Why SA needs an HIV-responsive, equity-centred cervical cancer elimination strategy

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Cervical cancer is preventable and treatable if diagnosed early and treated promptly.

Yet in South Africa, it remains a leading cancer killer among women.

Today, with powerful tools at our disposal, elimination is within reach.

By prioritising HIV-positive women, expanding protection to those who never received HPV vaccination, and applying regional best practices, South Africa can accelerate progress toward eliminating cervical cancer as a public health threat.

We stand ready to support the development and execution of policies, programmes, and partnerships that advance these goals and to work with national and regional stakeholders to ensure no woman is left unprotected.

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Decisive policy action

This is not merely a health agenda; it is a moral and socioeconomic imperative that requires decisive policy action, sustained funding, and coordinated action across sectors.

Recently, Gavi’s inclusion of higher-valency HPV vaccines is an important development in the global HPV prevention landscape and a relevant consideration for countries across sub-Saharan Africa as they continue to strengthen cervical cancer prevention efforts.

The partnership between the public and private sectors, along with civil society and communities, is critical if the world is to realise a comprehensive approach to eliminating cervical cancer, especially as 2030 looms large and considering where South Africa stands in relation to the WHO’s 90-70-90 targets.

This approach must be rooted in the integration of healthcare services, leaning on primary health care delivery models and the involvement of communities, if significant progress is to be made.

Central to this approach is a sharp focus on two critical groups: women living with human immunodeficiency viruses (HIV) and the cohort of women who never received the human papillomavirus (HPV) vaccination.

These groups bear a disproportionate burden and warrant targeted interventions within South Africa’s national strategy.

South Africa has significantly more women living with HIV than men, with approximately 5.2 million women compared to 2.6 million men, making a total of around eight million people with HIV, with women bearing a disproportionate burden, especially among young people.

This number represents people, and more importantly, people at an increased risk of cervical cancer.

With the national HPV vaccination programme, which targets adolescent girls aged nine to 15, having started in 2014, this means that all other unvaccinated women remain at risk of developing cervical cancer, particularly women living with HIV (WHIV), who are six times more likely to contract the disease.

Given the sub-optimal levels of screening, the risk of late-stage presentation and higher mortality remains high, with cervical cancer presenting as the highest cause of cancer-related mortality amongst women in South Africa.

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Dedicated strategy

The World Health Organisation (WHO) advocacy calls for a dedicated strategy for WHIV in cervical cancer prevention.

South Africa’s current HPV vaccination and screening architecture must adapt to guarantee that HIV-positive women receive prioritised access to vaccination (where appropriate), screening, and treatment.

This is aligned with the push to transition to HPV DNA testing as the primary screening modality and the emphasis on a life-course approach to prevention and care.

A policy that explicitly centres HIV-positive women within the elimination strategy will accelerate progress toward the 2030 targets.

Recently, it has been shown via a modelling study that vaccinating women with HIV initiating or on anti-retroviral therapy (ART) aged 10-45 years old would reduce new cases by 4.7% overall, or by 10% among WHIV between 2024 and 2120.

Lessons to learn

​Two neighbouring countries, Botswana and Eswatini, have implemented strategies to vaccinate and protect women living with HIV, offering practical examples from which South Africa can take some lessons:

• Integrating vaccination and protection measures within HIV care and cervical cancer prevention services to minimise missed opportunities.

• Coordinating across HIV programmes, immunisation services, and cervical cancer control to create a seamless, patient-centred pathway.

• Strengthening advocacy and messaging around HIV-aware vaccination and screening, with attention to equity and access.

• South Africa should translate regional best practices into national messaging and programme design, reinforcing the coherence of a regional approach to elimination.

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What South Africa needs to do

1. Explicitly centre HIV-positive women in the elimination strategy

   • Create a dedicated cervical cancer prevention track within national HIV programmes, ensuring HIV-positive women have prioritised access to HPV vaccination (where evidence supports benefit), enhanced screening (including HPV DNA testing), and timely treatment.

   • Develop clear, evidence-based guidelines on vaccination for HIV-positive women within safety and efficacy frameworks approved by national authorities and WHO.

2. Extend protection to the unvaccinated

   • Implement catch-up vaccination campaigns targeting cohorts that missed adolescent vaccination, with targeted outreach for HIV-positive women and those in high-need settings.

   • Integrate vaccination outreach into reproductive health services, HIV clinics, and primary care to reduce barriers and maximise coverage.

   • Include cervical cancer prevention, including vaccination and DNA screening, as a prescribed minimum benefit, requiring private medical aids to reimburse all women from the age of nine to at least 45 years for HPV vaccines.

3. Strengthen screening and treatment integration

   • Normalise vaccination and screening as a continuum of care within HIV services, leveraging integrated service delivery models and one-stop clinics where feasible.

   • Scale up HPV DNA testing as the primary screening modality, with robust referral and treatment pathways to reduce loss to follow-up and improve outcomes.

4. Data-driven planning and accountability

   • Invest in surveillance systems to monitor vaccination coverage, HPV infection rates, screening uptake, and cervical cancer outcomes among HIV-positive and unvaccinated women.

   • Set measurable targets aligned with national elimination goals and WHO milestones, with transparent reporting to policymakers, funders, and communities.

5. Messaging that resonates regionally and ethically

   • Use consistent messaging that centres on HIV-positive women and the unvaccinated, framing elimination as a health equity and social justice issue.

   • Ensure messaging that makes vaccination central to prevention efforts, in both adolescents and unvaccinated women, especially those at highest risk.