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H. (MH) Botha, G. Albero, L. Bruni (November 2022). South Africa. Human Papillomavirus and Related Cancers, Fact Sheet
www.HPVWorld.com, 215

Comment:

South Africa (SA) has seen a steady increase in gross domestic product per capita over the last four or five decades. It is regarded by the World Bank as an upper middle-income country with health care spending comprising 8% of GDP.¹ Despite this economic growth and healthcare investment, there is still a very high rate of invasive cervical cancer with a high mortality to incidence ratio. An age-standardised rate of 35.3 and a mortality rate of 19.6 is very far away from the target of cancer elimination as outlined in the World Health Organisation’s Call to Action. Many factors contribute to the high cancer rates, including historic and persistent wealth disparities (SA has the highest Gini index in the world), a high rate of people living with HIV and competing health priorities.

The lack of progress in cervical cancer prevention is particularly concerning in an era when effective preventative strategies are available. Like in most other geographies, HPV 16 and 18 are the most important oncogenic strains detected in invasive cervical cancer in SA, which means that all the currently available vaccines should be effective in preventing cervical cancer and many high-grade precancerous lesions.

Primary prevention through school-based HPV vaccination was introduced in 2014 and initially relatively high rates of coverage was achieved for the first dose with a significant drop off with a second dose. Only girls are vaccinated in the SA school-based program and the coverage has decreased dramatically during the COVID pandemic with only 3% of the target population receiving the vaccine in 2020. HPV vaccination coverage to achieve herd protection must remain the most important focus and increasing the cohorts for vaccination (all genders and more age cohorts) provides the best hope for reduction in new cervical cancer cases. Other primary preventative strategies (including controlling the HIV pandemic and reduction in smoking) are also extremely important priorities.² HIV co-infection increases the risk for persistent HPV infection with subsequent increased risk for invasive cervical carcinoma. Data about other HPV-related cancers in SA is less robust but in the context of the high HIV burden, it makes sense to vaccinate as many individuals as possible, regardless of gender.

The current South African HPV vaccine program utilises a bivalent vaccine in a 2-dose regime which should provide long-term protection against infection and disease. With the persistent high background risk for HIV infection in up to 20% of young adults, there is concern about the effectiveness of a single dose strategy and more robust information is needed about reduced-dose schedules in at-risk, immune-compromised populations.

Secondary prevention through cervical cytology has achieved minimal success in reducing cancer rates. Low coverage of the population combined with a test strategy with imperfect sensitivity, especially when the test is done with wide time intervals, is not an effective way of achieving success. HPV DNA testing is feasible and scalable in the SA health care sector where there are already well-established HIV clinical control programs with all the laboratory support for high-volume PCR testing in metropolitan centres. Many rural health care facilities have tabletop PCR testing platforms that have been rolled out as part of HIV control programs or as part of the COVID pandemic response. A combination of population-based and opportunistic or campaign-based screening strategies utilising self-collected samples have the potential to be more effective in identifying individuals with an increased risk for disease. The most recent national cervical cancer control policy outlines a path towards complete transition to HPV based screening over the next decade.³

Treatment options for pre-cancer must be scalable in a country with huge health care disparities between urban and rural environments and may include ablative options like thermal ablation or cryotherapy. One concern about ablative therapies is the long-term cure rate in people living with HIV. This needs further prospective study.

References

1. World Health Organisation Global Health Expenditure database. Available from: https://apps.who.int/nha/database (last accessed: Nov 13th, 2022)

2. Zeier MD, Botha MH, Engelbrecht S, Machekano RN, Jacobs GB, Isaacs S, et al. Combination antiretroviral therapy reduces the detection risk of cervical human papillomavirus infection in women living with HIV. AIDS. 2015;29(1):59-66. Available from: https://doi.org/10.1097/qad.0000000000000512

3. Cervical Cancer Prevention and Control Policy. National Department of Health, 2017. Republic of South Africa. Available from: https://www.health.gov.za/wp-content/uploads/2021/07/cervical-cancer-policy.pdf (last accessed: Nov 13th, 2022)

The Catalan Institute of Oncology (ICO) in Barcelona, Spain and the International Agency for Research on Cancer (IARC) in Lyon, France jointly lead the HPV Information Centre, a web-based resource that compiles, processes and disseminates published information on HPV infection and HPV-related diseases for all countries of the world.

Country-specific Fact Sheets are standardized summaries of HPV-related disease burden and associated risk factors, prevention strategies, screening activities, and immunization programs for each of the 194 WHO member states. Fact Sheets include concise, self-explanatory graphs and tables to offer a quick overview of the situation in the designated population. The system allows queries to generate statistics for individual countries, groups of countries, geographical regions or worldwide summaries.

More elaborated supplementary tables and comments can also be found in country-specific, regional and worldwide Full Reports from the original database (www.hpvcentre.net). The HPV Information Centre publishes internationally recognized review monographs and targeted scientific publications to address relevant questions in the path to the cervical cancer elimination campaign. The HPV Information Centre is an open access, publicly funded resource to support the work of the scientific HPV community worldwide.

South Africa: key data on HPV and HPV-related cancers¹

South Africa has a population of 22.2 million women aged 15 years and older who are at risk of developing cervical cancer. Current estimates indicate that every year 10702 women are diagnosed with cervical cancer and 5870 die from the disease. Cervical cancer ranks as the 2nd most frequent cancer among women in South Africa and the 1st most frequent cancer among women between 15 and 44 years of age. About 3.2% of women in the general population are estimated to harbor cervical HPV-16/18 infection at a given time, and 64.2% of invasive cervical cancers are attributed to HPVs 16 or 18.

complementary data on cervical cancer¹



References

1. Bruni L, Albero G, Serrano B et al. ICO/IARC Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in South Africa Summary Report 22 October 2021. Available from: https://hpvcentre.net/statistics/reports/ZAF.pdf?t=1668367618799

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