by Dr Ernestina Coast and Jannah Wigle

Women in low and middle-income countries experience the greatest burden of cervical cancer in the world, with more than 88% of the 275,000 deaths annually taking place in these areas. The human papillomavirus (HPV) is the most common sexually transmitted infection globally and is the major cause of cervical cancer. Two preventive vaccines were licensed in 2006 and boast great potential for reducing the burden of cervical cancer. 

Despite the fact that the vaccine has proven to be safe and effective against HPV, there has been a significant lag to delivering it in low and middle income countries (LMICs). Using both a literature review and interviewing experts working in the HPV vaccine field we investigated the current challenges to introducing the HPV vaccine.   

We found that although early research anticipated the biggest challenge to be the sociocultural barriers including potential stigma or concerns to vaccinating girls 9-13 years against a sexually transmitted infection, this wasn’t really the case in the literature or as expressed by experts. The need to communicate and educate or ‘sensitise’ the public, policymakers and various stakeholders on the vaccine, HPV and its link to cervical cancer were important to overcoming and preventing these issues.

The main challenges that were identified included those relating to the logistics and delivery of a new vaccine to a new target group – teenage girls as well as countries’ infrastructure and storage systems. Countries performing demonstration projects have proven that it is possible to reach these girls, vaccinating at schools, health centres, campaigns or often through more than one avenue and have achieved higher coverage of the HPV vaccine than in many high income countries like the United States or the Netherlands. 

Financing of the HPV vaccine has been a topic of much debate worldwide as costs for the vaccine ranges from US$13 to US$100 for each dose, making it unaffordable to most LMICs. Vaccine financing through mechanisms such as the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunisation) are improving access to LICs to vaccines through negotiating lower vaccine prices and co-financing until countries can afford the vaccines. However other costs, including start-up and on-going implementation costs to sustain programmes are still significant challenges.

Finally, the third main challenges were the political barriers and facilitators to introducing the HPV vaccine. Expensive, new public health interventions, such as the HPV vaccine, demand more evidence to convince countries that it is a worthy cause in which to invest their limited resources and represents an important barrier that needs to be overcome. 

Excitingly, many demonstration programmes and pilot projects are currently testing out what works and how it can be made sustainable long term. Our study helps to document not only the challenges that have been identified but how national immunization programmes, demonstration and pilot projects are overcoming and successfully implementing the HPV vaccine, so that others considering its introduction can learn and continue to build upon their experiences.

Further information

Wigle J, Coast E, Watson-Jones D (2013) Human Papillomavirus (HPV) vaccine implementation in low and middle-income countries (LMICs): health system experiences and prospects, Vaccine, Online. ISSN 0264-410X