A call for the introduction of gender-neutral HPV vaccination to national immunisation programmes in Africa
Authors: Onyema Greg Chido-Amajuoyi, Joël Fokom Domgue, Chisom Obi-Jeff, Kathleen Schmeler, Sanjay Shete
Journal: The Lancet Global Health (2018)

Human papillomavirus (HPV) causes more than 90% of cervical and anal cancers, more than 70% of oropharyngeal cancers, and a substantial proportion of vaginal, vulvar, and penile cancers. About 85% of women and 91% of men with a sexual partner will be infected with HPV in their lifetime.1Chesson HW Dunne EF Hariri S Markowitz LE The estimated lifetime probability of acquiring human papillomavirus in the United States.Sex Transm Dis. 2014; 41: 660-664Crossref PubMed Scopus (271) Google Scholar However, if countries can attain 80% HPV vaccination coverage in both men and women, HPV-associated cancers could be eliminated.2Brisson M Bénard É Drolet M et al.Population-level impact, herd immunity, and elimination after human papillomavirus vaccination: a systematic review and meta-analysis of predictions from transmission-dynamic models.Lancet Public Health. 2016; 1: e8-e17Summary Full Text Full Text PDF PubMed Scopus (166) Google Scholar The theme of the upcoming European Research Organization on Genital Infection and Neoplasia conference, due to be held in December 2018—"From control to elimination of HPV induced cancers: time to match visions with actions"—could not be more pertinent to the African continent. Evidence3Jemal A Simard EP Dorell C et al.Annual report to the nation on the status of cancer, 1975–2009, featuring the burden and trends in human papillomavirus (HPV)–associated cancers and HPV vaccination coverage levels.J Natl Cancer Inst. 2013; 105: 175-201Crossref PubMed Scopus (803) Google Scholar suggests that the global prevalence of HPV-associated cancers is increasing, with the highest burden of cervical cancer in Africa.4Ginsburg O Bray F Coleman MP et al.The global burden of women's cancers: a grand challenge in global health.Lancet. 2017; 389: 847-860Summary Full Text Full Text PDF PubMed Scopus (508) Google Scholar However, as of May 2018, only seven African countries (Libya, Uganda, Seychelles, Rwanda, South Africa, Botswana, and Lesotho; appendix) had started offering HPV vaccination for girls through their national immunisation programmes. Furthermore, no countries in western and central Africa had introduced widespread HPV vaccination in their national immunisation programmes. Although the HPV vaccine might be offered sporadically by institutions or missions in some nations, the importance of inclusion of vaccines in the national immunisation programme is well documented,5Tabrizi SN Brotherton JM Kaldor JM et al.Fall in human papillomavirus prevalence following a national vaccination program.J Infect Dis. 2012; 206: 1645-1651Crossref PubMed Scopus (211) Google Scholar since it represents a commitment at the national level to tackle a disease and includes benefits such as reduced cost of vaccination. Studies3Jemal A Simard EP Dorell C et al.Annual report to the nation on the status of cancer, 1975–2009, featuring the burden and trends in human papillomavirus (HPV)–associated cancers and HPV vaccination coverage levels.J Natl Cancer Inst. 2013; 105: 175-201Crossref PubMed Scopus (803) Google Scholar demonstrating the rising prevalence of oropharyngeal carcinomas have shown that incidence is higher in men than in women. Collated data from some African regions largely corroborate this finding (appendix). However, HPV is still largely considered a disease of predominant concern to women, and thus HPV vaccines are not widely offered to men. At present, no countries in Africa offer HPV vaccination to men (appendix). The prevalence of genital HPV infection is as high as 45% in men, and up to 25% of men carry at least one high-risk HPV subtype;6Han JJ Beltran TH Song JW Klaric J Choi YS Prevalence of genital human papillomavirus infection and human papillomavirus vaccination rates among US adult men: National Health and Nutrition Examination Survey (NHANES) 2013–2014.JAMA Oncol. 2017; 3: 810-816Crossref PubMed Scopus (80) Google Scholar therefore, male HPV vaccination might have greater utility for cancer prevention in men and women than previously estimated.6Han JJ Beltran TH Song JW Klaric J Choi YS Prevalence of genital human papillomavirus infection and human papillomavirus vaccination rates among US adult men: National Health and Nutrition Examination Survey (NHANES) 2013–2014.JAMA Oncol. 2017; 3: 810-816Crossref PubMed Scopus (80) Google Scholar Globally, the initial formulation and rollout of the HPV vaccine focused on women and has resulted in disparities between the sexes in the prevention of HPV-related cancers;7Daley EM Vamos CA Zimet GD Rosberger Z Thompson EL Merrell L The feminization of HPV: reversing gender biases in US human papillomavirus vaccine policy.Am J Public Health. 2016; 106: 983Crossref PubMed Scopus (36) Google Scholar however, several countries across Europe, the USA, and Asia have since introduced HPV vaccination for men. In June 2018, all cancer centres in the USA aligned with the National Cancer Institute set a goal of eliminating HPV-associated cancers through gender-neutral HPV vaccination. Debate is ongoing about the cost-effectiveness of male HPV vaccination,8Chesson HW Ekwueme DU Saraiya M Dunne EF Markowitz LE The cost-effectiveness of male HPV vaccination in the United States.Vaccine. 2011; 29: 8443-8450Crossref PubMed Scopus (156) Google Scholar, 9Brisson M Jit M Boily M et al.Modelling estimates of the incremental effectiveness & cost-effectiveness of HPV vaccination.http://www.who.int/immunization/sage/meetings/2016/october/07_Modelling_HPV_immunization_strategies.pdfDate accessed: November 23, 2018Google Scholar but evidence suggests marked benefits.10Bogaards JA Wallinga J Brakenhoff RH Meijer CJ Berkhof J Direct benefit of vaccinating boys along with girls against oncogenic human papillomavirus: bayesian evidence synthesis.BMJ. 2015; 350: h2016Crossref PubMed Scopus (58) Google Scholar Cost-effectiveness models dissuading gender-neutral vaccination are inadvertently skewed, since they are based on either male or female vaccination as opposed to both.11Daley EM Vamos CA Thompson EL et al.The feminization of HPV: how science, politics, economics and gender norms shaped US HPV vaccine implementation.Papillomavirus Res. 2017; 3: 142-148Crossref PubMed Scopus (72) Google Scholar Additionally, economic evaluations of HPV vaccination in Africa are severely limited; current recommendations for women-only HPV vaccination are based on studies done in other regions with dissimilar distributions of HPV infection and associated cancers. Cost-benefit models often underestimate the added value of male vaccination, because they assume that female vaccination coverage is higher.8Chesson HW Ekwueme DU Saraiya M Dunne EF Markowitz LE The cost-effectiveness of male HPV vaccination in the United States.Vaccine. 2011; 29: 8443-8450Crossref PubMed Scopus (156) Google Scholar Considering the time it could take to fully implement programmes that would ensure herd immunity through female-only HPV vaccination, we strongly recommend gender-neutral HPV vaccination for the prompt prevention of HPV-associated cancers. Moreover, since screening for HPV-associated cancers is largely unavailable to men in Africa, vaccination represents the single most important preventive measure in this demographic. Gavi, the Vaccine Alliance, currently provides subsidised female-only HPV vaccines (US$4·50 per dose) to eligible African countries. Although the need for African nations to develop the capacity to sustainably finance human vaccines cannot be overemphasized, African Ministries of Health might be encouraged if gender-neutral HPV vaccines were also available through Gavi at similar subsidised rates. Studies have found similar efficacy between single and two-dose HPV vaccination, thus Ministries of Health in Africa might consider exploring single-dose HPV vaccination since this could be highly cost-effective and lead to higher HPV immunisation coverage in shorter time frames.12Burger EA Campos NG Sy S Regan C Kim JJ Health and economic benefits of single-dose HPV vaccination in a Gavi-eligible country.Vaccine. 2018; 36: 4823-4829Crossref PubMed Scopus (31) Google Scholar Although the number of HPV-attributed cancer cases among men is relatively few compared to that among women, in Africa, obtaining accurate health-related data and statistics remains a considerable problem, and the true burden of HPV-associated cancers remains unclear. Considering the growing prevalence of HPV-associated cancers in other parts of the world, it is imperative that preventive measures are established by incorporating gender-neutral HPV vaccination into the immunisation programmes of all African nations. We declare no competing interests. This work was supported in part by the Barnhart Family Distinguished Professorship in Targeted Therapy, the Duncan Family Institute for Cancer Prevention and Risk Assessment, the Cancer Prevention Research Institute of Texas (RP170259), and the MD Anderson Cancer Center (CA016672). Download .pdf (.13 MB) Help with pdf files Supplementary appendix Gender-neutral HPV vaccination in AfricaOnyema Chido-Amajuoyi and colleagues (January, 2019)1 appeal for the introduction of gender-neutral human papillomavirus (HPV) vaccination to national immunisation programmes in Africa, as has been done in many developed countries such as the USA and Australia. Gender-neutral HPV vaccination seems to have become a trend worldwide, but its introduction might not be a simple task to achieve in Africa. Full-Text PDF Open AccessGender-neutral HPV vaccination in Africa – Authors' replyWe thank Ruo-Yu Zhuang and colleagues for their interest in our recent Comment.1 We acknowledge their points in support of an initial introduction of human papillomavirus (HPV) vaccination for females, later followed by the inclusion of males. Full-Text PDF Open Access