Human Papilloma Virus Infections and Cervical Cancer in Africa: A Call for Action

Human Papilloma Virus (HPV) is a common virus that can infect the skin, genital area and throat of both men and women. There are many types of HPV, but some of them are more dangerous than others. These are called high-risk HPV types, and they can cause different types of cancers, especially cervical cancer in women. Cervical cancer is the cancer of the neck of the womb, and it is the leading cause of cancer deaths among women in Africa.

How common is HPV and cervical cancer in Africa?

According to the World Health Organization (WHO), HPV infection is very common worldwide, and almost all sexually active people will be infected at some point in their lives. However, HPV prevalence is among the highest in sub-Saharan Africa, at an average of 24%. This means that one in four women in this region has HPV infection. HPV infection is more common among women living with HIV, men who have sex with men, immunocompromised individuals, people with co-infection with other sexually transmitted infections, people who receive immunosuppressive medications and children who have been through sexual abuse.

HPV infection can cause abnormal cells to grow in the cervix, which can become cancerous over time. Cervical cancer is the most common type of cancer caused by HPV, but other less common cancers affecting men and women, such as anal, vulvar, vaginal, mouth/throat and penile cancers, can also be caused by HPV. HPV infection causes about 5% of all cancers worldwide, with an estimated 625 600 women and 69 400 men getting an HPV-related cancer each year.

In Africa, cervical cancer accounts for 22.5% of all female cancers and 12.9% of all female cancer deaths. In 2020, there were an estimated 119 284 new cases and 81 072 deaths from cervical cancer in Africa. Nigeria, the most populous country in Africa, had the highest number of new cases (25 398) and deaths (14 943) from cervical cancer in the continent.

How can HPV and cervical cancer be prevented?

The good news is that HPV and cervical cancer can be prevented with vaccines and screening. Vaccines can protect against the most common and dangerous types of HPV, such as HPV 16 and 18, which are responsible for approximately 70% of cervical cancer cases. The optimal age of vaccination is in the early adolescent period, before sexual debut and possible HPV infection. The vaccine does not contain any live virus or DNA from the virus, so it cannot cause cancer or other HPV-related illnesses. The vaccine is not used to treat HPV infections or diseases caused by HPV, but instead to prevent the development of cancers.

WHO now recommends:

• A one or two-dose schedule for girls aged 9-14 years.
• A one or two-dose schedule for girls and women aged 15-20 years.
• Two doses with a 6-month interval for women older than 21 years.

Boys can also benefit from HPV vaccination, as it can protect them from HPV-related cancers and genital warts and reduce the transmission of HPV to their sexual partners.

Screening is another way to prevent cervical cancer, by detecting and treating precancerous cell changes before they become cancer. Screening tests are used to check for disease when there are no symptoms. The goal of screening for cervical cancer is to find precancerous cell changes before they become cancer and when treatment can prevent cancer from developing. Screening for cervical cancer is an important part of routine health care for people who have a cervix. This includes women and transgender men who still have a cervix.

WHO recommends that all women aged 30-49 years undergo screening for cervical cancer at least once in their lifetime, using one of the following methods:

• HPV DNA testing: This is a test that detects the presence of high-risk HPV types in the cervix. It is the most accurate and effective method of screening, as it can identify women who are at high risk of developing cervical cancer. Women who test positive for HPV DNA should receive treatment or further testing to confirm the presence of precancerous lesions. Women who test negative for HPV DNA can safely wait for five years before repeating the test.
• Visual inspection with acetic acid (VIA): This is a test that involves applying a vinegar solution to the cervix and looking for any abnormal areas that turn white. It is a simple and low-cost method that can be done by trained health workers in low-resource settings. Women who test positive for VIA should receive immediate treatment or further testing to confirm the presence of precancerous lesions. Women who test negative for VIA can safely wait for three years before repeating the test.
• Pap smear: This is a test that involves collecting cells from the cervix and examining them under a microscope for any abnormal changes. It is a widely used method that requires laboratory and skilled personnel. Women who test positive for Pap smear should receive further testing or treatment to confirm the presence of precancerous lesions. Women who test negative for Pap smear can safely wait for three to five years before repeating the test.

Treatment of precancerous lesions can be done by various methods, such as cryotherapy, loop electrosurgical excision procedure (LEEP), or cold coagulation. These methods involve destroying or removing the abnormal cells from the cervix, using cold, heat, or electricity. They are usually done as outpatient procedures, with minimal pain and complications. Treatment of precancerous lesions can prevent up to 80% of cervical cancers.

What are the challenges and solutions for HPV vaccination and screening in Africa?

Despite the availability and effectiveness of HPV vaccines and screening, many women and girls in Africa do not have access to these lifesaving interventions. According to WHO, only 27 African countries have introduced HPV vaccines in their national immunization programmes, and 34 have started cervical cancer screening programmes, with 14 using HPV DNA testing. The African countries that have introduced the HPV vaccine had by 2020 delivered the first dose to 33% of girls aged 9-14. The COVID-19 pandemic has also disrupted immunization and screening programmes, as well as cancer diagnosis and treatment services, in many countries.

Some of the challenges that hinder the implementation and uptake of HPV vaccination and screening in Africa include:

• Limited health system capacities: Many African countries lack the infrastructure, human resources, equipment, and supplies to deliver HPV vaccines and screening services, especially in rural and remote areas. There is also a need for better surveillance, monitoring, and evaluation systems to track the coverage and impact of these interventions.
• Socio-economic status: Poverty, illiteracy, and lack of education are barriers to accessing and utilizing HPV vaccines and screening services, as well as seeking timely treatment for cervical cancer. Many women and girls cannot afford the cost of transportation, vaccines, tests, or treatment, or they face opportunity costs of losing income or time. Many women and girls also lack awareness and knowledge about HPV, cervical cancer, and the benefits of prevention.
• Stigma, fear, and myths: HPV and cervical cancer are often associated with shame, guilt, and blame, as they are linked to sexual activity and infection. Many women and girls fear the social consequences of being diagnosed with HPV or cervical cancer, such as rejection, discrimination, or violence. Many women and girls also have misconceptions and fears about the safety and efficacy of HPV vaccines and screening tests, such as believing that they can cause infertility, cancer, or other diseases, or that they are not compatible with their religious or cultural beliefs.
• Negative experience with vaccinations: Some women and girls have had bad experiences with previous vaccination campaigns, such as adverse reactions, lack of consent, or misinformation. This can erode their trust and confidence in the health system and the HPV vaccine, and make them reluctant to accept or return for the second dose.
• Lack of correct information, health education, and consent: Many women and girls do not receive adequate and accurate information about HPV, cervical cancer, and the prevention options, from reliable and trusted sources. There is also a need for more health education and communication campaigns to raise awareness and demand for HPV vaccines and screening services, and to address the stigma, fear, and myths that surround them. Moreover, there is a need for more respect for the rights and autonomy of women and girls, and to ensure that they give informed consent before receiving HPV vaccines or screening tests.

To overcome these challenges and to accelerate the elimination of cervical cancer in Africa, there is a need for concerted and coordinated action from all stakeholders, including governments, health authorities, donors, partners, civil society, communities, and individuals. Some of the possible solutions and recommendations include:

• Strengthening health system capacities: There is a need to invest in and improve the infrastructure, human resources, equipment, and supplies for delivering HPV vaccines and screening services, especially in rural and remote areas. There is also a need to strengthen the surveillance, monitoring, and evaluation systems to track the coverage and impact of these interventions, and to use the data for evidence-based decision making and planning.
• Embracing innovation and integration: There is a need to embrace innovation and adopt the latest WHO recommendations and guidelines for HPV vaccination and screening, such as switching to a single-dose HPV vaccine schedule, using HPV DNA testing as the primary screening method, and integrating HPV vaccines and screening services with other health interventions.
• Stakeholder engagement and innovative awareness creation strategies must be deployed to foster acceptability and uptake. This should include the use of mass media, social media and other locally-endorsed and acceptable communication channels. The content of such communication activities should include though not limited to dispelling of rumours and misinformation around safety and reasons for HPV vaccination.

Human Papilloma Virus is a threat to Africa. But this should not be with the availablity of life-saving vaccines. More efforts are needed to deploy the vaccines – and even more commitment and efforts to make them accessible and acceptable to the people.

The video linked below provides additional information about HPV.