HPV Vaccination in Latin America: Global Challenges and Feasible Solutions

"There is a great need for vigilance in the ongoing implementation of the HPV vaccine in Latin America; understanding the unique social and structural barriers pertaining to HPV vaccination and mounting a strong and timely response is needed to attain a substantial impact in HPV-related cancers."

As of 2019, the human papillomavirus (HPV) vaccine is available to more than 80% of adolescent girls in Latin America in the public health systems, but HPV vaccine uptake has been lower than expected for several reasons. This article discusses the current status of HPV vaccine coverage in Latin America and the main barriers that must be overcome to achieve adequate coverage.

The author describes as "alarming" the reduction in uptake of even the first vaccine dose in the years following the introduction of HPV vaccination into national immunisation calendars. For example, in Brazil, vaccination coverage with one or more doses decreased from 92% of girls aged 11-13 in 2014, when it was implemented, to 69.5% girls aged 9-11 in 2015. A similar trend was observed in Guadalajara, Mexico, which saw a 22% reduction in first-dose uptake from 2009 to 2013. Colombia has faced the deepest decrease in adherence. In 2013, Colombia had reached a first-dose coverage rate of 97.5%, the second-best rate worldwide after Australia. However, after the "Carmen de Bolivar episode", in which families in one Colombian town claimed the vaccine made girls sick, the coverage decreased to a mere 20.4% by the end of 2014. Furthermore, the rates of second and third doses are far below first-dose rates in Latin America.

"In light of trends like this and the unique nature of the HPV vaccine, countries in Latin America should delineate strategies for measuring and evaluating high vaccine compliance before launching their national programs."

According to parents and healthcare professionals, barriers to HPV vaccination are multifactorial but tend to fall into 4 main categories:

1. Limited knowledge of HPV, HPV-related diseases, and the features of the HPV vaccine - A Brazilian cross-sectional study cited here found that, while 40.0% of participants reported having heard about HPV, on closer questioning, only 8.6% had heard of HPV vaccines. Once the participants were informed of the existence of HPV vaccines, about 94% reported that they would get vaccinated and/or vaccinate their teenage children if vaccines were available in the public health system. "Increasing endorsement from trustable references for parents, like doctors and schools, is an essential step to leverage HPV vaccination in Latin America."
2. Misguided safety concerns by parents and some policymakers - According to the World Health Organization (WHO), more than 200 million doses of HPV vaccines have been distributed globally as of January 2016, and the Global Advisory Committee on Vaccine Safety has not found any safety issue that would alter its current recommendations for the use of HPV vaccination. "Like the important role of the health care provider in recommending the HPV vaccine to parents, providers should also inform parents about its overall safety as part of their recommendation, to dispel these misconceptions and improve acceptance." Ensuring sufficient time for doctor-patient communication during longer vaccination appointments and presenting the HPV vaccine in the context of other common and historically accepted childhood vaccines are among the recommended strategies.
3. Cost to health systems - Many countries in Latin America have begun to include the HPV vaccine within public health insurance systems, thereby increasing its accessibility and uptake. However, national governments must also take into account the additional resources required for vaccine delivery.
4. Cultural barriers - "Religious conservatism and the nature of HPV as a sexually transmitted infection have allowed cultural taboos to hinder communication and education about HPV. Specifically, there is a general discomfort among both parents and providers to discuss sex...and an unfounded belief that the HPV vaccine would increase adolescent sexual activity, which deters some parents from giving their child the vaccine....However, extensive studies have shown that HPV vaccination is not associated with increased sexual activity or earlier sexual activity among adolescents....Such information must be properly promoted by medical societies in Latin America and communicated to parents by primary health care providers in an effort to dispel taboos that prevent the uptake of beneficial health interventions. The focus of the HPV vaccine narrative must be shifted away from cultural taboos and toward the prevention of life-threatening diseases."

In conclusion: "Proper strategies for vaccine implementation, integrated monitoring, and a strong and timely response to barriers are needed to ensure successful uptake throughout the region."