Incidence and predictors of anemia among adults on HIV care at South Gondar Zone Public General Hospital Northwest Ethiopia, 2020; retrospective cohort study.

BACKGROUND: Anemia is a major public health problem worldwide which accounts 24.8% of the population. Subsequently, anemia is a leading killer of people living with human immunodeficiency virus and many of these deaths occur in developing countries including Ethiopia. Cross sectional studies have done on anemia and human immunodeficiency virus. However, there is limited study on incidence of anemia and its predictors among adults on HIV care, especially no survival study has been conducted in the study area.
OBJECTIVE: To assess incidence and predictors of anemia among adults on Human immunodeficiency virus care.
METHODS: An institution-based retrospective cohort study was conducted among 434 adults on HIV care from January 1st 2015 to December 30th 2019 at Debre Tabor Referral Hospital. A computer-generated simple random sampling technique was employed to select the study participants. Ethical clearance was obtained from the Institutional Review Board of Bahir Dar University, and also, we got implied consent to review charts from the concerned bodies in the hospital. Data were entered using Epi-data version 3.1 and analyzed by using STATA version 14.0. A Kaplan Meier survival curve was utilized to estimate anemia free survival time. Bivariable and Multivariable Cox proportional hazards model were fitted to identify predictors of anemia.
RESULTS: The overall incidence density rate of anemia was 6.27 (95% CI: 0.051, 0.077) per 100 person years. Clinical stage III/IV (AHR = 1.04; 95% CI = 1.02, 1.06), Body Mass Index less than 18.5 kg/m2 (AHR = 3.11; 95% CI = 1.56, 6.22), serum creatinine greater than 1.1 IU/L(AHR = 2.07; 95% CI = 1.12, 3.81) and fair/poor level of adherence(AHR = 1.05; 95% CI = 1.03, 1.07) were statistically significant predictors of anemia while increased anti-retroviral treatment duration (AHR = 0.98; 95% CI = 0.97, 0.99) decrease the risk of anemia at 95% confidence level.
CONCLUSION: The overall incidence density rate of anemia was high. Patients with clinical stage III/IV, body mass index < 18.5 kg/m2, serum creatinine greater than 1.1 IU/L and fair/poor level of adherence were significant predictors of anemia while increased antiretroviral treatment duration had decreased the risk of anemia. RECOMMENDATION: Even if the overall incidence rate of anemia was lower as compared to previous studies in Ethiopia, still the incidence of anemia was high. So, prevention measures should be taken beside with HIV care especially within 6-months ART initiation.

Background

For human immunodeficiency virus [HIV] infected nonpregnant women and men whose age ≥15 years old, anemia defined as; the level of hemoglobin concentration < 11 g/dl [1-3].

The causes of HIV-related anemia include impaired hematopoietic due to increased cytokine production, decreased endogenous erythropoietin production, blood loss, hemolytic that may result from red blood cell [RBC] autoantibodies, infiltration of the bone marrow by neoplasm or HIV infection itself, opportunistic infections with Mycobacterium avium complex or parvovirus B-19 and drugs such as zidovudine or cotrimoxazole [4-7].

Anemia is a major public health problem that affects an estimated 1.62 billion people worldwide which equivalent to 24.8% the population [8, 9], in which, one of the sufferers are HIV infected individuals. The prevalence of anemia among HIV positive adults ranges between 16.2% and 69% in Africa [10-17] and between 11.4% and 42.9% in Ethiopia [12, 18–20].

Aside from the total diseases occurrence patients with symptomatic HIV infection account for 75–80% of comorbidity [21]. Regarding severity of the diseases, it increases with a decrease in Cluster of differentiation 4 [CD4] cell counts and advancement of HIV infection [3, 22, 23].

The risk of acquired immunodeficiency syndrome [AIDS] related death was more than double for patients with anemia compared with those without anemia due to its association with shorter time to immunologic disease progression, greater need for transfusion and poor quality of life [24-26].

Anemia among HIV patients can lead to impaired physical functioning, psychological distress, poor quality of life, accelerated disease progression and shorter life expectancy [27, 28] patients also suffer from fatigue, weakness, dyspnea, pallor, lethargy, depression, and impaired cognitive function [3, 24, 29].

The Potential factors for HIV patients at risk for developing anemia were female sex, patients with low CD4 cell count < 200 cells per mm3 and patients with advanced disease stage III / IV [30-32] and may result from genetic disorders, chronic diseases, and nutritional deficiencies [33, 34].

Since test and treat programs launched in 2013, it has achieved remarkable improvements in the prevention of HIV related opportunistic infections [OIs] [35-37]. Ethiopia is one of the countries, which adopted and implemented this program for HIV positive adults since June 2017 [38].

Optimization of current antiretroviral therapy(ART) regimens is a critical component to support country efforts to achieve the goal of end of acquired immunodeficiency syndrome [AIDS] pandemic as a public health threat by 2030 [39]. Following this, more than 50 low- and middle income countries (LMICs) are including or planning to include dolutegravir (DTG) containing regimens in their national protocols, as the preferred first-line option, particularly the fixed-dose combination (FDC) tenofovir/lamivudine/dolutegravir at the end of 2017. Even though Ethiopia is one of the countries which adopted and implemented this new HIV drug in 2018 [40], its impact on anemia is not understood.

Given the importance of knowing the incidence of anemia and its predictors in low-income settings is critical for improving health of HIV positive patients. However, research on the incidence of anemia in low-income countries is relatively sparse.

Few available cross-sectional studies cannot address the incidence and predictors of anemia after the new regimen has been started especially, the study area. To address this gap in the literature, this study aims to assess the incidence and predictors of anemia among HIV-infected adults at Debre Tabor general hospital.

Methods

Study setting and period

The study was conducted at Debre Tabor General Hospital (DTGH) ART clinic from January 1, 2015, to December 30, 2019. Debre Tabor General Hospital is found in Debre Tabor town. Debre Tabor is the capital town of the south Gondar zone. It is located 667 kilometers northwest of Addis Ababa, which is the capital city of Ethiopia and about 99 kilometers northeast of Bahir Dar, the capital city of the Amhara region. The Hospital is the only general hospital in South Gondar Zone which started giving ART service in 1997 E.C and the case-team comprised trained physician, nurses, pharmacists, laboratory technicians, data clerks, and ART education adherence counselors.

Study design and population

An institutional-based retrospective follow-up study was conducted at Debre Tabor General Hospital ART clinic. All HIV positive adults ever started ART at DTGH ART clinic who have follow up from January 1, 2015, to December 30, 2019 GC, and whose card available at the time of data collection was study population. Non-pregnant women and men HIV-infected adults and adolescents whose age ≥15 years old were included in the study. Adults who had anemia at the beginning of the follow-up and incomplete baseline data were excluded from the study.

Operational definitions

Event

The occurrence of anemia for HIV-positive adults after ART initiation until the end of the study that ascertained by patient document review.

Censored

Adults did not develop anemia (transfer out to other services, switch off antiretroviral therapy, Death, drop out, and still on ART in the Hospital) that ascertained by patient document review.

Level of adherence. Estimate adherence level using the table below taken from ART intake form.

Adherence percent missed doses.

Sample size and sampling procedure

The sample size was determined by a two-sample comparison of survival functions Log-rank test via Stata version 14.0 using 5% significant level, 80% power and one to one non exposed to exposed ratio, and considering significant predictors of developing anemia in the previous study in Ethiopia [41]. The final sample size was 434. The total records in the hospital among eligible study population were 2157 which was taken from Excel data in the hospital. 434 Charts were retrieved based on their medical registration number which was selected using a computer generated simple random sampling technique.

Data collection instrument and quality control

The data extraction checklist was adapted from the Federal Ministry of Health ART follow-up forms. Data were collected using this validated and reliable checklist. Patient’s socio-demographic variables, Clinical and treatment-related variables of HIV infected Adults were extracted from their chart. Pretest was conducted among 44 medical records to check the consistency of the abstraction tool. Two-day training was provided for data collectors and supervisor about how to review the documents, extract data from medical records for data collectors and about the entire data collection process. The filled formats were checked for completeness by the data collectors, supervisor and finally by principal investigator on daily bases.

Data collection

Data were collected by three BSc Nurses that had comprehensive HIV care training. An additional health care provider who has ART training certificate has participated as a supervisor. Once data extraction from patient charts has been completed, code was given for each chart to avoid duplication. The data collection period was from January 1, 2015, to December 30, 2019 GC.

Data processing and analysis

Clear and completed data were entered using EPI-data Version 3.1 and were analyzed using STATA Version 14 statistical software. Descriptive statistics were summarized using percentage and median, and presented using tables and figures. At the end of follow-up, the outcome of each study participant was dichotomized into censored or event. Assumption of Cox proportional hazard regression model was checked using Schoenfeld residual and Log-Log plot tests. In addition, the model goodness of fit was assessed using Cox-Snell residual test. The Kaplan Meier survival curve was used to estimate the anemia free survival time of HIV-positive adults on ART. Log-rank test was used to compare the survival curves of different categorical explanatory variables. Bi-variable Cox-proportional hazard regression model was used to select eligible variables for the final model. Variables having p-value ≤0.25 in the bi-variable analysis were fitted into the multivariable Cox proportional hazard regression model. Finally, adjusted hazard ratio with its corresponding 95% confidence interval was conveyed to declare the presence of significant association between the predictor and outcome variables.

Ethics approval and permission to chart review

Ethical clearance was obtained from Ethical Review Board of Bahir Dar University. Permission letter was obtained from concerned bodies of Debre Tabor General Hospital to review charts. Names and unique ART numbers of patients was not included in the checklist. Moreover, data collectors and the supervisor were health professionals who have work experience in the ART clinic to maintain confidentiality of people living with HIV/AIDS. Information retrieved was used only for the study purpose.

Results

Socio-demographic characteristics of adults on ART

A total of 434 chart of HIV positive adults whose age ≥ 15 years old were reviewed. Of these, 411 HIV positive patient’s medical records were included in the analysis with completeness rate of 94.7%. The median age of the entire cohort was 34 years (IQR; 12). More than half of religion follower were Orthodox Christian 323(78.6%) followed by Muslim 60(14.6%) and protestant 28(6.8%) follower and other Socio-demographic variables are showed in below.

Clinical and treatment related characteristics

The mean ART duration of the entire cohort was 86.75 months (IRR: 81.6–92). Two hundred six (60.1%) patients had changed their initial regimen during the follow up period. From the patients who have changed their initial regimen, 26(12.6%) patients switched to second-line HAART. The reason for changing the initial regimen was due to new drug available 99(48%) and due to drug side effects 80(40.2%). However, the remaining reason for changing initial regimen was not recorded ().

Incidence of anemia

Four hundred eleven (411) study participants were followed for five years which gave us 1419.63 person years of observation. During the follow up period, 89 new anemia cases were observed.

Hence, the overall anemia incidence density rate (IDR) in the cohort was 6.27 (95% CI: 0.051, 0.077) per 100 person years of observation and cumulative incidence was 21.65% while 322 (78.35%) were censored. Of the censored patients, 262 (81.4%) didn’t develop anemia until the end of the study, 31 (9.6%) were transferred out, 18 (5.59%) were dropped out, 4 (1.24%) were lost to follow up and the remaining 7 (2.17%) have died.

Study participants were followed for a minimum of 0.67 and a maximum of 60.63 months. The median follow-up period was 49.03(IQR; 35.3) months.

The highest anemia incidence density rate of adults living with HIV after enrolling HIV care was 74.58 per 100 person years of observation at 6-month follow-up period (95% CI = 0.24, 2.30) and decreased to 25.5/100 PYO (person years of observation) at 12-month follow-up period (95% CI = 0.11, 0.61).

The cumulative probability of anemia free survival of adults on HIV care at the median follow up period (4.09 year) was 79% (95% CI = 0.74, 0.83) and at the end of the fifth year was 71% (95% CI = .0.66, 0.76) ().

Log rank (Mantel-Cox) test of equality of survival for categories of WHO clinical staging was done. The median anemia free survival time for patients with clinical stage III/IV was 53.33 months. Patients with stage I/II survive better and the difference was statistically significant between survival curves among the groups (p-value = 0.000) (Fig 2).

Fig 2

Kaplan-Meier survival curve of anemia -free survival proportion based on WHO clinical staging among adults on HIV care.

Cox-regression analysis

Age category, sex, marital status, residence, educational status, occupation, disclosure status, Baseline WHO clinical stage, baseline CD4 cell count, functional status at enrolment, level of adherence, undernutrition, serum creatinine, serum ALT, past TB history, TB treatment, cotrimoxazole prophylaxis, isoniazid prophylaxis and recent viral load were eligible for multivariable analysis.

WHO clinical staging III/IV, undernutrition, increased serum creatinine and fair/poor adherence remained statistically significant predictors of increased anemia occurrence while increased ART duration was a significant predictor of decreased anemia occurrence ().

Discussion

This is a study of HIV positive adults whose age greater than or equal to 15 years old under DTGH HIV care in South Gondar zone, Northwest Ethiopia, to determine incidence of anemia and identify its predictors.

Almost one fifth (21.6%) of the study participants develop anemia giving an incidence density rate of 6.27(95% CI: 0.051, 0.077) per 100 person-years of observation. The overall incidence rate was lower than the study conducted in Northwest Ethiopia which was 27/100 PYO [41] and in the Capital city of Ethiopia which was 35.3/100 PYO [42]. This noticeable discrepancy might be related to early initiation of ART for participants in the current study irrespective of CD4 count and WHO clinical staging [35] and availability of new drug regimen (dolutegravir containing regimen). Dolutegravir drug has rapid viral suppression and higher genetic resistance to virus when compared with nonnucleoside reverse transcriptase inhibitors [40, 43, 44].

Similarly, the current study finding is also lower than the study conducted in Nigeria which was 38.2/100 PYO [23]. This variation might be related with utilization of zidovudine containing regimen in the previous study while this regimen has come down in the current study.

In the present study, adults living with HIV who were clinical stage III/IV at baseline have higher risk to develop anemia at any time as compared to those with WHO clinical stage I/II. This is supported by other evidence from Ethiopia [45], Tanzania [24] and South Africa [46]. This is due to the fact that, having advanced WHO clinical staging compromise immunity which leads to viral duplication and higher loads of opportunistic infections which results anemia via increased cytokine-mediated mylosuprression [47]. The current study suggests the need for anemia preventive measures along with HIV care for those patients who have advanced disease stage.

Additionally, early initiation of ART drug and good adherence should be encouraged to prevent the progression of advanced disease stage.

The current finding showed that, those HIV positive adult patients who were undernutrition at baseline have high risk to develop anemia at any time than those who were well-nourished. This finding is similar with study conducted in Northwest Ethiopia [41], Tanzania [24] and South Africa [46]. This is due to the fact that, patients who were undernutrition will have micronutrient deficiencies. The most common nutritional deficiencies are iron, folic acid, or vitamin B12 [29, 48].

This finding suggests that improving nutritional status of people living with HIV/AIDS taking ART drug through enhancing awareness of benefit of consuming balanced diet and micronutrient supplementation during follow-up may play significant role in decreasing anemia. Consuming a balanced diet helps the body in producing and proliferating enough amounts of red blood cells [49].

This finding also showed that, patients who have baseline serum creatinine level greater than 1.1 IU/L were more likely to develop anemia at any time as compared to those who have baseline serum creatinine less than or equal to 1.1 IU/L. Increased serum creatinine related to decrement of renal function to filter it which can result blunt erythropoietin production in response to lower hemoglobin concentration [50]. This finding suggests that, the need of erythropoietin treatment besides regular monitoring of hemoglobin concentration for patients who have elevated serum creatinine.

The present finding also showed that, patients who have fair/poor adherence were more likely to develop anemia at any time as compared to those who have good adherence. To the best of our understanding, patients who have missed their ART drug might be exposed to opportunistic infectious disease and increased the disease progression which leads to anemia via increased cytokine-mediated mylosuprression [47, 51]. This finding suggests that, more motivation, encouragement, and advice for HIV patients to adhere their ART drug therapy consistently so that to gain optimal therapeutic effect.

On the other hand, this study showed that, as ART duration increased the hazard of anemia was decreased by 2% times. It is in line with the study conducted in Tanzania [24]. Once ART has been initiated for HIV patients, there is quite a suppression of viral load that finally prevents and reverse anemia [27, 49, 52, 53] and as the duration of its utilization increased, the patients have sufficient time to recover from advanced disease progression [24]. Therefore, more Interventions to promote adherence to ART and continuous patient counseling are highly suggested.

Limitation of the study

Secondary data which lacks some variables like food diversity and income status cannot be assessed.

Conclusions

In sum, one out of five adult individuals develop anemia with a high incidence density rate.

Advanced clinical stage [III/IV], body mass index less than 18.5 Kg/m2, serum creatinine greater than 1.1 IU/L and fair/poor level of adherence were statistically significant predictors of anemia while increased ART duration decreases the risk of anemia. Even if the overall incidence rate of anemia was lower as compared to previous studies in Ethiopia, still the incidence of anemia was high. Therefore, Ethiopia Ministry of Health should design prevention measures by considering these factors besides of HIV care.

Early initiation of ART drug and good adherence level to ART should be encouraged to prevent advanced disease stage.

Well-integrated nutritional and HIV care system should be preserved to control the negative effect of undernutrition. Finally, a prospective study is highly suggested to include income status and dietary diversity assessment variables.

Anemia intervention measures would be designed for patients who have elevated serum creatinine along with HIV care.

Health care providers should give emphasizes adherence counseling, nutritional screening, renal function test and managements along with HIV care.

(DOCX)

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14 Jan 2021

PONE-D-20-26223

Incidence and Predictors of Anemia among Adults on HIV care at South  Gondar Zone Public General Hospital Northwest Ethiopia, 2020;  Retrospective Cohort Study.

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Reviewer #1: General comments:

1. This institution-based retrospective cohort study conducted in Ethiopia will add value to the existing literature. In this study, they have found a high incidence rate if anemia, and body mass index, SCr, poor adherence level, and increased ART duration remained significant predictors for developing anemia. However, there is some study bias regarding study population pre-selection which needs to be analyzed and discussed in more detail. Moreover, language polishing is required throughout the text.

Major revisions

Introduction

1. It appeared to be exaggerated. It should be concise and problem-oriented. Please rewrite it and highlight the magnitude and burden of anemia in HIV in the context of Ethiopia and globally as well.

2. Please mention some evidence on mortality and morbidity rate secondary to anemia.

3. The line 58 t0 68 seems exaggerated. Please consider removing these lines.

4. Authors have mentioned the several causes of HIV-related anemia without proper citation of individual independent factors. I would suggest citing each risk factor accordingly. Add vital socio-demographic factors that have been potentially linked to anemia in HIV individuals.

5. Please state the clinical relevance of this study in Ethiopia.

Methods

1. In exclusion criteria, authors have stated only pregnant women and anemia at the beginning of the follow-up as exclusion criteria; however, failed to discuss other potential factors such as active gastric bleeding, and some drugs which may contribute to developing anemia during follow-up.

2. Please highlight the core outcome variables and covariates analyzed in the study.

3. For the sample size calculation, the authors have considered significant predictors for the incidence of anemia from the earlier study. However, it is not clear whether it is the incidence rate or predictors that the authors have considered. Please make it clear.

4. Data collection procedure: Please be consistent with the sentence while writing the conduct of the study. Please consider re-writing it (page no. 134-137).

5. Data were entered using EPI-data Version 3.1. Clear and completed were analyzed using

STATA Version 14 statistical software. The sentence is not clear. Please re-write it.

6. How the missing data were handled?

Results:

7. The median age of the entire cohort was 34 years (IQR; 12). More than half (52.1%)

157 of people living with HIV [PLHIV] were females and 323(78.6%) were Orthodox Christian

158 followed by Muslim 60(14.6%) and protestant 28(6.8%) follower. Majority, 245 (59.6%), of the159 patients came from urban areas. A total of 382 (92.9%) patients had disclosed their HIV status to160 either their husband/wife or other family members.

Please present the above figures in a table format.

8. Clinical and treatment related characteristics should be presented in table form

9. Do the patients have any underlying medical conditions? If yes, please present them in table

10. How about alcohol and smoking habit?

11. The predominant regiments initially prescribed were 174 combination of TDF, 3TC and EFV (1e) 212(51.6%) followed by AZT, 3TC and NVP (1c) 76(18.5%). Please consider changing the word regiments to regimens

12. Two hundred six (60.1%) patients had changed their initial regimen during the follow up period. From the total participants, 26(12.6%) patients switched to second-line HAART.

Some Anti-retroviral agents have a great impact on blood profile which may contribute to anemia. Please mention the type of regimens and its length that were switched to another regimen

13. How did the authors assess the ART adherence level? Please describe it in the methodology section.

14. Authors have described nutritional status based on BMI. I would rather describe BMI as normal, overweight and obese. Please change it.

15. What were the criteria for anemia? Please illustrate this in the methodology section

16. I would suggest highlighting the prevalence rate of anemia at enrollment in the study.

17. Please illustrate the baseline Hb levels of the enrolled patients.

18. SCr was categorized as: SCr <1.1 IU/L and >1IU/L. what are the clinical relevance of this classification.

19. What is the median ART duration? Please present it as a continuous variable as well as categorical ( e.g. <1 year vs >1 year)

20. Drug regimens may have the potential to influence anemia in this particular group of population. Therefore, I would advise authors to consider these analyses in both bivariate and multivariate analysis.

21. I would consider adding P-value for the Bivariate Cox-proportional hazard regression model

22. Please state the variables that were adjusted in the mulvariable Cox regression model.

Discussion

23. This noticeable discrepancy might be related to early initiation of ART for participants in the current study irrespective of CD4 count and WHO clinical staging (17) and availability of new drug regimen (dolutegravir containing regimen).

The above statement needs to be justified by the results shown in the study. Authors have failed to demonstrate the proportion of individuals who started early ART. The differences may be due to the availability of dolutegravir containing regimen, which need to be justified by existing literature.

24. Increased serum creatinine related to decrement of renal function to filter it which can result blunt erythropoietin production in response to lower hemoglobin concentration (30). This finding suggests that, the need of erythropoietin treatment beside regular monitoring of hemoglobin concentration for patients who have elevated serum

Based on the above statement, it is not clear whether patients have had some kind of renal impairment; and this should be clearly mentioned in inclusion/ exclusion criteria. Moreover, being SCr> 1.1 IU/L as a risk factor for developing anemia does not imply that the patients require erythropoietin treatment. More assessment with respect to renal function is needed.

25. This drug is associated with a more rapid viral suppression and higher genetic resistance when compared with nonnucleoside reverse transcriptase inhibitors.

The above statement seems irrelevant to correlate with the discrepancy seen in the study.

Conclusion

26. Please be focused on major findings and draw the conclusion accordingly. Furthermore, some suggestions seem to be exaggerated. Please consider re-writing it.

Reviewer #2: Incidence and Predictors of Anemia among Adults on HIV care at South Gondar Zone Public General Hospital Northwest Ethiopia, 2020; Retrospective Cohort Study.

General comments

• the manuscript needs minor language edits

• the research question lacks novelty; the authors have tried to assess if dolutegravir based regimen has effect on anemia incidence; however not convincegly assessed

• there are multiple studies addressing similar research question in Northwest Ethiopia

• the authors mentioned dolutegravir might decrease the risk of anemia; similarly they mentioned that it is introduced to Ethiopia at 2018 (a year or 2 before the end of the follow up); it will be great if the number of participants on dolutegravir based regimen is mentioned.

• the difference in the incidence of anemia in those with dolutegravir based regimen and others should have been mentioned with its statistical significance.

Specific comments

• the methodology requires more clarification

• the frequency of followup visits; the frequency of hemoglobin/hematocrit determination is not mentioned.

• the followup is mentioned to be 5 years , does this is apply for all the participants or the follow up varies for each patient

• Results

• The person year calculation, looks wrong, please look at it

• discussion

• the discussion shall focused and supported by your result findings, e.g

• erythropoeitin supplementation discussion is not supoorted by the result of this study

• References

• some of the references are not properly cited, e.g

• reference No 8; it looks there are 7 authors, however, there are only 3 authors.

**********

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Reviewer #1: Yes: Shiv Kumar Sah

Reviewer #2: Yes: Oumer Abdu Muhie

[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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Submitted filename: comments.docx

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7 Apr 2021

We have provided reviewers comment.

Senior Editor:

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Thank you for your comment. We have revised the manuscript and our file names to conform to PLOS’s style requirements.

________________________________________

2. In your ethics statement in the Methods section and in the online submission form, please provide additional information about the data used in your retrospective study

Thank you for pointing out this comment. We have added the ethical statements on page 6, lines 171 to 177.

________________________________________

3. Please include the date(s) on which you accessed the databases or records to obtain the data used in your study.

Thank you for the highlight. In the retrospective cohort study, the data collection period is similar to the study period. We have added the date on page 4, lines 111 to 112.

________________________________________

4. We noted in your submission details that a portion of your manuscript may have been presented or published elsewhere.

Thank you so much for your detailed observation. Currently, this manuscript has not been presented or published elsewhere.

________________________________________

5. Funding information should not appear in the Acknowledgments section or other areas of your manuscript.

Thank you for your constructive suggestion. We accept the comments and have agreed to your decision to take the funding information which presents in the Funding Statement section of the online submission form.________________________________________

6. Please ensure that you have an ORCID ID and that it is validated in Editorial Manager.

Thank you for your recommendation. I have authenticated the existing ORCID ID to the editorial manager.

________________________________________

7. Please amend the manuscript submission data (via Edit Submission) to include authors Yeshiwork Beyene BSc, Temesgen Getaneh, Bogale Chekole, Getasew Legas, Getachew Aragie, Tigist Gebremaryam, Tamiru Alene, Getenet Dessie.

Thank you so much for considering coauthors to include them in the online submitted manuscript. We have done.

________________________________________

Reviewers' comments:

Reviewer #1:

Introduction

It appeared to be exaggerated. It should be concise and problem-oriented. Please rewrite it and highlight the magnitude and burden of anemia in HIV in the context of Ethiopia and globally as well.

Thank you so much for your constructive comment. We have done it on page 3, line 73 to 76.________________________________________

Please mention some evidence on mortality and morbidity rate secondary to anemia.

Thank you for your suggestion. Comorbidity was highlighted on page 3, line 77 to 78, and Mortality was highlighted on page 3, line 80 to 81. ________________________________________

Authors have mentioned the several causes of HIV-related anemia without proper citation of individual independent factors. I would suggest citing each risk factor accordingly. Add vital socio-demographic factors that have been potentially linked to anemia in HIV individuals.

Thank you for pointing out this oversight. We have added vital socio-demographic factors that have been potentially linked to anemia in HIV individuals with the appropriate citation on page 3, line 87 to 90.________________________________________

Please state the clinical relevance of this study in Ethiopia.

Thank you for this highlight. Conducting this study among adults on HIV care has a great significance to prevent, manage and reduce complications related to anemia for improving their health.

It is also important to health professionals to encourage linkage of ART care to nutritional screening service, adherence counseling, and to policy makers to enhance decision making and planning of appropriate interventional strategies to prevent this comorbidity in Ethiopia.________________________________________

Methods

In exclusion criteria, authors have stated only pregnant women and anemia at the beginning of the follow-up as exclusion criteria; however, failed to discuss other potential factors such as active gastric bleeding, and some drugs which may contribute to developing anemia during follow-up.

Thank you for this suggestion. Not only the mentioned potential factors but also we have assessed comorbid disorders that can lead to anemia like malaria, intestinal parasite, asthma, COPD, allergic disease but we did not get comorbid cases in our study.________________________________________

Please highlight the core outcome variables and covariates analyzed in the study.

Thank you for pointing out the highlights. We have written the core outcome variable on page 9, line 198 to 203, and covariates used in the analysis showed on page 10 to 11, line 225 to 233.________________________________________

For the sample size calculation, the authors have considered significant predictors for the incidence of anemia from the earlier study. However, it is not clear whether it is the incidence rate or predictors that the authors have considered. Please make it clear.

Thank you for this highlight. We have used significant predictors of anemia to calculate our sample size. We cannot calculate sample size by incidence rate by using single population proportion formula in survival analysis.________________________________________

Data were entered using EPI-data Version 3.1. Clear and completed were analyzed using

STATA Version 14 statistical software. The sentence is not clear. Please re-write it.

Thank you for your detailed highlight. We have corrected it on page 6, line 158 to 159.________________________________________

How the missing data were handled?

Thank you for this highlight. We have removed variables that have greater than 5% missing by using the variable selection method.________________________________________

Results:

The median age of the entire cohort was 34 years (IQR; 12). More than half (52.1%)

157 of people living with HIV [PLHIV] were females and 323(78.6%) were Orthodox Christian

158 followed by Muslim 60(14.6%) and protestant 28(6.8%) follower. Majority, 245 (59.6%), of the159 patients came from urban areas. A total of 382 (92.9%) patients had disclosed their HIV status to160 either their husband/wife or other family members.

Please present the above figures in a table format.

Thank you for this suggestion. We have presented the figures in table form on page 7, line 185 table 1.

________________________________________

Clinical and treatment related characteristics should be presented in table form

Thank you for this suggestion. We have presented the figures in table form on page 8 to 9, line 193 table 2.________________________________________

How about alcohol and smoking habit?

Thank you for this suggestion. These variables did not record in the patient’s chart since we have conducted a retrospective cohort study by chart review. ________________________________________

Two hundred six (60.1%) patients had changed their initial regimen during the follow up period. From the total participants, 26(12.6%) patients switched to second-line HAART.

Some Anti-retroviral agents have a great impact on blood profile which may contribute to anemia. Please mention the type of regimens and its length that were switched to another regimen.

Thank you for this suggestion. As our study finding showed that, currently there is no regimen that cause to anemia rather they change their initial regimen due to new drug available (48%) and due to drug side effects (40.2%). On page 8, line 190 to 191.________________________________________

How did the authors assess the ART adherence level? Please describe it in the methodology section.

Thank you for this suggestion. We have added the adherence assessment method in table form on page 5, line 131 to 133.________________________________________

Authors have described nutritional status based on BMI. I would rather describe BMI as normal, overweight and obese. Please change it.

Thank you for this recommendation. Even if we have considered it, but we didn’t get data that is ≥ 30 kg/m2 to classify obese based on BMI classification. Rather we have gotten data which is BMI ≥ 25 kg/m2 < 30 kg/m2 and it is classified as overweight.

________________________________________

What were the criteria for anemia? Please illustrate this in the methodology section

Thank you for this highlight. We have operationalized it on page 5, lines 126 to 127. ________________________________________

I would suggest highlighting the prevalence rate of anemia at enrollment in the study.

Thank you for this suggestion. We didn’t assess the prevalence of anemia at enrolment since it is not our study’s objective. The first objective of our study is determining the incidence density rate by following participants for five years retrospectively who didn’t develop anemia at enrolment or who haven’t a previous record of anemia before the study starts. So that, the incidence density rate was 6.27/100 person-years of observation in our study.

________________________________________

Please illustrate the baseline Hemoglobin levels of the enrolled patients.

We have observed the level of serum hemoglobin of enrolled patients’ charts. The charts which have recorded normal serum hemoglobin at enrollment were entered into the study whereas charts which have recorded serum hemoglobin <13 g/dl before starting the study period were not included in the study as indicated from exclusion criteria on page 5, line 123 to 124.________________________________________

SCr was categorized as: SCr <1.1 IU/L and >1 IU/L. what are the clinical relevance of this classification.

Thank you for this highlight. This classification has its own clinical relevance to assess kidney function. If the serum creatinine level is less than or equal to 1.1 IU/L, the renal function is normal to filter creatinine product. Whereas, increased serum creatinine level which is greater than 1.1 IU/L has related with a decrement of renal function to filter it which can result in blunt erythropoietin production in response to lower hemoglobin concentration.________________________________________

What is the median ART duration? Please present it as a continuous variable as well as categorical ( e.g. <1 year vs >1 year)

Thank you so much for the suggestion. The mean of ART duration has stated on page 7, line 187. But we didn’t get a reference to make the variable categorical.

________________________________________

Drug regimens may have the potential to influence anemia in this particular group of population. Therefore, I would advise authors to consider these analyses in both bivariate and multivariate analysis.

Thank you so much for this suggestion. We have considered it but it is not fulfill the Cox proportional hazard regression model assumption checked by Schoenfeld residual and Log-Log plot tests. So that, we didn’t consider it for analysis.________________________________________

I would consider adding P-value for the Bivariate Cox-proportional hazard regression model

Thank you for this suggestion. We have added P-value for Bivariable Cox- proportional hazard regression model on page 11 to 13, line 234, Table 3.________________________________________

Please state the variables that were adjusted in the multivariable Cox regression model.

Thank you for your suggestion. We have stated the variables on page 11, line 236 to 231.________________________________________ Discussion

This noticeable discrepancy might be related to early initiation of ART for participants in the current study irrespective of CD4 count and WHO clinical staging (17) and availability of new drug regimen (dolutegravir containing regimen).

The above statement needs to be justified by the results shown in the study. Authors have failed to demonstrate the proportion of individuals who started early ART. The differences may be due to the availability of dolutegravir containing regimen, which need to be justified by existing literature.

Thank you for this suggestion. We have justified it by existing literature on page 13, line 246 to 250. ________________________________________

Increased serum creatinine related to decrement of renal function to filter it which can result blunt erythropoietin production in response to lower hemoglobin concentration (30). This finding suggests that, the need of erythropoietin treatment beside regular monitoring of hemoglobin concentration for patients who have elevated serum

Based on the above statement, it is not clear whether patients have had some kind of renal impairment; and this should be clearly mentioned in inclusion/ exclusion criteria. Moreover, being SCr> 1.1 IU/L as a risk factor for developing anemia does not imply that the patients require erythropoietin treatment. More assessment with respect to renal function is needed.

Thank you for this highlight. Increased serum creatinine does not mean renal impairment but it is an indication for reducing renal function. So that, erythropoietin treatment shall be given as prophylaxis or as a treatment for those who have increased serum creatinine level.________________________________________

Conclusion

Please be focused on major findings and draw the conclusion accordingly. Furthermore, some suggestions seem to be exaggerated. Please consider re-writing it.

Thank you for the suggestion. We have taken the comment

Submitted filename: response to revision comments.docx

Click here for additional data file.

20 Sep 2021

PONE-D-20-26223R1Incidence and Predictors of Anemia among Adults on HIV care at South  Gondar Zone Public General Hospital Northwest Ethiopia, 2020;  Retrospective Cohort Study.PLOS ONE

Dear Mr Tigabu,

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.

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Kind regards,

Kwasi Torpey, MD PhD MPH

Academic Editor

PLOS ONE

Journal Requirements:

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 (if provided):

I strongly suggest the authors to adequately address comments from Reviewer 1. Furthermore copyediting the final document to improve the language will be helpful prior to submission

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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: (No Response)

Reviewer #2: All comments have been addressed

**********

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

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

Reviewer #1: Partly

Reviewer #2: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: 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 #2: 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: No

Reviewer #2: 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: Comments

The authors have attempted to address my previous concerns, yet there are many issues that need to be addressed properly before considering for publication. My specific comments are outlined below:

Abstract

-Anemia is a major public health problem worldwide which accounts 24.8% of the population. Few cross-sectional studies have been conducted on anemia and human immunodeficiency virus. However, it cannot address the incidence and predictors of anemia among human immunodeficiency virus -infected adults.

-The above statement does not support the relevance of the study, as there is a plethora of studies examining this issue globally as well as in Ethiopia also. Please consider rewriting the above statement again

-Moreover, the estimates presented in the background does not seem relevant at this stage

-Methods are not adequately described- such as population selection and outcome measures need to be clearly mentioned.

-The authors stated that a ethical clearance was obtained from the Institutional Review Board of Bahir Dar University, and also, we got permission letter to review charts from the concerned bodies in the hospital

-The above statement should be rephrased

-This is a similar confusion that which factors were from bivariate and multivariate analyses, and need to be very clearly described, and conclusion must be drawn from the appropriate findings.

Background:

-Line 63-67 seems irrelevant and exaggerated. It should be concise and problem-oriented.

-Please highlight the current burden of the disease globally, and especially in Ethiopia

-The authors failed to clearly summarize the current scenario of the topic. There seems to address the limitation of the current knowledge in this field, especially in Ethiopia

-The authors have revealed some data on the prevalence of anemia in Ethiopia; however, in this particular issue, providing data on the incidence of anemia in this particular setting is vital

-Line 87-89

The authors have indicated some contributing factors of developing anemia, yet there are many potential factors that contribute to this burden that needs to be considered.

-A strong rationale behind this study in this setting is needed

-Overall, the introduction needs to be fine-tuned to be more clear. The numerous grammatical errors and language needs to be considered.

Methods:

- In the exclusion criteria, authors have excluded only the pregnant women and anemia at the beginning of the follow-up . How about the other potential factors that may contribute to developing anemia during follow-up?

- Please highlight the core outcome variables and covariates analyzed in the study.

- Authors have assessed the adherence level based on the number of doses. I wonder how did the authors approach this, as the review was retrospective. Moreover, is this a standard tool for the assessment of the adherence level. Need citation and reliability of this tool.

- For the sample size calculation, the authors have used the significant predictors from previous studies. I wonder that there are numerous significant predictors for developing anemia, and which of them the author employed for calculating sample size.

-How the missing data were handled?

-In the methodology section, it is vital to include the clinical criteria for the diagnosis of anemia and its severity.

Results

-data should be presented in a well-fashioned manner. I see there are many results described which were not seen in table.

-The median age of the entire cohort was 34 years (IQR; 12). More than half (52.1%)

157 of people living with HIV [PLHIV] were females and 323(78.6%) were Orthodox Christian

158 followed by Muslim 60(14.6%) and protestant 28(6.8%) follower

The above statement should be presented in the table

Age group was categorized into :

15-<30;

30-<34

40-<50

≥50

Please state the rationale behind this classification. I do not see the age group of 35 to 30. Could you make clear about this?

-Clinical and treatment-related characteristics should be presented in table form

-Do the patients have any underlying medical conditions? If yes, please present them in table

- -it would be worth presenting baseline Hb level and prevalence of anemia.

- Some HAART regimens may contribute to developing anemia. Please consider this for analyses.

- Study participants were followed for a minimum of 0.67 and a maximum of 60.63 months.

-What does a minimum of 0.67 mean. Is this a good period for assessing the incidence of anemia?

- Please state the variables that were adjusted in the multivariable Cox regression model.

-This noticeable discrepancy might be related to early initiation of ART for participants in the current study irrespective of CD4 count and WHO clinical staging (17) and availability of new drug regimen (dolutegravir containing regimen).

The above statement needs to be justified by the results shown in the study. There is a need to describe the proportion of individuals who received ART, and need to be justified by the available evidence

-Increased serum creatinine related to decrement of renal function to filter it which can result blunt erythropoietin production in response to lower hemoglobin concentration (30). This finding suggests that, the need of erythropoietin treatment beside regular monitoring of hemoglobin concentration for patients who have elevated serum

-It is not clear whether patients have had some kind of renal impairment; and this should be clearly mentioned in inclusion/ exclusion criteria.

Reviewer #2: Thank you for addressing my concerns in the manuscript you submitted to the journal PLOS ONE. I appreciate your effort in that

**********

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: Yes: Shiv Kumar Sah

Reviewer #2: Yes: Oumer Abdu Muhie

[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.

Submitted filename: Comments.docx

Click here for additional data file.

11 Oct 2021

Agimasie Tigabu, BSc, MSc

Lecturer of Adult Health Nursing, Department of Nursing,

College of Medicine and Health Science

Debre Tabor University,

Debre Tabor, ETHIOPIA

Email: ethiomom23@gmail.com

Dr. Kwasi Torpey, MD PhD, MPH.

Academic Editor, PLOS ONE

Aug 21 2020 2:32AM

My colleagues and I are happy to re-submit to you a revised version of our manuscript PONE-D- 20-26223R1, Incidence and Predictors of Anemia among Adults on HIV care: A Retrospective cohort study. For PLOS One, Thank you for giving us the opportunity to revise and resubmit this manuscript. I am resubmitting this revision on15th October 2021.

We thank the reviewers for their detailed and thoughtful suggestions. We have incorporated the recommended changes in the manuscript to the best of our ability and we feel that our revised manuscript is significantly improved as a result of your advice.

We have responded specifically to each suggestion in the memo below and have highlighted our changes in the manuscript text. In the memo, portions of the reviewers’ comments are reproduced in italic text, and our responses to the reviewers' comments are listed beneath in the Norman text.

The authors received no specific funding for this work.

Thank you once again for your time and attention to our manuscript. We look forward to working with you and the reviewers to move this manuscript closer to publication.

Best regards,

Agimasie Tigabu

REVIEWER COMMENTS AND RESPONSES

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: (No Response)

Reviewer #2: All comments have been addressed

Thank you for your suggestion. Actually, we didn’t get such comments if there will be, we will indicate our conflict of interest statement to bypass comments to Author section and enter it to Editor Section. After we got acceptance, we will submit the acceptance recommendation.

We thank you reviewer #2 for your detail understanding of the response for previous round of review comments.

________________________________________

2. Is the manuscripts 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

Reviewer #2: Yes

Thank you so much for this oversight. As Reviewers said, the manuscript is a scientific research with the data that supports the conclusion and the conclusion has drawn based on the data presented.

________________________________________

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

Reviewer #1: Yes

Reviewer #2: Yes

Thank you so much for this suggestion. As the reviewers said, the statistical analysis has been performed appropriately and rigorously.________________________________________

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

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

Reviewer #1: Yes

Reviewer #2: Yes

Thank you so much for this suggestion. All data underlying the findings are fully available within the manuscript.________________________________________

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: No

Reviewer #2: Yes

Thank you so much for this suggestion. The manuscript is written in Standard English.________________________________________

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: Yes: Shiv Kumar Sah

Reviewer #2: Yes: Oumer Abdu Muhie

Thank you so much for this suggestion. We don’t want to our identity to be public. Thank you.

________________________________________

Review Comments to the Author

Reviewer #1:

1. Abstract

Anemia is a major public health problem worldwide which accounts 24.8% of the population. Few cross-sectional studies have been conducted on anemia and human immunodeficiency virus. However, it cannot address the incidence and predictors of anemia among human immunodeficiency virus -infected adults.

-The above statement does not support the relevance of the study, as there is a plethora of studies examining this issue globally as well as in Ethiopia also. Please consider rewriting the above statement again

-Moreover, the estimates presented in the background does not seem relevant at this stage

Methods are not adequately described- such as population selection and outcome measures need to be clearly mentioned.

-The authors stated that a ethical clearance was obtained from the Institutional Review Board of Bahir Dar University, and also, we got permission letter to review charts from the concerned bodies in the hospital

-The above statement should be rephrased

-This is a similar confusion that which factors were from bivariate and multivariate analyses, and need to be very clearly described, and conclusion must be drawn from the appropriate findings.

Thank you so much for your constructive comment. We have rewritten and rephrased the statements per the given comments on page 2, line number 29 to 34.

________________________________________

2. Background:

-Line 63-67 seems irrelevant and exaggerated. It should be concise and problem-oriented.

-Please highlight the current burden of the disease globally, and especially in Ethiopia

-The authors failed to clearly summarize the current scenario of the topic. There seems to address the limitation of the current knowledge in this field, especially in Ethiopia

-The authors have revealed some data on the prevalence of anemia in Ethiopia; however, in this particular issue, providing data on the incidence of anemia in this particular setting is vital

-Line 87-89

The authors have indicated some contributing factors of developing anemia, yet there are many potential factors that contribute to this burden that needs to be considered.

-A strong rationale behind this study in this setting is needed

-Overall, the introduction needs to be fine-tuned to be more clear. The numerous grammatical errors and language needs to be considered.

Thank you so much for your oversight. We have revised and edited the grammatical as well as language errors the background based on the given comments.

________________________________________

3. Methods:

- In the exclusion criteria, authors have excluded only the pregnant women and anemia at the beginning of the follow-up. How about the other potential factors that may contribute to developing anemia during follow-up?

- Please highlight the core outcome variables and covariates analyzed in the study.

- Authors have assessed the adherence level based on the number of doses. I wonder how did the authors approach this, as the review was retrospective. Moreover, is this a standard tool for the assessment of the adherence level. Need citation and reliability of this tool.

- For the sample size calculation, the authors have used the significant predictors from previous studies. I wonder that there are numerous significant predictors for developing anemia, and which of them the author employed for calculating sample size.

-How the missing data were handled?

-In the methodology section, it is vital to include the clinical criteria for the diagnosis of anemia and its severity.

Thank you so much for your oversight. We have highlighted the core outcome variable in the operational definition part which was dichotomized into event and censored.

Adherence level: - missing dose is a standard tool for the assessment of the adherence level which is taken from ART intake form. We have stated it on page 5, line number 121 to 122.

On sample size calculation: - as you have mentioned that, we have used three significant predictors from previous studies. Those are nutritional status, past TB history and sex. We used the largest of all which is 434 by using nutritional status whereas by using past TB history and sex were given 190 and 44 respectively.

The missing data was handled by adding 10 % non-response rate and by excluding the study participants chart who have greater than or equal to 5% incompleteness.

________________________________________

4. Results

-data should be presented in a well-fashioned manner. I see there are many results described which were not seen in table.

-The median age of the entire cohort was 34 years (IQR; 12). More than half (52.1%)

157 of people living with HIV [PLHIV] were females and 323(78.6%) were Orthodox Christian

158 followed by Muslim 60(14.6%) and protestant 28(6.8%) follower

The above statement should be presented in the table

Age group was categorized into :

15-<30;

30-<34

40-<50

≥50

Please state the rationale behind this classification. I do not see the age group of 35 to 30. Could you make clear about this?

-Clinical and treatment-related characteristics should be presented in table form

-Do the patients have any underlying medical conditions? If yes, please present them in table

- -it would be worth presenting baseline Hb level and prevalence of anemia.

- Some HAART regimens may contribute to developing anemia. Please consider this for analyses.

- Study participants were followed for a minimum of 0.67 and a maximum of 60.63 months.

-What does a minimum of 0.67 mean? Is this a good period for assessing the incidence of anemia?

- Please state the variables that were adjusted in the multivariable Cox regression model.

-Increased serum creatinine related to decrement of renal function to filter it which can result blunt erythropoietin production in response to lower hemoglobin concentration (30). This finding suggests that, the need of erythropoietin treatment besides regular monitoring of hemoglobin concentration for patients who have elevated serum

-It is not clear whether patients have had some kind of renal impairment; and this should be clearly mentioned in inclusion/ exclusion criteria.

Thank you so much for your constrictive comments. We described the frequencies of some variables in statement way and some are presented in table form.

Age categories: - we categorized it based on previous available literatures. 30 to 34 were written mistakenly. We have categorized it 30 years to 40 years on page 7.

Prevalence of anemia is not the study objective rather we have determined anemia incidence density rate and identified its predictors including their survival probability. We have written it on page 9, line number 185 to 187.

We have studied HAART regimens including changed regimen by considering a predictor variable for developing of anemia. In bivariable cox regression analysis, those regimens were not eligible for multivariable cox regression.

We have followed the study participants for five years duration. during the study period one study participant might be followed for a minimum of 0.67 months and one study participant might be followed for a maximum of 60.63 months.

We have listed the variables which are adjusted in the multivariable Cox regression model on page 11, line number 215 to 217.

Based on the adjusted cox regression analysis result, study participants who have increased serum creatinine level have high risk to develop anemia as compared to who have normal serum creatinine level. Based on this finding, we have written implication for it. Whether the study participants have renal impairment or not if they have fulfilled the inclusion criteria are considered as the study participants.

________________________________________

Reviewer #2:

Thank you for addressing my concerns in the manuscript you submitted to the journal PLOS ONE. I appreciate your effort in that.

Thank you so much.

________________________________________

Submitted filename: 2nd revision response to reviewer comments of Anemia.docx

Click here for additional data file.

19 Oct 2021

PONE-D-20-26223R2Incidence and Predictors of Anemia among Adults on HIV care at South  Gondar Zone Public General Hospital Northwest Ethiopia, 2020;  Retrospective Cohort Study.PLOS ONE

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29 Oct 2021

REVIEWER COMMENTS AND RESPONSES

Reviewer #1:

Introduction

1. It appeared to be exaggerated. It should be concise and problem-oriented. Please rewrite it and highlight the magnitude and burden of anemia in HIV in the context of Ethiopia and globally as well.

Thank you so much for your constructive comment. We have done it on page 3, line 69 to 70.

________________________________________

2. Please mention some evidence on mortality and morbidity rate secondary to anemia.

Thank you for your suggestion. Comorbidity was highlighted on page 3, line 71 to 72, and Mortality was highlighted on page 3, line 74 to 76.

________________________________________

3. Authors have mentioned the several causes of HIV-related anemia without proper citation of individual independent factors. I would suggest citing each risk factor accordingly. Add vital socio-demographic factors that have been potentially linked to anemia in HIV individuals.

Thank you for pointing out this oversight. We have added vital socio-demographic factors that have been potentially linked to anemia in HIV individuals with the appropriate citation on page 3, line 80 to 82.

________________________________________

4. Please state the clinical relevance of this study in Ethiopia.

Thank you for this highlight. Conducting this study among adults on HIV care has a great significance to prevent, manage and reduce complications related to anemia for improving their health. It is also important to health professionals to encourage linkage of ART care to nutritional screening service, adherence counseling, and to policy makers to enhance decision making and planning of appropriate interventional strategies to prevent this comorbidity in Ethiopia.

________________________________________

Methods

1. In exclusion criteria, authors have stated only pregnant women and anemia at the beginning of the follow-up as exclusion criteria; however, failed to discuss other potential factors such as active gastric bleeding, and some drugs which may contribute to developing anemia during follow-up.

Thank you for this suggestion. Not only the mentioned potential factors but also we have assessed comorbid disorders that can lead to anemia like malaria, intestinal parasite, asthma, COPD, allergic disease but we did not get comorbid cases in our study.

________________________________________

2. Please highlight the core outcome variables and covariates analyzed in the study.

Thank you for pointing out the highlights. We have written the core outcome variable on page 9, line 187 to 189, and covariates used in the analysis showed on page 10 to 13, line 210 to 217 and on table 3.

________________________________________

3. For the sample size calculation, the authors have considered significant predictors for the incidence of anemia from the earlier study. However, it is not clear whether it is the incidence rate or predictors that the authors have considered. Please make it clear.

Thank you for this highlight. We have used significant predictors of anemia to calculate our sample size. We cannot calculate sample size by incidence rate by using single population proportion formula in survival analysis.

________________________________________

4. Data were entered using EPI-data Version 3.1. Clear and completed were analyzed using STATA Version 14 statistical software. The sentence is not clear. Please re-write it.

Thank you for your detailed highlight. We have corrected it on page 6, line 147 to 148.

________________________________________

5. How the missing data were handled? Thank you for this highlight.

We have removed variables that have greater than 5% missing by using the variable selection method.

________________________________________

Results:

1. The median age of the entire cohort was 34 years (IQR; 12). More than half (52.1%) 157 of people living with HIV [PLHIV] were females and 323(78.6%) were Orthodox Christian 158 followed by Muslim 60(14.6%) and protestant 28(6.8%) follower. Majority, 245 (59.6%), of the159 patients came from urban areas. A total of 382 (92.9%) patients had disclosed their HIV status to160 either their husband/wife or other family members. Please present the above figures in a table format.

Thank you for this suggestion. We have presented the figures in table form on page 6, line 172 table 1.

________________________________________

2. Clinical and treatment related characteristics should be presented in table form Thank you for this suggestion.

We have presented the figures in table form on page 8 to 9, line 179 on table 2.

________________________________________

3. How about alcohol and smoking habit?

Thank you for this suggestion. These variables did not record in the patient’s chart since we have conducted a retrospective cohort study by chart review.

________________________________________

4. Two hundred six (60.1%) patients had changed their initial regimen during the follow up period. From the total participants, 26(12.6%) patients switched to second-line HAART. Some Anti-retroviral agents have a great impact on blood profile which may contribute to anemia. Please mention the type of regimens and its length that were switched to another regimen.

Thank you for this suggestion. As our study finding showed that, currently there is no regimen that cause to anemia rather they change their initial regimen due to new drug available (48%) and due to drug side effects (40.2%) on page 7, line 174 to 179.

________________________________________

5. How did the authors assess the ART adherence level? Please describe it in the methodology section.

Thank you for this suggestion. We have added the adherence assessment method in table form on page 5, line 121 to 123.

________________________________________

6. Authors have described nutritional status based on BMI. I would rather describe BMI as normal, overweight and obese. Please change it.

Thank you for this recommendation. Even if we have considered it, but we didn’t get data that is ≥ 30 kg/m2 to classify obese based on BMI classification. Rather we have gotten data which is BMI ≥ 25 kg/m2 < 30 kg/m2 and it is classified as overweight.

________________________________________

7. What were the criteria for anemia? Please illustrate this in the methodology section

Thank you for this highlight. We have operationalized it on page 4, lines 117 to 118.

________________________________________

8. I would suggest highlighting the prevalence rate of anemia at enrollment in the study.

Thank you for this suggestion. We didn’t assess the prevalence of anemia at enrolment since it is not our study’s objective. The first objective of our study is determining the incidence density rate by following participants for five years retrospectively who didn’t develop anemia at enrolment or who haven’t a previous record of anemia before the study starts. The incidence density rate of anemia was 6.27/100 person-years of observation in our study.

________________________________________

9. Please illustrate the baseline Hemoglobin levels of the enrolled patients. We have observed the level of serum hemoglobin of enrolled patients’ charts. The charts which have recorded normal serum hemoglobin at enrollment were entered into the study whereas charts which have recorded serum hemoglobin 1 IU/L. what are the clinical relevance of this classification.

Thank you for this highlight. This classification has its own clinical relevance to assess kidney function. If the serum creatinine level is less than or equal to 1.1 IU/L, the renal function is normal to filter creatinine product. Whereas, increased serum creatinine level which is greater than 1.1 IU/L has related with a decrement of renal function to filter it which can result in blunt erythropoietin production in response to lower hemoglobin concentration.

________________________________________

10. What is the median ART duration? Please present it as a continuous variable as well as categorical ( e.g. 1 year)

Thank you so much for the suggestion. The mean of ART duration has stated on page 7, line 187. But we didn’t get a reference to make the variable categorical.

________________________________________

11. Drug regimens may have the potential to influence anemia in this particular group of population. Therefore, I would advise authors to consider these analyses in both bivariate and multivariate analysis.

Thank you so much for this suggestion. We have considered it but it is not fulfill the Cox proportional hazard regression model assumption checked by Schoenfeld residual and Log-Log plot tests. Due to the above reason, we didn’t consider it for analysis.

________________________________________

I would consider adding P-value for the Bivariate Cox-proportional hazard regression model

Thank you for this suggestion. We have added P-value for Bivariable Cox- proportional hazard regression model on page 11 to 13, line 218 to 219, Table 3.

________________________________________

Please state the variables that were adjusted in the multivariable Cox regression model.

Thank you for your suggestion. We have stated the variables on page 11, line 215 to 217.

________________________________________

Discussion

1. This noticeable discrepancy might be related to early initiation of ART for participants in the current study irrespective of CD4 count and WHO clinical staging (17) and availability of new drug regimen (dolutegravir containing regimen) The above statement needs to be justified by the results shown in the study. Authors have failed to demonstrate the proportion of individuals who started early ART. The differences may be due to the availability of dolutegravir containing regimen, which need to be justified by existing literature.

Thank you for this suggestion. We have justified it by existing literature on page 13, line 233 to 234.

________________________________________

2. Increased serum creatinine related to decrement of renal function to filter it which can result blunt erythropoietin production in response to lower hemoglobin concentration (30). This finding suggests that, the need of erythropoietin treatment beside regular monitoring of hemoglobin concentration for patients who have elevated serum Based on the above statement, it is not clear whether patients have had some kind of renal impairment; and this should be clearly mentioned in inclusion/ exclusion criteria. Moreover, being SCr> 1.1 IU/L as a risk factor for developing anemia does not imply that the patients require erythropoietin treatment. More assessment with respect to renal function is needed.

Thank you for this highlight. Increased serum creatinine does not mean renal impairment but it is an indication for reducing renal function. So that, erythropoietin treatment shall be given as prophylaxis or as a treatment for those who have increased serum creatinine level.

________________________________________

Conclusion

1. Please be focused on major findings and draw the conclusion accordingly. Furthermore, some suggestions seem to be exaggerated. Please consider re-writing it.

Thank you for the suggestion. We have taken the comment

________________________________________

REVIEWER COMMENTS AND RESPONSES

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: (No Response)

Reviewer #2: All comments have been addressed

Thank you for your suggestion. Actually, we didn’t get such comments if there will be, we will indicate our conflict of interest statement to bypass comments to Author section and enter it to Editor Section. After we got acceptance, we will submit the acceptance recommendation.

We thank you reviewer #2 for your detail understanding of the response for previous round of review comments.

________________________________________

2. Is the manuscripts 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

Reviewer #2: Yes

Thank you so much for this oversight. As Reviewers said, the manuscript is a scientific research with the data that supports the conclusion and the conclusion has drawn based on the data presented.

________________________________________

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

Reviewer #1: Yes

Reviewer #2: Yes

Thank you so much for this suggestion. As the reviewers said, the statistical analysis has been performed appropriately and rigorously.________________________________________

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

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

Reviewer #1: Yes

Reviewer #2: Yes

Thank you so much for this suggestion. All data underlying the findings are fully available within the manuscript.________________________________________

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: No

Reviewer #2: Yes

Thank you so much for this suggestion. The manuscript is written in Standard English.________________________________________

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Reviewer #1: Yes: Shiv Kumar Sah

Reviewer #2: Yes: Oumer Abdu Muhie

Thank you so much for this suggestion. We don’t want to our identity to be public. Thank you.

________________________________________

Review Comments to the Author

Reviewer #1:

1. Abstract

Anemia is a major public health problem worldwide which accounts 24.8% of the population. Few cross-sectional studies have been conducted on anemia and human immunodeficiency virus. However, it cannot address the incidence and predictors of anemia among human immunodeficiency virus -infected adults.

-The above statement does not support the relevance of the study, as there is a plethora of studies examining this issue globally as well as in Ethiopia also. Please consider rewriting the above statement again

-Moreover, the estimates presented in the background does not seem relevant at this stage

Methods are not adequately described- such as population selection and outcome measures need to be clearly mentioned.

-The authors stated that a ethical clearance was obtained from the Institutional Review Board of Bahir Dar University, and also, we got permission letter to review charts from the concerned bodies in the hospital

-The above statement should be rephrased

-This is a similar confusion that which factors were from bivariate and multivariate analyses, and need to be very clearly described, and conclusion must be drawn from the appropriate findings.

Thank you so much for your constructive comment. We have rewritten and rephrased the statements per the given comments on page 2, line number 29 to 34.

________________________________________

2. Background:

-Line 63-67 seems irrelevant and exaggerated. It should be concise and problem-oriented.

-Please highlight the current burden of the disease globally, and especially in Ethiopia

-The authors failed to clearly summarize the current scenario of the topic. There seems to address the limitation of the current knowledge in this field, especially in Ethiopia

-The authors have revealed some data on the prevalence of anemia in Ethiopia; however, in this particular issue, providing data on the incidence of anemia in this particular setting is vital

-Line 87-89

The authors have indicated some contributing factors of developing anemia, yet there are many potential factors that contribute to this burden that needs to be considered.

-A strong rationale behind this study in this setting is needed

-Overall, the introduction needs to be fine-tuned to be more clear. The numerous grammatical errors and language needs to be considered.

Thank you so much for your oversight. We have revised and edited the grammatical as well as language errors of the background based on the given comments.

________________________________________

3. Methods:

- In the exclusion criteria, authors have excluded only the pregnant women and anemia at the beginning of the follow-up. How about the other potential factors that may contribute to developing anemia during follow-up?

- Please highlight the core outcome variables and covariates analyzed in the study.

- Authors have assessed the adherence level based on the number of doses. I wonder how the authors approached this, as the review was retrospective. Moreover, is this a standard tool for the assessment of the adherence level? Need citation and reliability of this tool.

- For the sample size calculation, the authors have used the significant predictors from previous studies. I wonder that there are numerous significant predictors for developing anemia, and which of them the author employed for calculating sample size.

-How the missing data were handled?

-In the methodology section, it is vital to include the clinical criteria for the diagnosis of anemia and its severity.

Thank you so much for your oversight. We have highlighted the core outcome variable in the operational definition part which was dichotomized into event and censored.

Adherence level: - missing dose is a standard tool for the assessment of the adherence level which is taken from ART intake form. We have stated it on page 5, line number 121 to 122.

On sample size calculation: - as you have mentioned that, we have used three significant predictors from previous studies. Those are nutritional status, past TB history and sex. We used the largest of all which is 434 by using nutritional status whereas by using past TB history and sex were given 190 and 44 respectively.

The missing data was handled by adding 10 % non-response rate and by excluding the study participants chart who have greater than or equal to 5% incompleteness.

________________________________________

4. Results

-data should be presented in a well-fashioned manner. I see there are many results described which were not seen in table.

-The median age of the entire cohort was 34 years (IQR; 12). More than half (52.1%)

157 of people living with HIV [PLHIV] were females and 323(78.6%) were Orthodox Christian

158 followed by Muslim 60(14.6%) and protestant 28(6.8%) follower

The above statement should be presented in the table

Age group was categorized into:

15-<30;

30-<34

40-<50

≥50

Please state the rationale behind this classification. I do not see the age group of 35 to 30. Could you make clear about this?

-Clinical and treatment-related characteristics should be presented in table form

-Do the patients have any underlying medical conditions? If yes, please present them in table

- -it would be worth presenting baseline Hb level and prevalence of anemia.

- Some HAART regimens may contribute to developing anemia. Please consider this for analyses.

- Study participants were followed for a minimum of 0.67 and a maximum of 60.63 months.

-What does a minimum of 0.67 mean? Is this a good period for assessing the incidence of anemia?

- Please state the variables that were adjusted in the multivariable Cox regression model.

-Increased serum creatinine related to decrement of renal function to filter it which can result blunt erythropoietin production in response to lower hemoglobin concentration (30). This finding suggests that, the need of erythropoietin treatment besides regular monitoring of hemoglobin concentration for patients who have elevated serum

-It is not clear whether patients have had some kind of renal impairment; and this should be clearly mentioned in inclusion/ exclusion criteria.

Thank you so much for your constrictive comments. We described the frequencies of some variables in statement way and some are presented in table form.

Age categories: - we categorized it based on previous available literatures. 30 to 34 were written mistakenly. We have categorized it 30 years to 40 years on page 7.

Prevalence of anemia is not the study objective rather we have determined anemia incidence density rate and identified its predictors including their survival probability. We have written it on page 9, line number 185 to 189.

We have studied HAART regimens including changed regimen by considering a predictor variable for developing of anemia. In bivariable cox regression analysis, those regimens were not eligible for multivariable cox regression.

We have followed the study participants for five years duration. during the study period one study participant might be followed for a minimum of 0.67 months and one study participant might be followed for a maximum of 60.63 months.

We have listed the variables which are adjusted in the multivariable Cox regression model on page 11, line number 215 to 217.

Based on the adjusted cox regression analysis result, study participants who have increased serum creatinine level have high risk to develop anemia as compared to who have normal serum creatinine level. Based on this finding, we have written implication for it. Whether the study participants have renal impairment or not if they have fulfilled the inclusion criteria are considered as the study participants.

________________________________________

Reviewer #2:

Thank you for addressing my concerns in the manuscript you submitted to the journal PLOS ONE. I appreciate your effort in that.

Thank you so much.

Submitted filename: 2nd revision response to reviewer comments of Anemia.docx

Click here for additional data file.

2 Nov 2021

Incidence and Predictors of Anemia among Adults on HIV care at South  Gondar Zone Public General Hospital Northwest Ethiopia, 2020;  Retrospective Cohort Study.

PONE-D-20-26223R3

Dear Mr Tigabu,

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,

Professor Kwasi Torpey, MD PhD MPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Please correct reference No.53 and ensure it is consistent with journal guidelines

Reviewers' comments:

2 Dec 2021

PONE-D-20-26223R3

Incidence and Predictors of Anemia among Adults on HIV care at South  Gondar Zone Public General Hospital Northwest Ethiopia, 2020;  Retrospective Cohort Study.

Dear Dr. Tigabu:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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on behalf of

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Level of adherence	Percent (%)	(of 30 doses)	(of 60 doses)
G(good)	> 95%	< 2 doses	< 3 doses
F(fair)	85–94%	2–5 doses	3–9 doses
P(poor)	< 85%	≥ 6 doses	> 9 doses

Table 1

Baseline socio demographic characteristics of adults on HIV care.

Characteristics	Number	Percent
Age
15 to <30	134	32.6
30 to <40	163	39.7
40 to <50	88	21.4
≥50 years	26	6.3
Sex
Male	197	47.9
Female	214	52.1
Residence
Urban residence	245	(59.6%),
Rural residence	166	40.04%
Marital Status
Married	210	51.1
Never married	72	17.5
Divorced	81	19.7
Widowed	48	19.7
Level of Educational status
No education	123	29.9
Primary	100	24.3
Secondary	115	28
Tertiary and above	73	17.8
Occupation
Employed	160	38.9
Unemployed	251	61.1

Table 2

Baseline clinical and treatment related characteristics of adults on HIV care.

Variables	Number	Percent (%)
Baseline CD4 count
> = 200 cells/ul	139	33.8
50 to<200 cell/ul	224	54.5
<50 cell/ul	48	11.7
WHO clinical stage
Clinical stage I/II	266	64.7
Clinical stage III/IV	145	35.3
BMI category
Normal	245	59.6
Obese	21	5.1
under nutrition	145	35.7
Serum creatinine
< = 1.1 IU/L	340	82.7
>1.1 IU/L	71	17.3
Serum alanine amino transferase
< = 50 IU/L	354	86.1
>50 IU/L	57	13.9
ART adherence
Good	331	80.5
fair/poor	80	19.5
Functional status
Working	298	72.5
Ambulatory	102	24.8
Bedridden	11	2.7
Past TB history
No	342	83.2
Yes	69	16.9
Cotrimoxazole prophylaxis
No	25	6.1
Yes	386	93.9
Isoniazid prophylaxis
No	82	20
Yes	329	80
Initial regimen
1j	9	2.2
1e	212	51.6
1a	50	12.2
ELSE*	64	15.6
1c	76	18.5
Changed Regimen
No	205	49.9
Yes	206	60.1
Changed regimen type
1j	99	48
1e	30	14.6
2f and 2h	26	12.6
ELSE**	26	12.6
1c	25	12.14
Recent viral load
not detected	384	93.4
<150 cells/ul	15	3.6
150 to <1000	5	1.2
> = 1000	7	1.7

ELSE* = [1b(d4t-3TC-EFV), 1d(AZT-3TC-EFV), 1f(TDF+3TC-NVP), 1g(ABC+3TC-EFV) and 1h(ABC-3TC-NVP)], ELSE** = [1a(d4t-3TC-NVP), 1b(d4t-3TC-EFV), 1d(AZT-3TC-EFV), 1f(TDF+3TC-NVP), 1g(ABC+3TC-EFV) and 1h(ABC-3TC-NVP)], 1j = TDF-3TC-DTG, 2f = AZT-3TC-ATV/r, 2h = TDF-3TC-ATV/r.

Table 3

Predictors of anemia among HIV positive adults on ART at Debre Tabor General Hospital, January 1, 2015 to December 30, 2019.

Variables		Censored	Anemia	Crude HR	P-value	Adjusted HR	P-value
				(95% CI)		(95% CI)
Age category	15 to <30 years	106	28			1
	30 to <40 years	140	23	0.7 (0.41, 1.22)	0.15	1.0(0.98, 1.02)	0.729
	40 to <50 years	65	23	1.37(0.79, 2.38)	0.08	1.02(1.00, 1.04)	0.063
	> = 50 years	11	15	3.37(1.8, 6.33)	0.04	1.01(0.99, 1.03)	0.434
Sex	Male	166	31			1
	Female	156	58	1.61(1.04, 2.49)	0.02	1.16(0.67, 2.02)	0.593
Marital status	Married	180	30			1
	Single	142	59	2.27(1.46, 3.52)	0.01	1.53(0.9, 2.62)	0.120
Residence	Urban	214	31			1
	Rural	108	58	3.23(2.1, 5)	0.03	0.9(0.51, 1.75)	0.852
Occupation	Employed	142	18			1
	Unemployed	180	71	2.76(1.64, 4.63)	0.05	0.74(0.26, 2.13)	0.582
Educational status	secondary and above	166	22			1
	Primary	75	25	2.17(1.22, 3.85)	0.02	2.11(0.87, 6.42)	0.090
	not educated	81	42	3.24(1.93, 5.43)	0.00	1.84(0.68, 4.98)	0.230
Disclosure status	Disclosed	308	74			1
	not disclose	14	15	4.21(2.4, 7.37)	0.05	1.46(0.71,3.02)	0.303
Clinical staging	stage I/II	245	21			1
	stage III/IV	77	68	6.6(4.08, 10.87)	0.00	1.03(1.01,1.06)	0.001 *
CD4 count category	> = 200 cells/ul	121	18			1
	50 to <200 cells/ul	173	51	1.74(1.02, 2.98)	0.02	1.19(0.6, 2.34)	0.618
	<50 cells/ul	28	20	3.23(1.71, 6.11)	0.01	1.47(0.68,3.15)	0.326
BMI category	Normal	231	14			1
	Overweight	19	2	1.55(0.35, 6.83)	0.18	1.7(0.32, 9)	0.535
	Undernutrition	72	73	11.2(6.33,19.93)	0.00	3.43(1.72, 6.83)	0.000*
Serum creatinine category	< = 1.1 IU/L	304	36			1
	>1.1 IU/L	18	53	10.2(6.65,15.76)	0.01	2.24(1.2, 4.2)	0.011 *
Serum ALT category	< = 50 IU/L	302	52			1
	>50 IU/L	20	37	6.31(4.12, 9.67)	0.03	1.49(0.85, 2.59)	0.164
Adherence category	Good	294	37			1
	fair/poor	28	52	8.11(5.23,12.47)	0.01	2.9(1.43, 5.97)	0.003*
Functional status	Working	272	26			1
	Ambulatory	47	55	6.88(4.31,10.98)	0.08	1.04(0.51, 2.12)	0.918
	Bedridden	3	8	11.8(5.33, 26.13	0.07	0.45(0.13, 1.55)	0.206
Past TB history	No	286	56			1
	Yes	36	33	3.62(2.36, 5.58)	0.1	1.02(0.51, 2.03)	0.953
TB treatment	No	269	48			1
	Yes	53	41	3.48 (2.29, 5.29)	0.06	2.00(0.91, 4.35)	0.083
Cotrimoxazole prophylaxis	No	16	9			1
	Yes	306	80	0.59(0.3,1.17)	0.09	0.63(0.24,1.66)	0.355
Isoniazid prophylaxis	No	44	38			1
	Yes	278	51	0.27(0.17, 0.40)	0.1	1.56(0.69,3.52)	0.289
Recent viral load	not detected	307	77			1
	<150 cells/ul	8	7	2.71(1.25, 5.88)	0.13	1.38(0.57, 3.35)	0.471
	> = 150<1000	2	3	3.02(0.95, 9.57)	0.08	0.29(0.07, 1.23)	0.092
	> = 1000	5	2	1.57(0.39, 6.4)	0.18	2.02(0.43, 9.5)	0.373
ART duration	------	-----	----	0.99(0.98, 0.99)		0.98(0.97, 0.99)	0.000*

Marital status: Single includes Unmarried, widowed and divorced; BMI = body mass index; ALT = alanine aminotransferase; ART = anti-retroviral therapy; IU/L = international unit per liter; Statistical significance at 95% CI, P < 0.05

*reference statistically significant.