Knowledge and Awareness of HPV Vaccine and Acceptability to Vaccinate in Sub-Saharan Africa: A Systematic Review

This systematic review of peer-reviewed studies on the knowledge and awareness of cervical cancer, human papillomavirus (HPV) and HPV vaccine, and willingness and acceptability to vaccinate was conducted to identify levels of awareness in sub-Saharan Africa (SSA) of HVP's relationship with cervical cancer and of the challenges of introducing the HPV vaccine, as well as concerns about safety, future fertility, and political factors. [Editor's note: Footnotes have been removed throughout this summary.]

An objective of the research was to assess the potential readiness for introduction of HPV vaccine in the African sub-continent and to find some of the challenges that might need to be addressed. GAVI Alliance criteria for vaccination support include: 1) a DTP3 threshold of 70% national coverage; and 2) a pilot demonstration of the ability to deliver a complete multi-dose series of vaccines. These determine eligibility for vaccination support, including HPV vaccine. Pilots or vaccine campaigns have been initiated in a number of countries, including Kenya, Rwanda, Cameroon, Tanzania, Lesotho, and South Africa, and demonstration projects are scheduled in 2014 for Mozambique, Zimbabwe, Ghana, Madagascar, Malawi, Niger, Sierra Leone, and Tanzania.  

Studies reviewed examined awareness, knowledge of cervical cancer, HPV, and acceptability of HPV vaccines in SSA. "Levels of awareness, knowledge, acceptability and willingness were broken down into these categories: 1) awareness of cervical cancer, HPV and/or HPV vaccine; 2) knowledge of cervical cancer, HPV and/or HPV vaccine; 3) acceptability of HPV vaccine (and in one case, acceptability of cervical cancer screening); and 4) willingness to vaccinate or get vaccinated."

"This review identified low levels of knowledge and mixed levels of awareness on cervical cancer, HPV and HPV vaccine, and high levels of acceptability of HPV vaccine among all key demographics. In particular, high acceptability of HPV vaccine despite the lack of knowledge about cervical cancer and HPV represents an opportunity for increased education and awareness strategies about cervical cancer, HPV and HPV vaccine." Challenges to public trust in HPV vaccines have occurred internationally and in Rwanda. "...[T]he qualitative insight provided by this review shows that factors influencing acceptability are often tied to issues of public trust, such as concerns over side effects and safety....Anti-vaccination groups frequently post inaccurate information about vaccine side effects on the web, which is publicized by both local and national media. These examples indicate the need to constantly engage and educate the public to avoid the risk of health programs failing. While it may not be advisable or possible to respond to all such misinformation, it is essential to counteract it by providing scientifically correct information in a proactive manner so people will seek appropriate medical advice for clarification....Tailored community-based interventions and sensitization programs are a viable means to achieve this for multiple reasons. They have the potential to curb concerns about safety and effectiveness of the vaccine while dispelling negative myths or controversies. Specific training for healthcare workers, the first contact point for patients, will provide them with the accurate knowledge and information necessary to discuss cervical cancer, HPV and HPV vaccine with their patients as well as the ability to properly detect, screen and test for HPV and cervical cancer."

Six countries met both GAVI criteria, although from 2008 through 2011 all SSA countries, with the exception of Mauritania and Nigeria, had reached or maintained DTP3 coverage at 70% or above. "Governments should leverage the high levels of acceptability and willingness to vaccinate by increasing education for healthcare workers, women/girls and parents/guardians. Governments should also determine appropriate strategies for disseminating information and vaccine delivery by building upon current infrastructures, such as existing EPIs [expanded programmes on immunisation] and school-based programs." Tailored community-based sensitisation campaigns aimed at a focus population also proved effective, suggesting that hybrid sensitisation and delivery models, per country, based on previous vaccination history, might be most effective.

The study concludes that: there are high levels of acceptability and willingness to vaccinate; tailored delivery strategies building on past immunisation campaigns can be used; six countries are GAVI-eligible; and there is a need for increased education and awareness.