The relational association between multiple sexual partners and HIV testing on cervical cancer screening among women of reproductive age in Ghana: A national population-based study

Agani Afaya; Wise Awunyo; Mary Adaeze Udeoha; Matilda Mawusi Kodjo; Maxwell Tii Kumbeni

doi:10.1371/journal.pone.0344086

Peer Review History

Original SubmissionJuly 22, 2025
13 Oct 2025 Decision Letter - Minal Dakhave, Editor 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. Please submit your revised manuscript by Nov 27 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). 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Please ensure that you refer to Table 2 in your text; if accepted, production will need this reference to link the reader to the Table. 4. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. Additional Editor Comments: General Assessment: The manuscript addresses an important public health topic—the influence of multiple sexual partners and HIV testing on cervical cancer screening among women of reproductive age in Ghana. The study is relevant and uses a nationally representative dataset. However, major revisions are needed to improve clarity, organization, scientific rigor, and readability. ******** Specific Comments: Introduction: Redundancy & Flow: Merge repeated global cervical cancer statistics; present global → regional (SSA) → Ghana sequentially. WHO Strategy: Provide context on progress toward the 90-70-90 targets, especially in LMICs/SSA, with recent references (2023–2024). Context for Ghana: Integrate fragmented national data into a cohesive paragraph; include screening programs, HPV vaccination, and HPV DNA testing availability. Use recent national surveys (e.g., GLOBOCAN 2022). Study Rationale: Clarify gaps in Ghana-specific data and how this study addresses them. Example: emphasize limited prior work on HIV testing and sexual behavior interactions in Ghana. Language & Style: Simplify long/redundant sentences, maintain consistent tense, and adopt academic terminology (e.g., “age-standardized incidence rate”). Avoid starting sentences with numerical data. Referencing: Verify all citations, update with recent literature, and ensure numerical references are accurate. Structure: Suggested flow: Global burden → SSA burden → Ghana → Screening & WHO strategy → Barriers → Study rationale Results: Clarity: Summarize key trends instead of repeating table data. Tables: Reorganize, align columns, label models clearly, and highlight significant results. Integration: Separate descriptive and inferential results with subheadings. Non-significant Variables: Interpret or explicitly note lack of association. Visual Aids: Consider bar charts for prevalence and forest plots for multivariable results. Discussion: Non-significant Findings: Expand discussion on cultural, behavioral, or structural factors influencing the lack of association between multiple sexual partners and screening. Policy Implications: Suggest interventions, e.g., integrating cervical screening with HIV services, school programs, or mobile clinics. Limitations: Specify potential misclassification due to stigma and inclusion of participants below recommended screening age (15–24 years) as factors possibly affecting results Conclusion: The study highlights low cervical cancer screening uptake in Ghana and identifies HIV testing as a significant predictor. Strengthening the discussion of context-specific factors and practical interventions will enhance the manuscript’s relevance and impact. Recommendation: Major revision required. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? Reviewer #1: Partly ****** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: No ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: No ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes ****** Reviewer #1: Thank you for the opportunity to review the study entitled “The relational association between multiple sexual partners and HIV testing on cervical cancer screening among women of reproductive age in Ghana.” Many thanks to the authors for doing this work. I have a few comments and suggestions that may help strengthen the paper. Introduction The paper examines the relationship between multiple sexual partners, HIV and cervical cancer screening. However, no background information on the burden of cervical cancer in Ghana is provided which will better situate the study. Since the focus is on the association between multiple sexual partners, HIV and cervical cancer screening, it would be useful to provide supporting literature on these relationships in the background section. Lines 111–115: The authors have not made a sufficiently strong case for why this study is necessary. This section should be expanded to highlight the research gap and rationale. Methods Lines 141–150: Both the outcome and exposure variables were self-reported. This introduces the potential for recall and reporting bias, which should be acknowledged as a limitation. Lines 164–172: Several indicators were adjusted for in the multivariable logistic regression model. How were these potential confounders identified? Please clarify the criteria used for their inclusion. Results Lines 191–199: The results section should begin by stating the total number of women included in the study sample. Lines 191–199: What was the mean or median age of the participants? This should be provided as part of the descriptive results. Lines 191–199: Percentages were reported in the text, but absolute numbers should also be included for clarity. Table 2: The heading and content should be revised. This is not an “association” table. Also, column percentages for each indicator should be included. Lines 206–210: Model 1 is the unadjusted model, while Model 2 is the adjusted model. This distinction should be clearly stated in the text. Table 3: Two additional columns should be added to show the distribution of the outcome variable across the exposures. Table 3: Results for some variables are missing in Model 1. These should be included to allow readers to see how the odds ratios change after adjustment. Discussion The discussion is too general. Given that the study focuses on the relationship between multiple sexual partners, HIV testing, and cervical cancer screening in Ghana, the discussion should highlight contextual factors specific to Ghana that may explain the findings. Lines 285–292: Since this is a cross-sectional study, causal inference cannot be made. However, the authors should indicate specific features of the study (eg., study population or unmeasured confounders) that may have influenced the results. The implications of the findings for cervical cancer screening programs in Ghana are not clear. The authors should expand this section to discuss how the study contributes to policy, practice or future interventions. ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/ . PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org . Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0344086.r001
Revision 1
3 Dec 2025 Author Response Dear Editor, We would like to thank you sincerely for the insightful reviewer comments on our manuscript and for the opportunity to resubmit the manuscript for a second round of review and further publication consideration. We find the comments very useful and have responded to them to the best of our knowledge. We acknowledge that the comments have no doubt helped improve the quality of our manuscript. We herein provide responses to detail how we have addressed the comments of the reviewers’ point-by-point. For easy identification, the reviewers’ comments have been repeated while Authors’ responses appear in Bold text. General Assessment: The manuscript addresses an important public health topic—the influence of multiple sexual partners and HIV testing on cervical cancer screening among women of reproductive age in Ghana. The study is relevant and uses a nationally representative dataset. However, major revisions are needed to improve clarity, organization, scientific rigor, and readability. Specific Comments: Introduction: 1. Redundancy & Flow: Merge repeated global cervical cancer statistics; present global → regional (SSA) → Ghana sequentially. Response: We have addressed the above comment within the background 2. WHO Strategy: Provide context on progress toward the 90-70-90 targets, especially in LMICs/SSA, with recent references (2023–2024). Response: We included this in the background as recommended 3. Context for Ghana: Integrate fragmented national data into a cohesive paragraph; include screening programs, HPV vaccination, and HPV DNA testing availability. Use recent national surveys (e.g., GLOBOCAN 2022). Response: we have provided the screening methods in Ghana and the availability HPV DNA testing in the background 4. Study Rationale: Clarify gaps in Ghana-specific data and how this study addresses them. Example: emphasize limited prior work on HIV testing and sexual behavior interactions in Ghana. Response: This has been indicated in the last paragraph 5. Language & Style: Simplify long/redundant sentences, maintain consistent tense, and adopt academic terminology (e.g., “age-standardized incidence rate”). Avoid starting sentences with numerical data. Response: The above comments have been addressed as suggested. 6. Referencing: Verify all citations, update with recent literature, and ensure numerical references are accurate. Response: Thank you, we have updated most of the references used in the study. 7. Structure: Suggested flow: Global burden → SSA burden → Ghana → Screening & WHO strategy → Barriers → Study rationale Response: The background was restructured as suggested above. Results: 1. Clarity: Summarize key trends instead of repeating table data. RESPONSE: We have summarized the key findings in the results section. 2. Tables: Reorganize, align columns, label models clearly, and highlight significant results. RESPONSE: We have revised the models clearly and highlighted significant results 3. Integration: Separate descriptive and inferential results with subheadings. RESPONSE: This has been done. 4. Non-significant Variables: Interpret or explicitly note lack of association. RESPONSE: This has been explained within the results section 5. Visual Aids: Consider bar charts for prevalence and forest plots for multivariable results. RESPONSE: Thank you, we have considered bar charts for prevalence and the forest plots for multivariable results. But it seems the table is more visible Discussion: 1. Non-significant Findings: Expand discussion on cultural, behavioral, or structural factors influencing the lack of association between multiple sexual partners and screening. RESPONSE: We have expanded on the discussion, focusing on cultural, behavioral, or structural factors influencing the lack of association between multiple sexual partners and screening 2. Policy Implications: Suggest interventions, e.g., integrating cervical screening with HIV services, school programs, or mobile clinics. RESPONSE: We have addressed this 3. Limitations: Specify potential misclassification due to stigma and inclusion of participants below recommended screening age (15–24 years) as factors possibly affecting results Conclusion: The study highlights low cervical cancer screening uptake in Ghana and identifies HIV testing as a significant predictor. Strengthening the discussion of context-specific factors and practical interventions will enhance the manuscript’s relevance and impact. REVIEWER ONE Reviewer #1: Thank you for the opportunity to review the study entitled “The relational association between multiple sexual partners and HIV testing on cervical cancer screening among women of reproductive age in Ghana.” Many thanks to the authors for doing this work. I have a few comments and suggestions that may help strengthen the paper. Introduction The paper examines the relationship between multiple sexual partners, HIV and cervical cancer screening. However, no background information on the burden of cervical cancer in Ghana is provided, which will better situate the study. RESPONSE: Thank you for this recommendation. We have therefore revised the background to include cervical cancer burden. Since the focus is on the association between multiple sexual partners, HIV, and cervical cancer screening, it would be useful to provide supporting literature on these relationships in the background section. RESPONSE: actually there are limited studies in Ghana that have assessed the relationship, but we have provided justification for this study. Lines 111–115: The authors have not made a sufficiently strong case for why this study is necessary. This section should be expanded to highlight the research gap and rationale. RESPONSE: We have included the research gap Methods Lines 141–150: Both the outcome and exposure variables were self-reported. This introduces the potential for recall and reporting bias, which should be acknowledged as a limitation. RESPONSE: This is already under the limitation section but we have still revised it. Lines 164–172: Several indicators were adjusted for in the multivariable logistic regression model. How were these potential confounders identified? Please clarify the criteria used for their inclusion. RESPONSE: We reviewed literature to identify the potential confounders and have referenced these studies Results Lines 191–199: The results section should begin by stating the total number of women included in the study sample. RESPONSE: This has been included in the first sentence under the results section. Lines 191–199: What was the mean or median age of the participants? This should be provided as part of the descriptive results. RESPONSE: We used the categorical variable, and it will be a form of repeating, which is why we could not include it. Lines 191–199: Percentages were reported in the text, but absolute numbers should also be included for clarity. RESPONSE We have included the percentages Table 2: The heading and content should be revised. This is not an “association” table. Also, column percentages for each indicator should be included. Response: This has been revised Lines 206–210: Model 1 is the unadjusted model, while Model 2 is the adjusted model. This distinction should be clearly stated in the text. RESPONSE: This has been corrected Table 3: Two additional columns should be added to show the distribution of the outcome variable across the exposures. RESPONSE: This has been shown in Table 1 Table 3: Results for some variables are missing in Model 1. These should be included to allow readers to see how the odds ratios change after adjustment. RESPONSE: We used chi-square analysis to determine the level of association for all the variables before adjusting for them in model II. This format is also acceptable as unadjusted odds and chi-square analysis are all bivariate in nature Discussion The discussion is too general. Given that the study focuses on the relationship between multiple sexual partners, HIV testing, and cervical cancer screening in Ghana, the discussion should highlight contextual factors specific to Ghana that may explain the findings. RESPONSE: We have addressed these concerns Lines 285–292: Since this is a cross-sectional study, causal inference cannot be made. However, the authors should indicate specific features of the study (eg., study population or unmeasured confounders) that may have influenced the results. RESPONSE: The implications of the findings for cervical cancer screening programs in Ghana are not clear. The authors should expand this section to discuss how the study contributes to policy, practice or future interventions. RESPONSE This section has been included. Attachments Attachment Submitted filename: Point-by-point response.docx https://doi.org/10.1371/journal.pone.0344086.r002
16 Feb 2026 Decision Letter - Minal Dakhave, Editor The relational association between multiple sexual partners and HIV testing on cervical cancer screening among women of reproductive age in Ghana: a national population analysis PONE-D-25-39510R1 Dear Dr. Wise Awunyo, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. For questions related to billing, please contact billing support . If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Minal Dakhave Academic Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: No ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes ****** Reviewer #1: Authors have addressed all my previous comments on the paper. I do not have any additional comment. ****** what does this mean? ). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy Reviewer #1: No ******** https://doi.org/10.1371/journal.pone.0344086.r003
Formally Accepted
Acceptance Letter - Minal Dakhave, Editor PONE-D-25-39510R1 PLOS One Dear Dr. Awunyo, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS One. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days to review your paper and let you know the next and final steps. Lastly, if your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. If we can help with anything else, please email us at customercare@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Minal Dakhave Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0344086.r004

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