Human Papillomavirus Vaccine Delivery Strategies That Achieved High Coverage in Low- and Middle-Income countries/Strategies De Delivrance Du Vaccin Contre le Papillomavirus Humain Ayant Realise Une Forte Couverture Vaccinale Dans Des Pays a Revenu Faible et moyen/Estrategias Para El Suministro De la Vacuna del Virus del Papiloma Humano Que Consiguieron Una Alta Cobertura En Paises Con Ingresos Bajos Y Medios

Introduction The global burden of cervical cancer is large and is increasing and it disproportionately affects low-resource countries. (1) In 2008 there were approximately 529 000 new cases and over 270 000 deaths, of which nearly 85% occurred in developing countries, (1) most often among women serving as caregivers and breadwinners in their communities. (2) Cervical cancer prevention programmes in developed countries, which are based on regular Papanicolaou (Pap) smears and appropriate treatment of precancerous lesions, have succeeded in reducing disease incidence and mortality since the 1970s, (3) but this expensive approach may prove difficult to implement and sustain in low-resource settings. (4,5) However, the Expanded Programme on Immunization (EPI), which has helped to reduce infectious disease rates and infant and child mortality throughout the world, provides a tested and effective infrastructure that could be used to prevent cervical cancer by adding the human papillomavirus (HPV) vaccine to the schedule. (6-8) The recent introduction of two highly efficacious vaccines against HPV--the necessary cause of cervical cancer--opens up new possibilities for disease prevention. (9) These vaccines can reduce cervical cancer deaths by more than 60% and the largest effects have been reported in countries that have received subsidized vaccine through the GAVI Alliance. (10) Vaccines against HPV are recommended by the World Health Organization (WHO) for girls aged 9 to 13 years before their sexual debut (11) and are prequalified (i.e. evaluated for the quality, safety and efficacy) for United Nations purchase. Recently, the GAVI Alliance announced a price of 5 United States dollars (US$) per dose for HPV vaccine, (12) a sum that approaches affordability for low-resource countries that are eligible for subsidized vaccine purchase and that increases the likelihood that the vaccine will be introduced. From 2006 to 2010, PATH, a global nongovernmental health organization, collaborated with the governments of India, Peru, Uganda and Viet Nam to gather evidence that would support decisions on whether and how to introduce HPV vaccines. Research was carried out in two phases: formative research and demonstration projects. During formative research, each country's sociocultural environment and the capacity of its health system and policy pathways were investigated before introducing HPV vaccination. (13) The results guided the development of the demonstration projects, which operated for 1 or 2 years in each country. (14-17) For each country and each strategy within a country, the principal research question was what level of HPV vaccination coverage--successful receipt of all three doses by the target population--could be achieved. This paper reports the HPV vaccination coverage achieved and the reasons that made individuals accept or decline vaccination. This information will assist government deliberations on the introduction of HPV vaccine programmes, particularly in low-resource settings. In-depth qualitative research on the acceptability of the HPV vaccine, the feasibility of different delivery strategies and the economic and programme costs of vaccine delivery were evaluated in separate studies and have been reported elsewhere. (18) Methods HPV vaccine demonstration projects The HPV vaccine demonstration projects were designed in partnership with the ministry of health, subnational health and education sector organizations and other key stakeholders in each country. Project locations were selected on the basis of the cervical cancer disease burden, the size of the target population, the local performance of the EPI, the interests of local health authorities, socioeconomic status, ethnic or linguistic diversity and geographical area. One of three vaccine delivery strategies was followed: school-based vaccination, health-centre-based vaccination or vaccination combined with other health interventions. …