References
steatosis, infections, Kayla RS, chronic hepatitis C infection, HIV/HCV coinfection, infection, depression, tumors, adverse drug reactions, renal dysfunction
VIRUS, VASCULAR COMPLICATIONS, INFLAMMATION, DISEASE, DIABETES MELLITUS, INFECTIONS, INFECTION, TUMORS, ADVERSE DRUG REACTIONS, STEATOSIS

Thank you for your comments, Major:
The sample size for randomized controlled trial was calculated according to the primary aim: to evaluate the effect of atorvastatin on carotid intima-media thickness in virally-suppressed HIV-infected patients with CMV seropositivity. The assumptions done were meant for the effect size (0.1) with a standard deviation of 0.12. We decided to use 90% for power and 5% for significant level for the sample size, resulting in 32 participants per arm. Considering an additional 20% drop in each arm, a total of 40 participants in each arm was needed.We considered HIV-infected participants the target population due to their sustained inflammation. We included additional information regarding this population in the second paragraph of the introduction.Protocol sections:
Participants, interventions, and outcomes
Thank you for the suggestion. We have changed it into “Participants and Interventions”.Study setting and sample size
Yes, we used a formula in order to determine the SD value in the sample size measurement. The formula is as follow:
Eligibility and enrollment
Stable ART is defined by “those who were receiving ART for at least 1 year with no adverse drug reactions requiring regular monitoring, no current illnesses or pregnancy, a good understanding of lifelong adherence, and evidence of treatment success”.
The limit period for VL result date is 1 year for the screening process.The cholesterol level was checked for every participant before statin therapy was given. Other examinations were done not as part of the study protocol, but were taken from medical record or history taking.Each exclusion condition was evaluated from the medical record. Diabetes mellitus, severe depression, and other conditions were defined by the medical record or history taking.Interventions and participant timeline
Thank you for the comment. We have moved it to the “Eligibility and enrollment” sub.Study outcomes
We chose sCD14, VCAM, ICAM, hsCRP, and β2M as the residual immune activation parameters for these reasons below:
sCD14 is expressed on macrophages as receptor for lipopolysaccharides on bacterial surfaces and has been reported to be higher in patients with residual HIV viral load than undetectable. Statin administration has the potency to reduce sCD14.
VCAM is an endothelial activation found higher in viral-suppressed patients than in control. Increased expression of VCAM is associated with inflammation-related vascular complications.
ICAM is expressed on endothelial cells and leukocytes at low levels but is stimulable to greater density by pro-inflammatory cytokines.
hsCRP is a pentametric protein produced by the liver in response to IL-6 secretion and is a biomarker for early inflammation. Statin is thought to reduce CRP by regulating CRP formation directly in hepatocytes.
β2M is a lymphocyte activation marker that increases in patients with tumors, renal dysfunction, immunoreactive conditions, or infections, including HIV.
We have modified the sentences so they are not redundant. Thank you for the input.Data collection and management
The baseline of the study is W0.Thank you for the input. We have changed the unit with weeks.Figure 1
Thank you for the suggestion. We have added more bullets to the box.We have added footnotes to the diagram.Table 1
We have added the details.We have changed the terms accordingly, as suggested.Waldrop G, Doherty M, Vitoria M, Ford N. Stable patients and patients with advanced disease: consensus definitions to support sustained scale up of antiretroviral therapy. Trop Med Int Health. 2016 Sep;21(9):1124-30. doi: 10.1111/tmi.12746. Epub 2016 Jul 22. PMID: 27371814.Falasca F, Di Carlo D, De Vito C, Bon I, d’Ettorre G, Fantauzzi A, et al. Evaluation of HIV-DNA and inflammatory markers in HIV-infected individuals with different viral load patterns. BMC Infect Dis. 2017;17: 581.Chastain DB, Kayla RS, Daniel MR. Evidence-based review of statin use in patients with HIV on antiretroviral therapy. J Clin Transl Endocrinol. 2017; 8: 6-14.Eckard AR, Yin J, Sara MD, et al. Effect of 24 weeks of statin therapy on systemic and vascular inflammation in HIV-infected subjects receiving antiretroviral therapy. J Infect Dis. 2014; 209(8): 1156-1164.El-Gohary AM, Fawaz NA, Hassoba HM, Serwah A, Ali M. Soluble ICAM-1 in patients with chronic hepatitis C infection: a prognostic marker of disease activity. Egypt J Immunol. 2004;11: 109–119.Videm V, M Albrigsten. Soluble ICAM-1 and VCAM-1 as markers og endothelial activation. Scandinavian Journal of Immunology. 2008; 67(5).Montecucco F, Burger F, Pelli G, et al. Statins inhibit c-reactive protein-induced chemokine secretion, ICAM-1 upregulation and chemotaxis in adherent human monocytes. Rheumatology (Oxford). 2009; 48(3): 233-42.Grady BPX, Nanlohy NM, van Baarle D. HCV monoinfection and HIV/HCV coinfection enhance T-cell immune senescence in injecting drug users early during infection. Immunity & Ageing. 2016 Dec 31;13(1):10.Rao M, Sayal SK, Uppal SS, Gupta RM, Ohri VC, Banerjee S. BETA-2-MICROGLOBULIN LEVELS IN HUMAN-IMMUNODEFICIENCY VIRUS INFECTED SUBJECTS. Med J Armed Forces India. 1997 Oct;53(4):251-254. doi: 10.1016/S0377-1237(17)30746-3. Epub 2017 Jun 26. PMID: 28769505; PMCID: PMC5531080. Evy
This manuscript is a research project that aims to analyze the effect of atorvastatin vs. placebo on carotid IMT variation over 48 weeks of treatment. The hypothesis is interesting, and the methods (double-blind, placebo-controlled) are correct. There are previous publications on this field that addresses the research hypothesis (PMID: 27203715
 On the other hand, the hypothesis that atorvastatin will reduce the degree of steatosis after one year does not have a solid background. It has not shown definitive efficacy in the general population without being associated with vitamin E (PMID: 20842109
Is the study design appropriate for the research question?PartlyIs the rationale for, and objectives of, the study clearly described?YesAre sufficient details of the methods provided to allow replication by others?YesAre the datasets clearly presented in a useable and accessible format?PartlyReviewer Expertise:HIVI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.