Review for 10.1186/s12876-022-02305-x (2022)

Title: Risk Factors of Severe Hepatotoxicity Among HIV-1 infected Individuals initiated on
Highly Active Antiretroviral Therapy in the Northwest Region of Cameroon
Version: 1 Date: 11 Dec 2021
Reviewer's report:
Unfortunately I am recommending not to accept the manuscript entitled "Risk Factors
of Severe Hepatotoxicity Among HIV-1 infected Individuals initiated on Highly Active
Antiretroviral Therapy in the Northwest Region of Cameroon" in its present version. The
manuscript is presented in very poor English and it would require a major language revision
throughout. Simultaneously it would benefit from some style corrections that would improve its
comprehensibility (I.e. some series of percentage values specified one after another with their
titles at the end difficult their understanding and would better presented with each title followed
by the corresponding value). Also, an entry for "Methods" is missing in the abstract.
Regarding the manuscript contents , there are also some significant flaws. Although the
geographical setting is well defined, a mention to demography of the region would help to put
the data into perspective. In particular whithout further explanations, it is surprising that only
100 patients were recruited for the study in a region where about 500000 are reported to be
living. In a country with an HIV prevalence between 3 and 4% and a yearly incidence of new
HIV diagnosis about 0,06% (as per 2020 data), a larger number of persons would be expected
to start HAART in the period defined. The date of the study, relative to the date of submission is
also a major drawback of the manuscript, as the  WHO HIV-treatment guidelines have changed
substantially in the 5 years ellapsed.
The difinition of toxicity categories should be referenced to the WHO classification,  not to
another article which has used it.
It is said in the last paragraph of the "Methods" section that squared-chi and unpaired t-tests
are used for comparisons, but they never appear throughout the text therefater. It is a universal
standard to define the level fo significance of the p value (most frequently <0,05).
The number of persons included in the study should be specified forefront at the beginning of
th "Results".  The age is presented as mean (range): either media (range) or mean (SEM or SD)
should be a better presentation.
Table 1 would be better completely re-made. Given that the study focuses in hepatotoxicity
and its associatted factors,  the presentation of the data divided by treatment regimens
is inappropriate. Treatment regimens should appear in the lines, whereas columns should
present totals and hepatotoxicity/not-hepatotoxicity. Figure 1 could be much improved also by
reclassifying the data with the x-axis representing time-points and y-axis percentages.
A p-value is given relative to the increment of AST, ALT and ALP values with the increments
of treatment duration. Only a p-value is given for three variables and two time-points. Also,  it
is not specified which test was used to study this association.
Table  3  presents p-values for each global variable in the univariate study, and for each subgroup
within the global variable in the multivariate study.  All p-values should be presented, global
and subgroups  in both substudies. There are important editing defects in the table that must
be corrected, including both style defects and serious discrepancies (with p-values indicating
statistically significant associations with non-significant ORs; and viceversa).
Finnally, but most important, the interpretation of ORs is mistaken in the text: an OR of 0.33
reveals a lower risk and so on. All the interpretation of the study is biased by these mistakes in
the interpretation of the direction of the ORs