Cervical cancer is caused by human papillomavirus (HPV) infection, the most common sexually transmitted viral infection worldwide (1, 2). It has been estimated that, in the United States, more than 80% of sexually active women and men will acquire at least one HPV infection by the age of 45 years (3). In women, 90% of incident genital HPV infections clear within 2 years without any clinical impact (4). However, when persistence occurs, HPV becomes a risk factor for malignant transformation. Out of the more than 200 HPV types identified, 12 high-risk HPVs are responsible for virtually all cases of cervical cancers (5, 6).

Cervical cancer is one of the few cancers preventable through both vaccination and screening. Several prophylactic HPV vaccines are available in most countries and the World Health Organization (WHO) currently recommends one or two-dose vaccination of girls aged 9 to 14 years (7). As various high-risk HPV types are not covered by the vaccines, high-quality screening programs are also paramount to prevent cervical cancer. Screening can detect premalignant and early malignant lesions that can be treated with a very good prognosis (8). Three different methods can be used to identify women who have, or are at risk of, cervical precancerous lesions and early invasive cancer: (1) detection of genital high-risk HPV infection through a DNA-based test on cervical or vaginal samples; (2) microscopic examination of cervical exfoliated cells, known as the Papanicolaou (Pap) cytology test; or (3) visual inspection of the cervix with acetic acid, in low-resource settings (7). In high-income countries, the implementation of screening and treatment programs since the 1950s followed by the introduction of HPV vaccination since 2006 has led to a dramatic reduction in both the prevalence of HPV vaccine-types and closely related HPV types and the incidence and mortality of cervical cancer (9–14). Before the effectiveness of these prevention measures, the WHO launched in 2020 a strategy for the global elimination of cervical cancer, with three main objectives to be reached by 2030: 90% vaccination rates, 70% screening rates and treatment for 90% of the invasive cancers for women in all countries (15).

Unfortunately, challenges persist in low- and middle-income countries in implementing cervical cancer screening programs and ensuring access to HPV vaccines. As a result, these countries currently bear the largest burden of this preventable disease, with cervical cancer incidence and mortality worldwide strongly correlated with country income level, human development index and living standards (16, 17). At present, cervical cancer ranks fourth in cancer incidence and mortality among women globally (18). In 2020 alone, an estimated 604,000 new cases and 342,000 deaths were reported, with over 80% of these cases occurring in low- and-middle-income countries (18, 19). In Latin America and the Caribbean (LAC), most of the countries have implemented cervical screening and HPV vaccination programs, and trends in cervical cancer incidence and mortality have decreased over the past 20 years (20, 21). However, several barriers to screening access and vaccination uptake persist (22, 23), and the age-standardized incidence and mortality rates in LAC in 2018 were 14.6 and 7.1 per 100,000, respectively, ranking second after the African region and slightly higher than the global rates (13.1 and 6.9, respectively) (20). In 2020, cervical cancer remained the leading cause of cancer death in women in Belize, Honduras, Nicaragua, Bolivia and Paraguay (18).

An estimated 58 million Indigenous people lived in Latin America in 2018, accounting for 10% of the total population of the subregion (24). While no formal definition has been adopted in international law, a contemporary and inclusive understanding of “Indigenous peoples” has been developed and includes those who self-identify and are identified as indigenous, exhibit historical continuity with precolonial societies, possess distinct social, economic, or political systems, maintain unique languages, cultures, and beliefs, and constitute nondominant groups of society (25, 26). In most LAC countries, the determination of indigenous status in population censuses relies on self-identification by individuals (26). The distribution of Indigenous people varies widely across LAC, both in terms of absolute numbers and relative proportions (Table 1). Guatemala, Bolivia and Peru have the highest proportions of indigenous population, with 43.6, 41.5 and 26.0%, respectively. Meanwhile, Mexico is the country with the largest number of indigenous individuals, totaling around 25 million.

Despite the inherent cultural, geographic, and genetic diversity among the more than 800 distinct ethnic groups in LAC (57), Indigenous peoples share a common history of colonization and ongoing dispossession of traditional lands, resources and practices (58). Consequently, Indigenous peoples suffer the greatest structural inequalities in Latin America and are over-represented among the socially disadvantaged in almost every country (59). According to estimations from 2020, 45.5% of Indigenous people in Latin America live in poverty and 7.1% in extremely poverty, more than twice the rates for non-Indigenous people in the region (60). Furthermore, in most LAC countries, indigenous people continue to primarily live in rural areas associated with their ancestral territories, and when they live in cities, it is often in extreme poverty in marginal areas, with trouble accessing basic services and decent jobs (59). One consequence of this marginalization is that Indigenous people in LAC have disproportionally worse health than their nonindigenous counterparts (61). Specifically, Indigenous women are directly impacted by the strong association between poverty and cervical cancer.

The primary objective of this perspective article is to examine the existing data on the burden of cervical cancer among Indigenous women in LAC. Moreover, it aims to identify the barriers potentially hindering their access to HPV vaccination, cervical cancer screening and treatment services. Finally, the article explores proven strategies from high-income countries that have successfully addressed similar challenges, with a view toward their potential applicability within LAC nations.

The articles included in this paper were obtained through a systematic literature search conducted on the PubMed Medline database from its inception to February 2024, using the following terms: (“cervical cancer” OR “papillomavirus”) AND “indigenous.” All abstracts retrieved were reviewed and assessed to identify relevant studies, including peer-reviewed original articles, meta-analyses, reviews, and reports published in English, Spanish or Portuguese. Additional articles were gathered from the references of selected publications. Studies were excluded if they: (1) were unrelated to human papillomavirus infection or cervical cancer; (2) did not clearly define Indigenous people as the study population; (3) were not published in peer-reviewed journals. Furthermore, demographic and epidemiological data specific to each LAC country, including cancer registries and population censuses, were manually searched for on official governmental websites. As a result, findings were categorized and presented through a narrative synthesis in subsequent sections.

Because they frequently experience both ethnic and gender discrimination, Indigenous women often face the most profound structural inequalities, especially concerning poverty, education, and healthcare (59). Consequently, they are particularly vulnerable to cervical cancer. Over the last decades, numerous studies have extensively reported and characterized the disproportionately high burden of cervical cancer incidence and mortality among Indigenous women compared to non-Indigenous ones in high-income countries, namely Australia, New Zealand, Canada and the United States (62–68). A higher prevalence of HPV infection has also been observed among Indigenous women compared to the general population in these countries (69–72).

On the contrary, in the LAC region, the actual magnitude of the burden of cervical cancer among Indigenous women remains largely unknown and may be substantially under-estimated due to insufficient data collection. To the best of available information, indigenous status is currently recorded in the population-based cancer registries of only six out of the 24 LAC countries with Indigenous population (Table 1) (26, 51–56). However, none of these six countries publicly provide cancer rates for Indigenous people in their registry reports. Two recent studies have estimated cervical cancer mortality among Indigenous women in Brazil, reporting a mean age-standardized mortality rate of 6.7 per 100,000 between 2000 and 2020, the highest among all ethnic groups in the country and corresponding to a significant 80% increase in cervical cancer death risk compared to white women (73, 74). Regarding cervical cancer incidence, a study conducted on the Indigenous population in the State of Acre, located in the Brazilian Western Amazon, reported that, between 2000 and 2012, cervical cancer was the most frequent neoplasm among indigenous women, and cervical cancer incidence was significantly higher compared to the reference population (Standardized Incidence Ratio: 4.49) (75). Similarly, an analysis of the population-based cancer registry of Guyana from 2000 to 2009 highlighted that cervical cancer was significantly more common among Indigenous Amerindian women compared to other ethnic groups (53). Based on the available information, the assessment of cervical cancer risk among Indigenous women in the rest of LAC relies exclusively on studies investigating the prevalence of cervical HPV infection and cervical intraepithelial lesions within Indigenous populations. Table 1 summarizes the findings of these studies. Reported rates of any-type HPV infection among Indigenous women in LAC are notably high, ranging from 12.6 to 72.0%. Importantly, the majority of studies (15/19) identified higher cervical HPV prevalence rates compared to the meta-analysis estimates for the general populations of Brazil and Latin America, respectively 25.41 and 16.1% (76, 77). Furthermore, a wide range of cervical intraepithelial lesions prevalence rates have been reported among Indigenous women across LAC, varying from 1.8 to 15.3%, except for a study in Mexico which documented an exceptionally high prevalence of 70.4% among Nahuatl women (50). Notably, nine out of the 20 identified studies reported a prevalence of cervical lesions exceeding 10%, while the prevalence of cervical lesions in women worldwide generally remains under 10% (78).

In conclusion, the currently available data suggest that Indigenous women in LAC face a heightened risk of cervical cancer incidence and mortality, mirroring trends observed in Indigenous populations in high-income countries and reflecting the health inequities they experience. However, there remains a significant lack of data on cervical cancer trends among Indigenous women in most LAC countries, including countries like Guatemala, Bolivia, and Mexico, which have some of the highest proportions of Indigenous populations in the region. The wide variations observed in the prevalence of HPV infection and cervical abnormalities may reflect disparities in cervical cancer risk linked to the heterogeneity of Indigenous groups across LAC, including differences in geographical location, degree of isolation, and social and sexual behaviors (35). Consequently, further research is imperative to comprehensively assess the burden of cervical cancer among Indigenous women both regionally and within each LAC country.

Indigenous women worldwide exhibit a higher prevalence of HPV infection as well as increased cervical cancer incidence and mortality rates compared to the general population. This disproportionate burden of cervical cancer in Indigenous women in both high- and low-and-middle-income countries could be explained by substantially lower rates of HPV vaccination (79–81), lower cervical screening coverage and longer time to clinical investigation (67, 82–85) in Indigenous women compared to non-Indigenous women. Numerous multifaceted barriers have been identified that hinder proper access for Indigenous women to HPV vaccination and cervical cancer screening and treatment (Table 2). While many of these obstacles are not exclusive to Indigenous individuals, the intricate interplay of structural, social and cultural barriers in cervical cancer prevention, diagnosis and treatment uniquely challenges Indigenous women, contributing to their disproportionate burden of this disease.

Cervical cancer poses a significant public health challenge for Indigenous women globally, demanding targeted strategies in response to the unique cultural and systemic factors hindering cervical screening and HPV vaccination uptake in Indigenous populations. Canada, Australia and New Zealand have implemented specific programs and initiatives of cancer screening and/or HPV vaccination that are showing promising results in reducing HPV-related diseases among Indigenous populations (97, 115–121). While taking example from these successful policies and strategies, it is imperative to devise solutions adapted to the socio-economic realities of LAC countries and the cultural diversity within Indigenous populations residing in the region.

Because they experience higher levels of poverty and health inequities, Indigenous women worldwide are more vulnerable to cervical cancer than non-Indigenous women. In high-income countries, the disproportionately high burden of cervical cancer among Indigenous populations has been extensively characterized. Studies have consistently revealed a higher prevalence of HPV infection and increased incidence and mortality of cervical cancer among Indigenous women compared to their non-Indigenous counterparts. In these countries, targeted programs and initiatives aimed at overcoming the multiple and complex structural, social, and cultural barriers hindering Indigenous women’s access to cervical screening and HPV vaccination are yielding promising results.

On the contrary, in LAC, where Indigenous people constitute 10% of the population, the true extent of the burden of cervical cancer among Indigenous women remains largely unknown. Through an extensive review of published literature, this study presents the currently available data concerning the prevalence of cervical cancer and HPV infection among Indigenous women in LAC, highlighting the paucity of existing data and the critical gaps in research and healthcare interventions that need to be fill. While the findings discussed in this article offer valuable insights, one notable limitation is the absence of a meta-analysis, which could have facilitated a comparative assessment of HPV infection and cervical lesion prevalence rates between Indigenous women in LAC and the general population. Because indigenous status is not recorded in cancer registries of most LAC countries, accurately quantifying and understanding the burden of cervical cancer among Indigenous women in the region remains a challenge. Nevertheless, the limited available data suggest that Indigenous women in LAC face a heightened risk of cervical cancer incidence and mortality, as observed in Indigenous populations in high-income countries.

Strategies to improve cervical screening and HPV vaccination uptake for Indigenous women in LAC must be culturally sensitive, education-focused, and community-engaged. Detailed data on screening behaviors, vaccination uptake, and barriers specific to Indigenous populations in the region are essential. While taking example from successful policies and initiatives implemented in high-income countries, solutions adapted to the socio-economic realities of LAC countries and acknowledging the diversity among the more than 800 Indigenous groups in the region need to be found for bridging existing disparities and achieving the global goal of cervical cancer elimination.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

CM: Conceptualization, Funding acquisition, Writing – original draft, Writing – review & editing.