Title: Capacity Assessment and Spatial Analysis of Cervical Cancer Services in The Gambia
Version: 1 Date: 04 Aug 2023
Reviewer's report:
This is an interesting paper reporting the results on cervical cancer facility and service readiness
assessment coupled with GIS based information to link population access to care.  The following
comments/suggestions comes from someone who does not know the Gambia as a country, its
twin burden of HIV and Cervical Cancer and the health infrastructure to take on these public
health problems; and an intent to have a better understanding of the context could  expand
insights to the challenges and highlight key recommendations for the Gambia.
Given the goal of the study is to assess the national capacity for comprehensive cervical cancer
services vis and vis the 2016-2020 strategic plan bench mark, it would be useful to succinctly
provide a bit more context on the following either in the background or overview or perhaps
in the discussion.
a) How the cervical cancer services are organized and delivered across the different levels of
health care system in the Gambia in both the public and private sectors.  This is particularly
relevant in comprehending what services are expected to be available at a level of care and what
the assessment found.  This would also clarify comparisons between hospitals and the category
of medical centers/clinics, as well as understand what cervical cancer services are offered by
the public sector vs private sector.
b)  The HPV Immunization program in The Gambia. It would be relevant to describe what the
approach is currently in place – is this a school based program or a facility based or a combination
of both. The immunization approach would probably affect which HF would be more involved
in the vaccination effort.
c) The national strategy incorporates the integration of HIV and Cervical Cancer prevention
services given that WLHIV may need to be screened earlier and more frequently.
d) One of the key aspects of the strategic plan is treatment and the preference for cryotherapy
and its provision in a single visit approach;and a reference to this would be relevant addition.
e) The use of GIS) technology to depict the location and distribution of services is quite
impressive but would suggest to the authors to describe a bit more how the Gambia is politically
organized into regions, the population and their relative urbanization vs rural, economic set up.
This would take out the guessing game that the WR 1 and 2 are better off vs the other 5 regions,
for example.
Given the complexity of the tools and the services that were being assessed/surveyed, it would
be relevant to describe a bit of the background of the RA who administered the tools and what
were they trained on and how were they supervised during the data collection?
In the Results section under Health Facilities – The authors can further streamline the description
of the results particularly clarifying the total number of HF in the table (78) with the preceding
descriptive text where there were 107 HF surveyed, 87 responded and only 78 offered some
form of cervical cancer services?
In the Result section and under invasive cancer, usually simple and radical hysterectomies are
performed at hospitals but there are only 3 hospitals listed in table 1 for WR1-unless some of
the medical centers/clinics are also hospitals? Perhaps clarify further?
In page 8:
on training:
• A finding that among those trained in VIA, a significant number are not practicing because
service is not available. Flagging this result for further consideration in the discussion section
particularly because maintaining VIA competency and proficiency relies heavily on clinical
practice, these providers may actually need refresher courses to reacquire and validate their VIA
skills.
• Please clarify if the training for HPV vaccine administration was inclusive of knowledge and
skills on advocacy and awareness raising given where the program is at now-the need to reach
the goal of 90 % coverage of girls up to 15 y of age.
Table 3 – the 1st 2 column can be confusing. For example, there are 10 HF offering VIA and
Cryo. What does the number 21 actually mean in the last row described as  “Potential access IF
VIA & Cryotherapy was offered at all Major Health Centers and Hospitals “ ? 10 + 11 more or
21 additional facilities? Another example, in table 1 there are 78 facilities involved in cervical
cancer but in table 3 only 21 facilities offer any screening test – would this mean that of the 78
HF with cervical cancer services only 21 offer any screening at all?
In Page 9,
Figures
Not sure if typos or just missing contextual explanation but suggest the authors check our Figure
3 – please compare and check out the “keys” in figures 2 and 3. In figure 2 the black dots are
tagged as VIA and in Figure 3 there are now VIA and Cryotherapy? And for the stars – in figure
2 this is tagged as offering both via and cryo but in figure 3 – this is not offering via and cryo.
Discussion – as noted above and perhaps also relevant here to quantify as well as qualitatively
describe the burden of cervical cancer in the Gambia to lend context to the strategic framework.
HPV vaccination goal discussion – please review and modify vis a vis the WHO statement:
“WHO targets that 90 % of girls by age 15 (not 15 yrs and older  to have been vaccinated with
HPV... and on HPV vaccine status and next steps –  may want to consider the current WHO
recommendations of 1or 2 dose HPV vaccination for girls under 14. Thus, the effort in the
Gambia perhaps would to have an all out drive to reach the remaining 19 % of under 14 y.o to
receive at least 1 dose?
In Page 10,
The discussion on HPV Test:
• I wonder about the HPV testing at these 13 HF-are they near point of care type eg. Genexpert
HPV, careHPV  or central such as Cobas or the generic molecular diagnostic assays...can they
be potential exemplars for how the Gambia can explore transitioning to high precision screening
with HPV DNA tests?
• A side comment on perhaps the continuing utility of training providers to do VIA even while
effort at transitioning. The Gambia can repurpose the VIA as either a triaging tool or as a means
for ablative treatment eligibility  as in VAT (visual assessment for treatment eligibility)  when
utilizing primary HPV for screen and treat or screen, triage and treat - given that cytology and/
or colposcopy resources are also limited and neeed more time and resources to build up.
In the discussion on screening availability – the following points are flagged for the authors’
consideration:
• Option for self collection is one aspect for improving screening uptake. The other consideration
is the effort at social and behaviour change communications to raise awareness and educate
communities on cervical cancer and HPV and its prevention and control. I wonder if the survey
also included what facilities in the public sector overall is doing to reach out and bring in girls
and women for cervical cancer prevention?
• On the 13 facilities doing HPV but not self collected. Is the issue a technical one  that the HPV
test offered at 13 HFs cited above are not validated to use self collected samples or they are not
equipped completely to collect samples and process?
• Access to treatment from ablation to excision is limited overall and suggest that this point
is also discussed. Of relevance is that the Gambia relies on cryotherapy. I wonder if data was
collected on both access as well as availability of service when accessed. While effective when
there is supply of gas, the challenge in most LMIC is resupply both from cost and transport.
The current WHO guidelines have expanded treatment options and perhaps preference, for now,
on using thermal ablation because of portability, battery powered instead of gas and equally
effective and easy to use?
In the concluding paragraph’s summary of recommendations particularly on HPV vaccination.
I wonder if the need is more than just vaccine distribution but policy changes inclusive of
recent guidelines development of 1-2 dosing schedule and as well as perhaps strengthening the
public awareness and education. There was a paper on the Gambia’s HPV vaccination where
despite the high acceptance, the recipients and their parents still had a lot of misconceptions-
Wilson RJ, Leigh L, Bah H, Larson HJ, Clarke E. HPV vaccination acceptance and perceptions
related to fertility and population control in the Gambia: An anthropological analysis. Vaccine.
2023 Jun 1;41(24):3647-3654. doi: 10.1016/j.vaccine.2023.04.072. Epub 2023 May 10. PMID:
37173265.