HPV vaccine recommendations
In October 2011, the CDC began recommending that adolescent males receive the HPV vaccine. In February 2015, the CDC incorporated the recently approved HPV9 vaccine in the recommendations for HPV prevention, thus rendering HPV9 or HPV4 vaccines accessible and approved for males.10 For a vaccine schedule initiated at age 11, the second dose is recommended 6 to 12 months after the initial dose (see Table 1). In instances in which the providers do not know which HPV vaccine was previously administered, the HPV vaccine available to the provider may be administered to continue or complete the series for males; if the vaccine schedule is interrupted, the series does not need to be restarted.10 In May 2017, HPV9 became the only HPV vaccine available in the United States.11 Most recent updates from the CDC11 now recommend that when administered to adolescents between the ages of 11 and 14 years, two doses of the vaccine, at least 6 months apart, provide effective protection; however, teens who begin the series at age 15 must complete the 3-dose series.11 Heterosexual males must complete the series by age 21.
Men who have sex with men (MSM), transgender persons, and certain immunocompromised males are a subgroup of males with an even higher risk for contracting HPV; oncogenic subtypes of HPV are transmitted via anal intercourse, penetrating the anogenital mucosa and leading to infection and possibly anal cancer. The incidence of HPV is higher in individuals who engage in anal intercourse, especially the receptive partner.12 The average age of disclosure of sexual orientation among MSM is the early 20s, and most MSM have had an average of 8 sexual partners by the time they disclose their sexual orientation.12 Moreover, the prevalence of HPV in MSM may be as high as 30%, compared with approximately 8% in heterosexual men.13
Because of the strong relationship among HPV, anal intercourse, and anal cancer, current CDC guidelines for HPV vaccination differ for MSM and their heterosexual counterparts because MSM have an increased risk for contracting HPV and not clearing the virus. For MSM who were not vaccinated as adolescents or did not complete the 3-dose series, the CDC recommends HPV vaccination up to age 26 years.14
The guidelines are different for MSM who are infected with the human immunodeficiency virus (HIV). According to current CDC guidelines, persons with an immunocompromising disease such as HIV need to receive the 3-vaccine series.15 As their immune function declines, patients with HIV have an even greater risk for developing an HPV-related cancer. One concern about administering the HPV vaccine to HIV-positive young adult men is the potential diminished immune response to the vaccine. Although data are limited, one study of 109 HIV-positive men aged 18 years or older found the quadrivalent HPV vaccine safe, without appreciable effect on the subjects’ CD4 cell counts or viral loads, and highly immunogenic, with seroconversion rates of 95%.16
Vaccine promotion in the clinical setting
Missed opportunity is a significant impediment to HPV vaccination in the male adolescent population. Bernstein and Bocchini17 noted that 65% of parents never received a recommendation for their child to receive the HPV vaccine, although provider recommendation has been shown to have a very positive influence on vaccination uptake.18 In a national survey, 600 men aged 18 to 59 years were asked about their willingness to be vaccinated against HPV. The results revealed that 60% wanted to receive the vaccine when told it could prevent cancer, compared with 42% who were willing to receive the vaccine when told it would protect only against genital warts. The study results emphasized the importance of healthcare providers educating parents and young male adults that HPV vaccination is a cancer prevention measure.19 Another study recently reported that a 3-dose regimen of the 4-valent HPV vaccine was immunogenic, clinically effective, and generally well tolerated in preadolescents and adolescents throughout 10 years of follow-up.20
Although routine vaccinations and follow-ups continue to occur during childhood and adolescence, the opportunity may be missed for providers to emphasize the value of HPV vaccine as cancer prevention of males and females during these visits. Recent studies indicate that HPV vaccines can be safely administered when giving routine adolescent immunizations such as tetanus, diphtheria, pertussis, and meningococcal.21 When advising young males and their parents to consider HPV vaccination, providers should remind them that men continue to be susceptible to HPV infection with increasing age.19
Patricia A. Obulaney, DNP, RN, ANP-C, is an assistant professor, clinical; Lydia T. Madsen, PhD, RN, CNS, is an assistant professor, clinical; and Kristin Ownby, PhD, RN, ACHPN, AOCN, CNS-BC, is an associate professor, clinical, Department of Acute and Continuing Care, Cizik School of Nursing, University of Texas Health Science Center at Houston.
- Han JJ, Beltran TH, Song JW, Klaric J, Choi S. Prevalence of genital human papillomavirus infection and human papillomavirus vaccination rates among US adult men: National Health and Nutrition Examination Survey (NHANES) 2013-2014. JAMA Oncol. 2017;3:810-816.
- Sonawane K, Suk R, Chiao EY, Chhatwal J, Qiu P, Wilkin T, et al. Oral human papillomavirus infection: differences in prevalence between sexes and concordance with genital human papillomavirus infection, NHANES 2011 to 2014. Ann Internal Med. 2017;167:714-724.
- CDC. Sexually transmitted infections in the United States. Available at: https://www.cdc.gov/nchhstp/newsroom/2013/sti-graphics.html
- Guo M, Lin CY, Gong Y, Cogdell DE, Zhang W, Lin E, et al. Human papillomavirus genotyping for the eight oncogenic types can improve specificity of HPV testing in women with mildly abnormal Pap results. Mod Pathology. 2008;21:1037-1043.
- Marklund L, Hammarstadt L. Impact of HPV in oropharyngeal cancer. J Oncol. Available at: http://citeseerx.ist.psu.edu/viewdoc/download;jsessionid=FEA8D1D0581A9F5C3B47F3E2A3D33327?doi=10.1.1.292.6471&rep=rep1&type=pdf
- CDC. HPV (Human papillomavirus) VIS. Available at: https://www.cdc.gov/vaccines/hcp/vis/vis-statements/hpv.html
- CDC. Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations of the Advisory Committee on Immunization Practices. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6411a3.htm
- Smith JS, Gilbert PA, Melendy A, Rana RK, Pimenta JM. Age-specific prevalence of human papillomavirus infection in males: a global review. J Adolesc Health. 2011;48:540–552.
- Schuler CL, DeSousa NS, Coyne-Beasley T. Parents’ decisions about HPV vaccine for sons: the importance of protecting sons’ future female partners. J Community Health. 2014;39:842–848.
- CDC. VFC-ACIP vaccine resolutions. Available at: http://www.cdc.gov/vaccines/programs/vfc/providers/resolutions.html
- CDC. HPV vaccine for preteens and teens. Available at: https://www.cdc.gov/vaccines/parents/diseases/teen/hpv.html
- Chin-Hong PV, Vittinghoff E, Cranston RD, Browne L, Buchbinder S, Colfax G, et al. Age-related prevalence of anal cancer precursors in homosexual men: the EXPLORE study. J Natl Cancer Inst. 2005;97:896-905.
- Goldstone S, Palesfsky JM, Giuliano AR, Moreira ED, Aranda C, Jessen H, et al. Prevalence of and risk factors for human papillomavirus (HPV) infection among HIV-seronegative men who have sex with men. J Infect Diseases. 2011;203;66-74.
- Petrosky E, Bocchini JA Jr, Hariri S, Chesson H, Curtis CR, Saraiya M, et al. Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2015;64:300-304.
- CDC. HPV vaccines: vaccinating your preteen or teen. Available at: https://www.cdc.gov/hpv/parents/vaccine.html
- Wilkin T, Lee JY, Lensing SY, Stier EA, Goldstone SE, Berry JM, et al. Safety and immunogenicity of the quadrivalent human papillomavirus vaccine in HIV-1 infected men. J Infect Dis. 2010;202:1246-1253.
- Bernstein HH, Bocchini JA Jr, Committee on Infectious Diseases. The need to optimize adolescent immunization. Pediatrics. 2017;139(3). doi: 10.1542/peds.2016-4168
- Ylitalo KR, Lee H, Mehta NK. Health care provider recommendation, human papillomavirus vaccination, and race/ethnicity in the US National Immunization Survey. Am J Public Health. 2013;103:164-169.
- McRee AL, Reiter PL, Chantala K, Brewer NT. Does framing human papillomavirus vaccine as preventing cancer in men increase vaccine acceptability? Cancer Epidemiol Biomarkers Prev. 2010;19:1937-1944.
- Ferris DG, Samakoses R, Block SL, Lazcano-Ponce E, Restrepo JA, Mehlsen J, et al. 4-Valent human papillomavirus (4vHPV) vaccine in preadolescents and adolescents after 10 years. Pediatrics. 2017;140(6). pii: e20163947. doi: 10.1542/peds.2016-3947.
- Walker TY, Elam-Evans LD, Singleton JA, Yankey D, Markowitz LE, Fredua B, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years—United States, 2016. MMWR Morb Mortal Wkly Rep. 2017;66:874-882. Available at: https://www.cdc.gov/mmwr/volumes/66/wr/mm6633a2.htm