Cervical cancer 2026: free HPV vaccine (11-13y), Pap smear every 3 years

01Cervical cancer in figures in Morocco#

Cervical cancer represents a major public health issue in Morocco. According to data from the National Oncology Institute (INO) and the National Cancer Prevention and Control Plan (PNPCC), approximately 3,388 new cases are diagnosed each year in the country, making it the second leading cause of female cancer after breast cancer, representing alone nearly 10% of all cancers in women. Mortality is high and largely avoidable: annual deaths related to this cancer in Morocco are estimated at nearly 2,200.

The epidemiological profile presents several worrying particularities. The average age at diagnosis is around 52 years, but cases occur from the thirties. Above all, about 65% of cases are diagnosed at a locally advanced or metastatic stage, while this cancer is one of the few for which organised screening could allow detection at a precancerous stage and therefore near-systematic cure. This massive proportion of late diagnoses reflects the still glaring insufficiency of mass screening in Morocco despite recent Ministry of Health efforts.

The contrast with countries that have implemented organised screening is striking. In Sweden, Finland or the United Kingdom, where Pap smear has been generalised since the 1960s-70s, the incidence and mortality of this cancer have fallen by 70 to 80%. Conversely, in countries without organised screening programmes, mortality remains high. This shows the importance of progressive deployment in Morocco of generalised screening, now facilitated by the arrival of high-performance HPV tests and integration of the HPV vaccine into the National Immunisation Programme since 2022.

02Human papillomavirus: the near-exclusive cause#

The major scientific advance of recent decades has been the demonstration that cervical cancer is caused in more than 99% of cases by persistent infection with certain high-risk oncogenic human papillomavirus (HPV) types. This discovery, which earned Harald zur Hausen the Nobel Prize in 2008, revolutionised our understanding of the disease and paved the way for vaccine prevention.

HPV is an extremely widespread virus, transmitted essentially through sexual contact (skin-to-skin at the genital level, not only through penetration). It is estimated that about 80% of sexually active adults are infected by at least one type of HPV during their lifetime. Fortunately, the vast majority of these infections are transient: 90% of HPV infections are spontaneously eliminated by the immune system within 2 years, without any lesion developing. Only persistent infections beyond 2 years can evolve, over a period of 10 to 20 years, towards precancerous and then cancerous lesions.

More than 200 types of HPV have been identified, but only about a dozen are classified as high-risk oncogenic. Among them, HPV 16 and HPV 18 alone are responsible for 70% of cervical cancers worldwide. Types 31, 33, 45, 52 and 58 complete the list of main culprits. Alongside this cancerous aspect, some low-risk HPVs (notably 6 and 11) cause condylomas (genital warts), benign but bothersome. HPV is also implicated in other cancers besides cervical: anal, oropharyngeal, vulvar, vaginal, penile cancers, which fully justifies the interest of vaccination in boys as well, integrated in several countries although not yet in Morocco.

03The HPV vaccine, now free in Morocco#

A historic milestone was reached in September 2022 when the Ministry of Health and Social Protection integrated the HPV vaccine into the National Immunisation Programme (NIP), making it completely free for young girls. This decision followed several years of advocacy from the Moroccan Society of Cancerology, the Lalla Salma Foundation for Cancer Prevention and Treatment, and gynaecologist associations, in line with WHO recommendations targeting the elimination of cervical cancer by 2030.

The vaccine target in Morocco consists of young girls aged 11 to 13, at a strategic age: before the usual start of sexual activity, therefore before any possible exposure to HPV, which allows maximum efficacy. The schedule includes two doses spaced 6 months apart. Vaccination is administered mainly in schools by school health teams, but also in Urban and Rural Health Centres for non-schooled girls or those who missed the school session. A catch-up is planned up to age 14 for girls not vaccinated in the initial window.

The vaccine efficacy is remarkable. Clinical trials and real-world data accumulated since the vaccine's introduction in more than 100 countries demonstrate a 99% efficacy on precancerous lesions due to HPV types 16 and 18 in young girls vaccinated before exposure. Several pioneering countries like Australia or the United Kingdom now observe a spectacular drop in the incidence of cervical precancerous lesions, and elimination of cervical cancer is concretely envisaged by 2030-2035 thanks to this strategy. The safety profile of the vaccine is excellent: more than 500 million doses have been administered worldwide, without any scientifically validated worrying safety signal. Adverse effects are limited to local reactions (pain, redness at injection site) in 30-50% of vaccinated and transient mild fever in 5-10%.

For older women not vaccinated in the NIP, it remains possible — and beneficial — to be vaccinated privately, up to age 45 according to available data. Efficacy is lower as the risk of having been already exposed to HPV increases with age and number of partners, but vaccination protects against types not yet encountered. Gardasil 9, a nonavalent vaccine covering 9 types of HPV (the most oncogenic plus those responsible for condylomas), is available in private pharmacy for approximately 900 to 1,500 MAD per dose (3 doses total in adults).

04Screening by Pap smear and HPV test#

The Pap smear remains the cornerstone of screening for cervical precancerous lesions. It consists of taking, during a few-minute gynaecological examination with a speculum, cells from the surface of the cervix, which are then analysed in the laboratory to look for cytological abnormalities.

Current recommendations in Morocco, aligned with international standards, recommend a smear every 3 years for all women between 25 and 65 whose previous smears are normal. This periodicity accounts for the slow natural evolution of HPV lesions, which generally take more than 10 years to progress from infection stage to invasive cancer — leaving ample time to detect an abnormality. Before age 25, screening is not recommended because cytological abnormalities are frequent but regress spontaneously, and unnecessary biopsies can weaken a cervix that will need to carry future pregnancies.

The cost of the smear varies depending on the sector: it is free in public Health Centres, and costs 150 to 300 MAD in private, with 70 to 80% reimbursement by CNOPS, CNSS or AMO Tadamon. The smear is also covered at 100% in women with ALD for related pathology. Several NGOs (Lalla Salma Foundation, AMSAC) organise mobile screening campaigns in remote areas, notably during pink October extended to female cancer.

The HPV DNA test is a recent innovation more sensitive than the Pap smear. It directly detects the presence of high-risk HPV types in cervical cells, rather than waiting for cytological abnormalities to appear. It is now recommended as first-line in women over 30 in several European countries (France since 2020) and progressively adopted in Morocco. Its cost is higher (450 to 700 MAD), but its frequency interval is longer (5 years in case of negative result), which balances the overall screening economy. The strategy underway in Morocco, under the National Cancer Plan, aims to progressively generalise the HPV DNA test as the main screening tool from age 30, with Pap smear in younger women.

05What to do in case of abnormal result#

The international classification system for smear results is called Bethesda, and it is essential to understand the meaning of terms not to give in to panic in case of abnormality.

An ASC-US result is very frequent and does not mean cancer: it simply means the pathologist saw cells whose appearance is not frankly normal but without being able to affirm a lesion. In 80% of cases, the subsequent check is normal. LSIL (CIN1) corresponds to active HPV infection with early cellular modifications, which regress spontaneously in 60-70% of cases within 2 years. HSIL (CIN2 or CIN3) is a true precancerous lesion: without treatment, about 30% will evolve to invasive cancer over 10 to 15 years. Treatment at this stage avoids almost all subsequent cancers.

Colposcopy is the reference examination in case of cytological abnormality. It consists of examining the cervix with a binocular magnifier (colposcope) under magnification, after application of revealing products (acetic acid, Lugol) that reveal suspicious areas. Targeted biopsies are performed if necessary. The examination lasts 10 to 15 minutes, is slightly uncomfortable but little painful, and costs 200 to 500 MAD depending on facilities, partially reimbursed.

In case of HSIL confirmed by biopsy, the reference treatment is conisation, which consists of surgically removing the diseased part of the cervix in a cone shape. Performed in day hospital under local anaesthesia or short general anaesthesia, conisation cures over 95% of HSILs with preservation of subsequent fertility. Close gynaecological follow-up is then organised to verify healing. In case of invasive cancer, management depends on stage: surgery for stage I (extended hysterectomy with or without ovarian conservation), radio-chemotherapy for stages II-III, palliative treatments and targeted therapies (bevacizumab, immunotherapy) for stage IV. The main reference centres in Morocco are the INO in Rabat, CHU Ibn Rochd in Casablanca, CHU Hassan II in Fes.

06WHO's 2030 elimination strategy#

WHO set an ambitious objective in 2020: the elimination of cervical cancer as a public health problem by 2030, defined as an annual incidence below 4 cases per 100,000 women. This objective passes through the so-called "90-70-90" strategy: 90% of girls vaccinated against HPV before age 15, 70% of women screened by HPV test at age 35 and 45, and 90% of women with precancerous lesion or invasive cancer correctly treated.

Morocco has committed to this objective with several levers to activate simultaneously. HPV vaccination must reach a target coverage of 90% in girls aged 11-13, compared to about 60% in 2023 — a deficit to be filled through communication, school mobilisation and training of health professionals. Generalised screening by smear or HPV test remains well below objectives, particularly in rural areas, and requires the establishment of an organised programme with systematic invitation of eligible women. Access to specialist care in case of abnormality must be guaranteed throughout the territory, which implies strengthening regional technical platforms.

On an individual level, every woman can contribute to this elimination by performing a regular smear or HPV test from age 25, by having her daughters vaccinated at the recommended age, and by promptly consulting a gynaecologist in case of unusual signs (bleeding outside periods, bleeding after intercourse, pelvic pain, abnormal discharge). A cancer caught in time is cured; an ignored cancer is often fatal.