Abstract
Immunocompromised girls, including girls living with HIV, face significantly increased risk for HPV-linked cervical cancer and require a differentiated human papillomavirus (HPV) vaccination schedule. While World Health Organization (WHO) vaccination guidelines exist, recommending immunocompromised individuals receive at least two, if possible three doses of HPV vaccine, little is known about how country health programs implement these recommendations. This study examines HPV vaccination policies, delivery strategies, barriers, and enablers for immunocompromised girls in Eswatini, Malawi, and Uganda-countries with a high burden of HIV and cervical cancer. A cross-sectional qualitative study was conducted through key informant interviews and focus group discussions with stakeholders from ministries of health, implementing partners, and health workers. A desk review of relevant policy documents was also conducted. Data were analyzed thematically to identify common and country-specific themes. All three countries follow the WHO's recommendation for a two-dose HPV vaccine schedule for immunocompromised girls. However, none have fully documented or consistently implemented policies or delivery strategies to reach immunocompromised girls with additional HPV vaccination doses. Stakeholder awareness of dosing schedules and strategies to vaccinate immunocompromised girls was limited and inconsistent, though higher in Eswatini than in Malawi or Uganda. Promising strategies were identified across the three countries, including use of Teen Clubs and adolescent HIV clinics to deliver HPV vaccines. Barriers included stigma, limited cold chain infrastructure, unclear operational policies, and weak data systems. Enablers included trusted health provider relationships, peer mentorship, and community awareness of cervical cancer risks. Improving HPV vaccine delivery for immunocompromised girls, including girls living with HIV, will require documenting and disseminating clear policies, integrating vaccination into HIV and adolescent health services, scaling successful strategies, and strengthening data systems to monitor coverage. Tailored, stigma-sensitive strategies are essential to ensure equitable cervical cancer prevention for immunocompromised adolescents in high HIV-burden settings.