Human Papillomavirus Vaccination in South Africa: Programmatic Challenges and Opportunities for Integration With Other Adolescent Health Services?

Abstract

Compared to other regions of the world, sub-Saharan Africa has made limited progress in the implementation and performance of nationwide human papillomavirus (HPV) vaccination programmes. Without urgent intervention, this will serve to undermine cervical cancer elimination efforts in this region. The primary intent of this narrative review is to highlight the programmatic successes and challenges of the school-based HPV vaccination programme in South Africa since its inception in 2014, with the aim of contributing to the evidence base needed to accelerate implementation and improve programme performance in other sub-Saharan African countries. As of 2020, the proportion of adolescent girls aged 15 years who had received at least one dose of the HPV vaccine at any time between ages 9–14 years was 75%, while 61% had completed the full recommended two-dose schedule. This gives some indication of the reach of the South African HPV vaccination programme over the past 6 years. Despite this, vaccine coverage and dose completion rates have persistently followed a downward trend, slowing progress toward attaining global elimination targets. There is evidence suggesting that declining public demand for the HPV vaccine may be a result of weakening social mobilization over time, inadequate reminder and tracking systems, and vaccine hesitancy. Another concern is the disproportionate burden of HPV and HIV co-infections among adolescent girls and young women in South Africa, which predisposes them to early development of invasive cervical cancer. Moving forward, national policy makers and implementers will have to explore reforms to current age eligibility criteria and vaccine dose schedules, as well as implement strategies to support vaccine uptake among populations like out-of-school girls, girls attending private schools, and HIV positive young women. Additional opportunities to strengthen the South African HPV vaccination programme can be achieved by scaling up the co-delivery of other adolescent health services such as comprehensive sexual and reproductive health and rights education, deworming, and health screening. This calls for reinforcing implementation of the integrated school health policy and leveraging existing adolescent health programmes and initiatives in South Africa. Ultimately, establishing tailored, adolescent-centered, integrated health programmes will require guidance from further operational research.

Key decision-making factors for human papillomavirus (HPV) vaccine program introduction in low-and-middle-income-countries: Global and national stakeholder perspectives

“… 18 Furthermore, countries that have not yet introduced HPV vaccines must choose to invest in either vaccines or screening programs and decide whether the two services can be integrated. 8 , 19 , 30 Increasing capacity, considering alternate delivery platforms, and evaluating the costs of additional resources required to successfully reach preadolescents and adolescents have also been noted as critical in the decision-making process. 31-33 …”

“…The selection of effective delivery platforms to promote HPV vaccination coverage among adolescent girls has remained a challenge in the implementation of HPV vaccination programs. 19 , 34 , 35 A lack of focus on adolescent health in many LMICs has resulted in poorly developed adolescent health services, which poses a considerable challenge to the implementation of HPV vaccination programs. 19 , 30 Overcoming these challenges mandates heightened collaboration and coordination between sectors at the national and global level.…”

“… 19 , 34 , 35 A lack of focus on adolescent health in many LMICs has resulted in poorly developed adolescent health services, which poses a considerable challenge to the implementation of HPV vaccination programs. 19 , 30 Overcoming these challenges mandates heightened collaboration and coordination between sectors at the national and global level. Coordination and communication among diverse stakeholders with their own agendas and priorities is a barrier to the decision-making process.…”

“… 16 , 17 Compared to other routine vaccination programs, introducing the HPV vaccine has been described as a unique intervention with substantial challenges related to the target age group and the resources required for delivery. 15 , 18 , 19 As many LMICs face health challenges that may impact the decision to introduce HPV vaccines, it is imperative to understand the decision-making processes behind the implementation of HPV vaccination programs.…”

Potential benefit of extended dose schedules of human papillomavirus vaccination in the context of scarce resources and COVID-19 disruptions in low-income and middle-income countries: a mathematical modelling analysis

“…33,44,[47][48][49][50][51][52][53][54][55][56] National HPV vaccination with the bivalent vaccine was introduced in 2014 among 9-year-olds public schoolgirls, which initially achieved a coverage of ∼80% and ∼60% for the 1st and 2nd dose, respectively, 57,58 but has decreased subsequently ( ∼40% in 2021). 59,60 Given the existence of a national screening program since 2000 in South Africa, the models' basecase scenarios assumed some levels of screening prior to 2020 (e.g. <13% of women aged 35-39 year-olds are screened annually while treatment success is low across models) (Table T3 of the technical appendix).…”