Analysis of HPV vaccination data across 28 Malawian districts from 2019-2024 reveals concerning coverage gaps, with first-dose uptake at 47% and second-dose completion dropping to just 32% — far below WHO's 90% elimination target. Surprisingly, urban areas with higher nighttime light intensity showed significantly lower vaccination rates, contradicting typical healthcare access patterns. This counterintuitive finding suggests urban barriers like healthcare system overwhelm, vaccine hesitancy, or competing health priorities may impede coverage more than rural access challenges. The spatial analysis reveals stark district-level heterogeneity, indicating that national averages mask critical local disparities. For global cervical cancer prevention, these findings highlight how urbanization doesn't automatically improve vaccine uptake and suggest targeted urban interventions may be essential. The study's strength lies in its comprehensive five-year surveillance across an entire country, though as a preprint awaiting peer review, these results require validation. The research provides actionable geographic targeting for intervention strategies, representing solid epidemiological work that confirms rather than revolutionizes our understanding of vaccine equity challenges in sub-Saharan Africa.