Should I or Shouldn’t I: Decision making, knowledge and behavioral effects of quadrivalent HPV vaccination in men who have sex with men
Introduction
Human papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the United States, with persistent infection causing significant morbidity, including genital warts, cervical, vulvar and vaginal cancer, and up to 93% of anal cancers [1]. HPV infection has become partially preventable in men with the development of Gardasil® (Merck & Co., Inc., Whitehouse Station, NJ, USA), a quadrivalent prophylactic HPV 6/11/16/18 virus-like particle vaccine. In June 2006, Gardasil® (qHPV) was FDA approved for women ages nine through 26 years for prevention of HPV types 6-, 11-, 16-, and 18-related cervical, vaginal, and vulvar cancer and precursor dysplastic lesions as well as genital warts [2]. In October 2009, this approval was extended to men ages nine through 26 years for prevention of HPV-related external genital lesions [3].
The incidence of new HPV infections is estimated at 6.2 million per year [4]. The Center for Disease Control and Prevention's (CDC) National Health and Nutrition Examination Survey 2003–2004 (NHANES) reported that 12.2% of male participants were infected with HPV type 6, 11, 16 or 18, and 6.3% of men had oncogenic HPV types 16 or 18, as measured by serum antibodies [5]. A study of 290 men in Arizona in 2005 revealed that 30.0% were infected with one of 37 tested HPV types, detected by PCR of genital swabs. The period prevalence of HPV infection in this study was 52.8% [6]. Genital warts, or condyloma acuminata, caused primarily by HPV 6 and 11, have an estimated lifetime cumulative prevalence of 4.9% and annual prevalence of 0.17–0.21% [5], [7]. Furthermore, the rate of HPV-associated invasive squamous cell anal carcinoma has risen in recent years [1]. While HPV is prevalent in all men, men who have sex with men (MSM) have higher rates of infection than heterosexual men. Among a sample of heterosexual men in Florida in 2007, 12.0% had anal HPV infection with any of 37 types, and 7.0% had oncogenic HPV infection [8]. In a large study of HIV-negative MSM, 57% had anal HPV infection with any of 22 tested HPV types, 26% of which were oncogenic [9]. MSM are at greater risk for HPV due to anal intercourse, which has been identified as an independently associated risk factor for HPV infection [5], [8], [10].
Administration of qHPV to women ages 24–45 years demonstrated 83% efficacy in protecting against HPV 16/18 infection or disease [11]. Studies in young men ages 16–26 years showed qHPV to be 90.4% effective against HPV 6/11/16/18-related external genital lesions and 85.6% effective against persistent HPV 6/11/16/18 infection [12]. The vaccine was not studied in older men. In acceptability studies, at least half of adult women and 74% of MSM claimed they would receive HPV vaccination [13], [14]. Another study of Australian MSM ages 19–71 years reported that nearly 50% of participants would pay Au$450 out of pocket for HPV vaccination [15].
Despite evidence that qHPV is effective and studies indicate that patients are willing to accept it, vaccination rates remain low. In 2008, 37.2% of adolescent females had begun the vaccination series (≥1 dose), while 17.9% had completed the series [16]. Barriers to vaccination in young women ages 9–26 years include not being sexually active, concern about vaccine safety, and cost [17]. Barriers to vaccination in adult women include cost, limited knowledge about HPV, and perception of a low risk for HPV infection or cervical cancer [13]. There is no published data to date examining qHPV vaccination rates in men.
In this pilot study, we sought to elicit reasons motivating MSM to either choose or refuse qHPV vaccination, effects of vaccination on subsequent sexual behavior as well as basic knowledge about HPV and vaccination in MSM offered qHPV.
Section snippets
Study population and procedure
Subjects were recruited between June 2009 and September 2009 from a surgical practice (SG) at which men and women are screened and treated for HPV-related anorectal disease. Off-label use of qHPV was first offered at this site in January 2007 for HIV-negative men up to age 55 years. Medical records were reviewed to identify MSM who either accepted or refused vaccination when offered. To be eligible, those that received qHPV had to have completed all three doses before entry. Subjects were
Results
191 MSM enrolled: 68 refused qHPV vaccination (RV), 71 were vaccinated with qHPV less than one year prior (V < 1), and 52 were vaccinated greater than one year prior (V > 1) (Table 1). Surveys were primarily conducted by telephone (overall 58%, n = 111; RV = 37%, n = 25; V < 1 = 61%, n = 43; V > 1 = 83%, n = 43).
Discussion
QHPV vaccination for HPV 6/11/16/18 was recently FDA approved for young men ages 9–26 years to prevent HPV related external genital lesions. Although not studied, it may also be beneficial for MSM older than 26 years. This pilot study is the first to compare MSM who have actually been offered and either refused or accepted qHPV vaccination to determine knowledge of HPV and vaccination, factors influencing decision making, and to ascertain possible effects on sexual behavior.
Conclusion
MSM exhibit a high level of knowledge about HPV and HPV vaccination. They received qHPV to prevent future disease, but understood that the vaccine may not prevent all future disease and will not cure ongoing disease. Vaccination did not affect frequency of anal sex or unprotected anal sex. Cost, lack of knowledge about the vaccine, and a feeling that they were already infected were major barriers to vaccination, while a desire to prevent future infection was a major driver to vaccination.
Acknowledgements
We thank Erin Moshier and Kristin Swedish for statistical analysis and Doug Marks and Nadia Scott for help with survey administration. Funding for this project was a summer stipend from the Mount Sinai School of Medicine.
References (27)
- et al.
Safety, immunogenicity, and efficacy of quadrivalent human papillomavirus (types 6, 11, 16, 18) recombinant vaccine in women aged 24–45 years: a randomised, double-blind trial
Lancet
(2009) - et al.
Literature review of human papillomavirus vaccine acceptability among women over 26 years
Vaccine
(2009) - et al.
Knowledge and early adoption of the HPV vaccine among girls and young women: results of a national survey
J Adolesc Health
(2009) - et al.
Counseling the patient who has genital herpes or genital human papillomavirus infection
Infect Dis Clin North Am.
(2005) - et al.
Understanding the burden of human papillomavirus-associated anal cancers in the US
Cancer
(2008) - Centers for Disease Control and Prevention (CDC). Quadrivalent human papillomavirus accine: recommendations of the...
- Centers for Disease Control and Prevention (CDC). FDA licensure of quadrivalent human papillomavirus vaccine (HPV4,...
- et al.
Sexually transmitted diseases among American youth: incidence and prevalence estimates 2000
Perspect Sex Reprod Health
(2004) - et al.
Seroprevalence of human papillomavirus types 6, 11, 16, and 18 in the United States: national health and nutrition examination survey 2003–2004
J Infect Dis
(2009) - et al.
Age-specific prevalence, incidence, and duration of human papillomavirus infections in a cohort of 290 US men
J Infect Dis
(2008)
National burden of genital warts: a first step in defining the problem
Sex Transm Dis
Prevalence of and risk factors for anal human papillomavirus infection in men who have sex with women: a cross-national study
J Infect Dis
Age-specific prevalence of anal human papillomavirus infection in HIV-negative sexually active men who have sex with men: the EXPLORE study
J Infect Dis
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