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The past 10 years have seen remarkable progress in the global scale-up of human papillomavirus (HPV) vaccinations. Forty-three low- and lower-middle-income countries (LLMICs) have gained experience in delivering this vaccine to young adolescent girls through pilot programs, demonstration programs, and national introductions and most of these have occurred in the last 4 years. The experience of Senegal is summarized as an illustrative country case study. Publication of numerous delivery experiences and lessons learned has demonstrated the acceptability and feasibility of HPV vaccinations in LLMICs. Four areas require dedicated action to overcome remaining challenges to national scaling-up: maintaining momentum politically, planning successfully, securing financing, and fostering sustainability. Advances in policy, programming, and science may help accelerate reaching 30 million girls in LLMICs with HPV vaccine by 2020.

Background: Cervical cancer is responsible for around one-quarter of all cancer deaths among Ghanaian women. Between 2013 and 2015, Ghana conducted a pilot of HPV vaccination among 10–14-year-old girls in four regions; however, the country has yet to introduce the vaccine nationally. This study projected the cost-effectiveness and budget impact of adding HPV vaccination into Ghana's national immunization program. Methods: We used a proportional outcomes model (UNIVAC, version 1.4) to evaluate the cost-effectiveness of introduction with bivalent (Cervarix™) and quadrivalent (Gardasil®) vaccines from government and societal perspectives. Vaccine introduction was modeled to start in 2022 and continue over ten birth cohorts using a combined delivery strategy of school (80%) and community outreach (20%). We modeled vaccination in a single age cohort of 9-year-old girls vs. a multi-age cohort of 9-year-old girls (routine) and 10–14-year-old girls (one-time campaign) compared to no vaccination. Health outcomes included cervical cancer cases, hospitalizations, deaths, and disability-adjusted life years (DALYs). We applied a discount rate of 3% to costs and outcomes. All monetary units are reported in USD 2018. Results: National HPV vaccination in Ghana was projected to be cost-effective compared to no vaccination in all scenarios evaluated. The most cost-effective and dominant strategy was vaccination among 9-year-old girls, plus a one-time campaign among 10–14-year-old with the bivalent vaccine ($158/DALY averted from the government perspective; 95% credible range: $19–$280/DALY averted). Projected average annual costs of the vaccine program ranged from $11.2 to $15.4 M, depending on strategy. This represents 11–15% of the estimated total immunization costs for 2022 ($100,857,875 based on Ghana's comprehensive Multi-Year Plan for Immunization, 2020–2024). Discussion: Our model suggests that introducing HPV vaccination would be cost-effective in Ghana under any strategy when willingness-to-pay is at least 40% GDP per capita ($881). Inclusion of a one-time catch-up campaign is shown to create greater value for money than routine immunization alone but would incur greater program costs.

Since 2007, low and middle-income countries (LMICs) have gained experience delivering HPV vaccines through HPV vaccination pilots, demonstration projects and national programmes. This commentary summarises lessons from HPV vaccination experiences in 45 LMICs and what works for HPV vaccination introduction. Methods included a systematic literature review, unpublished document review, and key informant interviews. Data were extracted from 61 peer-reviewed articles, 11 conference abstracts, 188 technical reports, and 56 interviews, with quantitative data analysed descriptively and qualitative data analysed thematically. Key lessons are described under five themes of preparation, communications, delivery, coverage achievements, and sustainability. Lessons learnt were generally consistent across countries and projects and sufficient lessons have been learnt for countries to deliver HPV vaccine through phased national rollout rather than demonstration projects. However, challenges remain in securing the political will and financial resources necessary to implement successful national programmes.

Since 2007, low and middle-income countries (LMICs) have gained experience delivering HPV vaccines through HPV vaccination pilots, demonstration projects and national programmes. This commentary summarises lessons from HPV vaccination experiences in 45 LMICs and what works for HPV vaccination introduction. Methods included a systematic literature review, unpublished document review, and key informant interviews. Data were extracted from 61 peer-reviewed articles, 11 conference abstracts, 188 technical reports, and 56 interviews, with quantitative data analysed descriptively and qualitative data analysed thematically. Key lessons are described under five themes of preparation, communications, delivery, coverage achievements, and sustainability. Lessons learnt were generally consistent across countries and projects and sufficient lessons have been learnt for countries to deliver HPV vaccine through phased national rollout rather than demonstration projects. However, challenges remain in securing the political will and financial resources necessary to implement successful national programmes.

Introduction of human papillomavirus (HPV) vaccine in national programs has proceeded apace since 2006, mostly in high-income countries. Recently concluded pilots of HPV vaccination in low-income countries have provided important lessons learned for these settings; however, rigorous evaluations of the feasibility of these delivery strategies that effectively reach young adolescents have been few. This paper presents results from a qualitative evaluation of a demonstration program which implemented school-based and health center–based HPV vaccinations to all girls in grade 6, or 11 years of age, for two years in four districts of Vietnam.

BACKGROUND: Social mobilisation during new vaccine introductions encourages acceptance, uptake and adherence to multi-dose schedules. Effective communication is considered especially important for human papillomavirus (HPV) vaccine, which targets girls of an often-novel age group. This study synthesised experiences and lessons learnt around social mobilisation, consent, and acceptability during 55 HPV vaccine demonstration projects and 8 national programmes in 37 low and middle-income countries (LMICs) between January 2007 and January 2015. METHODS: A qualitative study design included: (i) a systematic review, in which 1,301 abstracts from five databases were screened and 41 publications included; (ii) soliciting 124 unpublished documents from governments and partner institutions; and (iii) conducting 27 key informant interviews. Data were extracted and analysed thematically. Additionally, first-dose coverage rates were categorised as above 90 %, 90-70 %, and below 70 %, and cross-tabulated with mobilisation timing, message content, materials and methods of delivery, and consent procedures. RESULTS: All but one delivery experience achieved over 70 % first-dose coverage; 60 % achieved over 90 %. Key informants emphasized the benefits of starting social mobilisation early and actively addressing rumours as they emerged. Interactive communication with parents appeared to achieve higher first-dose coverage than non-interactive messaging. Written parental consent (i.e., opt-in), though frequently used, resulted in lower reported coverage than implied consent (i.e., opt-out). Protection against cervical cancer was the primary reason for vaccine acceptability, whereas fear of adverse effects, exposure to rumours, lack of project/programme awareness, and schoolgirl absenteeism were major reasons for non-vaccination. CONCLUSIONS: Despite some challenges in obtaining parental consent and addressing rumours, experiences indicated effective social mobilisation and high HPV vaccine acceptability in LMICs. Social mobilisation, consent, and acceptability lessons were consistent across world regions and HPV vaccination projects/programmes. These can be used to guide HPV vaccination communication strategies without additional formative research.