1. HPV vaccination for men
Dr. Tom Nadarzynski
Lecturer in Health Psychology (Sexual Health)

2. Epidemiology Human Papilloma Virus (HPV) What about men?
   - Ano-genital, oral cancers, and genital warts
- Female HPV vaccination since 2008 with over 85% coverage
- Significant decline (from 17% to 4%) amongst younger women
What about men?
- 50% of oral cancers are due to HPV
- ‘Herd protection’ for heterosexual men
Men who have sex with men (MSM)
- Higher Basic Reproductive Ratio of HPV
- 72% are HPV positive
- High risk of anal cancer, especially for HIV+ [80:1]

3. JCVI position on HPV vaccination in MSM (Nov 2015)
JCVI recognised that
- MSM are unlikely to benefit from female HPV vaccination
 - MSM are at higher risk of acquiring HPV-related diseases
- Vaccination in MSM is cost-effective
JCVI recommended to targeted MSM
- Through GUM/sexual health clinics
- Up to the age of 45 years
- Three doses of HPV-Gardasil4
Additional recommendations
- MSM prisoners, transgender women, HIV+ women and men
- Clinical judgement (offered on a case-by-case basis)

4. HPV vaccination in MSM Country Current policy England
Pilot programme from June 2016 (assessing uptake/refusal and completion rates)
Scotland, Wales and Northern Ireland
Vaccination programmes for MSM as per JCVI recommendations
Ireland
Vaccination programmes for MSM under the age of 26 years
USA
Gender-neutral programme with catch-up for MSM through the age of 26 years and all HIV+
Canada (Ontario)
New Zealand 
MSM-targeted changed to gender-neutral strategy

5. HPV vaccination in Australia
Female-oriented strategy from 2007
- Adolescent girls targeted at school
- High female uptake > 85% (similar to the UK)
- Strong evidence for ‘herd protection’
Gender-neutral strategy from 2013
- Cost-effective despite high female uptake
- Reduced vaccine price by 60-90%?
- Aim: total eradication of HPV

6. JCVI position on gender-neutral vaccination (Nov 2017)
Extending the vaccine to boys is not cost-effective
- PHE Model
- Analysis from the University of Warwick
  - Meta-analysis by Brisson et al.
Increasing uptake in girls more cost-effective
What about men who have sex abroad?
Is HPV vaccination acceptable for MSM in the UK?

7. - 8 databases searched for HPV vaccination in MSM
Method
  - 8 databases searched for HPV vaccination in MSM
  - 16 studies identified
Results
   - Acceptability: average - 56% (range: 0-86%) 
   - Low levels of awareness and knowledge of HPV and anal cancer
   - Generally positive attitudes towards the HPV vaccine
   - Low perceptions of risk (not concerned about HPV)
   - Doctor's recommendation is a strong predictor of acceptability

8. - Qualitative analysis of interviews with 32 MSM in Brighton Results
Method
  - Qualitative analysis of interviews with 32 MSM in Brighton 
Results
   - Any vaccination against an STI is highly acceptable 
   - HPV seen as a 'female issue'
   - Not aware of the risk for MSM, but anxious about genital warts
   - Not perceiving themselves at risk of warts or cancers
   - Willing to accept the vaccine only if a doctor recommends it
   - Sexuality was seen as a barrier (identity & disclosure)
   - In favour of school-based HPV vaccination due to effectiveness
   - Concerns about stigma similar to AIDS

9. - 32% never tested for a STI and only 52% accessed GUM clinics
Method
  - Online survey of 1508 MSM (Mean age=22) recruited via Facebook
  - 32% never tested for a STI and only 52% accessed GUM clinics
Results
   - HPV vaccine is highly acceptable, but desirability is low
   - Men at the beginning of their sexual activity were less likely to accept it
   - HPV vaccine highly acceptable when offered by a doctor
   - Access to GUM and disclosure of sexuality as main barriers
   - The information about compromised vaccine effectiveness unlikely to decrease acceptability

12. - 11% already vaccinating MSM, 3% vaccinating heterosexual men
Method
  - Online survey of 325 sexual health workers (doctors, nurses, HA, etc)
  - Data collected (prior to guidelines)
Results
   - 11% already vaccinating MSM, 3% vaccinating heterosexual men
   - 87% would recommend gender-neutral HPV vaccination
   - 65% would support MSM-targeted HPV vaccination
   - 18% were against MSM-targeted HPV vaccination
   - 49% reported having knowledge and skills to identify MSM for HPV vaccination

13. - Telephone interviews with 19 sexual health workers Results
Method
  - Telephone interviews with 19 sexual health workers
Results
   - Concerns about equity, reach and cost-effectiveness
 - Gender-neutral and MSM-targeted strategies perceived as mutually exclusive
   - Comparisons to female vaccination as well as the US and Australian models, where epidemiology, vaccine price and uptake are different
   - Expressed a need for clear guidelines and recommendations
 “I know what my gut reaction is and I know what the data is and they are different. My gut reaction is to vaccinate everybody.” (Consultant)

14. Model of vaccination behaviour in MSM

15. Main barriers Access to GUM clinics Disclosure of sexual orientation
- NATSAL showed only 35% of MSM used GUM clinics
PHE estimated around 830,558 MSM in England
GUMCAD data analysis ( ) showed 374,983 MSM - 45%
Disclosure of sexual orientation
- MSM unwilling to disclose in primary care settings

16. What can we expect? Acceptability and uptake Uptake in MSM (US data)
   - HPV vaccination is acceptable (83%) but not highly desirable
   - MSM face multiple barriers to vaccinations via GUM
   - Estimated uptake 30%-65% in young MSM
Uptake in MSM (US data)
   - Collage: 2009 (8%), 2010 (20%), 2011 (24%), 2012 (31%), and 2013 (41%)
   - National HIV surveillance database 2014: 17% in MSM years old
Completion rates (US data)
- In clinical settings: 33%
- Self-reported in two online surveys: 41% & 52%
Sexual Orientation Monitoring & HPV vaccine uptake

17. Thanks to: Dr Daniel Richardson Dr Carrie Llewellyn Prof
Thanks to: Dr Daniel Richardson Dr Carrie Llewellyn Prof. Helen Smith Dr Christina Jones Dr Elizabeth Ford Alex Pollard Tom Nadarzynski