Reviewer ’s report  
 
Title: Evaluation of human -papillomavirus testing and visual inspection for cervical cancer 
screening in Rwanda  
 
Version: 1 Date: 25 Dec 2017  
 
Reviewer: David Walmer  
 
Reviewer's report:  
 
The question that is being addressed by this study is important because it evaluates t he actual 
performance of WHO recommended screening guidelines.  
Comments  
- On line 9 of the Abstract it says, "At visit 2, VIA was again used to triage HPV -positive 
women for treatment and to obtain biopsies from all women either from visible lesions or at  
12 o'clock of the squamocolumnar junction."  
  Comment: If there were any women who were + by VIA and not by the other two screening 
methods then the authors should not describe this group as being HPV -positive.  This group had 
at least one positive primar y test, which included a positive VIA.  
 
- The study N is very low given that this was data taken from a national screening program, 
which the authors acknowledge as a weakness.  This limitation is significant enough that I 
question the merits of it going to  publication at this point.  The only thing that allows me to 
consider publishing this study is the importance of the question being addressed and the fact 
that the Rwandan government stopped supporting careHPV as a primary screening strategy 
preventing th e authors from increasing the study size.  
 
- The validity of generating "corrected indices" is beyond my scope of expertise and either 
needs to be addressed by the other reviewers or sent to a statistician for review.  
 
- I believe that a major flaw of the 2 visit program being evaluated was the decision by the 
program organizers to allow VIA findings to trump HPV test results at the second screening. 
The authors note that the 2 visit approach of careHPV + VIA triage ended up performing 
similarly to VIA screen -and-treat.  This should have been expected because the advantage of 
performing the initial HPV testing was entirely negated by ignoring their results.  I believe 
that the authors should either acknowledge this program design flaw or explain why it isn't 
true. 
 
- In the final paragraph of the manuscript it says, "In the experience in Rwanda, the losses 
associated with requirement of a second visit and/or with VIA triage led to a 2 -visit approach 
of careHPV + VIA triage treating a similar number of hHSIL (6 o ut of 17) as VIA screen -
and-treat. Indeed, independently of the current analysis, the Rwanda MoH has decided, for 
pragmatic reasons, to resort to a recommendation of VIA screen -and-treat for cervical cancer 
screening for the time being."  
Comment:  This par agraph seems to ignore the design flaw of the program.  If the women who 
were HPV+ at the first visit had been evaluated visually merely for 'cryotherapy or 
thermoablation' eligibility then all of the HPV+ women would have been treated.  The authors 
should  address the program flaw in the final paragraph and point out how many hHSIL cases 
would have been treated if the visual inspection had not been diagnostic but rather performed as 
an eligibility evaluation.  My apologies if I am misunderstanding if the 2n d screen wasn't a 
formal VIA evaluation that could trump the HPV test results.  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please speci fy which controls are required in your comments to the authors.  
 
Yes 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or wou ld you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written Engl ish 
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
  
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursemen ts, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an org anization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer no to all o f the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name w ill be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along with the authors'  
responses. I agree for my report to be made available u nder an Open Access Creative Commons  
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments  
which I do not wish to be included in my named report can be included as confidential comments  
to the editors, which will not b e published.  
 
I agree to the open peer review policy of the journal