Reviewer’s report
Title: KNOWLEDGE AND EXPERIENCE OF A COHORT OF HIV-POSITIVE AND 
HIVNEGATIVE GHANAIAN WOMEN AFTER UNDERGOING HUMAN PAPILLOMAVIRUS
AND CERVICAL CANCER SCREENING
Version: 0 Date: 31 Aug 2018
Reviewer: Laura Marlow
Reviewer's report:
This paper presents mixed-method data exploring knowledge/experience of HPV and cervical 
screening in HIV-positive and HIV-negative women in Ghana. The sample was opportunistic recruiting  
women who had participated in a larger hospital-based study, which involved having an HPV self-test 
six months before data collection took place for the current study. As a result the sample is likely to be 
biased in terms of their knowledge of HPV and cervical cancer, so the generalizability of these findings  
is likely limited. Nevertheless, since there is a lack of research exploring these issues in this population,  
I think the paper does create a starting point for discussion of some issues that will become increasingly  
relevant if HPV testing becomes an option in West Africa.  
Background
There needs to be some context incorporated in the background section. What screening is offered to 
women in Ghana? What are the recommended ages? How much does it cost/is it funded at all? Any 
uptake data or studies in Ghana (or if not other SSA countries) that have tried to quantify how 
screening is utilized? You say "recently adopted HPV testing" when was this adopted, how is it offered?
The sentence "loss to follow-up for positive results, ranging from 10-40% in established screening 
programmes" needs clarifying. Please give more details of these studies and focus on ones that are 
relevant to your context. Loss to follow-up in an organized screening programme is small but this does 
not mean much for screening in Ghana perhaps - What is follow-up like across SSA or in other LMIC 
without organized programmes?
Some more detail about knowledge of HPV and cervical cancer would be useful. What previous levels 
have been found across SSA. Why is it important that we ensure good knowledge?
One of the potential strengths of the paper is that it is the first to recruit women, stratifying by HIV 
status. However, the background should really go into more detail about why this might be important. 
Why might HIV positive women have different levels of HPV knowledge or see HPV testing/cervical 
screening in a different way? Or why is it important to look at differences between these groups? One 
argument is that HIV-positive women are at increased risk of developing cervical cancer and so 
screening is arguably more important in this group. Perhaps the authors could think a bit more about 
justifying the need for their research question.  
Methods
Please describe the development of the quantitative measure in more detail. State in the methods that 
the questionnaire was designed specifically for the study and items were not adapted from elsewhere 
(this is mentioned in the limitations but is also needed in the methods). Was this developed by one 
researcher? Was it pilot tested? Also, the questionnaire should be included as supplementary material.
Women were considered to have adequate knowledge if they scored >9 out of 19, but it is not clear if 
women had to get the 9 'expected' items correct or if this could be any 9 items - please clarify. 
Qualitative methods: where/when were the groups held? Immediately after questionnaire or did they 
have to return? Were women paid to take part? The authors say that the "Participants were ot aware of 
other members HPV or cytology results" - did they know that they were all HIV negative/positive? 
Who carried out the analysis? Use the authors initials to clarify. It is important to be transparent about 
whether the analysis was carried out by one researcher or whether multiple researchers contributed to 
the process.
Results
When talking about experience of screening it is not really clear if women are talking about their past 
experiences of cervical screening before taking part in the "parent" study or if they are referring to 
HPV-self testing (this is also the case in the discussion). The title to the paper suggests both were 
explored. Please clarify and edit the title if necessary.
Discussion
Line 332 "no significant difference in knowledge score between groups" - this is not surprising given 
how women were recruited. The authors should make it clear that this might not be the case if a 
representative sample of HIV positive and negative women were recruited. 
The conclusion is a bit strong given the limitations of the sampling and the small sample size for the 
qualitative study. I suggest the authors edit this to be a bit more suggestive of what might be helpful to 
look at in future studies.
Figure 1 - I think it would be more useful to see the % per group who reported each symptom, rather 
than the proportion of total responses to multiple response item.
Minor points:
Line 74, add "screening and", i.e. "Understanding the screening process and the benefits of early 
treatment are fundamental to women engaging in screening and follow-up care"
Line 129 - "Transcripts were translated into English." 
Line 151 - "to highlight similarities and differences" I would remove this, it is not really appropriate.
Line 152 - "age (p=0.02)" this is p=.59 in the table - could you clarify.
Throughout the paper the authors present two percentages in brackets, which I assume relate to HPV 
positive and negative women. This should be explained somewhere.
Lines 184-186 - I'm not sure this should be in the main text
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
No
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.
No
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 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:
Acceptable
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