Cervical cancer is a serious problem in many low- and middle-income countries such as the African country of Rwanda. Although the cervical cancer rate in Rwanda remains more than twice the U.S. rate, there has been improvement in recent years that cancer research organizations can learn from to help other countries reduce their rates.
Regine Nshimiyimana Maniraho, DNP, PharmB, AOCNP
In their lifetime, sexually active males and females are likely to be infected with at least one type of human papillomavirus (HPV); some such infections cause cervical cancer, which may be prevented with immunization, screening, and treatment of precancerous lesions. To reduce this risk, it is important for health-care providers and policymakers to understand which prevention strategies would be best to implement to avert cervical cancer.
Rwanda, the most densely populated African country with a population of 13.2 million people, has involved clinicians and global health experts from research universities and international organizations in its effort to improve the health of its population.
Policy Background and Recommendations
In Rwanda, about 25.9% are up to age 9, 12.6% are between the ages of 10 and 14, 20.8% are between the ages of 15 and 24, and 39.2% are between the ages of 25 and 64.1 In 2020, the crude incidence rate of cervical cancer in Rwanda was 18.7 cases per 100,000 population compared with 7.7 cases in the United States. The annual number of cervical cancer cases in Rwanda is 1,229, and the annual number of cervical deaths is 829.2
In 2011, Rwanda introduced a national HPV vaccination program targeting sixth-grade girls, with the support of Merck sponsoring the three-dose HPV vaccine. In 2014, Rwanda switched to a two-dose schedule, and since then, GAVI, the Vaccine Alliance, paid for HPV vaccination in Rwanda.3
In 2013, Rwanda developed a comprehensive cervical screening plan using HPV DNA screening and visual inspection of the cervix after acetic acid application (VIA). However, in Rwanda, data on cervical cancer screening are limited, and there is no active invitation to screening.2
The path toward the elimination of cervical cancer by 2030 in low- and lower-middle–income countries, as proposed by the World Health Organization, is summed up in the 90-70-90 targets to achieve HPV vaccination against at least HPV types 16 and 18 for 90% of girls by age 15, twice-lifetime cervical screening by age 35 and 45 for 70% of women, and treatment of precervical cancer or invasive cervical disease for 90% of women.4
The recommendation of choice is to mobilize sponsors for enough HPV vaccines for all eligible males and females. Per the Centers for Disease Control and Prevention (in 2021), children aged 11 and 12 or 9 to 14 would receive two doses of the HPV vaccine, given 6 to 12 months apart. Those who start the HPV vaccine at age 15 or older would get three doses, given over 6 months. Those between the ages of 27 and 45 would receive three doses of Gardasil 9, the only HPV vaccine approved for that age group.
The economic viability of the HPV vaccine is credible enough to support the campaign of preventing cervical cancer through HPV vaccination for about 4 million men and women eligible to receive HPV vaccines. The value proposition of HPV vaccination aligns with the ideal approach of advancing preventive care whenever feasible to help people stay healthy rather than waiting until they become ill.
Quest to Improve Global Health Equity
There has been advancement in cervical cancer prevention through HPV vaccination in Rwanda. However, more than 4 million men and women have not yet been vaccinated. The progress made is attributable to the Rwandan leadership and the support of international organizations. This partnership can serve as an example for other low- and middle-income countries to partner with cancer research organizations interested in improving global health equity.
—Regine Nshimiyimana Maniraho, DNP, PharmB, AOCNP
A former pharmacist in Rwanda, Dr. Nshimiyimana Maniraho is currently an oncology nurse practitioner and PhD student in health policy at Thomas Jefferson University, Philadelphia.
REFERENCES
1. U.S. Census Bureau: Subnational Population Data by Geographic Area: Rwanda. Available at https://www.census.gov/geographies/mapping-files/time-series/demo/international-programs/subnationalpopulation.html. Accessed May 17, 2023.
2. Bruni L, Albero G, Serrano B, et al: ICO/IARC Information Centre on HPV and Cancer: Human Papillomavirus and Related Diseases in Rwanda. Summary Report 10, March 2023. Available at https://hpvcentre.net/statistics/reports/RWA.pdf. Accessed May 17, 2023.
3. GAVI: The Vaccine Alliance: WHO says just one dose of HPV vaccine protects against cervical cancer. April 12, 2022. Available at https://www.gavi.org/vaccineswork/who-says-just-one-dose-hpv-vaccine-protects-against-cervical-cancer. Accessed May 17, 2023.
4. World Health Organization: Human papillomavirus vaccines: WHO position paper, December 16, 2022. Available at https://www.who.int/teams/immunization-vaccines-and-biologicals/diseases/human-papillomavirus-vaccines-(HPV). Accessed May 17, 2023.
