HPV Vaccination In Rwanda

According to Ferlay et al, cervical cancer caused by Human Papilloma Virus (HPV) contributes to highest years of lost life claiming 275,000 lives of women annually in developing countries (Binagwaho et al., 2012). In a country with a population of about 11 million in 2010, Rwanda diagnosed 986 cases with 678 succumbing to the condition. By then, few private facilities and non-governmental organizations were offering screening services. With an estimated 77% new cases and 88% deaths of cervical cancer, Rwanda explored HPV vaccination to young girls as a prevention measure (Binagwaho et al., 2012).

The HPV vaccination targets young girls aged between 9-15 years before their sexual debut for life protection as the virus is transmitted through direct skin contact during sexual activity and women between 35 and 45 years living with HIV as they are susceptible to cervical cancer. In Rwandan context, Janet Kagame’s advocacy and mobilization of diverse partnerships saw the rollout of vaccination through the donation of 2 million doses of Gardasil vaccine for 3 years and subsidy of the cost of vaccines by Merck & Company to Rwandan government. This saw 92,107 girls vaccinated; 93% coverage in the first year and 139,968 girls; 96.6 % coverage in 2012 (Binagwaho et al., 2013).

This success defined health equity as young girls across the country got vaccinated for free.Despite the huge success, Rwandan HPV vaccination program faced global criticism that lacked basis. The Global Alliance for Vaccines and Immunization (GAVI) had expressed concerns of Rwanda not having the capacity to manage cold chain. They further doubted Rwandan ability to reach high coverage and mobilizing partners for program sustainability (Binagwaho et al., 2013). This made Merck & co develop cold feet on the vaccination project. Rwanda’s success through collaboration between different stakeholders ensured established vaccine delivery system with adequate cold chain, transportation, human resources and monitoring capacity (Binagwaho et al., 2012) proved international community wrong.

As a result, GAVI, PEPFAR and Global Fund to fight AIDS, TB and malaria rallied their support behind Rwanda in the vaccination program. Other private companies expressed interest to join war against cervical cancer through the provision of diagnostic tools and equipment following GAVI’s incorporation of HPV vaccine in its routine funding. Ouedrago and his colleagues made sentiments that the HPV vaccination program was not benefitting the people. To them, the 330,000 girls were lesser people and did not deserve vaccination. They further claimed that Rwanda with little resources should have prioritized other conditions like measles, tetanus and other highly ranked cancers but not cervical cancer that seemed more costly. Their retrogressive claims illustrate double standards of the international community (Binagwaho, Wagner, & Nutt, 2011).

Women in developed countries were accessing HPV vaccines whereas women born in the African continent to them, didn't deserve the vaccine contrary to universal health coverage agenda.The program was cited not to be cost-effective (Shulman et al., 2014). This claim was on basis that cancer was complex and too costly to be offered in poor countries. Instead, primary prevention that covers a third of preventable cancers was highly recommended.

In my view, this was discrimination based on financial ability similar experienced by Africans in fight for access to Ante-retroviral treatment (ART). The population affected by the two-thirds of unpreventable cancers were not factored to access to affordable, safe and effective treatment as a human right. Furthermore, no research had compared the cost of cancer treatment in developed and developing countries to justify funding treatment in developing countries. Rwanda demonstrated their commitment to protecting their constitution and upheld health human rights by caring for her citizens regardless of their ability to pay.

Critics also raised issues on vaccine market dynamics, tiered pricing agreements, and sustainability. The cost of Gardasil and GlaxoSmithKline’s HPV vaccine Cervarix approximated to USD 300 was opposed to the costs for a vaccinated individual that needed not to exceed US$10 for the three doses. The negotiated cost of USD16.95 per dose was used to threaten GAVI that the funding will be drained and will be forced to quit the highly publicized programs. There was also fear of diverting funds meant for health systems strengthening and cost-effective vaccines to purchase the “costly” HPV vaccines (Ouedraogo, Müller, Jahn, & Gerhardus, 2011).

The successful rollout vaccination saw Merck, QIAGEN commit themselves to donate to Rwanda and its funding partners HPV vaccines and DNA testing machines and kits for three-year periods together with subsidized vaccines and GAVI joined them later after 2014 against Rwanda's claim of inability to mobilize partners for sustainability (Binagwaho et al., 2013). On contrary, Rwanda showed political will and a coalition of partners including CDC engaged in scaling up screening, treatment and palliative care.The successful HPV program was not a coincidence, the Rwandan team had to coordinate, own, monitor and manage a program to unimaginable heights amidst resistance from the international community who have double standards of advocating for universal health coverage yet exercising discrimination based on your financial ability as a country.

As a global health personnel, am motivated than ever to advocate for health equity for the vulnerable and marginalized groups in the society. Everyone deserves to get health service when in need regardless of geographical, racial, gender, age or economical differences. I am left wondering, for how long will Africans remain victims of double standards? When shall implementation science inform health decisions? Attainment of Sustainable Development goals is at risk with organizations like WHO and GAVI sitting on the side lines.

01 April 2020
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