Imran Oludare Morhason-Bello, a professor of obstetrics and gynaecology and the HPV Consortium Project Directorate at the College of Medicine of the University of Ibadan, in this interview with SADE OGUNTOLA, he speaks about the burden of HPV-related cancers in Sub-Saharan Africa, focusing on how HPV-related research is working on its eradication.

IS HPV a problem in Africa, and then, by extension, globally?

Human papillomavirus (HPV) is a disease of inequity that is prevalent in sub-Saharan Africa due to lack of awareness and the changing sexual behaviours of people in sub-Saharan Africa. Africa has the highest burden of sexual risk behaviour globally. In a systematic review, we showed that young people and adults are beginning to change their sexual behaviours astronomically without necessarily knowing the burden of health issues that are associated with these changing behaviours. For example, people only think of unprotected sex from the perspective of penile-vaginal sex, forgetting that other forms of sex, including non-penetrative sex, could be a mode of transmitting sexually transmitted infections, including HPV infections. Generally, they think that oral and anal sex are not as risky as penile-vaginal sex; many do not even think masturbation could be risky.

Second, Africa has a high HPV rate because of the burden of HIV infection. There is a synergistic effect between HPV and HIV infection. So, HPV tends to be easily acquired and transmitted within the HIV population relative to the HIV-negative individual within the general population. We do not have a comparable health system similar to high-income countries that have infrastructure to prevent HPV infections and associated cancers relative to other parts of the world. For example, many high-income countries have already integrated HPV vaccination into their health systems, and it?s almost becoming routine now.

In 2023 Nigeria began the process of vaccinating her population. To date, the country has vaccinated over 13 million girls, the highest population ever vaccinated in a country at that time. We are delighted that Nigeria has adopted the routinisation of the HPV vaccine. However, many countries, like Ghana, Mali and Togo, have not started routine HPV vaccination. It?s only Rwanda that is in the league of other high-income countries. I?m confident Nigeria will soon achieve herd immunity, judging by the current level of commitment by the government and her collaborators. The National Primary Healthcare Development Agency under Dr. Muyi Aina is working hard to ensure that no eligible girls are left unvaccinated, a feat that is highly commendable.

Currently, sexually transmitted infection tends to be very high around the period of sexual debut. Studies have shown that sexual initiation is usually an unplanned event, and most of the time it is usually performed in an unprotected fashion. Particularly girls tend to be more exposed to sexually transmitted infections, of which HPV is one of them. However, many African countries have not institutionalized HPV screening in their health systems. Nigeria is currently at best doing opportunistic HPV screening. Even many healthcare workers who are women have not been screened for HPV. I?m aware that the Federal Government of Nigeria is making an effort to partner with the sub-national governments to kickstart HPV screening within the health system.

Now, look at the burden of HPV infection-associated cancers. When 10 people are infected with HPV, around eight or nine of them will clear the infection. Studies point to 10 to 15 per cent of individuals with HPV infections that will be unable to clear this infection, resulting in persistence. HPV infection is also very forgiving. It has a latency period of about 10 to 20 years before transiting to cancer when nothing is done.

Sub-Saharan Africa has the highest burden of cervical cancer globally, with East Africa having the highest burden of cervical cancer in the sub-region of Africa. So, the burden of HPV-associated cancer is high in sub-Saharan Africa because of our poor public health system to institutionalise preventive strategies.

What is the global impact of HPV-associated cancer, particularly in Nigeria?

Globally, HPV-associated cancer accounts for 5 per cent of all cancers. What are the cancers that are associated with HPV? Nearly 100 per cent of cervical cancers are HPV-associated. Many studies showed that the persistence of high-risk HPV infection is a necessary cause of cervical cancer.

Other HPV-associated cancers include oral and oropharyngeal cancers, which are cancers in the mouth and the throat. The squamous type of oral cancer occurs in 30%, while those that are due to HPV in the throat occur in 70%. Similarly, persistent HPV infections occur in 60 per cent of cases and more than 70 per cent in vulvar and vaginal cancers. Penile cancer is higher in populations of men that were uncircumcised relative to circumcised men; similarly, HPV-associated cancers in the anus are higher in men who have sex with men than men involved in heterosexual relationships.

However, increasingly, more young people are engaging in anal sex because young female adolescents want to preserve their virginity, even when they are supposedly in a heterosexual relationship. This suggests that sex without protection against HPV is common around the period of sexual initiation, making them vulnerable to infections. Vaccinating young people before sexual debut is a potent method to prevent the risk of acquisition and transmission of HPV infection, and by extension, leading to an increasing burden of HPV-related cancers may be the next epidemic. A gender-neutral vaccination is the best option. However, countries that could not afford vaccination, like Nigeria, could go for the easiest route to ensure herd immunity. If you achieve herd immunity, more people will be protected. However, I will always tell people that if you can afford the HPV vaccine, let your boys also get vaccinated.

So, how far has Nigeria gone with achieving the World Health Organisation?s 90, 70, 90 agenda for accelerating the elimination of cervical cancer as a public health problem?

The WHO?s target to accelerate the elimination of cervical cancer involves ensuring that 90 per cent of girls are fully vaccinated, 70 per cent of eligible women are screened for cervical cancer and 90 per cent of women identified with cervical cancer are treated. In its quest to achieve these targets, Nigeria set up the National Institute for Cancer Research and Treatment, NICRAT, headed by Professor Ali Usman. And thereafter, within NICRAT, the Honourable Minister of Health set up the National Task Force for Cervical Cancer Elimination, chaired by the former Minister of Health, Professor Isaac Adewole. It?s a 15-man committee, of which I?m also privileged to be a member.

The taskforce is currently being supported by the office of the First Lady to mobilise resources to ensure that Nigeria leapfrogs herself into the right path for cervical cancer elimination. What are we doing? Nigeria has vaccinated over 13 million girls and is about to institutionalize HPV screening and collection of data to know the total number of cervical cancer cases in Nigeria.

The Coordinating Minister of Health and Social Welfare, Professor Pate, recently talked about the establishment of comprehensive cancer centres in the country, with a promise that some will be available for public use before the end of this year. With the task force and the support we?re currently getting from NICRAT and the Federal Minister of Health and Social Welfare, Nigeria is on the right trajectory to ensure that the country attains those set goals.

How do you see the West African Self-Sampling HPV-based Cervical Cancer Control Programme (WASH-CC), implementing self-sampling HPV testing with Nigeria?s HIV programme, contributing to helping Nigeria eliminate cervical cancer?

The West African Self-Sampling HPV-based Cervical Cancer Control Programme is a U01 grant that is supported by the National Cancer Institute and the National Institute of Health in the U.S. It is a collaboration between Northwestern University in Chicago and two institutions in Nigeria and Mali, respectively. The study sites in Nigeria include the University of Jos and the University of Ibadan.

According to WHO, countries that are on the path to cervical cancer elimination need to screen with a high-output screening test. In Nigeria, we have challenges of manpower, but self-sampling for HPV will ensure more women can initiate screening on their own. She can take a swab sample of her private part by herself, drop it in a bottle, send it to a place where an HPV test can be performed within a few hours, and then she gets to know that same day whether she has HPV or not. And immediately, those with HPV can then be treated. Of course, this will bypass the bureaucratic bottleneck of a healthcare facility or lack of access to a facility for HPV screening.

It is expected that between 1 and 2 out of every 10 screened may be positive for HPV; maybe 1 out of 10 may be positive for higher-risk HPVs. But in the HIV population, it could be as high as 3 to 4 out of every 10 tested will be positive for HPV. Women that are positive at the facility will be further examined with colposcopy. If an abnormal result is seen, the woman is treated immediately with ablative or excisional technique and followed up every three years with the same swab.

No doubt, self-sampling for HPV will break the chain of pressure on the head facility and ensure that every woman has the opportunity to be screened in their lifetime, thus averting the risk of developing invasive cervical cancer. That is the ultimate.

However, the main challenge is that our women don?t know that this opportunity exists. So our hope is that by the time this project is over and our findings are disseminated, it can inform the government?s policy to integrate this into the health system. This way, women can walk in to get the swab, get tested, and then get treated for those that are positive, and then they move on with their lives. That way, we will avoid the current situation where we see almost 13,000 cases of cervical cancer every year and nearly 8,000 of them die from the disease.

Currently, there is inequity in access to health facilities, and healthcare financing is largely out-of-pocket spending occurring in nearly 80 per cent. For people who cannot afford healthcare and are in hard-to-reach areas, an innovative mechanism should be deployed. So, in a partnership between Northwestern University and the University of Ibadan, we sought support from the John R. Flanagan Charitable Foundation in Chicago to build a mobile truck clinic that is equipped for self-sampling, a diagnostic laboratory that could test for HPV types and a treatment room for those that are HPV positive. It took us almost a year to design the truck from scratch with the company. We plan to deploy the truck to rural areas where access to specialised care is almost zero.

Our plan as HPV Consortium is to pilot the mobile truck clinic in four selected local government areas, namely; Kajola, Iseyin, Ibadan North and Ibadan Northeast, in partnership the leadership of the Oyo State Primary Health Care Board, headed by Dr. Muideen Olatunji.

Aside from screening for cervical cancer, we also intend to screen for hypertension and diabetes. We have a defibrillator and ECG in the mobile clinic. There is an ultrasound machine ultrasound scanning. A state advisory board headed by a retired secretary to the government of Oyo State is to provide leadership and will be part of the piloting of the mobile clinic to evaluate the intervention in these local government areas. Already, talks are ongoing with the state government to ensure security in the community.

The study on epigenetic biomarkers of cervical cancer in women with HPV infection is exploring genetic means to predict individuals with HPV that can develop cervical cancer. Is this going to be helpful in cervical cancer elimination, eventually?

The study on epigenetic biomarkers of cervical cancer, which is called DNA methylation study, it aims to identify those markers for HPV that can predict the development of cervical cancer in the next 10 to 20 years if nothing is done about the infection. Individuals that elaborate any of these biomarkers will be put on surveillance relative to those without such biomarkers because of the likelihood of them developing cancer. Certainly, it will help us to triage and prioritise resources for those at the highest risk of developing cancer. We?re conducting similar study on oral and oropharyngeal cancer, too. Most of these studies are being conducted among the HIV positive population and key populations.

By the time our research is completed, we are going to disseminate our findings, and then we move to the next level of seeking approval if we get something substantial on how to make it a population-wide screening. Already, there are a couple of biomarkers that are commercially available to test if somebody is having a new infection or has a persistent infection. What are other things that may likely impart cervical cancer elimination eventually from research?

Well, without letting the cat out of the bag, our learning in the community is what is important. As a researcher, one may be thinking this is the best for our people. The people may agree that it is useful but request a different implementation strategy. The purpose of implementation science research is not to generate evidence but to learn how research ideas should be practically conducted within a setting and document the lesson learnt. The HPV Consortium already has evidence of what may work, but we now want to test how that evidence can be used efficiently and effectively within the community, leveraging the perspective of people in the community.

HPV-associated cancers cover broad anatomy, so the HPV Consortium, College of Medicine, University of Ibadan, which includes researchers from different faculties, including public health, basic clinical sciences, basic medical sciences, dentistry, social sciences and clinical sciences, is currently collaborating with different institutions, chiefly Northwestern University in Chicago. We are also collaborating with researchers from the University of Mali and the University of Jos, as well as 13 teaching hospitals in Nigeria. We are collaboratively working on cervical cancer and concordance with other anal and oral cancers. The HPV Consortium is also collaborating with the London School of Hygiene and Tropical Medicine, London, to evaluate the impact of the HPV vaccination programme in Nigeria and Tanzania; what are the lessons learnt? HPV vaccine hesitancy, the motivating factors for taking the vaccine and how governments can implement the programme in the future as well.

We are equipping a new laboratory specially set up for HPV genotyping and to conduct other molecular tests. This is probably the first big molecular laboratory that will be focusing on HPV-related research in Nigeria. We are setting up a telepathology laboratory for a multi-institutional engagement to discuss pathology. Professor Femi Ogunbiyi ? a senior member of the HPV consortium ? is leading it. Prof. Akinyele Adisa, another member of the HPV consortium, has a specialised microscope too, procured by the HPV consortium from our R01 grant to assist participating sites to support oral pathology diagnosis. (Nigerian Tribune)

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