Cervical Cancer Elimination: South Africa Needs to Make a Policy Call That Protects HIV-positive Women and the Unvaccinated

By Zwelethu Bashman, Managing Director, MSD South Africa and Dr. Ntombi Sigwebela, Chief Executive Officer, Health Systems Trust (HST)

Cervical cancer is preventable and treatable if diagnosed early and treated timely. Yet in South Africa, it remains a leading cancer killer among women. Today, with powerful tools at our disposal, elimination is within reach. 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 WHOs 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.

In partnership, MSD South Africa and Health Systems Trust (HST) advocate for a rights-based, equity-led approach to cervical cancer elimination. 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 8 million people with HIV, with females 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 9-15, 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 6-times more likely of contracting 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.

Why HIV-positive women and the unvaccinated matter most

1) Elevated risk among HIV-positive women

• An alarming 85% of women with both cervical cancer and HIV live in sub-Saharan Africa, underscoring the urgency of strong prevention strategies.
• Cervical cancer results from persistent infection with high-risk HPV types. WHIV experience higher incidence and faster progression from HPV infection to precancerous lesions and invasive cancer due to immune suppression.
• Their risk profile necessitates intensified prevention, screening, and treatment pathways
  integrated with HIV care.
• The country’s cervical cancer elimination policies need to explicitly address HIV-positive women, ensuring priority access to HPV vaccination where appropriate, HPV DNA- based screening, and timely treatment for precancerous lesions and cancer.

2) Gaps in protection: those who never received the HPV vaccine

• Despite the gains from HPV vaccination programs, a substantial cohort of women in South Africa remain unvaccinated—whether due to age, school-based rollout gaps, or access barriers. This unvaccinated group remains vulnerable to HPV infection and its sequelae.
• The current expanded program on immunisation (EPI) framework does not fully cover women who have not received vaccination, including those living with HIV. Closing this protection gap is essential for universal cervical cancer elimination.
• Until November 2024, girls attending private schools in South Africa were also excluded from the vaccine rollout. This segment of the population relied solely on out-of-pocket payment for the HPV vaccine or reimbursement for the vaccine by private medical schemes.

To date, only a handful of private medical schemes cater for the reimbursement of HPV vaccines, with very few even matching what is offered in the public sector.

Aligning with the latest guidance and WHO advocacy

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 prioritized 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.8 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.

The socioeconomic case: protecting mothers, workers, and families

• Women are central to South Africa’s economy and social fabric – contributing 35 – 45% of GDP. They are mothers, carers, and primary contributors to household livelihoods. When HIV-positive women and those who missed vaccination face cervical cancer, families bear the cost—lost livelihoods, caregiving burdens, and reduced economic participation.
• Protecting these women is not only a health priority but a strategic economic choice that sustains households, supports productivity, and advances sustainable development. Cervical cancer elimination must be pursued as a flagship equity initiative—ensuring dignity, opportunity, and protection for every woman, regardless of where she lives, how much she earns, or whether she is living with HIV.

Lessons from neighbouring countries

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 minimize missed opportunities.
• Coordinating across HIV programs, immunization 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 program design, reinforcing the coherence of a regional approach to elimination.

Policy recommendations – actionable steps for South Africa

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

• Create a dedicated cervical cancer prevention track within national HIV programs, ensuring HIV-positive women have prioritized 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 maximize coverage.
• Include cervical cancer prevention, including vaccination and DNA screening as a prescribed minimum benefit, requiring private medical aids to reimburse all women from age 9 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.

A call to action

MSD South Africa, in collaboration with Health Systems Trust, urges policymakers, funders, civil society, and communities to adopt an HIV-responsive, equity-centred cervical cancer elimination strategy. By prioritizing 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, programs, and partnerships that advance these goals and to work with national and regional stakeholders to ensure no woman is left unprotected.

References

1. South Africa National Department of Health. (2017). National policy on cervical cancer. https://www.health.gov.za/wp-content/uploads/2021/07/cervical-cancer-policy.pdf
2. Spotlight. (2025, March 31). 8 million people living with HIV in SA, according to latest estimates. https://www.spotlightnsp.co.za/2025/03/31/8-million-people-living-with-hiv- in-sa-according-to-latest-estimates/
3. Botswana Ministry of Health. (2023). HIV treatment guidelines. https://www.moh.gov.bw/Publications/HIV_treatment_guidelines.pdf moh.gov.bw
4. Liu, G., Sharma, M., Tan, N., C Barnabas, R. V. (2018). HIV-positive women have higher risk of HPV acquisition, precancerous lesions, and cervical cancer. AIDS, 32(6), 795– 808. https://doi.org/10.1097/?AD.0000000000001757
5. Travill, D. I., et al. (2024). High-risk HPV was very common in unvaccinated South Africa AGYW, especially among those living with HIV, highlighting the importance of HPV vaccination. Vaccine, 42(26). https://www.sciencedirect.com/science/article/pii/S0264410X24011241
6. South Africa National Department of Health. (2024). SA makes progress with HPV vaccination to prevent cervical cancer. https://www.health.gov.za/wp- content/uploads/2024/11/SA-makes-progress-with-HPV-vaccination-to-prevent- Cervical-Cancer.pdf
7. World Health Organization. (2022). Global strategy to accelerate the elimination of cervical cancer as a public health problem. https://www.who.int/publications/i/item/9789240014107
8. NCBI Bookshelf. (2022). Screening for cervical dysplasia and cancer in adults with HIV.
   https://www.ncbi.nlm.nih.gov/books/NBK604757/ NCBI
9. van Schalkwyk, C., Meyer-Rath, G., Masuku, S., Jamieson, L., Bloem, P., Rangaraj, A., Chidarikire, T., Dlamini-Nqeteko, S., Doherty, M., Johnson, L.F., Dalal, S. (2025). Cost- effectiveness of different HPV vaccination strategies for cervical cancer prevention in South Africa. Vaccine, 65. https://doi.org/10.1016/j.vaccine.2025.127797.
10. Government of South Africa. (2015). Status of women in South Africa’s economy. https://www.gov.za/sites/default/files/gcis_document/201508/statusofwomeninsaecon omy.pdf
11. World Health Organization Regional Office for Africa. (2025, May 29). HPV vaccination in Eswatini: A critical step towards curbing cervical cancer. https://www.afro.who.int/countries/eswatini/news/hpv-vaccination-eswatini-critical- step-towards-curbing-cervical-cancer

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Author: Tranica Ramsunder from BooST Communications – PR and Marketing on behalf of MSD.

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