Reviewer #3 (Public review):
The introduction does a very good job of discussing the issue around whether there is ongoing replication in people with HIV on antiretroviral therapy. Sporadic, non-sustained replication likely occurs in many PWH on ART related to adherence, drug-drug interactions and possibly penetration of antivirals into sanctuary areas of replication and as the authors point out proving it does not occur is likely not possible and proving it does occur is likely very dependent on the population studied and the design of the intervention. Whether the consequences of this replication in the absence of evolution toward resistance have clinical significance challenging question to address.
It is important to note that INSTI-based therapy may have a different impact on HIV replication events that results in differences in virus release for specific cell type (those responsible for "second phase" decay) by blocking integration in cells that have completed reverse transcription prior to ART initiation but have yet to be fully activated. In a PI or NNRTI-based regimen, those cells will release virus, whereas with an INSTI-based regimen, they will not.
Given the very small sample size, there is a substantial risk of imbalance between the groups in important baseline measures. Unfortunately, with the small sample size, a non-significant P value is not helpful when comparing baseline measures between groups. One suggestion would be to provide the full range as opposed to the inter-quartile range (essentially only 5 or 6 values). The authors could also report the proportion of participants with baseline HIV RNA target not detected in the two groups.
A suggestion that there is a critical imbalance between groups is that the control group has significantly lower total HIV DNA in PBMC, despite the small sample size. The control group also has numerically longer time of continuous suppression, lower unspliced RNA, and lower intact proviral DNA. These differences may have biased the ability to see changes in DNA and US RNA in the control group. Notably, there was no significant difference in the change in US RNA/DNA between groups (Figure 2C). The fact that the median relative change appears very similar in Figure 2C, yet there is a substantial difference in P values, is also a comment on the limits of the current sample size. The text should report the median change in US RNA and US RNA/DNA when describing Figures 2A-2C. This statistical comparison of changes in IPDA results between groups should be reported. The presentation of the absolute values of all the comparisons in the supplemental figures is a strength of the manuscript.
In the assessment of ART intensification on immune activation and exhaustion, the fact that none of the comparisons between randomized groups were significant should be noted and discussed.
The changes in CD4:CD8 ratio and sCD14 levels appear counterintuitive to the hypothesis and are commented on in the discussion.
Overall, the discussion highlights the significant changes in the intensified group, which are suggestive. There is limited discussion of the comparisons between group,s where the results are less convincing.
The limitations of the study should be more clearly discussed. The small sample size raises the possibility of imbalance at baseline. The supplemental figures (S3-S5) are helpful in showing the differences between groups at baseline, and the variability of measurements is more apparent. The lack of blinding is also a weakness, though the PK assessments do help (note 3TC levels rise substantially in both groups for most of the time on study (Figure S2).
The many assays and comparisons are listed as a strength. The many comparisons raise the possibility of finding significance by chance. In addition, if there is an imbalance at baseline outcomes, measuring related parameters will move in the same direction.
The limited impact on activation and inflammation should be addressed in the discussion, as they are highlighted as a potentially important consequence of intermittent, not sustained replication in the introduction.
The study is provocative and well executed, with the limitations listed above. Pharmacokinetic analyses help mitigate the lack of blinding. The major impact of this work is if it leads to a much larger randomized, controlled, blinded study of a longer duration, as the authors point out.