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: 30 Dec 2023
Reviewer's report:
A well-written manuscript addressing a critically important population and topic - how to
adequately reach the highest risk women, WLWH, to reach the WHO 90/70/90 elimination
targets:
Kindly consider the following suggestions:
Line 15:  Missing "women" between  words 'these' and 'experience'
Abstract background first sentence: Consider clarifying that screening is primary method
to prevent ca cervix among WLWH who have not been vaccinated against HPV, as HPV
vaccination is primary prevention. Also consider differentiating use of "primary prevention" to
refer to vaccination and secondary prevention to refer to screening for greater accuracy .
Sentence 32-33 in abstract results section: "Integrating HPV-DNA testing in HIV services was
perceived with ambivalence. " Consider clarifying this further to better represent findings related
to use of self-collection, and in view of importance of HPV self-collection in addressing  the
challenges e.g privacy addressed in the manuscript.
Define all acryonym the first time you use them, e.g, WHO in abstract conclusion is used without
full definition.
Sentence  49-50: "Women living with HIV (WLHIV) experience a greater incidence and
persistence of high-risk HPV infection and severe outcomes, including cervical cancer
comorbidities and ..." Is it true that WLWH have higher cervical cancer morbidity compared
to  HIV-negative women? Please cite sources. They do have worse outcomes related to cervical
precancer and likely cancer. Please be specific as to what comorbidities you refer to
Line 57: Use of term "Case treatment." Need  ore clarity on what this means -- do you refer to
cervical precancer treatment which is lagging in SSA?  Cancer treatment is very weak in SSA
including cervical cancer treatment, and would not be key reason for lack of decline in cervical
ca cases in SSA
Line 70: First word should be 'few' not 'fewer'
Line 71-72:  Rephrase  sentence starting with Symptom debut for better clarity. Are you missing
"factors likely" btwn cited and to promote?
Lines 71-76: Consider stating the setting of the cited studies to help interpret them in relation
to your work
Line 101: use of term "surgical treatment" as management option for cervical lesions -- be more
specific -- LEEP, CKC? Use of term 'cervical lesion' is nonspecific, and generally not used to
refer to cervical cancer, which is what would be treated with chemotherapy, which is included
in the same sentence as thermocoagulation. Need to differentiate between precancer treatment
(cervical precancer lesions) vs cancer treatment.
Line 103-104: "triage of positive precancer lesions" -- need more specificity of terms, we triage
postive VIA or HPV, not positive precancer lesions. Both postiive VIA or HPV may not be
precancer lesions, hence need for more specificity
Lines 222 - 223: Can you have a transition point to show that you are now referring to health
care providers as opposed to clients, i.e, who are the participants? At first read, one may think
you are still referring to the clients.
Line 228 - 229: "One participant reports several screening and management procedures she
could conduct regarding cervical cancer due to the training. "
- Need more clarity on type of providers (nurses only or other more advanced providers
like clinical officers, medical officers etc doing the screening?), and scope of work they
do. “Management” needs to be clear that it refers to cervical precancer treatment and
not management of cancer which is outside scope of nurses. Do nurses do LEEP/surgical
management? Need to make this clear
Line 231 - same as above, clarify what is meant by management and scope of providers
Lines 315 - 318: Sentence discusses "access to more cervical cancer screening options" but
includes theral ablation which is a treatment method for precancerous lesions, please rephras
for greater accuracy
Line 323: Skeptical is spelled with a k, not a c. Please edit.
Discussion:
Line 349 -350 on ambivalence twoards integrating screening in HIV service points:
- Make this clear - ambivalence from whom and why? In  your results one gets the sense that
women want integrated services to reduce lining up twice etc, yet this sentence seems to argue
the opposite
Line 353: missing cancer btwn cervical and screening
Lines 360 - 362 on self-collected tests and ambivalence:
- Consider discussing this more - why source of ambivalence, e.g, lack of knowledge among
health providers on the sensitivity of HPV testing and accuracy of vaginal samples compared
to cervical samples (i.e, sampling doesn’t need to be done at the cervix for high accuracy,
and multiple studies have demonstrated excellent sensitivity even among low-income women ).
Discuss recommendations on how to address this likely ignorance/misinformed opinion among
healthcare workers in such settings given the curcial importance of HPV self-collection which
can greatly impact reach and hence coverage, as well as address privacy issues  raised
Line 362 - 364 (last sentence of the paragraph:
- This sentence seems to contradict the sentence 349 - 350
Line 365: first sentence missing  "level" after lower
- consider rephrasing the sentence to  further clarify what the bottle necks experienced by lower
level facilties are, and how they hinder screen & treat (tie to the findings in results)
Line 367-369: Sencen starting with Leveraging...
- kindly define "community health structures" - what are they and how can they be used to
expand screening.
Lines 369-370: Clarify what gaps identified in the study private and non-govt partners can fill
in expanding screening
Line 373: Use of the term "optimise the HPV-DNA testing method"
- this sounds like technical optimizing of the assay/testing method (how sensitive/specific/
accurate it is). I believe you mean optimizing workflow or integration/use within HIV clinics/
among WLWH. Kindly rephrase for greater accuracy
Lines 373-375 (second sentence of this paragraph)
- Discuss more about the concerns regarding perceived low self-efficacy of  collecting HPV
samples in your study - what have other studies found in similar settings? What strategies have
been used to increase perceived self-efficacy that can be utilized here, given many studies that
show high acceptability of self-collection, and it's multiple benefits in aiding reaching the 70%
screening target?
Lines 376-377 on low uptake of self-collection among 25-65:
- My reading of this reference states that higher screenign uptake was demonstrated in women
aged 45-54 yrs comapred to 25-34, which is different from what you have. Please review and
clarify
- How is this important and relevant to your findings? Please address the possible reasons behind
this reduced uptake of self-collection in younger age groups shown in the Kenya study, how
is it relevant or similar to what you find in your study, and how it may impact an HPV-based
screening strategy based on self-collection in Uganda and in SSA?
Lniies 382-385 on screening uptake being consistently lower than awareness levels:
- In these %’s, what comes first, screening uptake % then awareness? The first should be lower
than the second per the sentence.  It is often not the case.
- Unclear what 100% for Botswana means.
- Need more analysis/description of why the disconnect btwn uptake % and awareness and tie
to findings from your study.
- How do these data on the divide btwn uptake and awareness  feed into the next sentence that
starts with "expanding screening access..."
Lines 386-387: We need more clarity on what updates are needed on country guidelines “to
WHO standards to harmonise hospital and publicly available information,” this isn’t clear and
doesn’t follow from prior sentences