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Infections caused by HPV - a group of more than 200 viruses - are among the most common sexually transmitted diseases (STD), and the main cause of cervical cancer.
“Are you married? If not, why are you taking this vaccine?” was the question directed to 24-year-old Rakshana R by a nurse when she visited a clinic to get the first dose of the Human papillomavirus (HPV) vaccine, earlier this year. After reading about the vaccine online, Rakshana had consulted a gynaecologist in Chennai, who later prescribed it to her.
Rakshana’s experience falls in line with the responses that other people, especially women receive when they try to avail of the vaccine. Infections caused by HPV - a group of more than 200 viruses - are among the most common sexually transmitted diseases (STD), and the main cause of cervical cancer. Cervical cancer ranks as the second most frequent cancer among women in India and about 5% of women in the general population are estimated to harbour cervical HPV-16/18 infections at a given point in time (the HPV types that commonly cause cervical cancers), according to the International Agency for Research on Cancer (IARC). The World Health Organisation (WHO) report suggests that vaccinating against HPV can significantly reduce cervical cancers caused by the virus.
In addition to cervical cancer, HPV can also cause cancers of the anus, vulva, vagina, penis, and oropharyngeal cancer (throat). Some types of HPV are known to cause genital warts which affect the moist tissues of the genital area, causing discomfort. Despite several studies conclusively proving the effectiveness of vaccines in the prevention of HPV diseases and the pressing need to implement them, there is little awareness about it. Apart from factors like affordability, accessibility, and non-inclusion in the country’s Universal Immunisation Programme (UIP), the stigma around discussing the sexual health of young adults and women contributes to this lack of awareness.
Read: ‘Raising girls right’: Stigma of HPV vaccine is increasing risk of cervical cancer
Who can take the HPV vaccine?
As per the guidelines updated in 2018, people between the ages of 9 and 45 are eligible to take the vaccine in India. “The best age to take the vaccine would be during adolescence, between 9-15 years of age, for all genders. It is usually administered before the first sexual contact of the recipient before they are exposed to the virus. The vaccine also mounts better immune responses when administered between the said ages,” says Dr TK Shaanthy Gunasingh, consultant gynaecologist at Mangalam Healthcare, and former director of the Obstetric and Gynaecological Society of India. Dr Shaanthy also adds that nevertheless, the vaccine can be taken by people who are sexually active or are above the aforementioned age since it would still offer protection against other strains of the virus that they have not been exposed to.
There is extensive ambiguity around whether men can take the vaccine. Gynaecologist Meenakshi Balasubramanian of Chennai’s KRIA Women’s clinic explains, “Cervarix offers protection against two strains of HPV- type 16 and 18 that causes cervical cancer. Gardasil and Gardasil 9 offer protection against four and nine strains of the virus respectively. It also covers HPV types that are not exclusively associated with cervical cancer, and hence, can be recommended to men as well. I recommend the vaccine for men also.”
Despite what the guidelines say, it is often not recommended by gynaecologists unless the patient takes an interest in it. 20-year-old Sandhya* who has taken two shots of the vaccine says to TNM that she did not get proper guidance when she first visited a gynaecologist in Chennai. “I came to know about HPV after a friend of a friend contracted the virus and had to be treated for genital warts. I had gone to the gynaecologist to get more details about the vaccine but the moment I told her I was sexually active and unmarried, I had to endure judgemental looks. Even when I was enquiring about the vaccine, she seemed to be unwillingly responding to my doubts. I started seeing another gynaecologist after this incident,” she says.
The stigma around HPV
Nirmala*, who tested HPV positive in 2020, shares that she had not heard about the vaccine as an adolescent and wishes she had taken it sooner. “I do not have abnormalities in my pap smear test and do not have genital warts either. The doctors have said other HPV types are transient and get cleared off our bodies on their own. But ever since I tested positive, I have been telling people in my social circle about the importance of the vaccine,” she shares.
People TNM spoke to who are eligible to take the vaccine mentioned that they were neither introduced to HPV vaccination during their years in school nor did some of the gynaecologists they consulted for other purposes recommend it to them. “The vaccine was recommended to me by a gynaec when I took a full body checkup at Apollo hospitals last year. But I was previously consulting a gynaecologist for treatment of UTI who had not told me about the vaccine,” says 23-year-old Shubhra Chakraborty.
The reluctance to take the vaccine also stems from the unwillingness of parents and doctors to discuss the sexual health of their children/ patients, and their tendency of preaching sexual abstinence to the latter. In some cases, the vaccine has not been recommended to married individuals, owing to the assumption that married couples would be in monogamous relationships, thus reducing the chances of being exposed to the virus.
“I took the vaccine under the advice of a gynaecologist from Joseph nursing home, post pregnancy. He clarified that women can take it after pregnancy too. He also advised me to administer the vaccine to my daughter when she turns 11. I consulted five different gynaecologists for my pregnancy and other reasons but did not hear about HPV from them. One of them was a doctor my mother and I regularly consulted with, which made it difficult for me to discuss my sexual health openly,” says 32-year-old Nandhini. She also adds, “Pre-marital sex is more common now than it was before. The onus is on us parents to normalise having conversations around the sexual and reproductive health of our children.”
Speaking to TNM, medical doctor and embryologist Tanaya, better known by her Instagram handle Dr Cuterus, who posts social media content simplifying sexual and reproductive health shares, “A lot of people reach out to me saying they came to know about the vaccine through my videos, but some people are also of the opinion that I am encouraging women to be more ‘promiscuous’. When I am recommending it to parents for their children, I often say it is a vaccine against cervical cancer, so that they are not reluctant to take it.”
She also explains how there is misinformation about the side effects of the vaccine. “There has been a huge anti-vaccine smear campaign against the vaccine. One of the groups was called ‘Girls against Gardasil’. Many studies, especially from the UK, have shown that the vaccine is highly effective in preventing cervical cancer,” Dr Tanaya observes.
Dr Shaanthy believes that the concerns regarding affordability are one of the reasons behind the apprehension towards the vaccine, while Dr Tanaya quips that more action at the policy level will help create more awareness.
Read: The unsuccessful hunt for an emergency contraceptive pill in Chennai
Cervarix and Gardasil reportedly became available in India in 2008 and 2009 respectively. The former is priced approximately between Rs 1800 and Rs 2500 per dose, while Gardasil is priced between Rs 3500 and Rs 4000 per shot. Gardasil 9, the nonavalent vaccine, which as its name suggests, offers protection against nine strains of the virus, was approved in India in September last year. It costs Rs 10,000 or above, per dose. While people below the age of 15 will be administered two doses of the vaccine, everyone above 15 is recommended to take three doses. All the vaccines can be obtained in private hospitals, but Gardasil 9 is not as freely available as the rest of them, and an order for it has to be placed by patients beforehand.
“Preventive measures against cervical cancer also include using protection and taking the pap smear test at regular intervals, which is to check for abnormalities or development of precancerous or cancerous cells in the cervix. Women above the age of 21 are recommended to take the test once in three years,” Dr Meenakshi Balasubramanian notes. Having multiple sexual partners, smoking, and poor hygiene are also other factors that increase exposure to HPV.
Adding to her point, Tanaya says, Men can take the anal pap smear test to look for development of pre-cancerous or cancerous cells. Genotype tests can also be taken to determine the strain of HPV one has contracted. However, it is only available in selective clinics. “Not everyone testing positive for HPV is diagnosed with cancerous strains. HPV is often transiently present, or our bodies fight the virus. Ensuring preventive measures which primarily includes taking the vaccine, and other secondary measures like pap smear tests are important because, in the case of cervical cancers, most of them have been found in women with a history of HPV infection,” Dr Shaanthy shares.
In many other parts of the world including Australia, the HPV vaccination has been made part of the centralised immunisation programme and has been distributed free of cost by the respective governments. Australia was one of the first countries to introduce a publicly-funded HPV vaccination programme in 2007 for girls between the ages of 12 and 26 years. In 2013, the vaccine was also introduced for boys in the same age group. The nonavalent vaccine introduced in 2018 is expected to prevent up to 90% of cervical and 96% of anal cancers, according to a study by PMC. Despite data proving its effectiveness, the HPV vaccine has not been integrated into the Universal Immunisation Programme.
“HPV vaccines are available in private hospitals, but they are unavailable in government hospitals, or for a subsidised price. Plans of supplying the vaccine as a pilot project in some districts might be in the works by National Health Mission (NHM),” says Dr Premalatha, who is the president of The Obstetric & Gynaecological Society of Southern India. The rollout of Cervavac, India’s first indigenously produced quadrivalent HPV vaccine by Serum Institute of India (SII) is expected to make the vaccine more affordable and accessible to all and will be costing between Rs 200 and Rs 400 a shot. As per media reports, the vaccine is likely to be available in 2023.
The 17th National Technical Advisory Group on Immunisation (NTAGI) which was held in June this year also discussed the introduction of India’s indigenously developed HPV in the UIP.
(*Names have been changed to protect anonymity)
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