title: Experiences and lessons learned from 29 HPV vaccination programs implemented in 19 low and middle-income countries, 2009-2014.
abstract: Cervical cancer is the greatest cause of age-weighted years of life lost in the developing world. Human papillomavirus (HPV) infection is associated with a high proportion of cervical cancers, and HPV vaccination may help to reduce the incidence of cancer. The aim of the study was to identify barriers, obstacles, and strategies and to analyze key concerns and lessons learned with respect to the implementation of HPV vaccination program in low- and middle-income countries.
  
  
  
  The Gardasil Access Program (GAP) is a donation program established to enable organizations and institutions in eligible low-resource countries to gain operational experience designing and implementing HPV vaccination programs. This study used an online survey to capture the experiences and insights of program managers participating in the GAP. Different factors related to HPV vaccination program management were collected. A mixed-method approach enabled the presentation of both quantitative measurements and qualitative insights.
  
  
  
  Twenty-nine programs implemented by 23 institutions in 19 low- and middle-income countries were included. Twenty programs managers (97.7 %) reported that their institution implemented sensitization strategies about vaccination prior to the launch of vaccination campaign. The most frequently reported obstacles to HPV vaccination by the program managers were erroneous perceptions of population related to the vaccine's safety and efficacy. Reaching and maintaining follow-up with target populations were identified as challenges. Insufficient infrastructure and human resources financing and the vaccine delivery method were identified as significant health system barriers. Coupling HPV vaccination with other health interventions for mothers of targeted girls helped to increase vaccination and cervical cancer screening. The majority of program managers reported that their programs had a positive impact on national HPV vaccination policy. The majority of institutions had national and international partners that provided support for human resources, technical assistance, and training and financial support for health professionals.
  
  
  
  Local organizations and institutions can implement successful HPV vaccination campaigns. Adequate and adapted planning and resources that support information sharing, sensitization, and mobilization are essential for such success. These results can inform the development of programs and policies related to HPV vaccination in low- and middle-income countries.
authors.affiliation: Epidemiology and Health Promotion Department, Rouen University Hospital, Hôpital Charles Nicolle. 1, rue de Germont, 76 031 Cedex, Rouen, France. joel.ladner@chu-rouen.fr.
authors.forename: Joël
authors.initials: J
authors.lastname: Ladner
authors.affiliation: Axios International, Paris, France.
authors.forename: Marie-Hélène
authors.initials: MH
authors.lastname: Besson
authors.affiliation: Hôpital Henri Mondor Hospital, Public Health, Assistance Publique Hôpitaux de Paris, Paris Est University, Créteil, France.
authors.forename: Etienne
authors.initials: E
authors.lastname: Audureau
authors.affiliation: Axios International, Paris, France.
authors.forename: Mariana
authors.initials: M
authors.lastname: Rodrigues
authors.affiliation: Axios International, Paris, France.
authors.forename: Joseph
authors.initials: J
authors.lastname: Saba
mesh_terms: D000293:Adolescent; D000328:Adult; D003906:Developing Countries; D055088:Early Detection of Cancer; D017598:Efficiency, Organizational; D005260:Female; D006078:Government Programs; D006801:Humans; D017589:Immunization Programs / Q000458:organization & administration*; D030361:Papillomavirus Infections / Q000517:prevention & control; D053918:Papillomavirus Vaccines / Q000008:administration & dosage*; D011314:Preventive Health Services; D016730:Program Development; D011795:Surveys and Questionnaires; D002583:Uterine Cervical Neoplasms / Q000517:prevention & control
chemical_list: D053918:Papillomavirus Vaccines
keywords: Developing countries; Human papillomavirus vaccine, type 16 L1, 18; Immunization uterine cervical neoplasms; Preventive health services; Program evaluation; Vaccination; Vaccines