No Waiting Until Tomorrow: A Q&A with PAHO Director Dr. Jarbas Barbosa

Renowned public health professional Dr. Jarbas Barbosa is currently director of the Pan American Health Organization (PAHO), an organization working to eliminate cervical cancer — one of 30 diseases targeted for elimination by 2030.  In September 2024, Dr. Barbosa called for urgent action to eliminate cervical cancer in the Americas, noting that of the 51 countries and territories of the Americas, 48 have already introduced the HPV vaccine, yet coverage varies widely, from less than 10% in some countries to over 80% in others. Below he explains how the Americas are working to become the first region in the world to eliminate cervical cancer.

What made you embrace cervical cancer elimination as a top priority under your leadership of PAHO?

We launched the Elimination Initiative last year that aims to eliminate more than 30 diseases and related conditions by the year 2030. Cervical cancer is one of the diseases we are actively working to eliminate, as we now possess effective tools to combat this prevalent health issue.

We have an excellent vaccine that only needs one dose to protect against Human Papilloma Virus infection, the precursor of cervical cancer, and we have 48 countries and territories of the Americas that are already using it. We are only missing three: Haiti, Cuba, and Venezuela. And we are supporting these three countries to include this vaccine into their routine schedule.

Currently, we have 24 countries and territories that have already adopted the one-dose schedule. Consequently, they have an increased supply of vaccines and are amplifying vaccination efforts. These countries are vaccinating boys and expanding the age groups eligible for vaccination. With unwavering commitment, we can achieve the goal of vaccinating 90% of girls and adolescents.

We also have a highly effective molecular test that is available for self-collection. The woman can conveniently collect the sample herself, allowing health community workers to distribute the collection kit and retrieve it afterward. This approach significantly reduces the time burden for women who currently need to visit a health center multiple times for the test. We possess this powerful tool, and we are collaborating with producers and manufacturers to lower its cost.

Additionally, we also have ablative treatments that can be performed at the primary healthcare level, to timely address pre-cancerous lesions. When combining these three pillars, it’s achievable to eliminate cervical cancer. I do believe that the Americas can be the first region in the world to eliminate this cancer and inspire other regions to follow us the same way.

While advocating for the single dose for girls, you have also been a big proponent of gender-neutral HPV vaccination. In your view, why is it vital to also vaccinate boys?

It is really important. We are encouraging our countries to move to the single-dose regimen. Doing this and maintaining the same quantity of doses they currently purchase annually will enable them to provide additional vaccines to the boys.

The latter will have at least two relevant benefits. First, we have sound evidence demonstrating that vaccinating boys also protects girls because we achieve herd immunity that is broader than if vaccination is limited to girls.

Second, let’s remember that the human papillomavirus (HPV) is not only related to cervical cancer but also to other cancers such as anus, throat, penis, and others, which can be prevented. We are benefiting the girls, and at the same time, we are protecting boys against other types of cancer.

How big is the financing challenge in Latin America when it comes to adopting the three-pronged strategy for cervical cancer elimination that you just outlined?

Our region is primarily made up of middle-income countries, and international financial support from partners for implementing cervical cancer strategies is limited. This could be seen as a challenge to making progress in the fight against cervical cancer. However, most countries have recognized the importance of intensifying efforts to eliminate this disease.

Regarding HPV vaccination, as mentioned before, 94% of countries have already included the vaccine in their routine immunization schedules, with many also implementing strategies supported by PAHO to boost coverage. Additionally, some countries are moving forward by incorporating modern technologies into primary health care to enable more efficient and timely screening, diagnosis, and treatment.

It is important to highlight that in the Americas, we have a unique immunization platform that provides easy access to affordable, high-quality vaccines like the HPV vaccine through a pooled-purchase system that significantly reduces prices. This system is PAHO Revolving Fund for Vaccines, which has been in operation for over forty years. It is an essential and distinctive resource for our region.

Other regions are interested in our approach and want PAHO’s help to set up similar systems. We are working together with the Africa CDC, for instance, and with WHO EMRO (World Health Organization Regional Office for the Eastern Mediterranean).

Also, we have the Strategic Regional Fund, which provides countries with access to high-quality laboratory, diagnostic, and health technologies. We are currently negotiating with manufacturers of the HPV molecular test, which currently costs between $25 and $28 per test. Our goal is to reduce this price by approximately four times, making it more affordable for many countries as they implement national plans to eliminate cervical cancer.

Guaranteeing access to this test is a significant part, as well as increasing vaccination rates and adopting strategies to reach adolescents in the places they go. We are also working with countries to strengthen primary health care, considering that the capacity of the health workforce is an important ally of this initiative to eliminate cervical cancer.

Typically, adolescents have been less of a target of vaccination than younger children, but they can be harder to reach.  What role can the private sector, such as trained pharmacists in community drug stores, play as service delivery points for vaccination and diagnostics?

Vaccine coverage in our region is low when offered only in health centers, as adolescents rarely visit them, and it’s not that easy for their mothers and fathers to take them to a health center.

School-based vaccination improves coverage but still falls short of the 90% goal. To reach this target, we need to expand access by potentiating social participation and taking advantage of every opportunity of contact with them.

Community drugstores are already an integral part of many neighborhoods, making them ideal points of contact for reaching this often-overlooked age group. Their accessibility and convenience, especially with extended hours and locations throughout both urban and rural areas, make them well-positioned to provide services that may be difficult for adolescents and their families to access through traditional public health facilities.

However, partnering solely with drug stores at the community level may be insufficient, as we might be losing great places such as malls, cinemas, and others where adolescents gather. We need to bring the vaccine closer to them.

Achieving 90% coverage is essential for eliminating the HPV virus in this generation. This can be accomplished by enhancing school vaccination programs and implementing out-of-school programs through a combination of delivery strategies.

How would these partnerships be established?

Vaccine distribution in the Americas is complex due to varying country laws and regulations. In some places, like the U.S. and Canada, vaccines are widely available at drugstores and pharmacies. However, access is more limited in many Latin American and Caribbean countries, with some vaccines like flu being available but others not.

To increase access, we support countries in finding the best alternatives within their legal frameworks. Depending on that framework, public health authorities could create formal agreements with drugstores where there is not direct freedom to work with, setting clear service standards and responsibilities. Training programs are essential to ensure those potentially vaccinating at the drugstores and other settings have the skills to deliver vaccines safely.

Financial incentives supported by the health sector, local governments, and social networks can encourage participation and support sustainability. Public health campaigns can help raise awareness while assisting logistics, like providing necessary storage equipment and ensuring services meet safety standards. Integrating data tracking systems can support program evaluation and follow-ups to adolescents.

We are also supporting countries in the Americas to identify the populations that are not getting vaccinated. We are adopting this micro-planning strategy that has been fundamental to identify the pockets of non-vaccinated – in the slums, in the big cities, in the rural areas.

Every country needs to review which are the best alternatives that they have, because the main objective is to increase the access and to guarantee that vaccines will be delivered to the population with no out of pocket payment.

One of the challenges with the HPV vaccine has been misperception and misinformation that this vaccine could encourage promiscuity among adolescent girls. What are some of the ways around this barrier?

To address the HPV vaccine’s misperception of it prompting promiscuity among adolescents, we need to engage with parents, adolescents, communities — including relevant stakeholders — in a meaningful way. This involves tailoring messages to specific audiences, partnering with trusted sources within those groups, and using various channels to reach parents and young people directly.

This vaccine can prevent 40,000 deaths annually in the Americas due to cervical cancer, and this might sound just an impressive statistical number. Still, it means the world to those families affected. Sharing experiences from the family members who went through these terrible stories can help convince others to act promptly.

Also, we need to double down on the fact that vaccines are mainly a preventative measure, not a treatment so, in many cases, to work they must be given several months to years before the potential microorganism might endanger any person; in this case, the sexually transmitted HPV.

Additionally, this vaccine doesn’t change the libido at all or have any effect on the hormonal system. Neither does it protect against other sexually transmitted microorganisms/diseases, so under no condition should it be understood that the HPV vaccine will give the green light or motivate adolescents to start sexual life earlier or be promiscuous. By addressing concerns head-on and providing accurate information, we can dispel myths and encourage vaccine uptake.

So, we need to facilitate access while we reduce or eliminate barriers. Primary health care, where you have diagnostics and treatment close to the communities, is the best answer for overcoming all these barriers.

We have seen that awareness about cervical cancer can be as low as 2% in some countries. How big is the need for building awareness and education of cervical cancer or HPV in the Americas?

When launching a public health initiative, it’s crucial to engage all stakeholders in the country — such as medical associations, the health workforce, communities, faith-based organizations, and the private sector — to collaborate effectively. We must build a robust alliance that unites these sectors and actors, along with families in the communities, to foster a shared understanding of the need to vaccinate to save lives. Achieving this is a vital objective.

We are assisting countries in creating communication strategies to ensure that a clear and strong message is conveyed.

We have an unacceptable number of deaths related to this cancer. About 40,000 women die of cervical cancer every year in our region, and we have the tools to eliminate this cancer.

When we acknowledge that we have the tools to eliminate this cancer, that is a powerful message. However, it is essential to spread this message so that families and communities can adopt it and prioritize it as their own goal.

As you go after this important priority, what is it that gives you hope and optimism?

As a public health professional, I am convinced that when we have public health problem that is bringing suffering and deaths that are leaving many families, poor families in our region, without a mother for the children, and yet we have the tools to eliminate this disease, I think we have a moral and ethical mandate to end it.

Doing so will help reduce the suffering of these families and will be a major step toward fostering equality in Latin America and the Caribbean.

The 40,000 deaths each year have a disproportionate impact on the region’s most vulnerable families, making this an essential contribution from the health sector to poverty alleviation. In half of the poorest households in the Americas, there is only one woman who provides an income. Losing her or seeing her endure a painful treatment for cervical cancer, would be devastating.

We need to act today. Waiting until tomorrow is simply too late.