Integrating HPV vaccination into adolescent health and routine immunization delivery platforms in rural and pastoralist Ethiopia: A mixed-methods implementation study of the HPV-VISION program
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Introduction
Vaccination against human papillomavirus (HPV) is the most effective strategy for preventing cervical cancer. We evaluated HPV Vaccine Integrated Service Implementation (HPV-VISION), a program aimed at integrating HPV vaccination with adolescent health (AH) services and the Expanded Program on Immunization (EPI) to improve vaccine uptake among girls aged 9 to 14 years in rural Ethiopia.
Methods
This mixed-methods implementation study was implemented in four woredas testing two models of integrating HPV vaccination into routine health services: integration with EPI and with an AH service package. We used program monitoring data; exit interviews, in-depth interviews, and focus group discussions with adolescent girls and caregivers; key informant interviews; and costing data. We analyzed effectiveness using negative binomial generalized estimating equation models with facility-level monthly HPV vaccinations as the primary outcome. We analyzed exit interview data descriptively across models. We analyzed qualitative data thematically and conducted a costing analysis.
Results
The HPV-VISION program delivered 25,821 HPV vaccinations from March to August 2025. Adjusting for baseline differences, facilities in the AH model delivered, on average, 34% fewer HPV vaccinations per month compared to those in the EPI model (adjusted IRR: 0.66; 95% CI: 0.51-0.87). Nearly all girls said they would be happy to receive services again at the place they were interviewed (EPI: 94%, AH: 98%). Experience of care was positive overall with individual measures varying across models. The incremental delivery cost (excluding vaccine cost) per vaccinated girl was USD $7.54 in the EPI model and USD $14.28 in the AH model.
Conclusion
We recommend that HPV vaccine delivery incorporates integration with AH services and routine vaccination to most efficiently reach underserved girls. An optimal mix of integration with the EPI program and AH services should be based on regional HPV vaccination indicators, other AH needs, population demographics, and costs of the models.
KEY MESSAGES
What is already known on this topic
Globally and in Ethiopia, HPV vaccine delivery relies heavily on school-based platforms and targeted outreach initiatives to reach large cohorts of eligible adolescents Addressing inequities in HPV vaccination coverage will require complementary facility-based and community-based strategies that directly engage girls while also addressing cultural misconceptions, mistrust, and other social barriers.
What this study adds
We found that two models for integrating HPV vaccination into routine healthcare delivery for girls aged 9 to 14 in Ethiopia performed well and were highly acceptable. Qualitative research confirmed perceptions that community engagement, school involvement, and health facility linkages were central to successful implementation, while exit interview data indicated that clients served by both models had positive experiences and were satisfied with the care they received.
How this study might affect research, practice or policy
We recommend that Ethiopia’s strategy to scale-up integrated HPV vaccine delivery maintains the existing lower cost school-based campaign approach, while also incorporating integration with both routine immunization and adolescent health services to most efficiently reach adolescent girls who are seeking various services, including puberty education and menstrual health products and services.
