Multi-level school-based intervention to improve HPV vaccine uptake and completion in South Africa

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PROJECT SUMMARY Human Papillomavirus (HPV) is the most common sexually transmitted infection globally, and is causally linked to cervical, anogenital, and oropharyngeal cancers. HPV-associated cancers have a disproportionate impact in low-resource settings and nowhere is this evident than in South Africa, which has a uniquely vulnerable population due to the convergence of the largest HIV epidemic globally, with HPV rates of up to 85% in young women under the age of 25. Cervical cancer is the leading cause of cancer-related mortality among women in South Africa. In 2014, the South African National Department of Health implemented a national, school-based HPV immunization program. Despite a promising start, vaccine coverage and dose completion rates dropped precipitously after 2014, with only 37% of girls receiving their first dose in 2021. Recent declines have been attributed to COVID-related program interruptions, increased medical mistrust, and vaccine hesitancy related to misinformation spread on social media. There are additional critical gaps in care – specifically boys who are ineligible for this program, as well as adolescents outside the public school system. There is an urgent need to identify effective, replicable, and scalable strategies to optimize HPV vaccine uptake and completion in school-age children. The overall objective of the proposed R34 is to refine and evaluate a school-based multi-level communications strategy that addresses intrapersonal, interpersonal, and institutional factors associated with HPV vaccine uptake and completion amongst fifth graders, as part of a pilot feasibility trial. The proposed study is led by investigators from the United States and South Africa in partnership with the Department of Health and elementary schools in an urban setting with high burden of HPV vaccine preventable cancers in KwaZulu Natal, South African. The project builds upon our team’s expertise in HPV prevention, vaccine decision making, health communications, participatory design, and community engagement to pursue the following Specific Aims. (1) To refine components of a school-based multi-level communication strategy to improve HPV vaccine uptake and completion among girls and boys, and (2) To evaluate preliminary effects of the communications strategy and key criteria to advance to a full- scale hybrid type 2 trial. Our systems-focused approach leverages established partnerships with area schools serving diverse populations who are not always effectively served by traditional healthcare channels. We will ensure health equity is at the core of our research integrating the voices of individuals living in low- resource settings to understand and reduce the barriers to HPV vaccine initiation and completion. This proposal is responsive to NCI’s call for cancer prevention and control clinical trials planning grants (PAR-22- 173) both in its active stakeholder engagement, and its focus on engaging a diverse, scientifically appropriate study population.