WHO and Gavi's global push for HPV vaccines gathers momentum

Nearly two decades since the only vaccine that protects against a type of cancer came into the market, it is beginning to make major inroads in low- and middle-income countries where it is sorely needed. India’s finance minister Nirmala Sitharaman announced in February that the world’s most populous country would introduce free HPV vaccinations to protect girls aged 9-14 but the specifics are still unclear. The HPV vaccine protects against cervical cancer caused by the persistent infection of the human papillomavirus. While the vaccine has been available in the private sector in India, so far it has not been a part of the government’s national immunization program. Its high cost meant that the uptake was limited. In 2022, there were an estimated 350,000 deaths worldwide due to cervical cancer. An overwhelming 90% of these deaths are in the low-and middle-income countries, according to estimates by the World Health Organization. India alone accounts for nearly a fourth of all global cervical cancer deaths. The HPV vaccine first became available in 2006 but supply constraints have proven to be a challenge. In addition, the COVID-19 pandemic caused progress to not just stall but backslide. In some communities, the vaccine was seen by parents as an encouragement for young girls to be sexually active given that HPV is sexually transmitted. Now a global push from WHO along with the global vaccine alliance Gavi is hoping to change that. “HPV vaccination is indeed a major global priority,” Anuradha Gupta, president of the global immunization at the Sabin Vaccine Institute, which spearheads the Global HPV Consortium, told Devex. She estimates that more than one-and-a-half dozen countries are gearing up to roll out the HPV vaccine this year although the exact number is a moving target. “Nigeria, the most populous country in Africa, recently embarked on a phased rollout. India, the world’s most populous country, is expected to introduce free HPV vaccines for girls later this year. This is a very promising trend,” she said. At WHO’s executive board sessions in January, small island nations such as Timor-Leste and Barbados also declared their intent to roll out and strengthen their HPV vaccination programs. A global push to scale up In early March, WHO organized a three-day forum in Cartagena, Colombia to mobilize countries to respond to cervical cancer. This is the latest in the series of pushes. Gavi has also been urging countries to consider including HPV vaccines in their routine immunization programs since 2012. In the decade until 2022, Gavi told Devex it supported 29 low- and middle-income countries to introduce the vaccine in their national immunization programs. In December 2022, Gavi approved an additional $600 million investment toward improving HPV vaccine access. In Cartagena, the Bill & Melinda Gates Foundation, UNICEF, and the World Bank announced an additional $600 million in funding. “To date, Gavi has partnered with over 35 countries across the world, helping to reach 16.3 million girls with HPV vaccine by the end of 2022. While global coverage of the HPV vaccine is now higher than it was prior to the pandemic at 21% for one dose, it's well below ideal levels and millions of girls continue to miss out,” a Gavi spokesperson told Devex. At the moment countries have varying levels of HPV vaccine coverage ranging from 0.2% to 52%, according to a WHO report. Evidence that the vaccine is effective is present. The United Kingdom introduced HPV vaccines in the country’s routine immunization in 2008, and a 2021 study done using data from the country found that in the cohort that was vaccinated young — 12-13 years old — there was a near total elimination of cervical cancer. Improving supply and slashing costs The limited supply of vaccines has been a challenge and has led to inequity where those most in need of the vaccines are still without them. The shortage has also forced countries to adopt a girls-only strategy. “WHO’s Strategic Advisory Group of Experts or SAGE recommends gender-neutral vaccination, recognizing boys as carriers and because HPV induces cancers among men, e.g., penile, head, neck, anal cancer. Given the supply constraints, SAGE in 2022 recommended that adolescent girls be prioritized for HPV vaccination. So nearly 90 countries have HPV vaccination limited to girls only,” Gupta said. This is also the demographic countries such as the Democratic Republic of Congo and Ethiopia are planning to prioritize in their latest commitments with help from Gavi. Studies have found that a girls-only vaccination strategy in low-resource settings is also effective, and vaccinating boys does not lead to significant additional benefits. The supply of vaccines is expected to ease in the coming years as more vaccines are expected to hit the market. Gavi’s vaccine arsenal currently has three HPV vaccines while WHO has approved six vaccines in all. An anticipated vaccine is Cervavac by the world’s largest vaccine manufacturer, the Serum Institute of India. The newly developed vaccine has been approved for use in India and the company’s CEO Adar Poonawalla has said in the coming years there will be enough for exports after meeting India’s domestic needs. Cervavac is likely to be priced around 200-400 Indian rupees ($3-$5) for a two-dose vial, Poonawalla has said in media interactions. The price is a huge drop from Merck and Co’s GARDASIL 9 HPV vaccine, which is priced at $286.78 for each dose in the United States. GSK’s Cervarix costs 510 Canadian dollars for three doses in Canada. A price drop will help middle-income countries that are not eligible for Gavi assistance to expand access. “HPV vaccine introductions are also buoyed by WHO’s recommendation that a single dose of HPV vaccine offers solid protection. A single dose regimen brings a triple benefit of reduced vaccine costs, easier program implementation, and optimization of vaccine supply,” Gupta said. A note of caution While vaccines are an effective measure, countries have been cautioned against going easy on screening. “Too much confidence in HPV vaccine can be harmful as the protection rate against cervical cancer is only 70%. Cervical cancer screening and avoiding unprotected multiple sex partners are still crucial,” Thailand said in a statement at WHO earlier this year. A similar note of caution came from former WHO Chief Scientist Soumya Swaminathan who has welcomed India’s push for HPV vaccines but stressed the need to combine it with screening and treatment. WHO has set a target of “90-70-90” by 2030 where countries aim to vaccinate 90% of girls with the HPV vaccine by the age of 15; screen 70% of women for cervical cancer by the age of 35 and then again by age 45; and treat 90% of women with pre-cancer and manage 90% of the cases of women with invasive cancer. “The encouraging news is that we are witnessing steady progress. For example, nearly 5 million girls in Nigeria alone have already received the HPV vaccine since it was introduced in October 2023,” the Gavi spokesperson said. “Over the next two years, we look forward to partnering with additional countries as we strive to meet our ambitious goal of protecting 86 million girls from the main cause of cervical cancer by 2025.” Update, March 20, 2024: This article has been updated to clarify that the Sabin Vaccine Institute spearheads the Global HPV Consortium.