Money, sex and rumours: Tanzania faces challenges to protect girls from HPV

When health workers arrived at Upendo Primary School on the outskirts of the Tanzanian capital, they instructed girls who would turn 14 this year to line up to get an injection. Quinn Chengo held an urgent, whispered consultation with her friends. What was the injection actually for? Could it be a Covid vaccine? (They had heard rumors about it.) Or was it to prevent them from having babies?

Ms. Chengo was not at ease, but she remembered that her sister received this injection for human papillomavirus last year. So she got in line. However, some girls snuck away and hid behind the school buildings. When some of Ms. Chengo’s friends came home that night, they received questions from their parents, who were concerned that their children might feel more comfortable with the idea of ​​having sex – even if some of them didn’t want to come out right away and say So.

The HPV vaccine, which provides nearly complete protection against the sexually transmitted virus that causes cervical cancer, has been given to adolescents in the United States and other industrialized countries for nearly 20 years. But it’s only now beginning to be widely introduced in lower-income countries, where 90 percent of cervical cancer deaths occur.

Tanzania’s experience – with disinformation, with cultural and religious discomfort, and with supply and logistical obstacles – highlights some of the challenges countries face in implementing what is seen as a critical health intervention in the region.

Cancer screening and treatment are limited in Tanzania; the shot could greatly reduce deaths from cervical cancer, the deadliest form of cancer for Tanzanian women.

HPV vaccination efforts have been hampered across Africa for years. Many countries had programs designed to begin in 2018, in partnership with Gavi, a global organization that supplies vaccines to low-income countries. But Gavi couldn’t arrange injections for them.

In the United States, the HPV vaccine costs about $250; Gavi, which typically negotiates deep discounts from drug companies, planned to pay $3 to $5 per injection for the large quantities of vaccine it wanted to buy. But as high-income countries also expanded their programs, the vaccine makers – Merck and GlaxoSmithKline – focused on those markets, leaving little for developing countries.

“Even though we had spoken out about the supply we needed from manufacturers, it fell through,” said Aurélia Nguyen, Gavi’s chief strategy officer. “And so we had 22 million girls that had asked countries to be vaccinated for whom we had no supply at the time. That was a very painful situation.”

Lower-income countries have had to make a decision about the destination of the limited amounts of vaccine they have received. Tanzania chose to target 14-year-olds first who, as the oldest eligible girls, were most likely to initiate sexual activity. Girls start to drop out at that age, before the transition to high school; the country planned to deliver the vaccines mainly to schools.

But vaccinating a teen against HPV is not the same as giving a measles shot to a baby, said Dr. Florian Tinuga, program manager of the Department of Health’s Department of Immunization and Vaccine Development. Fourteen-year-olds need to be convinced. But since they are not yet adults, parents must also be won over. That means talking openly about sex, a sensitive issue in the country.

And because the 14-year-olds were seen as young women almost old enough to get married, rumors quickly spread on social media and messaging apps about what’s really in the picture: Could it be a secret birth control campaign coming out of the West? comes?

The government had not foreseen that problem, Dr. Tinuga said sadly. The rumors were difficult to refute in a population with a limited understanding of research or scientific evidence.

The Covid pandemic further complicated the HPV campaign as it disrupted health systems, forced school closures and created new levels of vaccine hesitancy.

“Parents pull children out of school when they hear the vaccine is coming,” said Khalila Mbowe, who heads the Tanzanian office of Girl Effect, a non-governmental organization funded by Gavi to boost demand for the vaccine. “After Covid, the problems with vaccination have increased enormously.”

Girl Effect produced a radio drama, slick posters, chatbots and social media campaigns encouraging girls to get the shot. But those efforts and other efforts in Tanzania have focused on motivating girls to accept the vaccine, without giving due consideration to the power of other gatekeepers, including religious leaders and school officials, who have a strong say in the decision, he said. Mrs Mbowe.

Asia Shomari, 16, was shocked last year when health workers came to her school on the outskirts of Dar es Salaam. The students were not informed and did not know what the shot was for. It was an Islamic school where sex was never discussed, Ms. Shomari said. She and some friends hid behind a toilet block until the nurses left.

“Most of us decided to run,” she said. When she went home and told what had happened, her mother said she had done the right thing: any vaccine involving reproductive organs was suspect.

But now her mother, Pili Abdallah, is starting to reconsider. “Girls her age are sexually active and there is a lot of cancer,” she said. “If she could be protected, that would be good.”

While Girl Effect directed some messages at mothers, the truth is that fathers have the final say in most families, Ms Mbowe said. “The decision-making power is not with the girl.”

Despite all the challenges, Tanzania managed to vaccinate almost three-quarters of its 14-year-old girls with a first dose in 2021. (Tanzania reached that goal for first-dose coverage twice as fast as the United States.) It was harder to convince people to come back for a second dose: Only 57 percent got the second shot six months later. A similar gap persists in most sub-Saharan countries that have begun HPV vaccination.

As Tanzania largely relies on pop-up clinics in schools to deliver the injections, some girls miss the second dose because they have left school by the time health workers return.

Rahma Said was vaccinated at school in 2019, when she was 14. But not long after, she failed the high school exams and dropped out. Ms Said tried a few times to get a second shot at public health clinics in her area, but no one had the vaccine, and last year, she said, she gave up.

Next year, Tanzania will most likely switch to a single-dose regimen, said Dr. Tinuga. There is growing evidence that a single injection of the HPV vaccine will provide adequate protection, and in 2022 WHO recommended that countries switch to a single-dose campaign, which would improve cost and vaccine supply and reduce the challenge of trying to vaccinate girls would take away a second time.

Another cost-cutting step, public health experts say, would be to move from school vaccination to making the HPV shot one of the routine vaccines offered at health centers. Making that shift will require a massive and sustained effort from public education.

“We have to make sure that demand is very, very strong because they normally won’t come to facilities for other interventions,” Gavi’s Ms. Nguyen said.

Now stockpiles of the vaccine have finally been built up, Ms Nguyen said, and new versions of the vaccine have entered the market from companies in China, India and Indonesia. Supply is expected to triple by 2025.

Populated countries, including Indonesia, Nigeria, India, Ethiopia and Bangladesh, plan to introduce or expand the vaccine this year, which could even test the extensive supply. But the hope is that there will soon be enough doses for countries to vaccinate all girls between the ages of 9 and 14, Ms Nguyen said. Once they catch up, the vaccine will become routine for 9-year-olds.

“We have set a goal to have 86 million girls by the end of 2025,” she said. “That will prevent 1.4 million deaths.”

Ms. Chengo and her friends went into convulsions with giggles at the mere mention of sex, but they said that in fact many girls in their class were already sexually active, and that it would be better if Tanzania introduced girls at the age of 9 can vaccinate.

“Eleven is too late,” said Restuta Chunja, shaking his head gloomily.

Ms Chengo, a sparkling-eyed 13-year-old who plans to become a pilot when she finishes school, said her mother had told her the vaccine would protect her against cancer but she shouldn’t get any ideas.

“She told me not to get married or be involved in sexual activities because that would be bad and you could get something like HIV”

The HPV vaccine is offered to both boys and girls in higher-income countries, but the WHO advises prioritizing girls in developing countries with existing vaccine offerings because women get 90 percent of HPV-related cancers.

“From a Gavi perspective, we’re not there yet, adding guys,” Ms Nguyen said.

Dr. Mary Rose Giattas, a cervical cancer expert and medical director in Tanzania for Jhpiego, a healthcare nonprofit affiliated with Johns Hopkins University, believes any remaining hesitation can be overcome. When she informs the public about the shot, she talks about Australia.

“I say forget the rumours: Australia has almost eradicated cervical cancer. And why? Because they vaccinate. And if the vaccine caused a fertility problem, we would know because they were one of the first countries to use it.”

Misconceptions can be cleared up with “chewable pieces of evidence,” she said. “I say, our Ministry of Health is taking serious steps to test drugs: they don’t come directly from Europe to your clinic. I say to women, ‘Unfortunately, you and I missed it because of our age, but I wish I could get vaccinated now.’”