Human Papillomavirus (HPV) Vaccination in the Indian Health Service

The Indian Health Service (IHS) provides healthcare services to approximately 1.4 million American Indian/Alaska Native (AI/AN) people in the U.S. IHS-funded services are provided in IHS, Tribal and Urban Indian (I/T/U) facilities in 35 states. Historically, AI/AN women have experienced a higher incidence of cervical cancer than non-Hispanic White women. We describe HPV vaccination uptake among AI/AN adolescents served by the IHS, and discuss how financing may affect HPV vaccination uptake among AI/AN women.

Starting in 2008, data on HPV vaccine coverage for ~ 30,000 AI/AN females aged 13 – 17 years were collected quarterly from I/T/U facilities. In addition, an on-line survey with a convenience sample of 268 I/T/U providers were conducted in 2009-2010 to provide insight into provider practices and perceived barriers to HPV vaccination.

Coverage with 1 dose of HPV vaccine among AI/AN females aged 13 – 17 years served by I/T/U facilities increased from 33% in the beginning of 2008 to 69% as of 12/31/09. Steady increases have also been seen in coverage with 2 doses (17% to 53%) and 3 doses (6% to 36%) of HPV vaccine.

While all I/T/U facilities routinely offer HPV vaccine to patients aged 11 – 18 years, not all offer it to women aged 19 – 26 years. In the online survey, 33% of the respondents indicated that their facility does not offer vaccine to 19 – 26 year olds. Barriers cited included upfront costs (57%) and reimbursement issues (58%). Twelve percent of providers surveyed indicated that their facility participates in the Merck Patient Assistance Program(MPAP), which provides free vaccine to uninsured, low-income women. In the IHS experience, the public financing of HPV vaccination through the Vaccines for Children (VFC) program is a key component in the uptake of HPV vaccine. AI/AN people aged < 19 years are categorically eligible to receive free vaccines through the VFC program. Because of this, all I/T/U facilities currently provide HPV vaccine to females < 19 years of age, which likely accounts for the steady increases in HPV vaccine initiation coverage to levels higher than estimates for the general U.S. population. HPV vaccine coverage rates in the IHS are also comparable to coverage rates seen in countries with school-based implementation policies. In contrast, vaccine for women aged 19 – 26 years is not universally available in I/T/U facilities, and those that do may limit it to women with other sources of reimbursement (e.g. Medicaid,MPAP).