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HPV Vaccination in Men

Updated: Sep 5, 2019

Mercy Asiedu

Introduction

In 2009, the quadrivalent HPV vaccine was licensed in the USA for men and in 2011, the US Advisory Committee on Immunization Practices recommended routine use of the vaccines for boys aged 11–21 years, with approval for administration up to age 26 years (1). The vaccine is highly effective in preventing various types of HPV infections and genital warts in young men (2). Despite the vaccine’s demonstrated efficacy and regulatory endorsements, vaccination uptake among males is relatively low in the US. The various barriers to access can be grouped in 3 broad categories: availability, acceptability, and awareness(3).


HPV Vaccination for Men

Some insurance providers have refrained from providing coverage for HPV vaccination for males because they were advised by their internal public health experts that vaccinating men would be mostly altruistic, or because the CDC did not recommend the vaccination for males (4). While these claims may have been true based on the prevailing knowledge at the time of decision-making, we know now them to be spurious. Many of these recommendations are founded on cost effectiveness studies that have demonstrated diminishing incremental gains with the addition of men to vaccination programs. However, these studies assume significant coverage in girls. At least as of December 2015, the CDC recommends the HPV vaccine for boys 11-12 years of age; this age group was selected because the optimal immune response is achieved at this stage and because the HPV vaccine needs to be taken before exposure to the virus for maximal protection from risks (5). Furthermore, HPV is now known to be highly correlated with both throat and anal cancer. 72% of throat cancers and 91% of anal cancers are associated with HPV, and both of these are significant risks to men as well as women with over 12,000 and 4,000 reported annual cases respectively in the USA (6, 7). Indeed, the CDC estimates that mouth and throat cancer will surpass the annual number of cervical cancers by 2020 (8). Given this information, is evident that there exists a strong motive to vaccinate men for HPV, well beyond preventing the spread of the virus to women.


Barriers to HPV vaccination in men have included

Availability: Cost effectiveness studies have shown that vaccinating males and females is less cost effective than vaccinating females alone. As such, many insurance companies do not cover the vaccination for males (9). Irregular preventative care as well as dosage logistics are also challenges to vaccine access.

Acceptability: Country promotion of female campaigns more than male campaigns (3).

Awareness: Knowledge of HPV, health implications, and prevention methods as well as concerns regarding promotion of promiscuity and misunderstanding of benefits to males (among other social influences).

Group Study/Project Objective

Determine barriers to HPV vaccination among college educated men.

Methods

For our study a brief survey for men was composed which required the age and country of origin. The men were then asked whether or not they had received the HPV vaccine. If they had not received the vaccine, they were asked to select from a list of choices, the reasons why they had not received the vaccine. The survey was distributed via social media as well as in person.

Participant characteristics: There were 47 total number of participants in the study. 19.1% had been vaccinated while 80.9% had not been vaccinated.

Results and brief discussion

We received responses from 47 men from 14 different countries with ages ranging from 19 - 33 years. Majority of the men surveyed were from the United States. 19.1% of the men had received the HPV vaccine while 80.9% had not. Majority of those vaccinated (55.6%) fell within the 26-30 age range. However a higher proportion of the 18-20 age range (60%) had been vaccinated compared to other age ranges. 77.8% of the men vaccinated were from the United States with the others being from France and Canada. Most men from other areas (mainly LMICs) had not been vaccinated.

There were 12 possible responses for why men had not received vaccination under 4 main categories: Lack of awareness/knowledge about the HPV vaccine, availability of the vaccine, personal reasons and other. Our results found that most men who were not HPV vaccinated cited reasons that fell under the categories of lack of awareness and lack of availability. As shown in the chart, most men indicated that they did not know the vaccine was available to men or that the vaccine was not made available to them by their health care provider. No one cited expense of vaccine, or disbelief in vaccines as a reason and only 2 men indicated that they believed only women should receive the vaccine. The men who indicated other cited reasons as healthcare provider not stressing on importance of vaccine, being currently monogamous and age. This survey demonstrates that the main barriers to HPV vaccination even to college educated men are lack of awareness and lack of availability.

Our results agree with previous studies looking into variables associated with HPV vaccination and men. Several studies have found that most men are very ill-informed about HPV infections and its effects on male health and transmission of the virus (10-13). A study conducted by Ferris et al. studying factors for HPV vaccine acceptance with men found that men with higher general education, more knowledge about HPV as well as high risk sexual behaviors were more likely to want the HPV vaccine (14). Worries about vaccine side effects and safety were also found to correlate to whether or not HPV vaccine was accepted by men (14). Another study looking at HPV vaccine acceptance in adolescence found that most parents and sons were unaware that the vaccine could be given to males (12). They also found that parents were more willing to vaccinate their sons if they perceived high effectiveness and adolescent males were more willing to get vaccinated if they perceived higher peer acceptance or higher chance of developing an HPV infection (12).

Global Disparity and Interventions

In the US, only 38% of adolescent females and just 14% of adolescent males had received the HPV vaccine as of 2013 [6]. Yet countries like Australia, Canada, and many countries in Western Europe have vaccination rates more than double those in the US. But there are also disparities between states in the US; many southern states like Alabama, Arkansas, Tennessee, and Virginia suffer extremely low vaccination rates while most states in the northeast, north, and California have relatively high rates (15).

The differences between vaccination rates within the US and internationally can be accounted for by the same framework of availability, acceptability, and awareness. Those US regions with higher rates tend to have more comprehensive sexual health education programs and more liberal attitudes towards sexuality in general, thus making the vaccine more palatable to parents and raising awareness of the vaccine’s necessity in the target population. Sexual education reform or standardization across all states to communicate the importance of HPV vaccination to parents and adolescents would be a logical intervention for the US, especially since so many men don’t know that the vaccine is available to them. From our study alone, lack of awareness that an HPV vaccine even existed, let alone was available to men, was a key barrier to male vaccination.

From our study, men from the US and many other countries suffer from similar accessibility and HPV education barriers, but still some countries far outperform the US in HPV vaccination rates. In most countries with high vaccination rates (and thus low rates of HPV infection, cervical cancer, and other HPV-associated cancers in males and females), the governments instituted partial to full subsidies of the vaccine, making cancer prevention available to all adolescents regardless of parental income. Still, many countries with high female vaccination rates do not make those same subsidies available to males - increasing male accessibility will be a critical next step towards reducing cervical, penile, anal, and oropharyngeal cancers in addition to genital warts and other HPV-associated STIs. Unfortunately, many HPV education campaigns only target women, but the incorporation of men’s issues should be more easily made when the awareness structures and materials are already in place.

The HPV vaccine is highly effective in men yet there remain various barriers to male access to care. Various actors within the health care system have roles to play in increasing vaccination awareness and availability. Health care providers (and possibly even schools) can play a role in educating young males and their parents on the positive effects of the HPV vaccine. Additionally, payers should reconsider male coverage for the vaccine in order to reduce costs and increase accessibility. With increased awareness and acceptability of the vaccine, target populations will be more proactive in accessing care.

References

1. Centers for Disease C, Prevention, Dunne EF, Markowitz LE, Chesson H, Curtis CR, et al. Recommendations on the use of quadrivalent human papillomavirus vaccine in males--Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep. 2011;60(50):1705-8. 2. Reagan-Steiner S, Yankey D, Jeyarajah J, Elam-Evans LD, Singleton JA, Curtis CR, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years—United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(29):784-92. 3. Newman PA, Logie CH, Doukas N, Asakura K. HPV vaccine acceptability among men: a systematic review and meta-analysis. Sex Transm Infect. 2013;89(7):568-74. 4. Associates S. Gardasil Not Covered by Some Insurances, but Only for Males: Vaccine Injury Help Center; 2011 [Available from: https://vaccineinjuryhelpcenter.wordpress.com/2011/07/26/gardasil-not-covered-by-some-insurances-but-only-for-males/. 5. Prevention CfDCa. HPV Vaccine Is Recommended for Boys 2015 [Available from: http://www.cdc.gov/features/hpvvaccineboys/. 6. Centers for Disease C, Prevention. Human papillomavirus-associated cancers - United States, 2004-2008. MMWR Morb Mortal Wkly Rep. 2012;61:258-61. 7. (CDC) CfDCaP. How Many Cancers Are Linked with HPV Each Year? 2016 [Available from: http://www.cdc.gov/cancer/hpv/statistics/cases.htm. 8. Chaturvedi AK, Engels EA, Pfeiffer RM, Hernandez BY, Xiao W, Kim E, et al. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol. 2011;29(32):4294-301. 9. Zimet GD, Rosenthal SL. HPV vaccine and males: issues and challenges. Gynecol Oncol. 2010;117(2 Suppl):S26-31. 10. McPartland TS, Weaver BA, Lee SK, Koutsky LA. Men's perceptions and knowledge of human papillomavirus (HPV) infection and cervical cancer. J Am Coll Health. 2005;53(5):225-30. 11. Pitts MK, Fox C, Willis J, Anderson J. What do gay men know about human papillomavirus? Australian gay men's knowledge and experience of anal cancer screening and human papillomavirus. Sex Transm Dis. 2007;34(3):170-3. 12. Reiter PL, Brewer NT, Smith JS. Human papillomavirus knowledge and vaccine acceptability among a national sample of heterosexual men. Sexually transmitted infections. 2010;86(3):241-6. 13. Verhoeven V, Baay M, Colliers A, Verster A, Van Royen P, Avonts D, et al. The male factor in cervical carcinogenesis: a questionnaire study of men's awareness in primary care. Preventive medicine. 2006;43(5):389-93. 14. Ferris DG, Waller JL, Miller J, Patel P, Price GA, Jackson L, et al. Variables associated with human papillomavirus (HPV) vaccine acceptance by men. J Am Board Fam Med. 2009;22(1):34-42. 15. Diseases NFfI. Call to Action: HPV Vaccination as a Public Health Priority2014 Sept 30 2016. Available from: www.nfid.org/homepage/additional-offerings/hpv-call-to-action.pdf.


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