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 document review of national policies and global publications 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 differentiated dosing schedules and strategies to vaccinate immunocompromised girls was limited and inconsistent. Promising strategies were identified, 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.

The authors have declared no competing interest.

This study was funded by the Gates Foundation HAPPI Consortium (Grant INV-046461) via a sub-award to the Clinton Health Access Initiative through JSI. The manuscript's contents are the responsibility of the authors and do not necessarily represent the official views of the funders. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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This study was reviewed by the Clinton Health Access Initiative’s internal Scientific and Ethical Review Committee (SERC) and approved by the Eswatini Health and Human Research Review Board (EHHRRB089/2024), the Malawi National Health Sciences Research Committee (NHSRC) (24/09/4522), and the Uganda National Council for Science and Technology (UNCST) (HS4994ES).

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The qualitative data for this study were collected using structured note-taking matrices rather than full transcripts. These de-identified matrices contain potentially sensitive information and are not publicly available. However, de-identified data for each country included in the study may be made available upon reasonable request to the corresponding author and subject to approval from the relevant national ethics committee in each country.