Human Papilloma Virus in the developing world

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The Human Papilloma Virus (HPV) is one of the most common sexually transmitted infections among adults worldwide and it is estimated that 80% of women in America will have contracted at least one type of HPV by the age of 50. Most are unaware they have carried it and their body will recover over a time period of approximately 8 to 14 months. Despite many of the different strains of the virus  posing no health detriment, types 16 and 18 have been shown to cause 7 out of 10 (70%) cervical cancers.

HPV is a virus from the Papillomavirus family that affects the human skin and moist membranes that line the body such as the throat, mouth, feet, fingers, nails, anus and cervix. Of the 100 types of HPV, 40 can affect the genital area. Most types can go by unnoticed with 90% of infections being destroyed by the body’s immune system. Some types of HPV can cause genital warts and throat warts but can be easily treated and do not affect a person’s health long term. However, the HPV strains that cause cervical cancer alter the cells in the body so that they become cancerous.

Each year an estimated 529,000 new cases of cervical cancer are diagnosed of which 275,000 will die of their disease. As a worldwide statistics this isn’t particularly shocking, until discovering that about 85% of the new cases detected and 80% of deaths from cervical cancer occur in the developing world.

In 2006, the first HPV vaccine program was introduced in Austria which offered two revolutionary drugs; Gardasil and Cervarix. Both have shown to provide protection from types 16 and 18 whilst Gardasil also protects against HPV types 6 and 11, which can cause 90% of genital warts. The vaccine is primarily targeted at young females between the ages of 9 to 25 as they are unlikely to have been exposed to HPV.

While both the UK, America and other well developed countries have now introduced HPV vaccination programs, the price of the vaccine presents a problem for low and middle income countries. For example in Kenya, whilst both HPV drugs have been approved by the Pharmacy and Poison Board, at a cost of approximately 20,000 Kenyan shillings (US$232.70) which is more than the average annual family income, many Kenyans are unable to afford the vaccine.

In other developing countries such as Tanzania, cervical cancer is the most common cause of cancer-related deaths among women of which most cases are caused by carcinogenic HPV types (types 16 and 18). The introduction of this vaccine could offer a new opportunity for cervical cancer control but whilst the cost provides a barrier, less economically fortunate countries could miss out on a life-saving opportunity. Fortunately, in November 2011 the GAVI-Alliance (Global Alliance for Vaccines and Immunizations) announced their move towards providing financial support to eligible countries, allowing the HPV vaccine to become an option.

However, in such highly populated countries  and where, for example, in Tanzania the median age among females is 19 years old, information of country-wide implementation costs is necessary but is somewhat lacking. A paper recently published in BMC Medicine entitled “Costs of Delivering Human Papillomavirus Vaccination to School Girls in Mwanza Region, Tanzania” attempted to tackle this issue by estimating the costs of a school-based HPV vaccine project that compared two different vaccine delivery strategies: class-based and age-based vaccination with health centre vaccination for those that missed a dose at school. The results showed that costs for class-based delivery rather than age-based delivery were lower, and the economic scaled-up costs for Tanzania’s Mwanza region were an estimated US$1.3 million.

Another paper published in BMC Medicine also examined “Costing nationwide HPV vaccine delivery in Low and Middle Income Countries using the WHO Cervical Cancer Prevention and Control Costing Tool: A case study of The United Republic of Tanzania” where the World Health Organization (WHO) and colleagues tested the new WHO Cervical Cancer Prevention and Control Costing (C4P) tool over a five-year planning period. This tool aimed to assist low-and middle-income countries with planning their HPV vaccine programs and estimates costs to the health system of vaccinating adolescent girls through schools, health facilities and outreach-based strategies. It was estimated that the vaccine could be delivered at US$12.40 per fully immunized girl in terms of economic costs, again excluding vaccine costs. The authors noted that introducing these vaccination programs will incur initial start-up costs to fund pre-introduction activities such as training and to ensure that the vaccine is delivered on an ongoing basis. Yet after this introduction the costs would be cheaper and make HPV vaccination even more affordable. Lead author on both papers, Raymond Hutubessy from the WHO commented, “These figures will enable governments to plan ahead so that they can adequately secure the financial resources required to introduce HPV vaccination programs.”

The current financial challenges mean that cervical cancer screenings and treatment are not readily available, and the ordinary working-class citizen is unlikely to receive what could be a life-saving treatment. The importance of these studies is not only the statistics they provide but also their ability to raise global awareness of HPV and cervical cancer and how with a public intervention, the 85% of diagnosed cases and the 80% of mortalities throughout the developing world could be significantly reduced.

For more information on HPV in the developing world, visit the WHO website.