchi, MD

Academic Editor

PLOS One

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 #2: All comments have been addressed

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

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #2: Yes

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

Reviewer #2: I Don't Know

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

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g., participant privacy or use of third-party data—they must be specified.-->

Reviewer #2: Yes

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

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.-->

Reviewer #2: Yes

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-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #2: Greetings

The authors have addressed all comments and revised the manuscript accordingly; it is now suitable for publication.

Kind regards,

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-->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.

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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: No

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