Background
Human papillomavirus (HPV) is a necessary cause of cervical cancer and a major etiological agent of anogenital and oropharyngeal malignancies, contributing substantially to global cancer morbidity and mortality. In 2023, HPV was estimated to account for approximately 1.3 million incident cancer cases and 740,000 deaths worldwide, including ~660,000 cervical cancer cases and ~350,000 deaths, with the remaining burden attributable to other HPV-related cancers. In Eastern Europe and the South Caucasus, progress toward elimination targets remains heterogeneous. Armenia reports approximately 250 incident cervical cancer cases and 115 deaths annually, corresponding to age-standardised incidence and mortality rates of 7.83 and 4.64 per 100,000 women, respectively. Cervical cancer represents the eighth most common malignancy among Armenian women and the second leading cause of cancer among women aged 15–44 years. Armenia introduced quadrivalent HPV vaccination for girls aged 13–14 years in 2017, expanded eligibility to women aged 15–45 years in 2019.Cervical cancer screening remains predominantly opportunistic and cytology-based, with limited population coverage and pandemic-related service disruptions.
Methods
We applied a mixed-methods epidemiological and policy analysis to quantify the national burden of HPV-attributable cancers and assess prevention strategies. Incidence, mortality, years of life lost (YLLs), and disability-adjusted life years (DALYs) were estimated using Global Burden of Disease (GBD) 2023 data, Armeniannational cancer registry statistics, and WHO life tables. DALYs were monetised using Armenia’s gross domestic product (GDP) per capita (USD 8,053; World Bank 2023). A cross-sectional Knowledge, Attitudes, and Practices (KAP) survey of 79 women aged ≥18 years assessed awareness and uptake of HPV vaccination and cervical cancer screening. Semi-structured interviews with 35 healthcare professionals were conducted to identify health system constraints and implementation feasibility. Policy options were evaluated using the WHO Evidence-to-Recommendation (EtR) framework, incorporating effectiveness, cost-effectiveness, equity, acceptability, and feasibility domains.
Results
HPV-attributable malignancies in Armenia were estimated to result in approximately 515 new cases annually, corresponding to ~5000 DALYs and an annual economic loss of USD 36.1 million (0.22% of GDP). Cervical cancer accounted for the majority of the burden; however, a substantial proportion of HPV-related oropharyngeal and head and neck cancers occurred among men, supporting the epidemiological rationale for gender-neutral vaccination. Vaccination uptake among survey respondents was low (8%), with 37% unaware of free vaccination services and 65% uncertain regarding vaccine effectiveness. Only 40% reported ever having undergone cervical screening. Key barriers included time constraints, discomfort, lack of provider recommendation, and financial limitations. Healthcare professionals prioritised transition to gender-neutral, single-dose HPV vaccination for adolescents aged 9–20 years and adoption of HPV PCR testing as the primary screening modality, supplemented by cytology and AI-assisted colposcopy where resource constraints persist. EtR appraisal indicated high anticipated population-level impact, favourable cost-effectiveness, and potential equity gains.
Conclusion/Implication for policy
Expansion to gender-neutral single-dose vaccination and implementation of HPV DNA–based primary screening are epidemiologically justified and aligned with WHO elimination targets. These strategies offer a feasible pathway to reduce HPV-attributable cancer burden and accelerate progress toward cervical cancer elimination in the South Caucasus.
 

Incidence of Cervical Cancer in Armenia