The controversy in the United States over whether to make HPV vaccination mandatory for preadolescent and adolescent girls has overlooked a more pressing global public health issue: the women and girls who need the vaccine the most do not live in the U.S.

The HPV vaccine protects against two types of the human papillomavirus, a common sexually transmitted infection that can lead to cervical cancer. This disease is relatively rare in the U.S., however. The American Cancer Society estimates that there will be 11,150 new cases of cervical cancer in the U.S. in 2007 and 3,670 deaths from the disease. In contrast, 95% of the nearly 260,000 deaths from cervical cancer in 2005 occurred in the developing world. Most of these deaths occurred in sub-Saharan Africa, Asia, and South America.

According to the World Health Organization (WHO), cervical cancer deaths will rise by almost 25% over the next decade. Thus, the HPV vaccine is a welcome addition to the global fight against sexually transmitted infections and cervical cancer. Unfortunately, many obstacles prevent quick roll-out of the vaccine in developing countries. The most important of the obstacles are the vaccine’s high purchase and delivery costs. Other problems are the weak health and distribution infrastructures in developing countries and social and political forces that prevent women and girls from gaining access to health services. These obstacles have also hampered access to HIV/AIDS treatments in the developing world and may hinder quick roll-out of a future HIV/AIDS vaccine or microbicide.

How much the HPV vaccine will cost outside the U.S. is anyone’s guess, but it will not be cheap. For the U.S. market, the three-dose regimen is expected to cost about $360, a sum beyond the reach those in resource-poor countries. To this cost must be added expenses for needles and syringes, vaccine delivery and storage, and program administration. And even if developing countries could afford these costs, many of them lack the distribution mechanisms and health workers to administer the vaccine.

Several factors the WHO and other organizations have identified as contributing to the high cervical cancer death rate in developing countries must also be addressed. Many women, health care providers, and policymakers in these countries do not recognize cervical cancer as a health problem. Despite the increase in cervical cancer control programs in the developing world, some countries still have low-quality screening and follow-up programs, and some have no programs at all. And most women in these countries have limited access to any routine health care services.

Social and cultural norms in developing countries may discourage discussion and education about sexually transmitted infections and diseases affecting the genital tract. Yet greater awareness about HPV and cervical cancer helps little if women have no access to HPV and cancer screening. This screening will still be necessary even if they are vaccinated, since the HPV vaccine does not protect women against HPV types linked to approximately 30% of cervical cancers. Moreover, no data show whether the vaccine can prevent cervical cancer in women already infected with HPV or whether it will be effective beyond five years. That many women and adolescent girls in developing countries lack access to basic health services – including cervical cancer screening – makes implementing an immunization program all the more difficult.

Global health policymakers should take note of a key lesson from the HPV vaccine controversy in the U.S. Failure to identify and respond to societal concerns about vaccinating preteens and adolescent girls against sexually transmitted infections before a vaccine becomes available can lead to a backlash against an effective public health intervention. Matters of sexual health, sexuality, and sexually transmitted infections remain complex issues throughout the world because they often collide with social, cultural, and religious attitudes and beliefs.

Consent and privacy issues also complicate vaccine roll-out in developing countries. In the U.S., many state laws permit adolescents under age 18 to receive preventive services and treatments for sexually transmitted infections without parental consent. Because adolescent consent laws in developing countries may be more restrictive, effective strategies are needed to inform parents about the health benefits of the HPV vaccine and to explain to them that administering the vaccine does not imply that the adolescent is or should be sexually active, and that therefore vaccination to protect against cervical cancer should not be stigmatizing.

Several global health partnerships are working to lower the cost of the HPV vaccine, to facilitate local, regional, and global collaboration for vaccine delivery to developing countries, and to educate key audiences that HPV and cervical cancer are important global health concerns. Yet the difficulties encountered in providing affordable HIV/AIDS drugs to developing countries suggest that getting the HPV vaccine quickly to those who need it most presents a formidable challenge. It will take enormous commitment by governmental and nongovernmental global health organizations, women’s health advocates, finance ministries, and vaccine manufacturers to reverse the historical delays in introducing life-saving public health interventions to resource-poor countries.