“I didn’t even know what it was,” said the 50-year-old Egyptian mother about the cluster of skintag-like growths around her exterior genitalia that was caused by a virus commonly transmitted sexually.
She was shocked when her gynecologist informed her that the growths were caused by the human papillomavirus, known as HPV. She was then referred for a test that would be able to detect any irregularities in her cervical cells. Luckily, no changes in those cells were found.
Her case is one of many in Egypt, and comes as activists and medical workers sound alarm bells over a problem they say is overlooked in the country – namely the reluctance of many conservative doctors and parents to give the HPV vaccine to young girls.
The problem, experts say, stems from a lack of awareness and understanding of the virus, as well as persistent social stigma about the disease being a sign of promiscuity among women.
This has led countless women down painful roads with HPV, experts say, the virus that causes more than 95% of cervical cancers in women, according to the World Health Organization (WHO).
Cervical cancer is the fourth most common type of cancer among women globally, says WHO, and in 2020 it killed some 342,000 women globally. About 90% of new cases and deaths that year occurred in low-income and middle-income countries.
Egypt is a lower-middle income country, according to the World Bank.
“The main problem is that it is actually not a common vaccination in the Global South,” said Lobna Darwish, gender and human rights officer at the Egyptian Initiative for Personal Rights (EIPR), which launched its own awareness campaign in March 2022.
“Very few countries in the Global South are actually doing (routine HPV vaccines), and Egypt has an opportunity to be one of the leaders (on this program),” she said.
Egypt’s ministry of health has published brief awareness pamphlets on its social media platforms about the virus, noting some of its key symptoms and asking women to schedule routine check-ups. The ministry has also advised women to take the HPV vaccine.
In 2020, WHO launched the Global Strategy to Accelerate the Elimination of Cervical Cancer, the first-ever global commitment to eliminate the cancer, setting a target of getting 90% of girls fully vaccinated against HPV by the age of 15.
Yet progress has been slow in Egypt. Activists and medical workers say that as well as a lack of awareness of the virus and social stigma around sex and sexually transmitted infections, poor advice from some clinicians and even the price of the vaccine may all be contributing to the crisis.
The vaccine is not subsidized in Egypt, leaving it as a luxury only the wealthy can afford.
The HPV vaccine costs between 800 EGP ($25.9) to 1,000 EGP ($32) per dose. The average household income in Egypt is 69,000 EGP annually, or just over $2,200, according to official figures.
The number of doses and their schedule depend on the age of the recipient, according to the WHO December 2022 recommendation, but some can require up to three doses. WHO last year, however, decided that based on the latest science, one shot would provide enough protection for girls and women under the age of 20.
The vaccine arrived in Egypt in 2009. And while Egypt’s official vaccination center offers two brands at a few locations, experts say not many people have been keen to make use of them.
‘These things don’t happen in our community’
Cervical cancer can be completely treatable if detected in its early stages.
It is however common for medical professionals and ordinary people in Egypt to stigmatize people with HPV and other sexually transmitted infections, and believe they’ve strayed from religious and cultural norms.
Others have long viewed the vaccine with suspicion due to misinformation.
“People would say: This is a foreign vaccine trying to make girls barren,” said the 50-year-old mother. “And others would say: This will only spread obscenity and vice, and will make women too (sexually) comfortable.”
In Egypt, extramarital sex remains a major social taboo, and screenings for sexually transmitted diseases and infections in public clinics are not easy to undertake, especially when the patients are unmarried.
Patients often have to seek screenings and treatment from costly private clinics that are mostly concentrated around the capital Cairo.
But campaigners are determined to change this. Ola Arafa, a 26-year-old medical graduate from the Mansoura Manchester Medical Program at the University of Mansoura, has been working with her supervisor, gynecology professor Dr. Rafik Barakat, to study the prevalence of HPV in the northeastern city Mansoura and spread awareness among patients and doctors.
Arafa conducted a survey in- a number of outpatient clinics around the University of Mansoura, where she found that although more than half of participants had heard of cervical cancer, they did not know its relation to HPV, nor how to prevent it.
Her findings only made her aim of raising awareness on the issue with “different ages and socioeconomic groups” all the more urgent.
Barakat said some doctors are reluctant to explain the nature of HPV for fear of a backlash.
“But slowly, these (traditions) are naturally shaken up,” he said, adding that as more and more patients present themselves with genital warts in clinics, the discussion of HPV is inevitably opened up.
Egypt does not have national HPV screening programs, said Barakat, but they “exist in spots” in some cities and provinces.
Other Middle Eastern countries have added the HPV vaccine to their national immunization programs, including Saudi Arabia, the United Arab Emirates and Libya.
While Egypt’s progress on the issue is slow, change is nevertheless underway.
One member of the Egyptian House of Representatives and professor of microbiology and immunology at Mansoura University, Nisreen Salah Omar, has been campaigning since December 2022 for the HPV vaccine to be routinely given to all children in Egypt under the state’s health care system.
Those efforts got a boost in January, when the House accepted her demand and sent an official recommendation to the minister of health.
Many are waiting to see the fruits of years of campaigning for the vaccine, hoping to finally put an end to a preventable virus that can be a silent killer.
“This is an illness and it can be controlled,” said the 50-year-old woman. “In spite of how dangerous it is, it can be controlled.”