Prevention of Cervical Cancer in Sub-Saharan Africa: The Advantages and Challenges of HPV Vaccination

Abstract

Cervical cancer is a critical public health issue in sub-Saharan Africa (SSA), where it is the second leading cause of cancer among women and the leading cause of female cancer deaths. Incidence and mortality rates are substantially higher than in high-income countries with population-based screening programs, yet implementing screening programs in SSA has so far proven to be challenging due to financial, logistical, and sociocultural factors. Human Papillomavirus (HPV) vaccination is an effective approach for primary prevention of cervical cancer and presents an opportunity to reduce the burden from cervical cancer in SSA. With a number of SSA countries now eligible for Global Alliance for Vaccines and Immunization (GAVI) support for vaccine introduction, it is timely to consider the factors that impede and facilitate implementation of vaccine programs in SSA. This article describes epidemiological features of cervical cancer in SSA and the current status of HPV vaccine implementation in SSA countries. Rwanda’s experience of achieving high vaccination coverage in their national HPV immunization program is used as a case study to explore effective approaches to the design and implementation of HPV vaccination programs in SSA. Key factors in Rwanda’s successful implementation included government ownership and support for the program, school-based delivery, social mobilization, and strategies for reaching out-of-school girls. These findings might usefully be applied to other SSA countries planning for HPV vaccination.

Elimination of cervical cancer: challenges for developing countries

“…Unfortunately in most countries with inadequate health and social systems, these basic tools are lacking, and compounded with limited cervical cancer awareness and education, elimination of this disease is a major challenge [9]. In Sub-Saharan Africa (SSA), although incidence rates vary from country to country, approximately 93,225 new cases of cervical cancer occurred in 2012, making it the second most common cancer of reproductive-aged women in the region [10]. South Africa and East Africa share the highest burden of cervical cancer, where age-standardised incidence rates of 43.1 and 40.1 per 100,000, respectively, exist [11].…”

“…Moreover, spiritual leaders, government officials, teachers and volunteers supported educational programmes, direct person-to-person and billboard advertising. Rwanda has surpassed Australia in HPV vaccination coverage reaching >93% of girls aged 11-15 years old [10]. Simultaneously, Rwanda has initiated national cervical cancer screening using visual inspection with acetic acid (VIA), as well as breast cancer screening using clinical breast exam (CBE).…”

“…Strong government buy-in (including strong support from the First Lady and the Minister of Health), and advocacy, as well as partnerships with international and private sector organisations, made the Rwanda vaccine roll out possible. A 3-year cost-free provision of vaccines and concessional pricing for the future will help to provide sustainability of Rwanda's primary prevention program [10]. A cervical cancer screening program using VIA and care HPV has been launched in Rwanda.…”

Cancer in Africa 2018: The role of infections

“…Introduction of vaccination is more challenging—leaving aside cost considerations, the introduction of vaccination programs has been restricted by the difficulty of reaching the target population of adolescent girls and cultural challenges . Implementation has so far been gradual, although several African countries are moving ahead with national programs . A reduction in incidence of invasive cancer will only occur many years after the introduction of vaccination, because of the long latency period between chronic infection with HPV and onset of malignancy .…”

“…30 Implementation has so far been gradual, although several African countries are moving ahead with national programs. 31 A reduction in incidence of invasive cancer will only occur many years after the introduction of vaccination, because of the long latency period between chronic infection with HPV and onset of malignancy. 32 A more rapid effect can be achieved through population-based screening for cervix cancer and precursor lesions, which has been highly effective in reducing incidence of the disease in high and middle-income countries, where such programs have been implemented.…”