Title: Cervical cancer screening program in Indonesia, is it time for HPV-DNA tests? results of
a qualitative study exploring the stakeholders’ perspectives
Version: 2 Date: 15 Dec 2023
Reviewer's report:
Congratulations to the authors for undertaking the effort.
This study is part of larger initiative undertaken in Indonesia to explore expanding the screening
program to include high precision testing using HPV DNA.  With that as a context, the study
offers a snapshot of of provider - stakeholders perspective on the state as well as feasibility of
incorporating HPV DNA testing. Overall, the study captures that particular intent but could be
made more clearer with line editing the text. Additionally, there are a couple of suggestions and
comments proposed to the authors to consider in the process of revising the manuscript. These
are organized into line number, page number and the comment/suggestion:
LINE # PAGE # COMMENT
9 2 Would women be stakeholders involved in cervical cancer screening?
17 2 Supply side stakeholders
6 3 What is the 2018 report in relation to screening and progress?
9 3 A note that screening and early detection are related but not the same…suggest revising
if the intent is to reference screening (asymptomatic) vs early detection (symptomatic) https://
is.gd/ClDotK
10  Suggest using this link for ease in accessing the information: https://is.gd/IdG3ru
27 3 Suggest using the sensitivity/specificity study of VIA, Cytology and HPV in citation
18 for comparison inclusive of VIA. Citation 17 is about cost effectiveness focused on cost
effectiveness and targets a group of women in China compared to the citation 18 that crosses
borders.
31 3 the citation is about HPV mRNA. The authors can reference back citation 14 already cited
above
37 3 Ministry?
40 3 Added to the biblio?
4 4 Per SPQR – suggest adding a bit more context on the researchers attributes particularly as
it relates to the topic – cervical cancer prevention and control
7 4 Instead of using going use performing
24 4 Describe if this is representative of Indonesia as a whole or in part? Among the participants
their level of involvement in screening and treatment as well as their baseline knowledge on
cytology, VIA and HPV DNA testing for screening. See SPQR on sampling strategy
19 5 Were there subject matter experts involved with the researchers to conceptualize, draft, test
and analyze the results from the mock activities?
20-21 5 Suggest:  using “mock” rather than “mocking”
39-40 5 Mainly from the island of Java.. It would be relevant to note if the clinical group are
actively involved in the screening activity vs in the detection and management of frank cervical
cancer
11 6 Explain further the process – are all VIA encounters, both negatives and positives vetted
through teledovia? If not what cases are usually taken up for remote consulting. How would the
process used for teledovia impact sensitivity and specificity?
17 6 As in co-testing or cytology with reflex to HPV or primary cytology or primary HPV?
19 6 And the assay performed where? I primary HPV DNA also available in public and private
sector facilities?
22 6 What is a PA expert
26 6 Please add context to “disposables”
30 6 State more clearly what is meant or rephrase for clarity “by applied screening programs
have been applied in practice?” I wonder if the authors meant “How the screening program is
implemented in Java/Indonesia?”
19 7 This is a temporary or a transient event rather than a persistent or even a recurring situation.
Curious though if the authors/respondent feels that the post covid transition back to “normal”
will be prolonged or have continuing impact in the near future?
20-25 7 There is a variance between what is in the preceding paragraph on restrictions at the
facility due to pandemic vs the statement which seems to imply unwillingness of the women
to come to the facility?
34-35 7 Is HPV already covered by the JKN?
4-8 8 Suggest providing a bit more context or information on the policy gap on screening,
treatment and how its inclusion as an NCD initiatives are impacting screening?
17 8 Reluctant of the screening for cancer or reluctant of the current procedure for screening
requiring a pelvic examination –see FGD statement below?
21 8 Suggest ... when the patient comes in for family planning services?
23 8 Spell out general practitioners (GPs) can legally perform screening?
40 8 Suggest editing to “This discussion then raised several issues.”
1-2 9 Citation particularly for the 100 %?
3 9 Meaning more expensive or as expensive as cytology or VIA?
9 9 Edit further for clarity
9 10 urban areas such as in the provinces of Java and Bali?
10 10 West Papua?
21 10 ts wide availability
21-24 10 Suggest further editing for clarity
37 10 To save or alternatively say to prevent cervical cancer in Indonesia?
46-47 10 I wonder if the authors would add women as stakeholders and thus one more limitation
is their voices on influencing approaches and modalities for participating in the screening
program?
1-3 11 Suggest editing a long sentence.
4 11 Perhaps one more limitation is a fuller picture of extent of access to HPV DNA test
in Indonesia in both private and public sectors? One of the problem with VIA financing is
reimbursement during mass screening/outside facility. With HPV DNA tests and self collection,
this issue will also be more acute given that not only is this going to be outside of a facility
but perhaps at home ? Ensuring financing across the modalities of sample collection would be
relevant to supporting improved screening coverage. Finally, suggest to the authors to explore
primary HPV testing with or without triaging with cytology or VIA vs co-testing modes cytology
+ HPV only?