Individual-level HPV vaccination verification in Botswana: lessons learned from implementation of the HOPE II trial

The World Health Organization (WHO) estimated 660,000 new cervical cancer cases and 350,000 deaths globally in 2022, with over 90% occurring in low- and middle-income countries (LMICs). Global elimination targets call for vaccination of >90% of girls against human papillomavirus (HPV) by age 15 by 2030. While Botswana's national policy aligns with these targets, progress monitoring is constrained by fragmented, predominantly paper-based health information systems. We describe our experience verifying individual-level HPV vaccination status among adolescent girls and young women living with HIV (AGYWLWH) in Botswana. This activity was conducted to determine eligibility for the HOPE II trial, a randomized controlled study evaluating the efficacy of a single-dose nonavalent HPV vaccine. Verification followed the national rollout of school-based HPV vaccination in 2015, targeting girls aged 9-13 years. Participants provided pre-screening consent for review of vaccination records held in school health systems, Ministry of Health (MoH) registers, and participant-held vaccination cards where available. We sought HPV vaccination records for 80 potential participants across 80 schools and 68 clinics. Only 15 participants (18.8%) had verifiable records: 2 (2.5%) retained vaccination cards, 4 (5.0%) had documentation in school records, and 9 (11.3%) had entries in MoH registers. Most school records were incomplete or missing, and several sites reported loss or disposal of records due to relocation, fire damage, or storage constraints. These findings highlight critical gaps in HPV vaccination documentation. Strengthening electronic immunization registries, standardizing record transfer, and improving data integration could enhance monitoring and support equitable progress toward cervical cancer elimination.