Reviewer ’s report  
 
Title: Comparison of the Prevalence, Severity, and R isk Factors for Hepatic Steatosis in HIV -
Infected and Uninfected People  
 
Version: 0 Date: 16 Nov 2018  
 
Reviewer: Lydia Giannitrapani  
 
Reviewer's report:  
 
The paper by Torgensen et al. entitled:  "Comparison of the Prevalence, Severity, and Risk 
Factors for Hepatic Steatosis in HIV -Infected and Uninfected People", aimed to compare the 
prevalence an d severity of hepatic steatosis determined by noncontrast abdominal computed 
tomography (CT) between HIV+ and uninfected persons within a subcohort of the Veterans 
Aging Cohort Study (VACS) and to evaluate risk factors for greater severity of steatosis wit hin 
both groups. The study is well conducted and methodology and statistical analysis are correct 
however there are some points that reduce the strength of the results that have to be more deeply 
commented.  
The first point regards the nature itself of the  study group that included almost only male 
subjects, this limiting possibility of extending the conclusions to the whole population of HIV 
infected subjects.  
The second point is about the choice of the methodology to study liver fibrosis. In fact, the 
steatosis evaluation with CT could be acceptable having a good sensitivity and specificity, even 
if it is not the gold standard i.e. liver histology ,nor the best accurate imaging technique that is 
MRI proton -density fat fraction [Br J Radiol 2018 91(1089)]. As regard the non invasive 
methods to evaluate liver fibrosis, a recent meta -analysis about the comparison of laboratory 
tests, US, MR and elastography to evaluate fibrosis found that FIB -4 at the threshold of 3.25 
have a good specificity but a very low se nsitivity (Hepatology 2017) and that the best non 
invasive tool should be transient elastography.  
Finally one word should be spent about anti -retroviral therapy. In fact, although new anti -
retroviral drugs are less toxic and associated with fewer metabolic  complications, metabolic 
abnormalities persist in HIV patients and this aspect should be evaluated in the study and pointed 
out in the discussion.  
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Unable to assess  
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects requ ire further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain  or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the fut ure? 
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of  the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I declare that I have no competing i nterests' below  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is acce pted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license  (http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
 
 
 
 
Reviewer ’s report  
 
Title: Comparison of the Prevalence, Severity, and R isk Factors for Hepatic Steatosis in HIV -
Infected and Uninfected People  
 
Version: 0 Date: 16 Nov 2018  
 
Reviewer: Lydia Giannitrapani  
 
Reviewer's report:  
 
The paper by Torgensen et al. entitled:  "Comparison of the Prevalence, Severity, and Risk 
Factors for Hepatic Steatosis in HIV -Infected and Uninfected People", aimed to compare the 
prevalence an d severity of hepatic steatosis determined by noncontrast abdominal computed 
tomography (CT) between HIV+ and uninfected persons within a subcohort of the Veterans 
Aging Cohort Study (VACS) and to evaluate risk factors for greater severity of steatosis wit hin 
both groups. The study is well conducted and methodology and statistical analysis are correct 
however there are some points that reduce the strength of the results that have to be more deeply 
commented.  
The first point regards the nature itself of the  study group that included almost only male 
subjects, this limiting possibility of extending the conclusions to the whole population of HIV 
infected subjects.  
The second point is about the choice of the methodology to study liver fibrosis. In fact, the 
steatosis evaluation with CT could be acceptable having a good sensitivity and specificity, even 
if it is not the gold standard i.e. liver histology ,nor the best accurate imaging technique that is 
MRI proton -density fat fraction [Br J Radiol 2018 91(1089)]. As regard the non invasive 
methods to evaluate liver fibrosis, a recent meta -analysis about the comparison of laboratory 
tests, US, MR and elastography to evaluate fibrosis found that FIB -4 at the threshold of 3.25 
have a good specificity but a very low se nsitivity (Hepatology 2017) and that the best non 
invasive tool should be transient elastography.  
Finally one word should be spent about anti -retroviral therapy. In fact, although new anti -
retroviral drugs are less toxic and associated with fewer metabolic  complications, metabolic 
abnormalities persist in HIV patients and this aspect should be evaluated in the study and pointed 
out in the discussion.  
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Unable to assess  
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects requ ire further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain  or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the fut ure? 
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of  the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I declare that I have no competing i nterests' below  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is acce pted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license  (http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
 
 
 
 
Please review this paper.
user
Reviewer ’s report  
 
Title: Comparison of the Prevalence, Severity, and R isk Factors for Hepatic Steatosis in HIV -
Infected and Uninfected People  
 
Version: 0 Date: 16 Nov 2018  
 
Reviewer: Lydia Giannitrapani  
 
Reviewer's report:  
 
The paper by Torgensen et al. entitled:  "Comparison of the Prevalence, Severity, and Risk 
Factors for Hepatic Steatosis in HIV -Infected and Uninfected People", aimed to compare the 
prevalence an d severity of hepatic steatosis determined by noncontrast abdominal computed 
tomography (CT) between HIV+ and uninfected persons within a subcohort of the Veterans 
Aging Cohort Study (VACS) and to evaluate risk factors for greater severity of steatosis wit hin 
both groups. The study is well conducted and methodology and statistical analysis are correct 
however there are some points that reduce the strength of the results that have to be more deeply 
commented.  
The first point regards the nature itself of the  study group that included almost only male 
subjects, this limiting possibility of extending the conclusions to the whole population of HIV 
infected subjects.  
The second point is about the choice of the methodology to study liver fibrosis. In fact, the 
steatosis evaluation with CT could be acceptable having a good sensitivity and specificity, even 
if it is not the gold standard i.e. liver histology ,nor the best accurate imaging technique that is 
MRI proton -density fat fraction [Br J Radiol 2018 91(1089)]. As regard the non invasive 
methods to evaluate liver fibrosis, a recent meta -analysis about the comparison of laboratory 
tests, US, MR and elastography to evaluate fibrosis found that FIB -4 at the threshold of 3.25 
have a good specificity but a very low se nsitivity (Hepatology 2017) and that the best non 
invasive tool should be transient elastography.  
Finally one word should be spent about anti -retroviral therapy. In fact, although new anti -
retroviral drugs are less toxic and associated with fewer metabolic  complications, metabolic 
abnormalities persist in HIV patients and this aspect should be evaluated in the study and pointed 
out in the discussion.  
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Unable to assess  
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects requ ire further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain  or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the fut ure? 
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of  the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I declare that I have no competing i nterests' below  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is acce pted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY license  (http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
 
 
 
 
assistant