"Collaboration between SSA [Sub-Saharan Africa] countries, partners, public health actors and the scientific community is crucial if the region's cervical cancer burden is to be reduced and for collectively working...to achieve HPV vaccine uptake."

Uptake or introduction of the human papillomavirus (HPV) vaccine has been challenging in some Sub-Saharan African (SSA) countries and was further negatively impacted by the COVID-19 pandemic. In response, stakeholders - in collaboration with the World Health Organization (WHO) Regional Office for Africa, regional partners, and the countries' Ministries of Health - organised this regional knowledge-sharing focus group study on HPV vaccination acceleration and/or introduction in SSA. The study aims to understand the key challenges facing the HPV vaccine and to develop a roadmap to accelerate uptake in light of the 2030 agenda of cervical cancer elimination.

The investigation took place from March-July 2023. Fourteen SSA countries were included, using a cohort design methodology. The Africa region was stratified into three focus group discussion (FGD) cohorts, comprising countries that have already and those about to introduce the HPV vaccine. The study engaged 78 key stakeholders, comprising 30 participants in cohort one, 21 in cohort two, and 27 in cohort three. In each country, the Expanded Program on Immunization (EPI) manager, the National Immunization Technical Advisory Group (NITAG) chair or representatives, and an HPV-focal researcher were selected participants. The methods involved a collaborative and knowledge-sharing format through regional and country-specific discussions, plenary discussions, and workshop-style group missions.

For example, the FGDs featured workshops designed to help each country develop a recovery plan or an HPV vaccination acceleration or introduction plan, which would be implementable upon return home. The workshop outcomes, which were presented by each country, involved a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis of the HPV vaccination programme or introduction plans of each country that defined the strategic vision/goal and then mapped into categories the priority strategies envisaged for achieving set goals, such as health policy, demand generation, surveillance, implementation research, and vaccine logistics. The priority strategies were backed-up with actionable activities, timelines, and expected outcomes/impacts. The finalised roadmaps were presented at plenary of each cohort for feedback and input from other countries.

Select examples of communication-related insights to emerge from each cohort follow:

• Cohort one: With regard to maximising coverage: "The four nations shared core principles in their HPV vaccination initiatives, such as community engagement, school-based methods, and confronting challenges like funding constraints and misinformation. Yet, they exhibited differences in performance metrics, precise strategies, integration with other health initiatives, and future planning."
• Cohort two: With regard to challenges "...Côte d'Ivoire: Insufficient communication, poor awareness, and vaccine hesitancy"; "...Cameroon: Strong opposition from religious leaders, communication gaps, and weak leadership commitment"; "...Senegal: Rumors, misinformation, and insufficient community activities leads to decline in demand."
• Cohort three: The cohort collectively brainstormed on some fundamental pull and push factors driving low HPV vaccine uptake in the region and how to address them. Common to all: "Multi-sectoral collaboration, especially between ministries of health and education, is essential."

Selected implications of the study outcomes include:

• The focus groups helped to unravel the problems of vaccine coverage and demand disparities across the Francophone Africa region. The poor or stagnant coverage in Côte d'Ivoire and some other countries is largely attributable to vaccine hesitancy and further complicated by other factors such as ineffective communication, low appropriation of vaccination by health workers, poor micro-planning, and inadequate awareness. Although Senegal's experience of a drastic decline in coverage from 94% in 2019 to 22% in 2022 was attributed primarily to the uncurbed impacts of misinformation and inadequate community engagement, both situations must be considered independent of each other, despite both being in the Francophone African cluster.
• Senegal's and Cameroon's struggles were found to be particularly linked to opposition from religious leaders, weak implementation strategies, and a lack of commitment in some districts due to poor engagement. The roadmap developed during the study has incorporated these inputs.
• Critical barriers or challenges to HPV vaccination uptake common to all the countries, besides Rwanda, were budget constraints (funding), data quality issues, and misconceptions about HPV vaccine or vaccine hesitancy. Myths and misconceptions around the HPV vaccine seem to be recurrent impediments to HPV vaccination uptake among the 14 countries. These were primary ingredients for inflaming vaccine hesitancy.
• Strategies to optimise coverage were maximised in Rwanda, Ethiopia, Nigeria, Kenya, and a few other countries by leveraging a blend of school-based strategies, community outreach, and health facility delivery. The blend was particularly aimed at reaching in-school and out-of-school girls. This approach provides template for replication in the region.
• Any national HPV vaccination strategy using a school-based approach must integrate the school calendar into its implementation plans; otherwise, it will be ineffective. That is, full involvement from the Ministries of Education in HPV vaccination produced better coverage, based on coverage data from countries who had done so compared to others in the cohorts that had not.
• The inclusion of wives of political figures such as first ladies and female elected leaders as the faces of the HPV vaccination campaign seems a positive strategy. The study outcome showed that countries that adopted this strategy had better uptake than others that did not.
• Despite consensus on common strategies for improving HPV vaccination uptake, the success of each country's approach is intricately linked to maximisation of their unique local circumstances, opportunities, and how they are able to mitigate obstacles.

Based on the outcomes of the study, recommendations - including the following examples - are offered:

1. A dual anchor system should be initiated to support countries to overcome not only the decline in HPV dose 2 uptake, which the sharing of lessons learned among peers could help to mitigate, but also to overcome their population's perception issues that contribute to low uptake or vaccine hesitancy.
   • The first anchor should focus on implementation research to support the EPI programme with scientific evidence to build resilience and steady uptake.
   • The second anchor, based on the two positive outcomes of this study (sharing opinions/experiences and developing recovery roadmaps), suggests that future public health research in low-resource settings, such as SSA, should be multifaceted, i.e., understanding the drivers of problems and also finding approaches for solutions.
2. Several countries attributed the decline of HPV vaccination to increased rumours and misinformation as well as to disinformation campaigns. So, concerted efforts using the traditional institutions (religious and cultural) are advised, in addition to the retraining of healthcare workers.
3. NITAGs of various African countries should consider the recommendations for the single-dose option. Multi-dose vaccine schedules are expensive and complex to deliver, and the logistics associated with vast and scattered populations make it less likely that the region will achieve the 2030 target.
4. Coordination and collaboration should be increased in light of the similar peculiarities of the challenges surrounding HPV vaccination in the region. There is a need to:
   • Strengthen intersectoral coordination around HPV vaccination, involving key actors such as the education system, professional associations, and community leaders.
   • Promote exchanges and cooperation between SSA countries by creating a research network for sharing information and scientific knowledge.
   • Organise inter-country roadmap appraisal in the form of a bi-annual experience-sharing focus group on HPV vaccination.
   • Revitalise initiatives on the association of first ladies with HPV vaccination. Lessons from peers on how to do so abound.

The researchers conclude that, besides being an empirical study, the study approach and methods facilitated peer mentorship and learning among African countries, especially sharing lessons on strategies that have worked and those that have not. This exchange was reportedly inspirational for countries who have just introduced HPV vaccination or are about to do so - e.g., Eswatini, Burkina Faso, Cameroon, and Nigeria. "It is essential that there is continued support for these countries in their efforts to overcome the challenges identified and ensure equitable access to HPV vaccination, in addition to fighting against the misconceptions and misinformation that breed vaccine hesitancy."