Submission to the International Development Committee’s Inquiry into FCDO’s Approach to Sexual and Reproductive Health, June 2023

Background

Gavi’s HPV Vaccine Programme

The HPV Vaccine Programme is an important part of Gavi’s mission to save lives and protect people's health by increasing equitable and sustainable use of vaccines. More than 95% of cervical cancers are caused by the human papillomavirus (HPV) – which is transmitted from person-to-person during sexual contact. Of the vaccines in Gavi’s portfolio – which protect against 19 infectious diseases – the HPV vaccine is one of the most impactful, averting 17 deaths for every 1,000 children vaccinated. It is the key intervention towards achieving cervical cancer elimination and provides a unique opportunity to invest in the health of women and the future of girls. HPV vaccination is recommended particularly for girls 9-14 years of age. Adolescents are an underserved population for whom health investments would have both rapid and lasting impact with behaviours formed in adolescence influencing health and morbidity across life. Therefore, there is an opportunity to integrate HPV vaccination with other critical adolescent health needs, such as menstrual health, sexual reproductive health and rights (SRHR), nutrition, immunisation boosters, and deworming.

With cervical cancer causing 342,000 deaths in 2020, 90% of which are in low- and middle-income countries, the HPV vaccine has an important role in stemming the tide of these deaths. Gavi has set an ambitious goal to reach over 86 million girls by 2025, aiming to avert over 1.4 million future deaths from cervical cancer.

The Vaccine Alliance began supporting countries with HPV vaccines in 2012. Currently, HPV vaccines are supplied to 28 Gavi-supported countries, including 19 African countries.[1] These deployments include countries with the highest burden of cervical cancer in the world such as Malawi, Uganda, Tanzania, Zambia, and Zimbabwe – and most recently in Kyrgyzstan, Burkina Faso, Lesotho and Sierra Leone – essentially confronting this deadly cancer head on. In addition, some of the countries that Gavi anticipates will receive support in the next twelve months include Bangladesh, Cambodia, Ethiopia, Indonesia, Kenya, Nigeria, and Togo. As a result of these interventions, 3.9 million girls have been protected against HPV.

Severe global supply constraints, combined with the unique challenge of reaching adolescent girls with the HPV vaccine due to cultural sensitivities and gender-related barriers, have hampered the ability to improve coverage. The COVID-19 pandemic also severely impacted HPV vaccination programmes, resulting in girls missing out on life-saving vaccines. Consequently, global HPV vaccination coverage with the full series remains low at 12%.

To mitigate these challenges, Gavi and partners have been working relentlessly with manufacturers to support the development of a healthier HPV vaccine market. Supply challenges are now easing, thanks to increased production capacity and new vaccines receiving pre-qualification from the World Health Organisation. In addition, the WHO recommendation for a single-dose HPV vaccination schedule creates an opportunity for increased uptake and coverage, reduced vaccine and programme implementation costs, enhanced programme flexibility, and increased financial sustainability of vaccine delivery. These developments present a unique opportunity to accelerate progress toward reaching vaccination targets.

The sustained impact of the pandemic on routine immunisation particularly affected HPV vaccination due to restricted resources and prolonged school closures, resulting in a decline of programme performance, particularly in African countries. Governmental and partner commitment to HPV vaccine programmes – and to women’s and girls’ health – has never been more important; therefore, Gavi will seize the opportunity to prioritise relaunch of the HPV programme with an investment of over US$600 million. The funding will be used to purchase HPV vaccines, fund health systems strengthening activities and provide technical support to implementing countries.

Following the Board’s approval to revitalise Gavi’s HPV programme, the Vaccine Alliance – which includes country governments, World Health Organisation, UNICEF, Bill & Melinda Gates Foundation, civil society and other key partners – will work with low- and lower-middle income countries to help even more adolescent girls access this life-saving vaccine. The action plan to achieve this objective is three-pronged and includes:

• New funding and technical assistance to introduce the HPV vaccine into country health systems.
• Implementing multi-age cohort vaccination to rapidly catch-up and improve coverage.
• Driving sustainability through the integration of HPV vaccination into routine immunisation and primary health care.

Gavi will continue to work with countries that have already introduced the vaccine to help improve coverage. In parallel, Gavi will also offer support to countries to optimise the 2022 WHO Strategic Advisory Group of Experts on Immunisation (SAGE) one-dose recommendation, which now enables countries to opt for a single-dose schedule for the HPV vaccine and thus reach more girls with available supply. Country-led decision-making to adopt and implement the new guidelines will be critical to ensure political buy-in and stakeholder support.

Given the unique challenges of HPV vaccination; such as service delivery constraints, gender-related barriers, cultural nuances, and the importance of implementing effective and inclusive vaccination campaigns, Gavi will establish a learning agenda to support the integration of the HPV vaccination programme into routine immunisation programmes and adolescent health/primary health care services in low- and lower-middle income countries. HPV vaccination is often cited as an opportunity for immunisation and the broader health sector to connect with adolescents, and for secondary cervical cancer prevention interventions. However, there is limited experience of implementing HPV vaccination within routine immunisation or with other adolescent health interventions. Lessons learned from Tanzania and Togo show that operational details are key to success or failure.[2] For these reasons, Gavi has proposed an operational research agenda to enable programmatic learning on life-course vaccination and integration of HPV with adolescent health/primary health care. The approach will aim to provide evidence on reaching specific groups like out-of-school girls, HIV+ populations, delivery in fragile settings, and addressing gender-related barriers. This operational research conducted across multiple countries will carry important learnings for HPV introduction in fragile and conflict settings. As a key component of Gavi’s HPV vaccine revitalisation effort, the HPV learning agenda will help inform scale-up of sustainable, equitable, and impactful delivery strategies. Community engagement across diverse settings and the collaborative efforts of partners – including civil society organisations, the private sector, WHO, UNICEF, and governments – will be critical to the success of this agenda.