The Department of Health has announced that it is moving from a two-dose to a single-dose HPV (human papilloma virus) vaccine regimen and that pupils in private schools will also be offered the government-subsidised jabs.
The decision is backed by evidence showing one-dose regimens provide similar protection against HPV infection to that offered by multi-dose regimens, writes Catherine Tomlinson for Spotlight.
HPV infection is the leading cause of cervical cancer, which is the second leading cause of cancer in women in South Africa. In efforts to mitigate this, the government launched the national HPV vaccination campaign in 2014.
Most South African girls and women between 10 and 20 should now be vaccinated against HPV. Since 2020, the vaccine has been given to grade 5 girls who are 10 turning 11: previously, it was offered to grade 4 girls.
Acting Chief Director of Maternal, Child and Women’s Health in the Department of Health Lesley Bamford told Spotlight that HPV vaccination coverage among eligible pupils has consistently been between 80% and 85% – higher than coverage rates reported in relevant academic work and estimated by the World Health Organisation.
The government now aims to increase HPV vaccination coverage to 90% as part of the global efforts spearheaded by the WHO to eliminate cervical cancer by 2030 – by switching from a two-dose to a single-dose HPV vaccine schedule and also offering the jabs in private and independent schools.
The GSK Cervarix vaccine, which contains two doses per vial, costs R394 per vial (or R197 per dose). When procured through the private sector, it costs R964 for a single dose formulation, excluding dispensing fees.
Moving from two doses to one
Between 2014 and 2023, the HPV vaccination campaign ran twice annually in government schools. During the first campaign cycle, typically fell between February and March, eligible girls were offered their first dose, and in the second campaign cycle, usually between September and November, the second dose.
But from this year, girls who received their first dose of HPV vaccination during February or March will not be offered a second dose later in the year. Instead, the second round of the campaign, scheduled from 1 October to 15 November, will be used to offer catch-up doses to girls who were not vaccinated in previous campaigns, and to provide HPV vaccination in private and independent schools.
Bamford said reaching girls in private and independent schools is essential to eliminating cervical cancer, and that the departments of health and basic education are in discussions with the sector’s schools about this.
As with government schools, parents must provide consent for their daughters to be vaccinated, but there were concerns, Bamford added, that vaccine hesitancy might be more widespread in private schools.
What is the evidence for moving to single dose?
While going from a two-dose to a single-dose vaccine regimen will save costs and simplify logistics, it is also backed by strong scientific evidence.
The WHO Strategic Advisory Group of Experts on Immunisation’s (SAGE) had concluded in 2022 that single-dose vaccination provides solid protection that is comparable to two- or three-dose regimens.
A randomised controlled trial in Kenya demonstrated the effectiveness of single-dose HPV vaccination regimens in preventing HPV infections over an 18-month study timeframe, while observational studies in India and Costa Rica found that single-dose HPV vaccination works as well as multi-dose regimens in preventing HPV infections 10 years after vaccination.
But what about girls with HIV?
While there is strong evidence warranting a shift to single dose HPV vaccination in HIV negative girls, there are still outstanding questions on whether a single dose provides adequate protection against HPV infection in girls and women who have HIV.
Bamford said that this year, HIV+ girls will not be offered a second dose of HPV vaccination but in coming years, the intention is to make second doses available at clinics for girls with HIV.
“That won’t happen this year,” she said, “but we will look at that for 2025, or possibly 2026.”
The late Professor Lynette Denny, a leading cervical cancer expert at the University of Cape Town, had previously told Spotlight that while more evidence is needed on the effectiveness of single-dose HPV vaccination in preventing HPV infection in HIV positive women, there was already evidence that girls with HIV generate protective antibodies against HPV after single dose vaccination.
“We did a randomised trial comparing the response of the body to the HPV vaccine in HIV positive versus HIV negative woman, and we didn’t show a difference,” said Denny, who died on 9 June 2024.
Professor Sinead Delany-Moretlwe, director of Research at Wits RHI, told Spotlight that existing data suggest a person on antiretroviral therapy is likely to have the same response to a single dose as someone without HIV.
Very few girls in South Africa were HIV positive at the age at which they were eligible for HPV vaccination, she said, and those who were, had typically been infected perinatally and were already on ARVs.
However, she cautioned that in addition to data on the effectiveness of single dose HPV jabs in HIV-positive girls, more data were needed on the effectiveness of single dose vaccination in girls who become HIV-positive after having the shots.
A study called HOPE 2 will begin this year to assess the benefits of a second dose of HPV vaccination to girls who were HIV-positive at the time of their first vaccination or who subsequently contracted HIV.
The study will have sites in South Africa, Rwanda and Botswana, and data from this study will be available in the next three years.
See more from MedicalBrief archives:
Millions of girls in Africa will miss HPV shots this year
Wits RHI launch Africa's first HPV vaccine impact evaluation project
One HPV jab effective for three years, gold-standard Kenya trial finds
SA makes strides with HPV vaccine campaign, but not fast enough