Table 1 From Laboratories to People: Barriers in HPV vaccine implementation

Patent monopolies [19].

Inadequate regulatory mechanisms, resources and infrastructure, i.e., for reporting of adverse events and post-market surveillance [23, 129].

High vaccine costs [18].

Parents and adolescents[94–97, 99–109]

Scarcity of instruments and models for technology transfer of inexpensive biogenerics [19, 21].

Cold chain issues, preventing quality- assured and controlled transportation and storage of vaccines [23, 129].

Competing health priorities (e.g., HIV/AIDS, malaria) [105].

Perceived low HPV/STI susceptibility.

Gaps in multilateral funding for vaccine procurement [20].

Controversies over HPV vaccine mandates [64–66, 86, 89–91].

Unwillingness to discuss sex and STI.

Inadequate knowledge exchange about STI risks and need for prevention [110, 113, 114].

Perceived inappropriateness for pre-adolescents.

Stigma, loss of privacy.

Concerns about adolescent promiscuity and beliefs in moral education and marital monogamy.

Suspicion of commercial motives and unethical vaccine trials.

Worry about vaccine ingredients and adverse effects.

Needle fears.

Gaps in availability and access. Competing life priorities and pressures.

Vaccine costs and duration of effectiveness.

Healthcare providers[98, 110]

Unwillingness to endorse vaccine, discuss sex and STI, or to stock vaccine

Lack of personnel and facilities for vaccination and heavy case loads in clinics.