Professor Isaac Adewole, a consultant obstetrician and gynaecologist and former health minister, speaks in this interview with Sade Oguntola about what Nigerians must know about the virus that causes cervical cancer and the importance of the vaccine against the cancer, among other issues.
At different times, you were involved with decision-making on cervical cancer screening in Nigeria and were a member of the International Taskforce on the Elimination of Cervical Cancer in the Common Wealth. What specific steps have been taken to combat cervical cancer?
Well, we have supported the elimination of cervical cancer in Nigeria for over 20 years, which started with the establishment of centres of excellence in six sites in Nigeria using generous grants from the Amazon Mobile Foundation. The established sites were Ibadan, University College Hospital, Port Harcourt Teaching Hospital, Enugu, Jos, Zaria, and Lagos, and we concentrated on prevention and building the surgical skills of gynaecology oncologists. And from there, we’ll move on to promoting different types of screening for cervical cancer and the introduction of human papillomavirus (HPV) vaccines. For instance, I served on the data safety management board of the vaccine trials in Tanzania, Senegal, and South Africa.
Vaccination of girls with the HPV vaccine is ongoing in Nigeria; do parents have any reason to fear allowing their girls to take the vaccine?
Yes, we started vaccination in October 2023. There is no reason for parents to fear allowing girls to have the vaccine. Since it has been in use for more than 15 years, there have been no known side effects. This vaccine has been in use for over 15 years; it is safe, and no adverse effects have been demonstrated. These vaccinations have no serious side effects other than injection-site soreness, which is common as it is an injection.
The HPV vaccine has no contraindication; there is absolutely none, except that we advise that it should not be given during pregnancy. The few people who have had it during pregnancy have not shown any adverse effects in terms of malformations and so on. The fact that the vaccination is taking place in two phases, starting with 14 states and later on in the other states, is merely for convenience. It is not because HPV, or cervical cancer, is more prevalent in one part of the country than the other.
What is the major factor responsible for the spread of HPV? Why are young individuals contracting the virus?
Well, the major factor responsible for the spread of HPV is a lack of protection. What we do not know is why girls don’t clear the virus from their bodies as much as boys do. When you look at the global picture, most girls who acquired the viral infection within two years of their sexual debut have cleared it off, but in Sub-Saharan Africa, it is not the same. Our girls tend to keep the virus, and we don’t know why the virus persists in them compared to girls in other parts of the world. It might have to do with their immunity, acquiring multiple infections from multiple partners, or the environment.
There are about 100 types of HPV variants, but less than 15 of them are actually pathogenic on the cervix. The most common are HPV 16, HPV 18, and HPV 35. We found HPV 35 to be common in sub-Saharan Africa. Unfortunately, there is no vaccine type that covers HPV 35.
What are the problems HPV portends in pregnancy before and after birth?
If a woman has it, it is possible for the newborn, while passing through the birth canal, to also contract it, particularly in the throat. HPV is also responsible for some cancers, even outside of the genital area. It is responsible for cancer in the oral pharyngeal space.
Is it possible to use medication, like with HIV, to stop the transfer of HPV from mother to child?
Such medications are still not available in the market space; what we have in the marketplace are preventive vaccines, not therapeutics. She will need her therapeutic vaccines, and I think in the next few years, they should be available.
Is there any prophylaxis to prevent transmission of HPV from mother to child?
It is an HPV vaccination. They would have given the women the vaccine before they got pregnant. You know we are targeting all our girls, who are ages 9 to 14. This implies that they are safe and that, in the event that they become pregnant, their unborn child will not be in danger of contracting HPV. They are almost protected for life. So far, the vaccine has been on trial for almost 30 years, and you still find the immune level to be high, showing that it’s still within the protective level.
The involvement of men is mentioned in many health interventions; how can they help to ensure a boost in uptake of the HPV vaccine in Nigeria?
Well, it is an interesting field: men’s involvement in reproductive health. It is an important one, and we all need to encourage them to support their wives and partners to take vaccines, go for family planning, go for antenatal care, and support them during labour and the period after childbirth. We also need to educate them with regards to cervical cancer screening and vaccination. Currently, countries like the UK, Austria, and Australia are vaccinating boys against HPV. That will be the ideal; it is only in resource-constrained settings that you’re vaccinating girls only.
Cervical cancer can be prevented in part by screening, but how do you address the situation when women who receive positive test results for the disease may not receive treatment right away?
There are new approaches that will make you screen and treat almost immediately so that the woman doesn’t have to come back. When you do a pap smear test, you have to wait almost a month before you get your result. There are faster tests; for instance, if you do HPV testing, you can get the result the same day, and if there is a need for treatments, you can then do what we call triaging because the fact that somebody has HPV does not imply that there is disease. So, you now need to do a colonoscopy to find out signs of disease, and if there’s disease, you can treat it.
The best test based on WHO recommendations is the high-precision HPV test. We have it in Nigeria, including at the University College Hospital. But for now, it is still essentially a research tool. Very soon, we’ll make it available to everybody who wants to have it done. But I am sure places like the Nigerian Institute for Medical Research (NIMR) in Lagos offer the HPV test.
What will be your advice regarding regular HPV screening in women to prevent cervical cancer?
What the World Health Organisation recommends is screening twice a lifetime for HPV at ages 35 and 45. Since this is a high-precision HPV test, its accuracy is high, and if it says there’s no HPV, truly there is no HPV. Since the condition takes time to manifest, a target age of 35 is recommended. A younger person might clear the virus from her body; as such, there is no point in testing a younger person. HPV is not a disease; it is a virus. When people have HPV, that means they have the virus. It does not necessarily mean that they have HPV disease or a lesion due to HPV. But what we know is that certain things can predispose people to acquire an HPV infection, like smoking and HIV. HIV infection increases the likelihood of having an HPV infection by about sixfold.
So, why are we putting more emphasis on HPV in women than in men?
One is that it is easier to detect HPV in women. Second, its outcome is more devastating for women. It is almost a hundred percent likely that when there is cancer of the cervix, it is due to HPV. In men, it causes penile cancer. But penile cancer is not as common as cancer of the cervix. So when you look at the burden of disease, it is more like cervical cancer. Anal, vulva, and oropharyngeal cancers are also all due to HPV. So HPV is beyond just sex and the genital area.
Do you envisage increased cases of HPV, particularly among young people, considering the change in their sexual practices?
Certainly, this could lead to an increase in cases of HPV among young people involved in these different sexual practices. It is simple and straight forward: the more nongenital sexual activity that people embark on, the higher the likelihood that they will have HPV infection in the genital space. And by so doing, it could increase the likelihood of oropharyngeal cancer.
Talking about safe sex, can condoms protect you from contracting HPV?
Yes, if there is no leakage of sperm. But there will always be leakage, even from the sides. A condom is not foolproof, but it is better than nothing. I would rather prescribe abstinence for young people. If in a martial union, why do you want to use a condom, except for family planning but certainly not for HPV protection?
Does Nigeria have a policy on cervical cancer?
We don’t have a policy on HPV, but we do have one on cervical cancer. Although I’m not sure if we need a policy on HPV, I do think we should have one on cervical cancer that will include the newest information on what to test for when contemplating screening, including HPV. If you look at previous guidelines, it talks about the use of pap smears for cervical cancer testing. But what WHO now recommends is HPV testing. That, to me, is the gold standard. That should come into our book. The insurance requirements for cervical cancer testing should also be addressed. They mention pap smear examinations, which are too logistically challenging and technically demanding for us to do. So, we should change the insurance policy so that it pays for cancer screening but leaves the type of screening open.
Many apps have been developing that promise to help with many things, including monitoring blood pressure, heart rate, vision, and so on. What is your opinion about this?
There is absolutely nothing wrong with them for as long as they don’t cross the boundary, for as long as they don’t mislead people, and for as long as they don’t offer the wrong medication. Apps that ask people to check blood sugar, check urine, reduce salt intake, and so on—to me, they are nice.
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