PONE-D-25-13630Determinants of cervical high-risk human papillomavirus positivity among Rwandan women with human immunodeficiency virusPLOS ONE

Dear Dr. Murenzi,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. The reviewers have offered editorial suggestions, which you may consider, and questions aboout methods and rationale for analysis which should be answered. Please look carefully at the reviewers’ comments, and revise or respond as appropriate. The succinctness of this paper is admirable. However, it would be helpful if you could provide more rationale with regard to a few issues.

Please ensure that the following issues are clearly explained:

The selection of sample size.

The decision to exclude women with CIN2+ from the study.

The decision to merge the data for 2 channels and >2 channels positive in analysing ‘multilevel positivity’.

Is it possible to comment or provide data on the acceptance rate for the study among women who were eligible for or were offered HPV testing?

Reviewer 2 has asked a number of questions about study design. Please review these carefully and, if it is not possible to answer the question directly, consider discussing these issues as study limitations.One question, regarding use of the multilevel data, may have already been covered in your manuscript. If so, please ensure that the contribution of the multilevel data to the analyses is clearly described, and that the results are highlighted in the discussion.

One issue raised by both reviewers is that of viral load data and its potential use as a predictor or correlate. Please comment on whether such data would be useful, given the high rate of compliance with ARV treatment. If so, pllease consider including the data.  In some situations in Africa, viral load is used more than CD4 for immune monitoring; will CD4 data be available going forward in Rwanda, and if not, what is the implication.

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: Yes

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is a well written paper.

Title

The title of the manuscript should read: Determinants of cervical high-risk human papillomavirus positivity among Rwandan women living with human immunodeficiency virus.

Abstract

Here, authors stated that they screened women from 2016 to 2020, but in the paper, but line 102 shows they screened participants from 2016 to 2018. Authors should please state the reasons for the discrepancy.

Ethics Statement

Authors should please include the ethical clearance reference number.

Material and Methods

Since the study is aimed at identifying key determinants of hrHPV among women living with HIV, it is unclear why the authors did not include women uninfected with HIV as control.

Authors mentioned that the collected data on viral load (line 117) but presented none. Was it an omission?

How was the CD4 T cell counted? Authors should state the controls used for the CD4 T cell count and HPV DNA testing.

Results

What was the overall prevalence of hrHPV among women diagnosed of <cin and="" cin2="">

Discussion

Authors alluded that the lower prevalence of hrHPV in Rwanda is because of ART coverage in Rwanda. Did the authors assess the rate of participants’ compliance to ART regime in their study and the studies they referenced? It is unclear if the authors assess HPV vaccination among the participants as it could impact on the prevalence rate of hrHPV.</cin>

Reviewer #2: 1. This study addresses a crucial public health issue: the intersection between HIV infection and cervical cancer risk, particularly through hrHPV infection. The authors tackle this issue with impressive breadth, drawing attention to a vulnerable population in a region where data is urgently needed. But as I read the introduction, I wonder — could the research question be more explicitly stated? While the rationale is strong, the specific hypothesis or aim feels somewhat implied rather than clearly declared.

2. The connection drawn between the WHO’s 90-70-90 targets and the reality of hrHPV testing availability in sub-Saharan Africa is compelling. The authors rightfully highlight the gap between global goals and local capacities. However, I am left wondering: how was Rwanda’s specific readiness for HPV DNA testing evaluated before the 2019 screening program launch? More context on this local implementation process would strengthen the narrative.

3. The methodology stands out for its rigor. The combination of HPV DNA testing, VIA, and confirmatory colposcopy with biopsy is robust and aligns with best practices. I appreciate the detail provided on lab testing and the conservative diagnostic algorithm. Still, does the use of pooled hrHPV typing (except for HPV16) limit our ability to identify the specific subtypes driving disease in this population?

4. The sample size — over 5,000 women — is remarkable and lends strong credibility to the findings. The demographic spread across all Rwandan provinces increases generalizability. Yet, I’m curious: were there any regional differences in hrHPV prevalence or immune status that could be relevant for tailoring interventions?

5. The data collection methods are thorough, combining nurse-administered questionnaires with EMR extraction. This mixed approach likely improves completeness, but could the reliance on self-reported sexual and reproductive history introduce recall bias? How might this have influenced the associations observed?

6. The statistical analyses are appropriately complex and well-executed. Stratified analyses by age and CD4 count bring valuable nuance. That said, the decision to exclude women with CIN2+ from the final analysis raises questions. Could this exclusion have masked relevant associations between risk factors and disease progression?

7. One of the most striking findings is the strong inverse association between CD4 count and hrHPV positivity, particularly for multiple HPV channel infections. This points to immunosuppression as a major driver of viral persistence. But it also prompts a question: could ART duration or viral suppression levels provide further insight into this relationship?

8. The multivariable model is well-constructed and interpretable, with adjusted odds ratios that clearly illustrate the strength of associations. However, I wonder whether any interaction terms (e.g., between age and CD4 count, or ART use and number of partners) were explored? Such analyses could reveal more complex dynamics at play.

9. The authors report an overall hrHPV prevalence of 25.5%, which is lower than in many other SSA studies. This is attributed to Rwanda’s successful ART program. It’s a hopeful sign, but could selection bias (due to missing or excluded data) partially explain the lower prevalence?

10. The paper observes that in women aged 50–54, the expected decrease in hrHPV prevalence with higher CD4 counts was not observed. This is acknowledged but left somewhat unexplored. Could this be due to survival bias? Or might other factors like cervical epithelial changes with age play a role?

11. The findings regarding sexual behavior — such as number of partners and age at first sex — being associated with hrHPV positivity are not surprising, but still significant. I do wonder, though: to what extent are these factors modifiable in this population? How can these findings inform effective, culturally sensitive prevention strategies?

12. Oral contraceptive use was also associated with increased hrHPV positivity. While biologically plausible, this association warrants further exploration. Could this be a proxy for unprotected sex or other behaviors not fully captured in the dataset?

13. The authors mention that monthly income and number of live births were only weakly associated with multi-channel hrHPV positivity. Yet socioeconomic status often plays a critical role in health outcomes. Could this apparent lack of association reflect limitations in how income was measured?

14. I appreciated the transparency in discussing the study’s limitations. The lack of type-specific HPV analysis due to pooled testing is a clear constraint. Might future studies in Rwanda benefit from using assays that provide more granular typing?

15. Another limitation — the relatively low CIN2+ prevalence and loss to follow-up — could influence both the interpretation and generalizability of findings. Could a follow-up study or cohort design provide better insight into progression risk and persistence?

16. The ethical conduct of the study is commendable, especially considering the sensitive nature of both HIV and HPV status. Participant protection and data integrity appear to have been taken seriously throughout.

17. The discussion of how findings relate to WHO elimination goals is strong. Still, I was hoping for more concrete policy recommendations. For instance, should screening intervals for WWH be adjusted based on CD4 count? What would an ideal integrated HIV-HPV care model look like in Rwanda?

18. A humanizing aspect of this study is how it captures the lived intersection of HIV and women’s health. Beyond statistical significance, the findings have real-world implications: each data point represents a woman at risk, navigating systems that may not always prioritize her dual burden of disease.

19. While this paper is methodologically sound and clinically relevant, it opens up several unanswered questions. Could longitudinal follow-up reveal more about which WWH are most at risk for progression to CIN2+ or cancer? What role does HPV vaccination have in this context — especially among younger HIV-positive women?

20. In conclusion, this study is a valuable contribution to cervical cancer research in HIV-positive populations. It brings both solid evidence and new questions to the table. The challenge now is to translate these findings into action — improving screening, investing in accessible HPV testing, and integrating prevention strategies into HIV care, all while continuing to listen to and understand the women at the center of these data.

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Reviewer #1: Yes:  Jude Ogechukwu Okoye

Reviewer #2: Yes:  Jonas Michel Wolf

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Determinants of cervical high-risk human papillomavirus positivity among Rwandan women living with human immunodeficiency virus

PONE-D-25-13630R1

Dear Dr. Murenzi,

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Thank you for your careful attention to the reviewers' detailed and insightful comments. There are a few instances in which you provide an excellent answer to the reviewer but do not include that answer in your manuscript. Sometimes, this is justified, for example if there is no clear and satisfying answer to a hypothetical question. However, you may wish to re-read your response letter and consider adding a sentence for a few instances where a reader may be considering the same question as the reviewer.

Reviewers' comments: