Title: Cervical cancer screening utilization and associated factors among women living with
HIV  in Ethiopia, 2024: systematic review and meta-analysis
Version: 1 Date: 05 Aug 2024
Reviewer:  Sahabi Kabir Sulaiman
Reviewer's report:
1. In the Methods section of the abstract, rather than stating search terms used, software used,
it is more important to state what analyses were done.
2. The data used in the first two sentences of the Introduction is outdated. Consider updating
them. Please, see:
https://www.who.int/news-room/fact-sheets/detail/cervical-cancer
3. What is the estimated global and regional burden of cervical cancer among women living with
HIV (your study population)? This is a huge gap in your study’s literature review. I noted that
the only paper (a below) that provide these estimates, which is one of the most important related
to the topic is not cited anywhere in your manuscript. Please go through this:
a. Stelzle, D., Tanaka, L. F., Lee, K. K., Khalil, A. I., Baussano, I., Shah, A. S., ... & Dalal, S.
(2021). Estimates of the global burden of cervical cancer associated with HIV. The lancet global
health, 9(2), e161-e169. https://doi.org/10.1016/S2214-109X(20)30459-9
b. Ibrahim Khalil, A., Mpunga, T., Wei, F., Baussano, I., De Martel, C., Bray, F., ... & Clifford,
G. M. (2022). Age#specific burden of cervical cancer associated with HIV: a global analysis
with a focus on sub#Saharan Africa. International journal of cancer, 150(5), 761-772. https://
doi.org/10.1002/ijc.33841
4.  Reference 6 (2010) is too old. Please update the entire manuscript with the most recent data.
See:
Singh, D., Vignat, J., Lorenzoni, V., Eslahi, M., Ginsburg, O., Lauby-Secretan, B., ... &
Vaccarella, S. (2023). Global estimates of incidence and mortality of cervical cancer in 2020: a
baseline analysis of the WHO Global Cervical Cancer Elimination Initiative. The lancet global
health, 11(2), e197-e206. https://doi.org/10.1016/S2214-109X(22)00501-0
5. Please provide the exact literature search methods used for each of the stated databases as
a supplementary file.
6. In their methods, the authors wrote: “First, the researchers screened articles by title and
abstract to identify those relevant to dental caries”. What has DENTAL CARIES got to do
with your work? ARE YOU SURE THIS WORK ISN’T PLAGIARISM OR AI-GENERATED
TEXT? HAVE ANYONE AMONG THE AUTHORS EVEN READ THIS MANUSCRIPT
FOLLOWING COMPILATION BEFORE SUBMISSION?  PLEASE EXPLAIN THIS TO
THE EDITOR.
7. Briefly, describe the NOS in your methods. Note that ref. 19 is not the right right reference
for NOS. Please also note the type of NOS you used because they are two types.
8. The authors also wrote: “The second outcome of interest in this meta-analysis was the factors
associated with cervical cancer screening, as reported by four or more studies”. Please, what
is the reason for considering 4 studies as the minimum number of studies for meta-analysis of
potential determinants? Any reference for this, e.g. a guideline?
9. Since the authors extracted on “adjusted data” to analyze determinants, how can they be sure
they used the most allowed confounding factor in their analysis of each determinats?
10. Despite all the included studies being cross-sectional and despite providing the JBI scores
of individual studies in Table 1, the authors stated that they used NOS initially, and later in
the Methods, they said they used the JBI. Why were 2 different quality assessments tools used
for the same types of studies mentioned in your Methods? ISN’T THIS PLAGIARIZED or AI-
GENERATED PORTION? Please, provide as a Supplementary file the table for the JBI scoring
with all it’s elements matched with each included study.
11. Under the Statistical Analysis sub-section of the Methods, they wrote: “A meta-analysis
of cervical cancer screening was performed using the random-effects (DerSimonian and Laird)
method to adjust for the determined variability[24, 25]” What variability are the authors referring
to here? And how are the referenced studies (refs 24 and 25) related to this?
12. Consider doing further subgroup analysis to explore more potential sources of heterogeneity,
e.g. region, and assessment tool used, peer-reviewed vs non-peer-reviewed 9since you said you
have included unpublished studies).
13. No description of the approach to meta-analysis of determinants is mentioned in the Analysis
sub-section. Please do this, and consider a minimum of two studies as the cut-off point for
analyzing a particular determinant.
14. Please, supply the STATA output of all potential determinants analyzed in your study.
15. Please supply the whole data extraction table. This is to enable the reviewers make a
confident judgment as to the accuracy of your statistical analysis because as they are, one cannot
vouch for them.
16. The narrative synthesis on study characteristics too shallow. Consider providing details on
other aspects, e.g. sampling technique used, and assessment tool used by the individual studies.
What is the cumulative sample size of participants from all the 12 included studies?
17. Please, supply the Egger graph in your manuscript.
18. Although Table 1 contained JBI scoring only, in the Strength and Limitations section, the
authors wrote: “Newcastle-Ottawa Scale to critically appraise the quality of the included studies,
ensuring only high-quality studies were included in the meta-analysis” And how does this even
constitute a strength to the study?
19. As part of the strengths, they also stated: “The authors used appropriate statistical methods,
such as random-effects meta-analysis, to pool the estimates and account for the heterogeneity
between studies and we also assessed publication bias using statistical tests and visual inspection
of funnel plots” . In addition, to not exploring further sources of heterogeneity, this actually a
part of your study’s limitation due to the small number of the included studies, which is also
stated in the reference you cited for your heterogeneity test.
20. Please, report all other limitations of this review.
Looking forward to reading a revised version of this manuscript