Lessons learned from Uganda: Delivering HPV vaccines to hard-to-reach girls
There is a major global equity gap in cervical cancer prevention. Approximately 266,000 cervical cancer deaths and 528,000 new cases occur each year, making it the fourth most common cancer among women worldwide. Nearly 90 percent of the global deaths from cervical cancer occur in low- and middle-income regions and 80 percent of women in these countries do not have access to cervical cancer screening –by the time they are diagnosed, the cancer has spread. More than 50 percent of women in the 6 countries CHAI supports (Uganda, Tanzania, Lesotho, Ethiopia, Kenya and Cameroon) die from the disease due to limited access to cervical cancer screening.
However, we now have access to an effective HPV vaccine that can prevent against HPV strains that cause more than 70 percent of all cervical cancers. The vaccine requires two standard intramuscular jabs in the arm, occurring between six and 18 months apart. In the 6 countries CHAI supports, if the governments can reach 85 percent coverage, 9,000 cervical cancer deaths can be averted annually. To this end, many governments are committed to introducing the vaccine into routine immunization and providing it to girls aged 9-14 for free.
But it is difficult to reach these girls for whom, traditionally, there are no specific, regular health services. As a result, in countries like Uganda, only 22 percent of girls targeted for their final dose of HPV vaccination by December 2016 were reached – despite the program having been available since November 2015. Where immunization programs have the resources to provide vaccinations at schools, they are still struggling to build efficient systems leveraging the education system; communicate disease and vaccine information to the girls, and ensure all girls are receiving both doses of the HPV vaccine. Some communities are also hesitant to accept the HPV vaccine because it’s targeted only at adolescent girls and is associated with a sexually transmitted disease. Moreover, the girls who are hardest to reach – they are often out of school, with less access to medical services – are also the girls with the least access to cervical cancer screening and treatment. Health programs are struggling to identify these girls and ensure they are protected by the vaccine, further compounding the inequitable realities of cervical cancer.
In 2017, CHAI began supporting the Ugandan government to understand why so many girls were not completing their HPV immunization course. Coordinating with the Ministry of Health, CHAI did a deep dive into HPV vaccination delivery in Karamoja region – one of the poorest and most remote regions of Uganda, which was also reporting the lowest uptake of HPV vaccination. CHAI discovered that there had been significant gaps in the training of health care workers on how to identify eligible adolescent girls (only half recalled receiving training, and of those only 40 percent knew the correct eligibility policy), the proper time between the delivery of the two vaccine doses (about a quarter of those trained did not know), and how to properly explain the facts around HPV disease and vaccine. Moreover, less than two thirds of caregivers had heard of HPV vaccination and of those, less than 2 percent knew when their girls were supposed to get vaccinated. Yet caregivers who had heard of the HPV vaccine were about 3 times more likely to seek it for their daughters.
CHAI also discovered that there was a bottleneck in the distribution of tools to support HPV programs – for example, less than half of health facilities in Karamoja region had HPV patient cards available, which are important tools to give to the girls as they help explain the risks of the disease, key HPV vaccination facts, and a reminder of when they should return for their second dose. No teachers had received job aids, which are guidelines to help lead girls through the HPV vaccination process, including providing them key information, warning of potential local irritation from vaccination, and reminders of when to expect or request their next dose of HPV vaccine. CHAI also discovered that most health facilities were carrying out HPV as a special activity – mostly during the months of April and October – rather than as a part of routine immunization.
CHAI then worked with the national government to clarify the HPV eligibility and schedule policy, inform community activists about the HPV vaccination program, and develop refresher trainings for all healthcare workers carrying out immunization activities. Additionally, CHAI supported immunization programs to test a new set of community engagement activities in 14 districts, including districts in Karamoja. This program reached 600 district health and education officials, as well as engaging local religious, community, and political leaders – and engaged parents by inviting them to ‘parent-teacher’ meetings at designated schools while healthcare workers were vaccinating. In these 14 districts, the number of girls that received their second dose of HPV went up by nearly 20 percent within a month of the engagement.
At the end of 2017, coverage for the second dose of HPV increased to 42 percent, still shy of the 85 percent target. However, with a clearer sense of the challenges, CHAI has been able to collaborate with the Ministry of Health and other key vaccination partners to develop a coverage improvement plan for the national program. This includes a national re-launch of the program that will engage community education, religious, and political leaders this year. The re-launch will also reengage schools and healthcare workers to strengthen their understanding of and role in the HPV vaccination program – including distribution of key materials and tools to all communities.
Moreover, CHAI has been able to use the lessons learned from the challenges the Ugandan program encountered to help other governments. Both Tanzania and Ethiopia are introducing HPV into routine immunization this year and are using the lessons learned from Uganda to clarify policies, engage the right stakeholders, and ensure that the right information is available to girls, schools, and teachers. In the coming years, at least three more countries are also preparing to leverage these learnings to strengthen introductions of the HPV vaccine with CHAI support.
The sharing of these best practices won’t be limited to countries where CHAI works. CHAI is working with a global group of partners who share information, challenges, and mitigation actions around HPV programs to ensure the success of countries eligible for Gavi support that have not yet introduced HPV programs.