Title: Providers and Women’s Perspectives on Opportunities, Challenges and
Recommendations to Improve Cervical Cancer Screening in Women Living with HIV at
Mbarara Regional Referral Hospital: A Qualitative Study
Version: 1 Date: 16 Jan 2024
Reviewer's report:
In this qualitative study, the authors present important data from multiple stakeholder
perspectives on current cervical cancer screening systems and challenges for women living with
HIV (WLHIV)  in this setting in Uganda. Though the paper meets major editorial criteria in
terms of qualitative research conventions, major revisions are recommended to strengthen the
clarity and quality of the paper.
Abstract: “Cervical cancer screening uptake remains low despite being the primary prevention
method for adult women living with HIV(WLHIV).” I would avoid using the term “primary
prevention” as this refers to vaccination and lifestyle measures, ; use perhaps “main” or most
important.
Introduction:
The introduction should be further developed to highlight that the goal of cervical cancer
screening is to detect precancerous lesions that can be treated and prevent the development
of invasive cancer. For WLHIV there is not a greater incidence and persistence of high-risk
HPV infection but more rapid progression to precancer and invasive cancer.  Screen-and-treat
approaches are mentioned in the discussion without ever being mentioned in the introduction
and should be included for context. There are also some inconsistencies in the listing of available
precancer treatments; i.e., they list only thermocoagulation in the introduction but participants
discuss cryotherapy and LEEP also. More clarity is needed about the screening and diagnostic/
treatment pathway in this setting so that authors can better understand the local context and
system.
Similarly, the results/discussion refer to lower health facilities but this is not well understood
without some explanation preceding it. The introduction should have some brief explanation of
where within the health system cervical cancer screening is available and what the pathway is
for referral is. The main focus of the study is on two specialty clinics but because other health
facilities come up in the results/discussion there needs to be some context.
Methods:
In the Study setting section, need to again more clearly outline the screening and diagnostic/
treatment pathway. Authors need to distinguish between treatment of precancerous lesions with
ablative therapy (thermocoagulation, cryotherapy) vs. treatment of invasive cancer.
“At the CCP clinic, screening for cervical cancer involves educational counselling, screening
tests with HPV DNA testing or visual inspection with acetic acid, followed by triage of positive
precancer lesions for colposcopy and biopsy to confirm cancer.” More accurately, Any women
with abnormal screening tests are referred for colposcopy and biopsy to confirm precancerous
or cancerous lesions. Unless this clinic uses a VIA screen and treat method or VIA triage for
HPV positive lesions in which case that should be explained.  Again there is a need to emphasize
the detection of treatable precancer.
Sample size: 6 key informant interviews is a small sample. It is unclear whether this represents
all of the healthcare providers at the two clinics and if so that should be clarified. Regardless,
some justification of this sample size, in keeping with qualitative methods, should be included.
In fact how investigators arrived at the sample size for both KIIs and FGDs should be included.
Data collection procedures: “We held all FGDs in a private waiting room in the CCP clinic
after all women living with HIV due for cervical cancer screening had completed the screening
exercise.”   Does screening “exercise” here refer to having undergone cervical cancer screening
or a screening questionnaire for the study?
Data analysis:  This section requires some revision to better explain how many research team
members participated in analysis, how interrater reliability in coding/analysis was assessed. In
addition authors refer to “theory-informed topical domains” but there is no explanation of or
reference for a theoretical framework in the introduction or methods sections.
Results: The presentation of findings as “opportunities, challenges, and recommendations” is a
bit confusing. It requires some explanation in the introduction or methods section (vs its brief
mention in the discussion of this choice vs presenting barriers and facilitators). This is perhaps
common in the business and policy realm, but requires some orientation for health services
researchers/qualitative researchers. When reading the “opportunities” section, for instance, it
is hard to distinguish what reflects existing realities for cervical cancer screening vs what is
aspirational and as such makes it difficult to distinguish that from recommendations.
Within each section, it would be helpful if the theme labels were more revealing, e.g., “peer-
led information sharing encourages cervical cancer screening” or “There are adequate skilled
healthcare workers to perform cervical cancer screening.” An example of a more directed theme
title is under challenges “Fragmentation of services leads to missed opportunities for screening.”
Wording of “Current screening options elude the privacy of patients” is awkward and should be
reworded. Within that section, colposcopy is incorrectly included as a screening test.
Throughout the results section, authors should be precise about whose perspective is being
represented in a summary paragraph (ie. Healthcare providers and or women/clients instead of
just saying participants)
Discussion: The discussion needs to be strengthened to highlight the main findings and compare
them with existing literature. There is overemphasis on HPV self collection, which is of course
an important solution, ignoring other very important findings such as the comments from women
about long queues in both the ISS and CCP clinics and not wanting to compromise their HIV
care and medication collection by leaving the queue, or the provider comment about having tried
in the past to make CC screening compulsory for provision of HIV meds. These are important
system barriers to be discussed for WLHIV. The discussion briefly mentions integration of
services but this should be discussed in the context of these key findings and include reference
to integration strategies in other settings.
As mentioned earlier, the lower health facilities reference here is out of context without some
health system overview in the introduction and/or methods.
Language throughout: authors should review carefully for consistency in language.
e.g., should use WLHIV abbreviation after they first introduce it unless they prefer to spell out
the term throughout the paper.
Providers, healthcare providers, and clinical care providers are used interchangeably and it
would be better for one term to be used consistently unless these signify different cadres of
healthcare workers, in which case that should be explained.