Title: Uptake and correlates of cervical cancer screening among women attending a community-
based multi-disease health campaign in Kenya
Version: 3 Date: 30 Sep 2021
Reviewer's report:
Cervical cancer remains a very real threat to women’s health, particularly in regions of Africa. To
meet the WHO call to eliminate cervical cancer by 2030, innovative and sustainable approaches
for screening need to be implemented in regions where the cervical cancer burden is highest. The
work presented in this manuscript is important and may answer questions regarding integrated
approaches to cervical cancer screening in regions that do not have routine screening. I admire
the authors exploration of this topic. The authors sought to evaluate uptake and acceptability of
an integrated model of care for HPV cervix screening in a multidisease campaign in a region of
Africa. I believe the methods of the study have some merit and can answer important questions.
Integrating cervical cancer screening into models of care that involve HIV services would most
definitely be beneficial and has the potential to save lives. Those with HIV are at higher risk of
cervical cancer. However, the association between HIV and cervical cancer is not as highlighted
in this paper, as one expects after reading the introduction.  I feel this paper requires major
revisions to be considered for publication. I offer some suggestions the authors may choose to
consider.
Abstract:
Results section-
Lines 48-51
Authors should indicate this was bivariate analysis. P-values in this sentence are all presented
differently, p<0.01, p=0.001 and p<0.05, should be presented consistently. In addition,
presenting the proportions vs. just the p-values alone would be more meaningful
Lines 51-58: Multivariable analysis presented in a confusing manner and should be presented
more consistently. In the last sentence should present ORs/effect sizes vs. just p-values, as this
is how was presented in previous sentence.
Line 62: Authors mention delays in procuring HPV kits. To my knowledge, this isn’t mentioned
elsewhere in the paper. It is standard practice that conclusions in the abstract should be reflected
in the body of the paper.
Introduction:
Line 104-105. This sentence sounds somewhat awkward and suggest finding a better way to say
that HIV and cervical cancer screening need to reach a broader population to make an impact.
Sentence starting on line 105 re: sizable donor investment. This statement should have a citation.
Same with same sentence re: cervical cancer screening. Citation required.
Section re: HPV testing starting at line 110. Some readers may not have the background
regarding the role of HPV in cervical cancer and the use of HPV testing in cervical cancer
screening. Authors may want to consider referencing some of the many papers that have explored
HPV self-collection in LMIC.
Line 126.  The authors are describing one of their objectives here, which should be in the same
section of primary objectives. The authors are indicating here things they seek to evaluate, but
don’t link back to this in the discussion section in a clear manner. In addition, the way this
sentence is stated, it sounds as though it’s a hypothesis of the authors (that there are drawbacks
to offering cervical cancer screening in an HIV or multidisease campaign). Is this the authors
hypothesis?
Methods:
General comment: Authors refer frequently to “self-administered HPV testing”. A more
accepted term is “self-collection”. Women aren’t actually performing HPV testing to
themselves. They are self-collecting swabs for cervical cancer screening, that will receive then
HPV testing.
Procedures:
Line 151. Authors state “As previously described…”. It’s unclear where this is previously
described in this particular manuscript.
Where the authors are describing services offered (155-157), is cervical cancer screening
routinely offered at the CHCs, or was it offered as a result of this study? Please clarify.
Section starting Line 159. Provide more detail regarding the education provided. Did education
involve information regarding the risk of HPV in HIV positive people, the purpose of cervical
cancer screening, who should get screened, what increases a persons risk of having HPV
(increased number of sexual partners, smoking). The intro of this paper emphasizes linking HIV
and HPV services. Did the authors educate people about the strong association between HIV
and cervical cancer? More detail about education provided would be useful.
169. Describe what open data kit is.
Line 182/183. Results of a follow-up strategy from another study are referred to. This is the first
mention that this project is related to another study.
Data analysis: The study populations (1, 1a, 1b, and 2) as described are hard to follow throughout
the paper. How are 1 and 1a different? Does 1b come only from 1a, or 1? Re: study population 2.
As described, it appears as though study population 2 could include people in study population
1, 1a, 1b, in addition to people not include in study population 1?? I encourage the authors to
ensure the labelling of their populations is clear to follow for the reader throughout the paper.
Line 205: What clinical variables are referred to?
Line 215: Was consent required only prior to self-collection and not for any of the surveys?
Results:
Line 227: To confirm, are these rates self-reported or as a result of screening at the CHC?
Line 231: Lines 192-93, study pop’n 1B is referred to as those who did complete cervical
cancer screening, but here, authors are referring to this group as those who completed or did
not complete? Please clarify.
238: Are the authors stating there was not a statistically significant difference?
Lines 240-241: How did the authors conclude to adjust for these variables?
Line 255: How did authors verify that women understood the information presented? Was this
a yes or no question, or did they verify if people understood the information by assessing
their specific responses to questions about cervical cancer screening etc (ex: Did they say they
understood the information presented, but answered true or false questions incorrectly?)
Line 272-273: An age difference of almost 3 years is not statistically or clinically significant
General questions: Authors did not appear to look at HPV prevalence by age. It’s well established
there is a higher prevalence of HPV in people under 35. Suggest the authors go back and look
at some of their findings stratified by age.
Discussion:
Line 301: Authors state the goal of this study was to assess feasibility and impact of HPV
based screening among women during a multidisease compaign but looking at factors related
to participation in screeners and non screeners. This is not consistent with what is stated in the
introduction section. The intro states authors are describing acceptability and uptake.
Line 303. Authors state that participation in screening was lower than anticipated, due to a higher
than anticipated rate of screening in the communities. In the results section, authors state 47%
of people indicated they had ever been screened (less than half). Are the authors stating 47%
is higher than expected? Did authors capture when a persons last screen was? In the education
module, was there a section on frequency of screening (do people in the communities think
screening is only required once?).
Lines 328-333. Authors indicate people who did not use a condom in the past 3 months
were more likely to get screened, and then conclude that this is consistent with literature
that described perceptions of the seriousness of cx ca predicted behaviours meant to prevent
cervical cancer. HPV is transmitted skin to skin contact. Condoms may decrease, but not
eliminate the transmission risk of HPV. As requested previously, more details regarding the
education provided in the module would be helpful. Lifetime number of sexual partners,
and smoking are considered greater risk factors for persistent HPV infections than lack of
condom use (particularly in the last 3 months). I recommend the authors re-examine their
conclusions re: condom use. Although bivariate analysis may have shown a relationship, a
broader understanding of HPV acquisition and the natural history of HPV would help the authors
draw more appropriate conclusions around their analyses.
Lines 340-341. Authors conclude (without justification) that older women are more likely to get
screened than younger women due to the fact they have had more sexual encounters. This is a
bold assumption to make without data to back this up from their analysis. It does not appear as
though the authors looked at number of lifetime sexual partners at all, or by age. Authors may
find it helpful to look at some of the findings stratified by age.
Line 370: Are the authors trying to indicate that it’s important that HIV and cervical cancer
screening services be linked? This is not clear.
Section starting at line 367. In the intro of this paper, an emphasis was placed on linking HIV and
cervical cancer screening services. This is the only section that appears to dive into this further.
However,  the HIV association with HPV positivity is buried with other factors associated to
HPV positivity. It is well known that women with HIV have a higher chance of having HPV
and of getting cervical cancer. This paper begins with a strong focus on linking HIV services
with cervical cancer screening; however, this linkage is lost in other elements in the results
and discussion and not linked back as well the the intro as it could be. The last sentence of
this section concludes that their findings highlight the need for a health campaign model that
integrates cervical cancer screening into rapid scale up of HIV testing----I believe this is very
important (not just HIV testing, but HIV care); however, but it’s unclear to the reader how
they’ve concluded this from their findings.