Reviewer ’s report  
Title: Low Uptake Of Cervical Cancer Screening Amo ng HIV Positive Women In Gondar 
University Referral Hospital, Northwest Ethiopia: Cross -sectional study  
 
Version: 1 Date: 29 Aug 2017  
 
Revi ewer: Karen Smith -Mccune  
 
Reviewer's report:  
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1. The groups with high uptake of cervical cancer screening had characteristics that indicated 
more frequent interactions with the health care system (parity, >10 years since diagnosis, l wo 
CD4 count). HAART status was not included as a variable, but might also be a surrogate for 
those with more exposure to the health care system and hence more likely to have been screened. 
Can the authors add this variable to their analysis?  
Thank you dea r reviewer for your important concern. As the authors described in the 
methodology particularly in data processing and analysis section, bivariate analysis was first 
done for each independent variables including ART status of the study participants and wom en's 
awareness. Then,  for the multivariable analysis,  we only considered factors which had P -value 
less than 0.2 in the bivariate analysis. Therefore, These two variables, ART status and women's 
awareness, were not included in the multivariable analysis because their P -value in the 
multivariable analysis were above the cut -off point used (P > 0.2).   
 
my response:  
Table 2 shows some of the variables that were looked at in the bivariate analysis, but not all 
apparently. For example, monthly income and mari tal status were not significantly associated 
with screening (p>0.2) but are shown in Table 2, which led me to believe that only the variables 
shown in Table 2 were studied. Better to list results for all the bivariate analyses that were 
performed.  
 
2. Ano ther association that might be interesting but was not studied regards the results in Figure 
1, re women's awareness of cervical cancer and of cervical cancer screening. In the discussion 
the authors propose that the variables associated with screening, su ch as level of education etc, 
might reflect women's better awareness about cervical cancer screening. But they can study this 
association directly in their dataset - ie were educated women/parous women/>10 years HIV+/or 
low CD4 women more likely to know abo ut cervical cancer and/or be aware of screening? (this 
is different than the analysis looking at predictors of who got screening). This would help tease 
apart the role of the women themselves in getting screened versus providers selectively directing 
some women to screening.  
Thank you. As the authors tried to respond for question #1, we tried to see the association 
between women's awareness, about cervical cancer and its screening, and uptake of cervical 
cancer screening in the bivariate analysis. But, the  output of this analysis showed that its P -value 
was greater than 0.2. Thus, the authors did not fit this variable in the multivariable analysis. That 
is why the variable is not displayed in the multivariable analysis table (Table 2).  
 
My response:  
As abo ve, I think this point is important enough that all of the negative the results for the 
bivariate analysis should be shown in Table 2 (as some already are) or listed in the text. Their 
absence in Table 2 suggests that they weren't done.  
 
6. Page 5 line 25 - what screening was available before 2013. Results on page 7 line 32 infer that 
women could get screened before the introduction of VIA/cryo in 2013.  
Before the emergence of VIA for cervical Ca screening, pap smear was available. However, it 
was not routi nely used for all HIV positive women. Instead, the physician ordered the pap smear 
only for women who were suspected for/have symptoms of cervical Ca irrespective of their HIV 
sero-status.  
my response: This information should be added to the paper, since apparently some women were 
screened before 2013 (Results section states that 86.9% were screened within the past 3 years, 
which I assume was 2013 -2016? Meaning some were screened before 2013 ?)  
 
other comments have been suitably addressed.  
New comment: The only figure in the paper is labelled Figure 2, but I assume it should be 1   
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comm ents 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 no t, please explain in your comments to the authors.  
No 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what asp ects require 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:  
Needs some language corrections before being published  
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