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Overcoming Barriers and Ensuring Access to HPV Vaccines in Low-Income Countries

Published online by Cambridge University Press:  06 January 2021

Vivien Davis Tsu
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Abstract

The inequitable burden of cervical cancer falls on women in poorer countries, due primarily to a disparity in access to screening services. To ensure that access to the new human papillomavirus (“HPV”) vaccines is not similarly skewed toward higher-income populations, it is important to understand the appropriate priority group for receiving vaccines, the potential barriers to reaching that group, and the options for overcoming those barriers. Based on vaccine efficacy data, the likelihood of achieving high coverage with various groups, and the resultant cost-effectiveness ratios, it is widely agreed that young adolescent girls should be the primary recipients. Potential barriers include the fact that young adolescents are not currently reached by many health services; that there might be stigma attached to a vaccine for a sexually transmitted infection; that financing for the vaccine must be allocated; and that there is limited political commitment to women's health, to cancer prevention, or to this particular vaccine when so many other new vaccines are also becoming available. Despite these very real challenges, there is reason to be cautiously optimistic that those most in need of an HPV vaccine can receive it in programs that are affordable, effective, and acceptable to girls, their families, and their societies.

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Article
Information
American Journal of Law & Medicine , Volume 35 , Issue 2-3 , June 2009 , pp. 401 - 413
Copyright
Copyright © American Society of Law, Medicine and Ethics and Boston University 2009

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References

1 D. Maxwell Parkin & Freddie Bray, Chapter 2: The Burden of HPV-Related Cancers, 24 Vaccine 11, 11 (Supp. 3 2006).

2 J. Ferlay et al., GLOBOCAN 2002: CANCER INCIDENCE, MORTALITY AND PREVALENCE WORLDWIDE (IARC Press 2004).

3 See, e.g., Leif Gustafsson et al., International Incidence Rates of Invasive Cervical Cancer Before Cytological Screening, 71 Int’l J. Cancer 159, 160 (1997); Leif Gustafsson et al., International Incidence Rates of Invasive Cervical Cancer After Introduction of Cytological Screening, 8 Cancer Causes Control 755, 757-759 (1997); J. F. Nygard et al., The Cervical Cancer Screening Programme in Norway, 1992-2000: Changes in Pap Smear Coverage and Incidence of Cervical Cancer, 9 J. Med. Screening, 86 (2002); Rengaswamy Sankaranarayanan et al., Effective Screening Programmes for Cervical Cancer in Low- and Middle-Income Developing Countries, 79 Bull. World Health Org. 954 (2001).

4 Henry C. Kitchener et al., Chapter 7: Achievements and Limitations of Cervical Cytology Screening, 24 Vaccine 63, 64 (Supp. 3 2006).

5 See, e.g., H. S. Cronjé, Screening for Cervical Cancer in the Developing World, 19 Best Prac. & Res. Clinical Obstetrics & Gynaecology 517, 517-518 (2005); Merle J. Lewis, World Health Organization, A Situational Analysis Of Cervical Cancer In Latin America And The Caribbean 7-8 (2004); Sankaranarayanan, supra, note 3, at 79.

6 See, e.g., Cronjé, supra note 5, at 520-21; Lynette Denny et al., Chapter 8: Screening for Cervical Cancer in Developing Countries, 24 Vaccine 71, 72-73 (Supp. 3 2006).

7 Allison Bingham et al., Factors Affecting Utilization of Cervical Cancer Prevention Services in Low-Resource Settings, 45 Salud Publica de Mex 408 (Supp. 3 2003); Bhagwan Nene et al., Determinants of Women's Participation in Cervical Cancer Screening Trial, Maharashtra, India, 85 Bull. World Health Org. 264 (2007); Vivien D. Tsu & Carol E. Levin, Making the Case for Cervical Cancer Prevention: What About Equity?, 16 Reprod. Health Matters 1 (2008).

8 Gary Clifford et al., Chapter 3: HPV Type-Distribution in Women With and Without Cervical Neoplastic Diseases, 24 Vaccine 26, 32-33 (Supp. 3 2006); The FUTURE II Study Group, Quadrivalent Vaccine Against Human Papillomavirus to Prevent High-Grade Cervical Lesions, 356 New Eng. J. Med. 1915, 1915 (2007); Jorma Paavonen et al., Efficacy of a Prophylactic Adjuvanted Bivalent L1 Virus-Like-Particle Vaccine Against Infection With Human Papillomavirus Types 16 and 18 in Young Women: an Interim Analysis of a Phase III Double-Blind, Randomised Controlled Trial, 369 Lancet 2161, 2161, 2167-68 (2007); Jennifer S. Smith et al., Human Papillomavirus Type Distribution in Invasive Cervical Cancer and High-Grade Cervical Lesions: A Meta-Analysis Update, 121 Int’l J. Cancer 621, 624 (2007); John T. Schiller et al., An Update of Prophylactic Human Papillomavirus L1 Virus-Like Particle Vaccine Clinical Trial Results, 26 Vaccine 53, 53, 56 (Supp. 10 2008).

9 Id.

10 Anna Koulova et al., Country Recommendations on the Inclusion of HPV Vaccines in National Immunization Programmes Among High-Income Countries, June 2006-January 2008, 26 Vaccine 6529, 6530 (2008).

11 See generally Abby Lippman et al., Do You Approve of Spending $300 Million on HPV Vaccination?: No, 54 Can. Fam. Physician 175 (2008); Marc Steben, Rebuttal: Do You Approve of Spending $300 Million on HPV Vaccination? Yes, 54 Can. Fam. Physician 342 (2008).

12 FUTURE II Study Group, supra note 8, at 1925.

13 Janet G. Baseman & Laura A. Koutsky, The Epidemiology of Human Papillomavirus Infections, 32 J. Clinical Virology 16, 18-19 (2005); F. Xavier Bosch et al., Epidemiology and Natural History of Human Papillomavirus Infections and Type-Specific Implications in Cervical Neoplasia, 26 Vaccine 1 (Supp. 10 2008); Jessica A. Kahn & Robert D. Burk, Papillomavirus Vaccines in Perspective, 369 Lancet 2135 (2007); Rachel L. Winer et al., Risk of Female Human Papillomavirus Acquisition Associated With First Male Sex Partner, 197 J. Infectious Diseases 279 (2008); Ciaran B. J. Woodman et al., Natural History of Cervical Human Papillomavirus Infection in Young Women: a Longitudinal Cohort Study, 357 Lancet 1831 (2001).

14 Stuart Collins et al., High Incidence of Cervical Human Papillomavirus Infection in Women During Their First Sexual Relationship, 109 BJOG 96 (2002).

15 K. A. Ault, Effect of Prophylactic Human Papillomavirus L1 Virus-Like-Particle Vaccine on Risk of Cervical Intraepithelial Neoplasia Grade 2, Grade 3, and Adenocarcinoma in Situ: A Combined Analysis of Four Randomised Clinical Trials, 369 Lancet 1861, 1865 (2007).

16 Akinrinola Bankole et al., Sexual Behavior, Knowledge and Information Sources of Very Young Adolescents in Four Sub-Saharan African Countries, 11 Afr. J. Reprod. Health 28, 33-34 (2007).

17 Keith S. Reisinger et al., Safety and Persistent Immunogenicity of a Quadrivalent Human Papillomavirus Types 6, 11, 16, 18 L1 Virus-Like Particle Vaccine in Preadolescents and Adolescents: a Randomized Controlled Trial, 26 Pediatric Infectious Disease J. 201 (2007).

18 Koulova, supra note 10, at 3534.

19 Id.

20 Eliav Barr & Heather L. Sings, Prophylactic HPV Vaccines: New Interventions for Cancer Control, 26 Vaccine 6244, 6254 (2008).

21 U.N. Econ. & Soc. Council [ECOSOC], The Millennium Development Goals Report 2008, U.N. Doc. E.08.I.18, 12-19 (August 2008).

22 Koulova, supra note 10, at 6531-33; Abigail Shefer et al., Early Experience With Human Papillomavirus Vaccine Introduction in the United States, Canada and Australia, 26 Vaccine 68, 71-73 (Supp. 10 2008).

23 Ruanne V. Barnabas et al., Epidemiology of HPV 16 and Cervical Cancer in Finland and the Potential Impact of Vaccination: Mathematical Modelling Analyses, 3 PLoS Med. e138 (2006); Elamin H. Elbasha et al., Model for Assessing Human Papillomavirus Vaccination Strategies, 13 Emerging Infectious Diseases 28, 35 (2007); Sue J. Goldie et al., Cost-Effectiveness of HPV 16, 18 Vaccination in Brazil, 25 Vaccine 6257, 6265-67 (2007); Ralph P. Insinga et al., Cost-Effectiveness of Quadrivalent Human Papillomavirus (HPV) Vaccination in Mexico: A Transmission Dynamic Model-Based Evaluation, 26 Vaccine 128, 136-37 (2007); Eugenio Suarez et al., Cost-Effectiveness of Vaccination Against Cervical Cancer: A Multi-Regional Analysis Assessing the Impact of Vaccine Characteristics and Alternative Vaccination Scenarios, 26 Vaccine 29, 38-39 (Supp. 5 2008).

24 Elbasha, supra note 23, at 34; Jane J. Kim & Sue J. Goldie, Health and Economic Implications of HPV Vaccination in the United States, 359 New Eng. J. Med. 821, 821 (2008).

25 Geoffrey P. Garnett, Role of Herd Immunity in Determining the Effect of Vaccines Against Sexually Transmitted Disease, 191 J. Infectious Diseases S97, S102 (Supp. I 2005); J. J. Kim et al., The Value of Including Boys in an HPV Vaccination Programme: A Cost- Effectiveness Analysis in a Low-Resource Setting, 97 Brit. J. Cancer 1322, 1324-27 (2007); J Roberto Leon, Ladies First: Should Boys Be Vaccinated Against HPV?, 54 Can. Fam. Physician 967, 967 (2008); J. Ryding et al., Seroepidemiology as Basis for Design of a Human Papillomavirus Vaccination Program, 26 Vaccine 5263 (2008).

26 Elbasha, supra note 23, at 30-33.

27 J. M. Msuya et al., Does Preventive Health Care Have a Chance in the Changing Health Sector in Tanzania?, 80 East. Afr. Med. J. 135-39 (2003).

28 Loretta Brabin et al., Current Issues in Adolescent Immunization, 26 Vaccine 4120, 4122 (2008); Amy B. Middleman, Adolescent Immunizations: Policies to Provide a Shot in the Arm for Adolescents, 41 J. Adolescent Health 109, 110-15 (2007).

29 P. Braveman & S. Gruskin, Defining Equity in Health, 57 J. Epidemiology Community Health 254, 254, 256 (2003); Davidson R. Gwatkin, 10 Best Resources on … Health Equity, 22 Health Pol’y Plan. 348, 348-49 (2007).

30 Margaret Whitehead, The Concepts and Principles of Equity and Health 12-14 (World Health Organization Regional Office for Europe 1990); see generally Aditi Iyer et al., The Dynamics of Gender and Class in Access to Health Care: Evidence from Rural Karnataka, India, 37 Int’l. J. Health Services 537 (2007) (discussing how gender and class can adversely impact one's ability to obtain access to health care treatment).

31 Vivien D. Tsu & Carol E. Levin, Making the Case for Cervical Cancer Prevention: What About Equity?, 16 Reprod. Health Mattters 104, 105 (2008); see also Amanda F. Dempsey & Gary L. Freed,. Human Papillomavirus Vaccination: Expected Impacts and Unresolved Issues, 152 J. of Pediatrics 305, 305-09 (2008).

32 Noel T. Brewer & Karah I. Fazekas, Predictors of HPV Vaccine Acceptability: A Theory-Informed, Systematic Review, 45 Preventative Med. 107, 111-12 (2007); Bernard Lo, HPV Vaccine and Adolescents’ Sexual Activity, 332 BMJ 1106, 1107 (2006); Sarah C. Woodhall et al., Anticipated Acceptance of HPV Vaccination at the Baseline of Implementation: A Survey of Parental and Adolescent Knowledge and Attitudes in Finland, 40 J. Adolescent Health 466, 467-68 (2007).

33 Gregory D. Zimet et al., Appropriate Use of Cervical Cancer Vaccine, 59 Ann. Rev. Med. 223, 229-30 (2008).

34 Id.

35 Brewer & Fazekas, supra note 32, at 112.

36 A. Bingham et al., Sociocultural Issues in the Introduction of Human Papillomavirus Vaccine in Low-Resource Settings, Archives Pediatric Adolescent Med. (forthcoming 2009).

37 Id.

38 Id.

39 Jacqueline Sherris et al., Chapter 25: Education, Training, and Communication for HPV Vaccines, 24 Vaccine S210, S214-15 (Supp. III 2006).

40 World Health Organization, Strategy to Prevent Cervical Cancer: Report of a Bi-Regional Consultation, Pattaya, Thailand, 11-13 April 2007 13-21 (WHO Regional Office for South-East Asia 2008); Jocelyn Kaiser, Price Is the Main Barrier to Wider Use of Papillomavirus Vaccine, 320 SCIENCE 860, 860 (2008).

41 Global Vaccine Alliance Board Approves $3.5B Investment Strategy that Includes HPV Vaccine, Med. News Today, June 27, 2008, http://www.medicalnewstoday.com/articles/113026.php.

42 Sarah Boseley, Where Lives Are Cheap, Guardian, Nov. 19, 2008, available at http://www.guardian.co.uk/commentisfree/2008/nov/19/cervical-cancer-vaccine-health.

43 Press Release, GAVI Alliance, GAVI Alliance to Vaccinate an Additional 6.6 Million Children Against Three Killer Diseases (Nov. 26, 2008), http://www.gavialliance.org/media_centre/press_releases/6_6_million_children_against_3_killer_diseases.php.

44 Jeremy Shiffman, Has Donor Prioritization of HIV/AIDS Displaced Aid for Other Health Issues?, 23 Health Pol’y Plan. 95, 97-99 (2008); Steven. W. Sinding, Keeping Sexual and Reproductive Health at the Forefront of Global Efforts to Reduce Poverty, 36 Stud. Fam. Plan. 140, 141 (2005).

45 Jude U. Ohaeri et al., The Psychosocial Burden of Caring for Some Nigerian Women With Breast Cancer and Cervical Cancer, 49 Soc. Sci. Med. 1541, 1542, 1545-49 (1999); Manfred Stommel et al., The Cost of Cancer Home Care to Families, 71 Cancer 1867, 1867-68, 1870-73 (1993); see Diane McIntyre et al., What Are the Economic Consequences for Households of Illness and of Paying for Health Care in Low- and Middle-Income Country Contexts?, 62 Soc. Sci. Med. 858, 858-59, 861-63 (2006).

46 Enid J. Schatz, “Taking Care of My Own Blood”: Older Women's Relationships to Their Households in Rural South Africa, 35 Scandinavian J. Pub. Health 147, 151-52 (Supp. 69 2007); Food and Agriculture Organization of the United Nations, FAO FOCUS: Women and Food Security, http://www.fao.org/FOCUS/E/Women/Sustin-e.htm (last visited Apr. 10, 2009).

47 United Nations Children's Fund, State of the World's Children (2008); F. E. Andre et al., Vaccination Greatly Reduces Disease, Disability, Death and Inequity Worldwide, 86 Bull. World Health Org. 140, 141-42 (2008); Enrique Delamonica et al., Monitoring Equity in Immunization Coverage, 83 Bull. World Health Org. 384, 389 (2005).

48 United Nations, The Millennium Development Goals Report (2008).

49 United Nations Children's Fund, Progress For Children: A World Fit for Children – Statistical Review (2007).

50 D. S. LaMontagne et al., Presentation at the 24th International Papillomavirus Conference, HPV Vaccine Implementation in Developing Countries: Understanding the Sociocultural Context, Health Systems Environment and Policy Landscape for Successful Vaccine Delivery (2007).

51 World Health Org., Diphtheria Vaccine (WHO position paper), 81 Wkly. Epidemiological Rec. 198-208 (2006).

52 PATH, Cervical cancer prevention initiatives at PATH: Two decades of progress toward a world free of HPV-related cancers (2009), http://www.rho.org/files/PATH_cxca_rep_to_world.pdf.

53 Id.

54 Id.

55 Id.

56 Id.

57 R. A. Katahoire et al., An Assessment of the Readiness for Introduction of the HPV Vaccine in Uganda, 12 Afr. J. Reprod. Health 159-72 (2008).

58 My thanks to D. S. LaMontagne, PATH, for these preliminary findings.

59 I. Ramos et al., Lessons Learned from Phase 1 of HPV Vaccination in Peru: 25th International Papillomavirus Conference (2009).

60 Id.

61 Id.

62 Press Release, GAVI Alliance, GAVI Alliance to Vaccinate an Additional 6.6 Million Children Against Three Killer Diseases, (Nov. 26, 2008), http://www.gavialliance.org/media_centre/press_releases/6_6_million_children_against_3_killer_diseases.php.

63 Richard T. Mahoney & James E. Maynard The Introduction of New Vaccines into Developing Countries, 17 Vaccine 646, 647, 649-51 (1999).

64 See generally Cervical Cancer Action, http://www.cervicalcanceraction.org (last visited Apr. 10, 2009).

65 Press Release, Pan American Health Organization, Experts Appeals for Integrated Programs to Prevent Cervical Cancer (May 14, 2008), www.paho.org/English/DD/PIN/pr080514.htm.

66 PAHO Directing Council Res. CD48.R10, 60th Sess. (Oct. 2, 2008), http://www.paho.org/English/GOV/CD/CD48.r10-e.pdf.

67 Princess Nikky Breast Cancer Foundation, 2nd Stop Cervical Cancer in Africa: Accelerating Access to HPV Vaccines Conference (2008), http://www.stopcervicalcancerinafrica.org/images/2008%20%20SCCA-%20Approved%20Final%20Report.doc.

68 See generally Carol E. Levin et al., Working Women in an Urban Setting: Traders, Vendors, and Food Security in Accra, 27 World Dev. 1977 (1999); U. N. Population Fund, Food for the Future: Women, Population, and Food Security (1996), http://www.unfpa.org/intercenter/food/.

69 See generally U.N. Dev. Fund for Women, Progress of the World's Women 2005: Women, Work & Poverty (2005) (prepared by Martha Chen et al.), available at http://www.unifem.org/resources/item_detail.php?ProductID=48.