clinics. over 200,000 new zealand girls and young women have received hpv immunization. panama the vaccine was added to the national immunization program in 2008, to target 10-year-old girls. south africa cervical cancer represents the most common cause of cancer-related deaths—more than 3,000 deaths per year—among women in south africa because of high hiv prevalence, making introduction of the vaccine highly desirable. a papanicolaou test program was established in 2000 to help screen for cervical cancer, but since this program has not been implemented widely, vaccination would offer more efficient form of prevention. in may 2013 the minister of health of south africa, aaron motsoaledi, announced the government would provide free hpv vaccines for girls aged 9 and 10 in the poorest 80% of schools starting in february 2014 and the fifth quintile later on. south africa will be the first african country with an immunisation schedule that includes vaccines to protect people from hpv infection, but because the effectiveness of the vaccines in women who later become infected with hiv is not yet fully understood, it is difficult to assess how cost-effective the vaccine will be. negotiations are currently underway for more affordable hpv vaccines since they are up to 10 times more expensive than others already included in the immunization schedule. south korea on 27 july 2007, south korean government approved gardasil for use in girls and women aged 9 to 26 and boys aged 9 to 15. approval for use in boys was based on safety and immunogenicity but not efficacy. since 2016, hpv vaccination has been part of the national immunization program, offered free of charge to all children under 12 in south korea, with costs fully covered by the korean government. for 2016 only, korean girls born between 1 january 2003 and 31 december 2004 were also eligible to receive the free vaccinations as a limited time offer. from 2017, the free vaccines are available to those under 12 only. trinidad and tobago introduced in 2013. target group 9–26. fully financed by national health authorities. but was suspended later on that year owing to objections and concerns raised by the catholic board, but fully available in local health centers. united arab emirates the world health organization ranks cervical cancer as the fourth most frequent cancer among women in uae, at 7.4 per 100,000 women, and according to abu dhabi health authority, the cancer is also the seventh highest cause of death of women in the u.a.e. in 2007, the hpv vaccine was approved for girls and young women, 15 to 26 years of age, and offered optionally at hospitals and clinics. moreover, starting 1 june 2013, the vaccine was offered free of charge for women between the ages of 18 and 26, in abu dhabi. however, on 14 september 2018, the u.a.e's ministry of health and community protection announced that hpv vaccine became a mandatory part of the routine vaccinations for all girls in the u.a.e. the vaccine is to be administers to all school girls in the 8th grade girls, aged 13. united kingdom in the uk the vaccine is licensed for females aged 9–26, for males aged 9–15, and for men who have sex with men aged 18–45. hpv vaccination was introduced into the national immunisation programme in september 2008, for girls aged 12–13 across the uk. a two-year catch-up campaign started in autumn 2009 to vaccinate all girls up to 18 years of age. catch up vaccination was offered to girls aged between 16 and 18 from autumn 2009, and girls aged between 15 and 17 from autumn 2010. it will be many years before the vaccination programme has an effect on cervical cancer incidence so women are advised to continue accepting their invitations for cervical screening. men who have sex with men up to and including the age of 45 became eligible for free hpv vaccination on the nhs in april 2018. they get the vaccine by visiting sexual health clinics and hiv clinics in england. a meta-analysis of vaccinations for men who have sex with men showed that this strategy is most effective when combined with gender-neutral vaccination of all boys, regardeless of their sexual orientation. from the 2019/2020 school year, it is expected that 12- to 13-year-old boys will also become eligible for the hpv vaccine as part of the national immunisation programme. this follows a statement by the joint committee on vaccination and immunisation. the first dose of the hpv vaccine will be offered routinely to boys aged 12 and 13 in school year 8, in the same way that it is currently (may 2018) offered to girls. boots uk had opened a private hpv vaccination service to boys and men aged 12–44 years in april 2017 at a cost of £150 per vaccination. in children aged 12–14 years two doses are recommended, while those aged 15–44 years a course of three is recommended. cervarix was the hpv vaccine offered from introduction in september 2008, to august 2012, with gardasil being offered from september 2012. the change was motivated by gardasil's added protection against genital warts. adoption as of late 2007, about one quarter of u.s. females age 13–17 years had received at least one of the three hpv shots. by 2014, the proportion of such females receiving an hpv vaccination had risen to 38%. the government began recommending vaccination for boys in 2011; by 2014, the vaccination rate among boys (at least one dose) had reached 35%. according to the u.s. centers for disease control and prevention (cdc), getting as many girls vaccinated as early and as quickly as possible will reduce the cases of cervical cancer among middle-aged women in 30 to 40 years and reduce the transmission of this highly communicable infection. barriers include the limited understanding by many people that hpv causes cervical cancer, the difficulty of getting pre-teens and teens into the doctor's office to get a shot, and the high cost of the vaccine ($120/dose, $360 total for the three required doses, plus the cost of doctor visits). community-based interventions can increase the uptake of hpv vaccination among adolescents. a survey was conducted in 2009 to gather information about knowledge and adoption of the hpv vaccine. thirty percent of 13- to 17-year-olds and 9% of 18- to 26-year-olds out of the total 1,011 young women surveyed reported receipt of at least one hpv injection. knowledge about hpv varied; however, 5% or fewer subjects believed that the hpv vaccine precluded the need for regular cervical cancer screening or safe-sex practices. few girls and young women overestimate the protection provided by the vaccine. despite moderate uptake, many females at risk of acquiring hpv have not yet received the vaccine. for example, young black women are less likely to receive hpv vaccines compared to young white women. additionally, young women of all races and ethnicities without health insurance are less likely to get vaccinated. since the approval of gardasil in 2006 and despite low vaccine uptake, prevalence of hpv among teenagers aged 14–19 has been cut in half with an 88% reduction among vaccinated women. no decline in prevalence was observed in other age groups, indicating the vaccine to have been responsible for the sharp decline in cases. the drop in number of infections is expected to in turn lead to a decline in cervical and other hpv-related cancers in the future. legislation four states have laws that require hpv vaccination for school students: hawaii, rhode island, virginia, and washington d.c. students in those states must have started hpv vaccination before entering the 7th grade. all school immunization laws grant exemptions to children for medical reasons, with other "opt-out" policies varying by state. shortly after the first hpv vaccine was approved, bills to make the vaccine mandatory for school attendance were introduced in many states. only two such bills passed (in virginia and washington dc) during the first four years after vaccine introduction. mandates have been effective at increasing uptake of other vaccines, such as mumps, measles, rubella, and hepatitis b (which is also sexually transmitted). however most such efforts developed for five or more years after vaccine release, while financing and supply were arranged, further safety data was gathered, and education efforts increased understanding, before mandates were considered. most public policies including school mandates have not been effective in promoting hpv vaccination while receiving a recommendation from a physician increased the probability of vaccination. in july 2015, rhode island added an hpv vaccine requirement for admittance into public school. this mandate requires all students entering the seventh grade to receive at least one dose of the hpv vaccine starting in august 2015, all students entering the eighth grade to receive at least two doses of the hpv vaccine starting in august 2016, and all students entering the ninth grade to receive at least three doses of the hpv vaccine starting in august 2017. no legislative action is required for the rhode island department of health to add new vaccine mandates. rhode island is the only state that requires the vaccine for both male and female 7th graders. immigrants between july 2008 and december 2009, proof of the first of three doses of hpv gardasil vaccine was required for women ages 11–26 intending to legally enter the united states. this requirement stirred controversy because of the cost of the vaccine, and because all the other vaccines so required prevent diseases which are spread by respiratory route and considered highly contagious. the centers for disease control and prevention repealed all hpv vaccination directives for immigrants effective 14 december 2009. uptake in the united states appears to vary by ethnicity and whether someone was born outside the united states. coverage measures have been considered including requiring insurers to cover hpv vaccination, and funding hpv vaccines for those without insurance. the cost of the hpv vaccines for females under 18 who are uninsured is covered under the federal vaccines for children program. as of 23 september 2010, vaccines are required to be covered by insurers under the patient protection and affordable care act. hpv vaccines specifically are to be covered at no charge for women, including those who are pregnant or nursing. medicaid covers hpv vaccination in accordance with the acip recommendations, and immunizations are a mandatory service under medicaid for eligible individuals under age 21. in addition, medicaid includes the vaccines for children program. this program provides immunization services for children 18 and under who are medicaid eligible, uninsured, underinsured, receiving immunizations through a federally qualified health center or rural health clinic, or are native american or alaska native. the vaccine manufacturers also offer help for people who cannot afford hpv vaccination. glaxosmithkline's vaccines access program provides cervarix free of charge 1-877-vacc-911 to low income women, ages 19 to 25, who do not have insurance. merck's vaccine patient assistance program 1-800-293-3881 provides gardasil free to low income women and men, ages 19 to 26, who do not have insurance, including immigrants who are legal residents. opposition in the united states