The launch of HPV (Human Papillomavirus) vaccination in India to prevent cervical cancer is accompanied by its share of debate and controversy. The vaccine is designed to prevent infection by high-risk strains of the HPV, which is related with development of cervical cancer in women. The programme is annually targeting around 1.15 crore girls aged 14 years, who will be vaccinated across all states of the country. The national rollout of this vaccination is a complex subject, with several evidence-based arguments favouring vaccination while critical questions are also being raised about the programme at the same time. Here we pose a series of questions on major areas of concern related to the HPV vaccination programme, and provide some answers – a reasonable, evidence based position about this major programme.Is cervical cancer a significant public health problem? Critics of HPV vaccination point out that cervical cancer incidence and mortality in India have already been declining over time. Current mortality from this cancer is estimated to be in the range of around 11 per 100,000 women, and given India’s resource-constrained public health system, some have argued that this is a lower priority compared to other major health problems. However, cervical cancer continues to be the second most common cancer affecting Indian women, causing nearly 80,000 deaths annually. The observed decline in cervical cancer is uneven across India; in poorer states and rural areas the burden remains significantly higher. Taken together, these points suggest that despite some decline in cervical cancer in India, the baseline burden still remains substantial, and is unevenly distributed. Cervical cancer merits continued public health attention and preventive strategies, provided they remain grounded in broader health needs of the population.How significant is the role of HPV infection in causing cervical cancer?It is argued that while HPV infection is the main cause of cervical cancer, other factors such as reproductive health conditions, sexual behaviour and access to healthcare also contribute. The prevalence of HPV infection among general women in the population in India is estimated to range from 7.5% to 16.9% and current vaccines cover only a small subset out of the 150–200 known HPV strains. However a substantial body of evidence shows that infection with high-risk HPV types 16 and 18 are responsible for over 70% of all cervical cancers globally, and an even higher proportion in India. Targeting these strains can lead to meaningful reductions in disease burden since HPV is the main factor for causing cervical cancer in overwhelming number of cases. Vaccines do not eliminate risk entirely, but they address a significant part of the causal pathway, making them a significant preventive tool.Does HPV infection always progress to develop cervical cancer?Most HPV infections do not lead to cancer. A large proportion of infections and pre-cancerous lesions such as Cervical Intraepithelial Neoplasia (CIN) resolve spontaneously, and only a small fraction progress to invasive cancer. However we cannot predict with certainty which infections will persist and progress to cancer.Also read: Eight-Year Wait for an Indigenous Option, Yet Cheaper, Made-In-India HPV Vaccine Elbowed OutPersistent infection with high-risk HPV types is the critical pathway which can eventually lead to cancer, often over many years. Vaccination does reduce the likelihood of persistent HPV infection, and the development of higher-grade pre-cancerous conditions, which can progress to cancer. The vaccine operates as a risk-reduction strategy, greatly reducing the probability of progression to cancer.Does evidence show reduction in cervical cancer due to HPV vaccination?Another critique is that most HPV vaccine trials have relied on surrogate endpoints such as antibody levels or reducing pre-cancerous conditions, rather than direct cancer reduction. While cervical cancer develops over decades, existing trials have not followed participants long enough to conclusively demonstrate reductions in cancer incidence. At the same time, long-term observational data – now spanning 15–20 years from other countries – show significant reductions in HPV infection rates and pre-cancerous conditions. There is also early evidence of reduced cervical cancer in population-based studies (e.g., Sweden and UK). Taken together, current evidence is strong regarding reduction of pre-cancerous conditions, and evolving for prevention of actual cancer, broadly supporting HPV vaccine efficacy.Is the HPV vaccine safe enough to warrant generalised administration?Safety concerns include the major controversy surrounding the 2009 HPV vaccine demonstration project in India (with seven deaths reported among participating girls), and critiques regarding trial design and reporting. However, global post-marketing surveillance data covering more than 500 million doses administered worldwide until now, has not shown causal links between HPV vaccines and deaths. Serious adverse events are rare, with anaphylaxis (severe allergic reaction) occurring in approximately 1.7 to three cases per million doses. Overall, the safety profile of HPV vaccine seems comparable to that of other widely used vaccines.We should neither dismiss vaccine safety concerns, nor exaggerate them. While existing large-scale evidence (mostly from other countries) suggests that serious harm from the HPV vaccine is very rare, we must recognise that there is a strong responsibility on Indian health systems to ensure extensive monitoring and reporting of any adverse events, with sustained long-term follow-up of vaccinated persons.What is the role of cancer screening vs vaccination for preventing cervical cancer?Experts agree that screening among women in the 30 to 65 years age group remains the most effective intervention for comprehensive prevention of cervical cancer. Methods such as visual inspection, Pap smears, and HPV testing detect pre-cancerous changes, allowing timely treatment. Such screening cannot be replaced by vaccination, in the foreseeable future. Hence the most effective strategy, based on current evidence, is a combined approach offering vaccination during adolescence, and regular cancer screening for adult women. There is a risk that HPV vaccination may be projected as a “complete solution” to cervical cancer, leading to neglect of screening programmes. Hence it is important to emphasise that vaccination and screening are complementary, not substitutes; women who receive the HPV vaccine still require screening later in life. Public health services need to urgently expand cancer screening services, while improving access to reproductive health services for women.How to ensure adequate monitoring of vaccine related side effects, and provision of related support?Monitoring of vaccine side-effects or ‘Adverse Events Following Immunisation’ (AEFI) remains a major concern in India. Existing systems are often weakly implemented, while tending to lack transparency. Adverse events may be dismissed as coincidental without thorough investigation. A programme like HPV vaccination requires credible and responsive safety monitoring and support systems, including establishment of autonomous review bodies at state and national levels, and creation of dedicated district-level AEFI hubs to carry out in-depth, time-bound investigation of all serious adverse events. In cases of adverse events, there must be provision of adequate medical and counselling support to affected recipients and families. Public disclosure of findings and actions taken should be ensured through periodic reports. A legally binding compensation framework can ensure that manufacturers remain financially liable for vaccine-related harm, preventing the privatisation of profits while the public bears the risk.What are the concerns about informed consent during HPV vaccination programmes?Serious concerns arise from the experience of the 2009 HPV vaccine demonstration project in India, where informed consent procedures were often violated since consent forms were signed by hostel wardens or teachers rather than parents. There remains a real risk, especially among girls from rural and low-income backgrounds, vaccination being driven through uninformed assent, or proxy consent by institutions. Vaccination against HPV is not an emergency intervention; it is a preventive measure administered to healthy adolescents, which places a higher bar on consent processes. HPV vaccination must be clearly communicated as being voluntary, not compulsory. Acceptance of the vaccine should be based on genuine informed consent, including written and verbal communication in local languages, accompanied by accessible information sharing, such as informational videos and education sessions for parents/guardians and girls. How does target-driven implementation pressurise frontline workers?There are concerns that HPV vaccination is being implemented through target-driven approaches, placing pressure on frontline workers such as ASHAs, ANMs, and school teachers to ensure high coverage. Due to such approaches, frontline workers may suffer disincentives in case of low vaccine acceptance by communities. While public health programmes benefit from persuasion-based promotion, coercive approaches are totally inappropriate in the context of HPV vaccination of adolescent girls. HPV vaccination must be de-linked from targets and disincentives for frontline workers; instead systems should focus on capacity building, so that frontline workers can communicate effectively and responsively about the programme. These workers should be provided adequate time, support, and remuneration for their roles in the programme. How should vaccination related misinformation be addressed?Misinformation related to HPV vaccination operates from two directions, both problematic. Official messaging may project the vaccine as a near-complete solution for preventing cervical cancer, while not communicating the need for continued screening and post vaccination follow up. On the other hand, there are reports from some states of societal misinformation about HPV vaccine circulating on social media, propagating false claims about infertility and unfounded reports of deaths. Such narratives create widespread distrust, contributing to mass refusal of vaccination. In this situation, public health communication must be transparent and balanced, clearly stating that acceptance of the vaccine is voluntary, that the vaccine significantly reduces cancer risk, and that later screening and other preventive measures remain necessary. Social media based misleading claims must be actively countered through credible public health messaging, and timely investigation and clarification of any incidents linked with vaccination. Naturally, beyond these ten questions, other concerns related to implementation also surround HPV vaccination in India. For instance, Union government procurement has sidelined a potentially more affordable, indigenously developed HPV vaccine (CERVAVAC) in favour of ‘Gardasil’ manufactured by Merck & Co., raising concerns about future pricing, transparency, and implications for self-reliance. There also questions about the cost-effectiveness of HPV vaccine in the Indian context which warrant in-depth examination, since it remains more costlier per death averted, compared to traditional paediatric vaccines which are currently provided through national programmes.Keeping this background in view, we would acknowledge that HPV vaccination can contribute to reducing cervical cancer risk in India as part of a wider strategy. However, whether our current health systems, vaccine related safeguards, and accountability processes match the requirements of large-scale rollout of this vaccine, remains a question. Health activists, women’s groups, and social organisations should demand that ethical and health rights dimensions of the programme must be definitely addressed, and that vaccination be accompanied by effective follow up, treatment and reporting of adverse effects, along with expanded screening and treatment of cancers and major improvement of women’s health services. It is important that alarmist social media-based misinformation be countered, and that parents as well as girls receiving the vaccine receive proper information, linked with offering genuinely informed consent. Implementing such a range of health system and social measures related with HPV vaccination, along with ensuring transparency and respect for rights at various levels, would be important conditions to be fulfilled while proceeding to implement the programme.Abhay Shukla is a public health physician and national co-convenor of Jan Swasthya Abhiyan.