AY NASSIMOLDINA

Dear Dr Tedros A. Ghebreyesus,  

The world is in a vulnerable state right now, and we have trusted you with the World Health Organization to lead us through a global health crisis. However, it is so vital not to relax or neglect health issues that might be veiled with seemingly optimal solutions. I appreciate and recognize the WHO’s commitment to eliminating cervical cancer globally. Still, I must advocate that you revise your guidelines to address the true culprit of cervical cancer: the human papillomavirus (HPV).  As a woman, I am writing to you to implore you to revise your strategies in addressing HPV and the vaccination against it as it does not only address cervical cancer but also protects the lives of women, as well as men, from the tens-of-thousands of diseases associated with this sexually transmitted virus.  

HPV is a particularly common DNA viral infection (WHO, 2020). 40 out of around 100 types of HPV infect the internal genital organs, and at least 14 of the HPV strains lead to anogenital cancers in both sexes (McCance, 2004). Primarily, HPV is responsible for all genital warts and over 90% of cervical and anal cancers. It is the root cause of most vaginal, oropharyngeal, vulvar and penile cancers and over a fifth of the oral cavity and laryngeal cancers (Saraiya et al., 2015).  

Despite the substantial burden of the infection on both sexes, the 2006 bivalent HPV vaccine, Gardasil by Merck, was rushed onto the US market following early government approval after testing was only completed on women, which led to the misleading marketing of this STI preventative as a ‘cervical cancer vaccine’ (Gottlieb, 2013). Despite the development of the 9-valent HPV vaccine, which protects against seven more HPV-types than the original bivalent vaccine and thus more effective in preventing HPV related diseases, the social discourse and narrative has not changed, even by the WHO, who still fail to urge countries to invest in the nonavalent vaccine (Daley et al., 2017). The WHO plays a significant role globally in public health, and you are responsible for the accuracy of the information and the culture your messages condone. It is disappointing to find your new global strategy to scale-up the HPV vaccine in national immunization programmes under the title of the paper “Global strategy to accelerate the elimination of cervical cancer as a public health problem” (2020) – as by overemphasizing the cervical cancer impact, you demonstrate that lack of awareness of the other victims of the many other HPV-related diseases.   

As part of your commitment to universal health coverage, your global strategy aims predominantly to establish a comprehensive approach for countries to follow to eliminate cervical cancer within the century (WHO, 2020). Your strategies aim to address cervical cancer “across the care continuum” by setting targets that focus on education, prevention, early detection and treatment through cost-effective measures (WHO, 2020; 19). Despite the precedence of the HPV vaccine in this strategy paper, its utility does not expand beyond its use for cervical cancer prevention.  

My position on this matter is that the WHO, and you as its director, need to realize that the HPV immunization program you champion is insufficient as it fails to consider the practicality of the nonavalent vaccine in preventing 49,649 other HPV associated cancers (Boseley, 2019). A revised new guideline is required to encourage world leaders and other health organizations to implement well-rounded strategies for targeting HPV prevention for public health rather than women’s health.   

Research shows that through the strategy of vaccinating only girls, it is improbable that the key HPV types will be eradicated via herd immunity (Hibbitts, 2009). Your strategy overlooks the other non-cervical diseases the infection causes that increase the burden of the disease on men. For example, HPV related oropharyngeal cancer in Denmark had increased three-fold between 2000-2017 and doubly impacted men over women (240 versus 77 per 100,000) (Zamani et al., 2020). In the US, oropharyngeal cancer is the second most common HPV-related cancer and, by 2020 had surpassed the incidence rate of cervical cancer (ICI Health, 2020). The 9vHPV vaccine can prevent three-times the oropharyngeal cancer cases in males over females (Daley et al., 2017).  The overall medical costs in the US for non-cervical HPV diseases was around $418million and 60% of that was attributed to genital warts treatment (Hibbitts, 2009). Long-term it will not only prove cost-effective by reducing cases in need of arduous treatment but will also produce more significant health benefits for a lower societal cost (Durham et al., 2016). 

I would like to clarify that I recognize the impact of cervical cancer as the fourth most commonly occurring cancer in women worldwide, with over 500,000 new cases annually and the burden that is felt by it, especially in low-middle-income countries (LMICs) (Ferlay et al., 2012). Global action needs to be taken to prevent and cure this disease which your strategy outlines. However, this imbalanced emphasis on protecting against cervical cancer is misleading and has caused the vaccine’s feminization. 

It is vital you do not undermine the impact the feminization of the HPV vaccine can have on women. The socially constructed focus on women stems from a corporate pharmaceutical rush to release a product to the public; however, this 2007 narrative should not still be leading the HPV discourse. According to the Sapir-Whorf principle, the structures of language influence people’s perceptions and can shape limited and sometimes problematic perspectives (Siu et al., 2019). Thus, by feminizing the vaccine, you suggest that women are more vulnerable to HPV than men. By making it a woman’s issue than a human issue, women are further seen in patriarchal societies as weaker and as “diseased bodies” in need of biomedical intervention (ibid.; 12). This leads to a dangerous pathologization of female sexuality (Polzer & Knabe, 2012). A study in Hong Kong found women avoided vaccination due to the social stigmas associated with HPV and sexual promiscuity (Siu et al., 2019). These sexist moralizations of the vaccination create extra challenges for the increased uptake of the vaccine in more conservative cultures, even though there is an over 80% chance to contract HPV from only one sexual partner in one’s lifetime (Daley et al., 2017). Therefore, by targeting only girls and excluding men from the dialogue, women are further burdened by reproductive healthcare’s responsibilities and psychologically burdened by the societal gender disparities. By placing shared responsibility on both sexes for transmission mitigation of the HPV virus, the stigmas associated with this STI can be normalized (Green, 2018). Thus, a gender-neutral strategy is crucial from both a health and a social point of view. The feminization of the vaccine has numerous negative consequences as it misinforms the public of the sexual nature of the infection and the potential of health risks it reduces in both women and men. Likewise, this approach leads to unfortunate research delays that can prove to be life-changing for men’s health, especially for males who have sex with males (MSM) (Daley et al., 2017). 

The associated heteronormativity with this vaccine systematically impacts MSM, who are disproportionately at a higher risk than heterosexual men for HPV-related cancers like anal (85%), penile (50%) and genital warts (90%) (Checchi et al., 2020). Anal HPV infections are “almost universal” among men with HIV with an estimated prevalence between 87 – 98% (Wang et al., 2017: 19). Likewise, HPV as well as anal warts will most likely progress to anal cancer in HIV patients (ibid.). More than half of cervical cancers also develop in women with HIV, which is more prevalent in LMICs and consequently need prioritization in preventative and treatment services (Hibbits, 2009). Thus, this shows us the risks of genital cancers escalating due to the syndemic synergy between HPV and other STIs. The concept of syndemics refers to two or more diseases adversely interacting with one another and “that are [further] exacerbated by the social, economic, environmental, and political” factors (The Lancet, 2017: 1). Studies have shown concerning syndemic interactions between HPV and other cofactors that increase health risks and complicate illnesses in both women and men (McCloskey et al., 2017). Such implications demand not only the advocacy of safe sexual behaviour but the additional vaccination of men against HPV, especially in regions with HIV prevalence, often LMICs due to the risks of biological and social interactions worsening health outcomes and reinforcing the disease burden (McCloskey et al., 2017).  

Moreover, I value the importance of evaluating the economic burden which you strongly have to consider in your recommendations. The reality of standard economic methods is that they do not assess the long-term implications of the HPV vaccine (Datta et al., 2019).  By including boys in routine national HPV immunization programs, models show long-term cost-effectiveness due to the prevention of burdensome and expensive treatment costs (Green, 2018). As well as the non-quantifiable factors of emotional and physical strains of illness that economic processes do not account for within families, finances and mental health (ibid). The advantages of vaccinating males against HPV would be additionally effective in situations where girls are less accessible, like in traditionalist patriarchal societies defined by systemic sexism and embodied corruption; where men frown upon preventive sexual health measures, especially that target pre-pubescent girls (Pop, 2016). Likewise, a heteronormative economic approach ignores MSM, who are unlikely to seek the vaccine during their sexually active years and thus fail to be protected by the current strategy (Daley et al., 2017).  

I am looking to you to reconsider the WHO’s stance on vaccinating just girls against HPV for cervical cancer prevention. I hope you listen to the robust evidence and arguments presented by me for promoting a gender-neutral strategy for an HPV immunization program — as the WHO is responsible for encouraging local governments to pursue health interventions based on most analytical research, which should include social and cultural evaluations. I hope you change the misleading narratives around HPV and make official changes to whom and how you promote the HPV immunization program as your voice can make a genuine difference for many people.   

I hope you will consider these arguments in your future policy review.

Sincerely, 

Ay Nassimoldina 

References

Boseley, S. (2019). HPV vaccine to be given to boys in effort to slash cancer rates. [online] the Guardian. Available at: https://www.theguardian.com/society/2019/jul/09/hpv-vaccine-to-be-given-to-boys-in-effort-to-slash-cancer-rates. 

Checch, M., Coukan, F., Mesher, D. and Soldan, K. (2020). Human papillomavirus (HPV) vaccination uptake in gay, bisexual and other men who have sex with men (MSM) National programme: 2018 annual report. Public Health England, pp.1–36.  

Datta, S., Pink, J., Medley, G.F., Petrou, S., Staniszewska, S., Underwood, M., Sonnenberg, P. and Keeling M.J. (2017). Assessing the cost-effectiveness of HPV vaccination strategies for adolescent girls and boys in the UK. BMC Infectious Diseases, 19, pp.552. 

Daley, E.M., Vamos, C.A., Thompson, E.L., Zimet, G.D., Rosberger, Z., Merrell, L. and Kline, N.S. (2017). The feminization of HPV: How science, politics, economics and gender norms shaped US HPV vaccine implementation. Papillomavirus Research, 3, pp.142–148. 

Durham, D.P., Ndeffo-Mbah, M.L., Skrip, L.A., Jones, F.K., Bauch, C.T. and Galvani, A.P. (2016). National- and state-level impact and cost-effectiveness of nonavalent HPV vaccination in the United States. Proceedings of the National Academy of Sciences, 113(18), pp.5107–5112. 

Ferlay, J., Soerjomataram, I., Dikshit, R., Eser, S., Mathers, C., Rebelo, M., Parkin, D.M., Forman, D. and Bray, F. (2014). Cancer incidence and mortality worldwide: Sources, methods and major patterns in GLOBOCAN 2012. International Journal of Cancer, 136(5), pp.359–386. 

Gottlieb, S.D. (2013). The Patient-Consumer-Advocate Nexus. Medical Anthropology Quarterly, 27(3), pp.330–347. 

Green, A. (2018). HPV vaccine to be offered to boys in England. The Lancet, 392(10145), p.374. 

Hibbitts, S. (2009). Should boys receive the human papillomavirus vaccine? Yes. BMJ, 339, pp.4928–4928. 

McCloskey, J.C., Martin Kast, W., Flexman, J.P., McCallum, D., French, M.A. and Phillips, M. (2017). Syndemic synergy of HPV and other sexually transmitted pathogens in the development of high-grade anal squamous intraepithelial lesions. Papillomavirus Research, 4, pp.90–98. 

Phumaphi, J., Gautam, KC and Mason, E. (2020). Increased production and comprehensive guidelines needed for HPV vaccine. The Lancet, 395(10221), pp.319–321. 

Polzer, J. and Knabe, S. (2012). From Desire to Disease: Human Papillomavirus (HPV) and the Medicalization of Nascent Female Sexuality. The Journal of Sex Research, 49(4), pp.344-352. 

Pop, CA (2016). Locating Purity within Corruption Rumors: Narratives of HPV Vaccination Refusal in a Peri-urban Community of Southern Romania. Medical Anthropology Quarterly, 30(4), pp.563–581. 

Public Health England (2020). HPV vaccine drives cancer causing infections down to very low levels. [online] GOV.UK. Available at: https://www.gov.uk/government/news/hpv-vaccine-drives-cancer-causing-infections-down-to-very-low-levels. 

Quinn, S. and Goldman, R.D. (2015). Human papillomavirus vaccination for boys. Canadian Family Physician, [online] 61(1), pp.43–46. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4301763/. 

Saraiya, M., Unger, E.R., Thompson, T.D., Lynch, C.F., Hernandez, B.Y., Lyu, C.W., Steinau, M., Watson, M., Wilkinson, E.J., Hopenhayn, C., Copeland, G., Cozen, W., Peters, E.S., Huang, Y., Saber, M.S., Altekruse, S. and Goodman, M.T. (2015). US Assessment of HPV Types in Cancers: Implications for Current and 9-Valent HPV Vaccines. JNCI: Journal of the National Cancer Institute, 107(6). 

Siu, J.Y., Fung, T.K.F. and Leung, L.H. (2019). Social and cultural construction processes involved in HPV vaccine hesitancy among Chinese women: a qualitative study. International Journal for Equity in Health, 18(1), pp.1–18. 

The Lancet (2017). Syndemics: health in context. The Lancet: Editorial, 384(10072). 

UCI Health (2020). HPV linked to epidemic of throat cancer. [online] http://www.ucihealth.org. Available at: https://www.ucihealth.org/blog/2020/01/hpv-throat-cancer. 

Wang, C. J., Sparano, J., and Palefsky, J. M. (2017). Human Immunodeficiency Virus/AIDS, Human Papillomavirus, and Anal Cancer. Surgical oncology clinics of North America, 26(1), pp.17–31. 

WHO (2017). Human papillomavirus vaccines: WHO position paper, May 2017. World Health Organisation Geneva, 92(19), pp.241–268. 

WHO (2020). Global strategy to accelerate the elimination of cervical cancer as a public health problem. World Health Organization Geneva, pp.1–56. 

Zamani, M., Grønhøj, C., Jensen, D.H., Carlander, A.F., Agander, T., Kiss, K., Olsen, C., Baandrup, L., Nielsen, F.C., Andersen, E., Friborg, J. and von Buchwald, C. (2020). The current epidemic of HPV-associated oropharyngeal cancer: An 18-year Danish population-based study with 2,169 patients. European Journal of Cancer, [online] 134, pp.52–59.