www.gavi.org

HPV VaccineLessons Learned & New Ways Forward

The Gavi AllianceJune 2016, Geneva

Overview

2

1 Background

2 Lessons learned

3 New Way Forward

Background1

3

HPV Background

Initially there was doubt whether HPV vaccination would be feasible

• Due to a lack of experience vaccinating adolescent girls.

Gavi started supporting the HPV vaccine in 2012

• Gavi provided funding for HPV demonstration programmes for countries with no experience.

• Gavi provided opportunity for national roll-outs for countries with experience.

4

HPV is responsible for a

growing burden of cervical

cancer

• 266,000 deaths per year

(GLOBOCAN 2012)

• 85% of the disease burden in

developing countries

In 2012 there was very limited

access to HPV vaccine in

Gavi countries

2012

20

10

1-4 1-4

<1

1-4

<1

1-4

<1

1-4

<1 <1

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Hep B

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Hib

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Rubella

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ca

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Me

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routin

e)

Me

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(ca

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Me

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JE

HPV is one of the highest impact vaccines in Gavi’s portfolio

5

HPV vaccines offer strong efficacy

• The two vaccines currently on the market

protect against 70% of HPV related cervical

cancers.

• New vaccines (with increased strain coverage)

entering the market could yield up to 90%

protection.

Gavi negotiated a price reduction for the

HPV vaccine

• Gavi achieved a reduction from $150/dose in

developed countries to just $4.50/dose for

Gavi eligible countries.

HPV vaccine is one of the highest impact

vaccines in Gavi’s portfolio

• 20 deaths are averted per 1,000 vaccinated.

Deaths averted per 1,000 vaccinated

Demand for demonstration programmes is high

30 countries have applied to the HPV

demonstration program

• 28 have been approved and 23 have

introduced

Five countries have applied for

national HPV introduction support

without Gavi-supported demo

• 4 have been approved and 3 countries

have introduced

Transition from demo to national has

been slower than expected

• Only one country with a completed demo

has applied for national

6

HPV Program status in Gavi-eligible countries

National

Demonstration underway

Demonstration complete

11

5

19

12

3

1

0

5

10

15

20

25

30

Introduced Approved Not applied forGavi support

Ghana

Kenya

Lao PDR

Madagascar

Malawi

Mozambique

Zimbabwe

Cameroon

The Gambia

Senegal

Tanzania

2011Pre-

2010

20162015201420132012 2017 2018

+

National

National

PCV

PENTA ROTA HPV

demo

YF MENA

IPV

(planned)

MEASLES/MR

Campaign

JE

Competing priorities in countries that have completed Gavi demonstration programme

7

National

National

National

National

National

National

National

National

National

April 2016

OPV switch

Co

un

trie

s t

hat

ha

ve

co

mp

lete

d G

avi

de

mo

Lessons learned2

8

HPV Vaccine implementation has been demonstrated to be feasible

Countries used school-based delivery

• Most countries opted to vaccinate at a younger

age due to higher school enrolment.

• Challenges in enumerating and follow-up of out-

of-school girls.

Communication and social mobilisation

ensure high coverage

• Messaging focused on cervical cancer

prevention.

• Early, face-to-face engagement with

communities and religious leaders.

Engagement of key stakeholders and

building political will at all levels is vital

Ownership by EPI is critical for

programme success

9

0 20 40 60 80 100

Cameroon

Gambia

Ghana

Kenya

Lao PDR

Madagascar

Malawi

Mozambique

Niger

Senegal

Solomon

Tanzania

Coverage (%)

Administrative Survey

Most countries achieved high coverage

around 80%

Countries recognise the opportunity for adolescent health integration

HPV was successfully integrated

with some adolescent health

interventions

• Deworming, health education and

health worker training.

There exist opportunities for

strengthening integration to

facilitate cost sharing

• Identify harmonised funding for

integrated delivery.

• Improve coordination and ownership

between departments.

• Overcome implementation challenges

for joint delivery.

10

0

1

2

3

4

Dew

orm

ing

Va

ccin

ation

Hea

lth

Ed

uca

tion

SR

H

He

arin

g/E

ye

te

st

Hea

lth

wo

rker

tra

inin

g

Identified in desk review

Implemented demo year 2

Number of countries

Operational cost of HPV demonstration programme is relatively high

Demonstration programme design did

not incentivise testing of sustainable

delivery strategies

• National projected cost per dose is ~$2.50,

a significant reduction from the ~$6.50

observed in demonstration projects*.

Key cost drivers:

• High social mobilisation to reach a non-

traditional target; service delivery &

supervision (variation between countries).

• School based delivery via campaign-like

approach incurred additional costs, e.g.

renumeration for multiple stakeholders.

Gavi provides $0.65 per target for

other SIAs

11

* Cost estimates from the WHO Cervical Cancer Prevention and Control Costing Tool (C4P)

4.0

6.0

2.0

5.0

7.0

3.0

1.0

0.0

National

projection

Demonstration

Cold chain

Supervision

Other

Microplanning

Service delivery

Training

Social mobilisation and IEC

Madagascar

Cost per dose US$

Other Gavi

SIAs

US$

Cost of HPV Vaccination is decreased when Service Delivery is integrated with routine immunisation

School-based delivery costs decrease by

leveraging routine outreach

• The implementation cost per dose decreased from

$2.97 in campaign mode to $0.51 when leveraging

routine outreach in Rwanda, while maintaining

coverage >95%.

• Uganda and Tanzania followed a similar model.

Bhutan tested a health-centre approach

• Coverage reduced from 90% to 75% following a

switch from school based delivery.

• Country was able to make an informed decision

based on trade-offs of coverage and cost.

Indonesia will try an annual vaccination

schedule which could reduce costs further

12

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Campaign

strategy

Routine

-83%

Implementation cost per dose (Rwanda)

Operational cost

Other

Supervision

Key lessons learned

13

1) EPI ownership of HPV programme and multi-stakeholder engagement are

critical for scale-up.

2) Service delivery strategies for HPV should be integrated into routine

immunisation platforms e.g. mix of outreach and health facility.

3) Programme adjustments at the national level may be required to optimise cost

and coverage objectives e.g. Rwanda and Bhutan.

4) Early, effective social mobilisation and primary communication, focussed on

cervical cancer and country appropriate messaging, are necessary to ensure

successful uptake.

5) HPV integration with adolescent health interventions may offer opportunities

for improved coverage and operational cost sharing.

New Way Forward3

14

Where are we today in reaching our target?

2015 target to reach 1 million girls has been achieved

Emerging risk of missing 30 million girls by 2020, due to a combination of

factors:

1. Programme design does not encourage cost-effective, sustainable strategies and

delays national scale-up.

2. Country hesitancy from perceived programmatic and co-financing cost.

3. Weak programme ownership by EPI.

4. External factors including competing health and vaccine priorities.

With accelerated transition from demo to national introduction, the original

target may be achievable

Allowing countries to vaccinate multiple cohorts could increase number of

girls reached

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

Nepal

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er

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jibou

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bo

dia

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ladesh

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mar

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ire

La

o P

DR

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urita

nia

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ga

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am

ero

on

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ara

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ras

0.07%

0.10%

0.12%

Preparatory transition phaseInitial self-financingAccelerated transition

phase

HPV vaccine would constitute a small percentage of overall health expenditure

16

Note: Co-financing grouping at time of HPV introduction

Bars indicate percentage of health expenditure on vaccines – the darker bar indicates the

incremental increase with introduction of national HPV, as forecast by SDFv12

Va

ccin

e c

ost a

s a

sh

are

of

glo

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l

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rnm

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ea

lth

exp

en

diture

New Way Forward: Implementing programmatic changes

Gavi will consider providing front loaded technical

support

• Platform to share key lessons learned on HPV roll-out

strategy (e.g. delivery strategy, social mobilisation, …)

• Modelling costs for different delivery strategies

Gavi proposes moving away from demonstration

projects towards national introduction

• Encourage of the use of sustainable strategies for scale-up

• Phased roll-out possible for countries without experience

• Reduce administrative delay through single pathway

Gavi will assess the impact of vaccinating multi-

year cohort in the first year of national introduction

• Earlier potential health benefits, programme resilience and

lower operational cost per dose

• Increase in the number of girls reached from 2016 to 2020

Programmatic

changes

Adolescent health

integration

17

Targeted country

consultations

New Way Forward: Integration with adolescent health

Gavi will expand partnerships (e.g. UNAIDS, Global

Fund, Girl Effect, USAID, GFF, PEPFAR’S DREAMS)

• Leverage resources from adolescent health, reproductive

health, HIV/AIDS and NCD/cancer prevention and control

18

Programmatic

changes

Adolescent health

integration

Targeted country

consultations

New Way Forward: Targeted country consultations

Gavi will run country consultations to understand

the factors affecting national decision making

This will be undertaken in countries who have

completed demonstration projects (>1 yr) but

have not moved to national roll-out

Factors to be considered:

• Cost of introduction

• Vaccine price

• Competing priorities in the health-care space

• Human resource capacity

• Fiscal space

Findings will inform a revised Alliance approach

for the HPV programme

19

Programmatic

changes

Adolescent health

integration

Targeted country

consultations

Next steps

20

June –

September ‘16

Run consultations to discuss the proposed changes

moving forward

• Gavi will convene a high level consultation with an

HPV expert working group to discuss programme

scalability

• Consultation with key country stakeholders

October ’16 Review proposed HPV programme changes with the

PPC

December ’16 Present any necessary programme changes to the Board

With thanks to

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www.gavi.org

THANK YOU