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HPV vaccine strategies: equitable and effective?
  1. Sarah Hawkes1,
  2. David A Lewis2,3
  1. 1Institute for Global Health, University College London, London, UK
  2. 2Western Sydney Sexual Health Centre, Parramatta, New South Wales, Australia
  3. 3Department of Medicine (Immunology and Infectious Diseases), Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
  1. Correspondence to Dr Sarah Hawkes, Institute for Global Health, University College London, London WC1N 1EH, UK; s.hawkes{at}

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Immunisation programmes are recognised as being among the world's most successful public health programmes. Their impact on rates of infectious diseases (and subsequent reduction in complications and health burden) makes them one among the most cost effective and economically attractive of all health interventions. Indeed, the influential 2008 Copenhagen Consensus identified childhood vaccines as the fourth ranked ‘best buy’ for all global development interventions.1

In the same year, the GAVI Alliance (a global public-private partnership that currently works to increase access to immunisations in 53 eligible low-income and lower-middle-income countries) prioritised support for human papillomavirus (HPV) vaccines—and this was followed by financial commitments in 2011, based on a price reduction to an acceptable and feasible price to achieve increased coverage of the vaccine. GAVI has now secured a price of US$4.50 for the HPV vaccine—a remarkable reduction on the market price of this life-saving intervention.2

This achievement is made even more notable by the fact that the HPV vaccine is to be offered to girls aged 9–13 years: a demographic that falls outside the remit of most public health programmes in low-income and lower-middle-income countries. Several countries have struggled to find ways to reach their target population—a feat made more challenging by the fact that in 2013, 57 million school-age children were not in education, half of them living in sub-Saharan Africa—and with a disproportionate number among girls from the poorest socioeconomic quintile of society.3 Thus, school-based programmes have to be supplemented with programmes to reach those girls who are kept out of school on the grounds of poverty, accessibility (eg, due to distance to travel to school) or gender.

Finding innovative ways to deliver health interventions equitably to the population of girls who are most in need of HPV vaccines is hampered by a range of well-known barriers to vaccine uptake and acceptance including: lack of knowledge; suspicion and concern around the potential negative health impacts of vaccines (resulting in what is termed by ethicists as ‘justifiable dissent’4); and given the particular concerns of a vaccine targeted at adolescents, debates around who can consent (or refuse) vaccine uptake.5 Nonetheless, the rollout of HPV vaccine is underway—as of February 2014, 66 countries (including 2 low-income countries) have incorporated HPV vaccination into their national programmes and a further 40 countries (including 16 low-income ones) have pilot programmes underway.6 Progress is impressive, but the countries with the highest cervical cancer rates have not yet implemented vaccine schedules.7

More recently, increased attention has been paid to the issue of HPV vaccination for boys. The rationale for this is based on greater appreciation of the spectrum of HPV-related cancers which affect both genders, particularly, anal and oral cancers. Although significant reduction in the numbers of young men with genital warts has been demonstrated in a predominantly school-based HPV vaccination programme for girls in Australia,8 modelling suggests that high vaccination coverage rates for girls (>80%) are required to achieve substantial protection from herd immunity.9 Notwithstanding the ethical issues surrounding gender-based HPV vaccination programmes, in those situations where school-based HPV vaccination coverage rates are low, there may be a cost benefit from vaccinating boys as well as girls, in order to obtain improved herd immunity among youth in the general population. Indeed, Australia has now revised its national school-based HPV vaccination strategy to include immunisation of both boys and girls.10

As men who have sex with men (MSM) are at very high risk of HPV-associated anal cancer relative to heterosexual men and women,11–13 they are an important target group for HPV vaccination. In this journal, Nadarzynski and colleagues have reviewed evidence around HPV and vaccine-related perceptions among MSM.14 Such a review provides a welcome addition to the vast literature on public engagement with vaccine programmes (see, eg, the work of the Vaccine Confidence Project which monitors public confidence in immunisation programmes15). Nadarzynski's paper focuses on one area of burden of disease associated with HPV that is often under-reported in global vaccine discourse. The paper systematically reviews global evidence concerning HPV vaccine acceptability among MSM and concludes ‘the feasibility of targeted vaccination in various settings needs to be explored’.

We are concerned that this may be a premature conclusion for several reasons. The major reason, as identified by the authors themselves, concerns the lack of a truly global database on which to formulate such conclusions. The paper reviewed 16 studies from eight countries—six in the global north (including eight of the 16 papers from the USA), and one each from Malaysia and China (Hong Kong). These settings provide scant evidence on which to draw recommendations that can be generalised more globally.

The global sexual health of MSM is, indeed, under-researched, under-reported and under-resourced.16 Providing services for such a diverse, distinct and often marginalised population globally has been on the global health agenda for a relatively short period of time, and reviews of flows of finance to the health sector at national levels consistently show that services for MSM are not funded commensurate with need.17 Very few countries have health systems that are able to consider providing specialised services for populations on the basis of sexual orientation, and, as the authors correctly point out, even when MSM do reach health services, they may be unwilling or unable to openly discuss their sexuality.

Given this more restricted and restrictive view of the policy and programme options currently available for delivering sexual health interventions to those most in need, we would like, instead, to propose that additional consideration be given to the question of HPV vaccine delivery to ALL adolescents/young people, regardless of gender or sexual orientation. Providing HPV vaccine for both boys and girls is not only likely to increase public health impact for everyone, but it may more equitably reach the population of future MSM with an intervention that is both timely and effective at a time before they become sexually active. If research and programme funds are to be spent on identifying interventions which provide the most cost effective and acceptable solutions for public health problems, we believe that enhancing the evidence base for equitable HPV vaccine delivery to both boys and girls would be a worthwhile investment.



  • Competing interests None.

  • Provenance and peer review Commissioned; internally peer reviewed.

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