Background: Despite being preventable, cervical cancer is the third most common cancer in India, accounting for the highest number of cancer deaths. India has made limited progress toward introducing the safe and effective vaccine to prevent human papilloma virus (HPV) infections, which has been available for a decade. Aim: Using qualitative research, we examined opportunities for comprehensive cervical cancer prevention, including HPV vaccination in two Indian states - Tamil Nadu (TN) and Karnataka (KA). Methods: We used a socio-ecological framework to identify and map key stakeholders and structures that create the ecosystem for comprehensive cervical cancer prevention. Data were collected through semistructured in-depth interviews and focus group discussions. Key stakeholders included women and men (30-45 years) residing in selected slums/villages, community influencers (village government, self-help group members), district and state-level government health and education officials, specialist doctors, frontline health workers, staff of cancer-related nongovernmental organizations, and journalists. Results: As neither state had initiated public provision of the HPV vaccine, discussions focused on stakeholders' knowledge about the vaccine and factors that could inform a policy decision and facilitate or pose barriers to roll-out. Government officials and specialists in both states were aware of HPV vaccination for primary prevention of cervical cancer. Officials in KA noted concerns about the vaccine's safety and efficacy more emphatically than officials in TN. Specialists, particularly those in leadership positions in the Federation of Obstetrics and Gynecology Societies of India and the Indian Academy of Pediatrics were strong advocates of vaccination. Several specialists contrasted the numerous implementation challenges of cervical cancer screening with India's successes in routine immunization. However, a few specialists also expressed concerns regarding safety of the HPV vaccine. Community members lacked awareness about the vaccine and raised concerns on its safety, side effects and benefits as they would have for any new vaccine. All stakeholders highlighted cost as a major barrier to public provision of the vaccine. Government officials were concerned about how a vaccine program could be financed and sustained. The consensus, particularly in TN, was that the HPV vaccine would need to be introduced through the Universal Immunization Program as a partnership between the health and education departments to ensure widespread access. Conclusion: State-level implementation of comprehensive cervical cancer prevention hinges on the inclusion of HPV vaccination in the national immunization program. Cultivating vaccine champions and identifying appropriate financing mechanisms to implement and sustain comprehensive cervical cancer prevention along with careful planning and implementation has the potential to save the lives of many women.
