Gay Men Are Missing Out on HPV Vaccines

Gay, bisexual and other men who have sex with men are at far greater risk for anal dysplasia and cancer, and the risk rises further for those living with HIV. Yet more than half of HIV-positive and HIV-negative gay men in San Francisco said they had not received a human papillomavirus (HPV) vaccine, which can prevent anal and oral cancer, according to a study presented at the International AIDS Conference (#AIDS2024).

“To close the gap, we recommend health care providers verify past vaccination history and offer HPV vaccination to unvaccinated men, particularly those who disclose being men who have sex with men, who are older and not vaccinated as children and those who are living with HIV,” the researchers suggested.

HPV triggers abnormal cell growth that can lead to genital and anal warts, precancerous cell changes (dysplasia and intraepithelial neoplasia) and, if left untreated, anal cancer, cervical cancer, mouth and throat (oropharyngeal) cancer and genital malignancies.

The Gardasil 9 HPV vaccine, approved in 2014, protects against the two main cancer-causing HPV types (16 and 18), five other high-risk types and two types (6 and 11) that cause genital and anal warts. The original quadrivalent Gardasil vaccine, approved in 2006, targets four HPV types, while the Cervarix vaccine targets two types.

Most people acquire one or more types of HPV soon after they become sexually active. For this reason, the Centers for Disease Control and Prevention (CDC) recommends Gardasil 9 for girls and boys at age 11 or 12, with catch-up vaccination for those up to age 26. The vaccine was recommended for girls in 2006 and for boys in 2011, but by that time, two thirds of U.S. men were above that age range. The Food and Drug Administration has approved the vaccine for people up to age 45, however, and the CDC advises that older individuals can talk with their doctor about whether they might still benefit.

The vaccine prevents HPV infection, precancerous cell changes and invasive cancer in both men and women. A recent study showed that vaccinated women had a lower risk for cervical cancer and vaccinated men had a decreased risk for head and neck cancer (which includes oral cancer), but there were not enough cases of anal cancer to do a meaningful analysis.

To learn more about HPV vaccination rates among gay and bisexual men, Paloma Lucia Ramirez, of Faculdade de Ciências Médicas da Santa Casa de São Paulo in Brazil, and colleagues with the San Francisco Department of Public Health assessed data from the CDC’s National HIV Behavioral Surveillance study. Participants were recruited in 2023 at venues in San Francisco frequented by gay and bisexual men. Face-to-face interviews were conducted to collect information about demographics, sexual behavior, sexual health history, access to health care and HIV status.

Most of the 497 participants were cisgender men (92%) and identified as gay (87%). A majority were above the age for recommended vaccination. About one quarter were living with HIV, 60% of HIV-negative men were on pre-exposure prophylaxis (PrEP) and 90% had seen a health care provider within the past year.

The survey revealed that 45% recalled having received an HPV vaccine, leaving 55% presumably unvaccinated. Among those living with HIV, 56% were unvaccinated. Men who had seen a health care provider within the past year were more likely to have gotten the vaccine (47% versus 20%), as were those who had told their provider that they had sex with men (46% versus 24%). Men on PrEP were most likely to be vaccinated, at 63%.

Not surprisingly, given the timing of vaccine approvals and recommendations, younger men were more likely to have been vaccinated. About three quarters of men ages 18 to 29 had received the vaccine, compared with just 23% of those ages 50 or older. Most men who received the vaccine did so by age 26, though the median age at the time of the first vaccine suggests a substantial number were vaccinated later.

Current federal HIV treatment guidelines say that HPV vaccine recommendations for HIV-positive people do not differ from those for the general population, though people with HIV should receive the full three-dose series, not the abbreviated two-dose option. There is a lack of data about whether people who received the older quadrivalent vaccine should get Gardasil 9 for protection against additional HPV types.

The researchers suggested that guidelines should be changed to recommend HPV vaccination for gay men and other men who have sex with men of all ages. For HIV-positive men, HIV care is an opportunity to check HPV vaccine status, and for HIV-negative men, HPV vaccination can be integrated into HIV prevention services.