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After revisions, two reviewers agreed to publish the manuscript. I also reviewed the manuscript and found no obvious risks to publication. Therefore, I also approve the publication of this manuscript.
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The authors are requested to carefully revise the manuscript and answer the questions raised by the reviewers.
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Method:
The Kappa coefficient is traditionally used to compare two variables. Fleiss' Kappa could be performed to compare more than two variables, such as WHR with WHtR with CI. It is not appropriate to apply exact Kappa/Fleiss' Kappa to all types of parameters in Table 3. You can apply exact Kappa to all A with B parameters and Fleiss' Kappa to A with B with C parameters.
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• Language Quality: The manuscript, while comprehensible, is often marred by cumbersome language and occasional grammatical inaccuracies. The authors should revise for clarity, conciseness, and professional tone throughout. For example, sections such as "Following the introduction of antiretroviral therapy, individuals living with HIV (PLHIV) began to exhibit an increase in body weight" could be made more direct. I suggest seeking assistance from a proficient English editor or using advanced language-check tools.
• Literature Context: The introduction provides sufficient context but does not sufficiently emphasize the novelty or importance of this study. The authors should better delineate the specific knowledge gap this research fills. More references to the most recent and relevant literature are needed to bolster the study's significance.
Please read and evaluate to cite the following articles: 10.3390/idr16050066; 10.3390/biomedicines12102311; 10.3390/idr14050071.
• Figures and Tables: The tables are informative but need clearer, more descriptive titles and legends. Ensure that figures are of high resolution and adequately referenced in the text. The visual presentation should be revisited for any potential overlaps or ambiguities.
• Data Transparency: Ensure that all raw data has been appropriately referenced and that the supplementary material contains all necessary details for verification. Without these, the manuscript lacks transparency.
• Alignment with Journal Scope: The study is original and fits within the journal's scope. However, the authors should more explicitly state how the research question addresses an identified knowledge gap in the existing literature.
• Methodological Details: While the methods are generally well-described, there are several areas that require more detail for full replication. The description of the statistical analyses, specifically the rationale for the use of the Kappa and Pearson's coefficients, needs clearer justification. Any potential limitations or biases inherent in the cross-sectional design should be discussed upfront.
• Ethical Statement: The ethical compliance is mentioned, but the approval number should be better highlighted and a sentence included to affirm no identifiable data is presented.
• Data Soundness and Robustness: The results appear valid, but the statistical strength of some findings is weak due to the limited sample size (n=17). This significantly impacts the generalizability of the conclusions. The authors should be forthright about this limitation and discuss how it affects the robustness of the findings.
• Conclusions and Data Linkage: The conclusions drawn align with the data presented, but the authors overstate the implications of the findings. Phrases like “more reliable to associate WHR, WHtR, and CI together” should be softened or qualified with caveats about sample size and generalizability.
• Replication Potential: The manuscript fails to suggest the utility of these findings in future research or practical settings. A clearer emphasis on how these results could inspire future longitudinal studies or interventions is needed.
• Strengths: The study is commendable for addressing a relevant clinical issue with a comprehensive data set, exploring multiple anthropometric indices and their relationships to body composition in PLHIV.
• Weaknesses:
o The small sample size severely undermines the strength of the study. The authors must acknowledge this limitation more transparently and suggest that future studies use larger, more diverse cohorts.
o The analysis of the duration of HIV infection did not yield significant results. The authors should discuss whether this is due to a lack of power, a possible confounding factor, or if it suggests that duration may not be impactful within the range studied.
• Clarity: Certain sections, especially the "Materials & Methods," are overly verbose. Streamline these to enhance readability.
The authors are requested to carefully revise the manuscript and answer the questions raised by the reviewers. In particular, you must address the concerns about the statistics, which have been raised by more than one reviewer.
[# PeerJ Staff Note: It is PeerJ policy that additional references suggested during the peer-review process should *only* be included if the authors are in agreement that they are relevant and useful #]
This manuscript is well-written in wording and phrasing, the literature references are cited properly, the article structure is reasonabl. There are only minor comments for authors to improve the manuscript:
1. In abstract line 24, "individuals living with HIV (PLHIV)" should be changed to "people living with HIV (PLHIV)"
2. In abstract line 29-30, for the first sentence in Method, try to be more concise in phrasing. Something like: “An analytical cross-sectional study consisting of 17 PLHIV of both sexes is conducted.” Or “The present study is an analytical cross-sectional study, conducted with a sample of 17 PLHIV of both sexes.”
3. In Introduction line 52-54, "The mechanisms of CVD include traditional risk factors such as dyslipidemia, smoking, visceral adiposity and diabetes, as well as non-traditional HIV-related factors such as increased inflammation and immune activation ", you may also consider adding “obesity” which is a broader concept. See, e.g., “Liu, Z., Zhang, J., Yang, X. et al. The dynamic risk factors of cardiovascular disease among people living with HIV: a real-world data study. BMC Public Health 24, 1162 (2024).”
4. In Introduction line 67-68, "However, it should be noted that anthropometric indices were developed for subjects without HIV, such as the waist-to-hip ratio and waist-to-height ratio, for example." , here, “For example” is redundant, it can be left out.
5. In Introduction line 72-74, I don’t think it involves prediction because the study is a cross-sectional study. Consider replacing “prediction” with “assessment” or “evaluation” is more reasonable
6. In Materials & Methods line 152-153, "The absence of: 0.00–0.19: Poor; 0.20–0.39: Weak. 0.20-0.39: Moderate. 0.30-0.59: moderate; 0.60-0.79: substantial; ≥0.80: almost complete.", there are two “moderate”, need to revise the definition for magnitude.
The study aims to assess the agreement of CVD diagnosis among different anthropometric indices WHR, WHtR and CI and explore the association between these indices and CVD risk and HIV infection time among PLHIV population. The study is well designed and conducted. Only a few comments for authors to improve the manuscript:
1. In the cross-sectional study, the association between the risk of CVD and body composition, as well as the duration of HIV infection was investigated. I think more information about HIV infection time should be provided. For example, the minimum and maximum of HIV Infection time may be provided. Another question, why you cut the infection time into <15 yrs, >15 yrs. What is the basis for this division/cutoff?
2. Since the study is related to risk of CVD, I suggest the information about history of CVD and history of comorbidity related to CVD, and current CVD stutus should be provided to help reader know the study population better.
3. What's the collection date/period for the study population?
The findings and conclusions are well stated. Only one comment for authors:
1. In Results line 172, "Similarly, when all three indices were considered together, there was also agreement.", you may add the comparison of the difference in p-value and z-value between the results from WHR and CI and the results from all three indices. The extent of agreement is stronger when all three indices are considered together
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Introduction:
Please list some references to support the first sentence “It has been established that HIV infection causes human immunodeficiency, which is associated with an increased risk of cardiovascular disease (CVD).”.
Methods:
1. Body fat standards do not show the same percentages for females and males. Please list both consistently.
2. Please show the Normality check results. If the outlier exists, the results could be impacted significantly.
3. It is nice to claim the magnitude of the coefficient you believe is acceptable/sufficient.
4. Due to the small sample size, Person’s coefficient may lead to unreliable or unstable results and make it difficult to detect significant correlations. Although the normality was checked, it is nice to check the confidence intervals around the correlation coefficient to assess its precision.
5. The Kappa coefficient is traditionally used to compare two methods. I believe Fleiss' Kappa could be performed to compare more than two methods, such as WHR with WHtR with CI. Please specify the statistics methods you applied.
Results:
1. In Table 3, the kappa coefficient is 0.6 and 0.5 for WHR with CI and WHR with WHtR with CI. It is nice to add information of magnitude except for the significance.
Discussion:
1. Except for significance, the magnitude should also be discussed. Please discuss whether/why the moderate agreement is acceptable/reliable.
2. The discussion mentioned the use of ART affects the adipose tissue. It is nice to adjust the ART when you measure the associations and compare it with existing studies.
Title and Abstract.
The results section in the abstract should be revised:
a) In the first sentence, list the three indices regarding the risk of CVD to make the audience clear which three indices.
b) In the second sentence, drop WHtR. Listing three indices can mislead the audience into thinking that three indices are all significantly negatively associated with BF.
The concept of the study is great, however the sample size is too small and results are not significative.
I suggest expanding sample size to gain statistical power.
The study's sample size is very small (n=17), which limit the power of the statistical analyses and the generalizability of the findings. Such a small sample size could be inadequate for the robust statistical analysis required to validate the associations claimed, especially when dealing with complex variables like cardiovascular risks and anthropometric measures in HIV-positive populations.
In addition, the cross-sectional design of the study restricts the ability to establish causality between anthropometric indices and cardiovascular risk. Longitudinal data would be more appropriate to assess how these risks develop over time in the HIV-positive population.
Furthermore, there seems to be an inconsistency in the population and sampling methods. The text notes that participants were engaged in regular physical activity, which might not represent the broader population of individuals living with HIV, potentially biasing the results.
Also, the use of multiple indices (WHR, WHtR, CI) and their inter-correlations might require more complex analytical approaches to adjust for multiple comparisons and interactions, which does not seem to be addressed adequately.
Inconsistent since the small sample size
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