Title: Utilizing First Void Urine for High-Risk HPV Testing for Cervical Cancer Screening in
HIV-Positive Women in Katete, Zambia
Version: 1 Date: 16 Dec 2022
Reviewer's report:
This is a very clear and nicely presented small study, comparing first void urine and clinical
cervical samples using GenXpert HPV test. The setting of routine ART clinics where cervical
screening also takes place for HIV infected women enabled collection of 100 consecutive
consented women over a short 2 month period. With 98% of urine samples valid and almost
90% agreement between the two sample types, the results are very encouraging for the use of
non-invasive urine as a collection sample for cervical screening.
There are however so many studies currently trying urine as an obvious replacement for vaginal
self-sampling, it is important to emphasise what this particular manuscript is really telling us.
Some of these points are technical, but credit should be given to those who originated such
details, including
• Use of readily available and inexpensive solution of EDTA to prevent DNA degradation –
where did evidence for this come from? This should be explained or referenced
• Use of 2mls of treated sample i.e. to max of Xpert cartridge instead of manufacturer’s
recommended 1ml.  Where did suggestion or evidence for this come from? This should be
explained or referenced.
• Peeing into a 50ml pot was acceptable to 90% of the women, but why was 17mls chosen and
how was it measured?
A number of the Figures and Tables are superfluous and it would be adequate to give the details
in the text (as has also been done). This is particularly true for Figures 3 and 5 and Tables 1,4
and 6, again remembering what the aim is for this submission. It is not to have every detail
published in what was a short (but well executed) project. An internal report should of course
have all this detail.
The manuscript would benefit by cutting the comparisons with different studies in different
continents and populations (Discussion from line 308-352), remembering that prevalence in a
sample size of 100 is meaningless and therefore such comparisons are not helpful. Paragraph
from line 354-368 is in contrast highly relevant to the content.
Specific text comments:
Lines 133 and 143: Figs 1 and 2 could be combined into Fig 1 a and b for ease of comparison
Line 194: Table 1 could be part of supplementary information
Line 219: not ‘all HrHPV were detected’ but ‘all groups of HrHPV were represented in one
woman’s sample’.  The brackets with Fig4 should be at end of following sentence.
Line 396: Collecting urine from home for cervical screening has the potential for many errors,
not least of which is preventing DNA degradation and ensuring the sample isa ctually first void.
I do not think it is a limitation that in this study a health facility to which the women were coming
anyway was used. It also allowed for rapid turn around due to onsite lab, very important for
high quality of results.
Line 403 ff: The recommendations go beyond the results from this study and should be scaled
back appropriately
Line 412-413 – this statement needs to be justified or referenced
Lines 538 and 540: Reference 19 is superfluous and suggests a student level of statistical
understanding; Reference 20 seems to be missing from text – is it needed?