Posted 30th Apr 2015
Whether boys should be included in the national HPV vaccination programme has recently become a very live issue in the UK.
36 patient and professional organisations have joined together as HPV Action to make the case for gender-neutral vaccination. Its members include MEDFASH, Brook, FPA, Terrence Higgins Trust, the British Association for Sexual Health and HIV (BASHH) and a wide range of other organisations with an interest in sexual health, cancer, public health, oral health, men’s health and gay men’s health.
The vaccination of boys is also supported by the BMA and Jo’s Cervical Cancer Trust as well as many individual clinicians, academics and politicians. The latter group includes the five chairs of the All Party Parliamentary Groups on Men’s Health, Cancer, Dentistry, Sexual and Reproductive Health, and HIV/AIDS.
The Joint Committee on Vaccination and Immunisation (JCVI), the government’s vaccination advisory body, is currently considering whether adolescent boys should be included in the vaccination programme and its decision is expected in 2017. Later this year, it is likely to decide on the related issue of whether men who have sex with men (MSM) should be routinely offered HPV vaccinations at sexual health clinics.
Gender-neutral vaccination is already practiced in Austria, Australia, the United States and parts of Canada. It will also start soon in Israel and is now recommended in Switzerland. So why not in the UK too?
There can be no dispute that HPV causes disease in men as well as women. It is not a cause of cervical cancer alone. HPV Action estimates that in the UK in 2011, HPV caused almost 5,000 cancer cases in women (cervical, vaginal, vulval, head and neck and anal) and over 2,000 cases in men (head and neck, anal and penile). In addition, HPV causes around 39,000 new cases of genital warts in women and 48,000 cases in men each year as well as the relatively rare but frequently disabling condition known as RRP (recurrent respiratory papillomatosis).
The main argument against vaccinating boys is that it is not cost-effective because, if enough girls are vaccinated (the proportion most often mentioned is 80%), then boys will be protected through ‘herd immunity’. The evidence cited in support of this is that, when large numbers of girls are vaccinated, the incidence of genital warts starts to fall in both sexes, suggesting that males are no longer being infected by females. In the UK, over 85% of girls are vaccinated, a high proportion by international standards.
There are several major problems with this argument, however. The first is that it completely overlooks a group of men – MSM – who are, for obvious reasons, completely unprotected by a girls-only vaccination programme, however high its uptake might be. MSM are at particular risk from HPV-related diseases, especially anal cancer and genital warts.
The solution to this cannot be to attempt to vaccinate just MSM. There can be no certainty that enough of the MSM population will be reached to produce herd immunity. The Stonewall health survey (1) found that 44% of gay and bisexual men had never discussed STIs with a healthcare professional, suggesting they may have never used a sexual health service, the most obvious setting for a MSM-targeted vaccination programme.
Offering HPV vaccinations to adult MSM would also be less effective because many will already have been infected with HPV. A study of teenage MSM in Australia found that 39% had at least one HPV DNA type and 23% had a HPV type preventable by the vaccine currently used in the UK.(2)
MSM often do not attend GUM services until their late 20s. A review of all MSM attending a level 3 sexual health service in Southampton in 2013-14 found that the median age at attendance was 32 and the median age at first attendance at the clinic was 28.(3) The data suggested that most MSM would have had multiple sexual partners with increased risk of HPV acquisition before they attended any clinic.
It is best practice to vaccinate before people become sexually active and have been infected by HPV. But it would, of course, be neither ethical nor practical to try to identify and vaccinate adolescent boys who might later become MSM. The best way of protecting all MSM is to vaccinate all boys. A vaccination programme for MSM, while welcome for the protection it would offer to some individuals, should be seen as no more than a first step towards vaccinating all boys.
Many heterosexual males also remain at risk from a girls-only vaccination programme. Even if 90% of girls were vaccinated, recently published research suggests that unvaccinated girls are more likely to be those who later adopt high-risk sexual behaviours, such as having a large number of partners, not using condoms and practising anal sex.(4) Many men will also have sex with women from countries where there is no HPV vaccination programme for girls, or from countries where uptake is relatively low.
There is also an important equity argument here: it surely cannot be right to exclude a group of people from a health intervention that can stop them developing a range of serious diseases simply because of their gender (in this case, male). It also cannot be right to expect one part of the population (in this case, female) to bear the sole burden of an invasive health intervention in order to protect the rest of the population.
The final issue concerns cost. Is it simply unaffordable to vaccinate boys as well as girls? HPV Action estimates that the likely additional annual cost of vaccinating 90% of 12/13 year old boys would be £20-22 million. These costs have to be set against those of treating HPV-related diseases. A study of the cost of treating nine major HPV-related diseases in Italy produced an estimate of almost €530 million a year (5); a similar study of the economic burden of HPV-related cancers in France estimated the cost to be about €240 million.(6) The cost of treating genital warts alone was over £52.4 million in the UK in 2010.(7)
The decision to introduce gender-neutral vaccination should not be made primarily on a financial basis, however. The opportunities for improving public health, tackling inequities and reducing suffering provide, on their own, an overwhelming and decisive argument.
(1) Guasp, Gay and Bisexual Men’s Health Survey, Stonewall 2012
(2) Zou et al., Early acquisition of anogenital human papillomavirus among teenage men who have sex with men Journal of Infectious Diseases 2014;209:642-651.
(3) Clarke et al, Genitourinary medicine clinics may not see young men who have sex with men before they become infected with human papillomavirus (HPV), BMJ 2014;349:g5215 doi: 10.1136/bmj.g5215.
(4) Sadler et al., Comparing risk behaviours of human papillomavirus-vaccinated and non-vaccinated women Journal of Family Planning and Reproductive Health Care doi:10.1136/jfprhc-2014-100896.
(5) Baio et al., Economic Burden of Human Papillomavirus-Related Diseases in Italy. PLoS ONE 2012; 7(11):e49699 doi:10.1371/journal.pone.0049699.
(6) Borget et al., Economic burden of HPV-related cancers in Franc, Vaccine 2011; 29:5245-5249.
(7) Lanitis et al., The cost of managing genital warts in the UK, International Journal of STDs and AIDS 2012:23(3):189-194.
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