Meeting NewsPerspective

Adults at high risk for HIV show ‘alarmingly’ low HPV vaccination rate

Photo of Lisa Wigfall
Lisa T. Wigfall

ATLANTA — Adults at high risk for HIV infection based on injectable drug use or high-risk sexual behavior showed low rates of HPV vaccination, according to study results presented at American Association of Cancer Research Annual Meeting.

Adults with HIV may be less able to fight off HPV infection — which is associated with anal, cervical and oral cancer, among others — due to their compromised immune systems. Given that HIV/AIDS and HPV often occur among racial/ethnic and sexual/gender minority populations, increasing HPV vaccination rates among HIV high-risk adults should be a public health priority, according to the researchers.

“I am very interested in reducing HPV-associated cancers among vulnerable populations, such as people living with HIV and men who have sex with men,” Lisa T. Wigfall, PhD, MCHES, assistant professor in the division of health education in the department of health and kinesiology in the College of Education and Human Development at Texas A&M University, told HemOnc Today. “Cost is a major barrier [to HPV vaccination] for those who are uninsured. Beyond cost, low knowledge about HPV and lack of provider recommendations about the HPV vaccine are also barriers.”

The CDC recommends adolescent boys and girls aged up to age 15 years receive two doses of the HPV vaccine beginning at age 11 or 12 years. They recommend three doses for those who initiate the series at age 15 to 26 years.

In October, the FDA expanded the approval of the HPV 9-valent vaccine (Gardasil 9, Merck) to include adults aged 27 to 45 years. However, current adult HPV vaccination recommendations are for females and gay/bisexual males aged 18 to 26 years, and heterosexual males aged 18 to 21 years.

The CDC also has recommended routine HIV testing since 2006.

Despite a goal to reach 80% HPV vaccination rates by 2020, as of 2017 only 49% of U.S. adolescents had received the series, and only 66% received the first dose.

Wigfall and colleagues evaluated data from the 2016 Behavioral Risk Factor Surveillance System survey (n = 486,303) to evaluate HPV vaccination rates among individuals who reported engaging in high-risk behaviors in the last year, defined as having used IV drugs, been diagnosed with a sexually transmitted infection, exchanged sex for money, had unprotected anal sex, or had four or more sexual partners.

Based on recommendations for HPV vaccination, researchers included all females aged 18 to 36 years, heterosexual males aged 18 to 28 years, and gay or bisexual males aged 18 to 33 years.

Overall, 16,507 survey respondents (3.39%) were classified as high risk for HIV infection. Of them, 416 (2.52%) had complete data and were included in the analysis.

Wigfall and colleagues found that only about a quarter (25.68%) of gay or bisexual males aged 18 to 33 years initiated the three-dose HPV vaccine series — with only 6.2% completing the series — and only 10.91% of heterosexual males aged 18 to 29 years initiated the series.

“The Advisory Committee on Immunization Practices considers people living with HIV infection a special population of interest because of their increased HPV-associated cancer risk,” the researchers wrote. “That said, it was alarming that HPV vaccination rates were low among HIV infection high-risk adults in our study, including gay/bisexual males who have the highest HPV-associated cancer risk.”

Only 25.01% of heterosexual females aged 18 to 36 years completed the three-dose series.

“It’s important to note that the vaccination rates among women compared with gay/bisexual men are similar, so there has been a lot of progress in that area [for men],” Wigfall said during a press conference. “However, more females have completed the vaccine, whereas a large number of gay/bisexual males have just reported that they initiated the vaccine.”

Further, all the transgender men and women and gender-nonconforming individuals were unvaccinated, although Wigfall noted that this was a very small proportion of the study population.

Also, almost all (96.09%) non-Hispanic black individuals were unvaccinated.

“When you take into consideration that regardless of age, gender and sexual orientation, African-Americans disproportionately are affected by HIV/AIDS, and given the length [of time] between HIV and HPV co-infection, we thought this was a very important result to take note of,” Wigfall said.

Age, sex and sexual orientation were significantly associated with HPV vaccination rates (P = .0047).

Researchers observed higher HPV vaccine initiation (11.91%) and completion (15.72%) rates among high-risk adults who had been tested for HIV, but this association did not reach statistical significance.

To increase HPV vaccination in these high-risk populations, “a necessary first step would be the wide adoption of routine HIV testing for all adolescents and adults, regardless of perceived risk,” Wigfall said in a press release.

It remains to be determined how the FDA’s recent approval expansion will impact this group of patients, Wigfall told HemOnc Today.

Research shows the HPV vaccine is still recommended for sexually experienced individuals because it is unlikely that they have been exposed to all nine HPV types covered by the 9-valent HPV vaccine, Wigfall said.

“The best way to maximize effectiveness of the HPV vaccine is for it to administered before sexual debut, which means getting more parents/caregivers to vaccinate their adolescent children,” she said. “Thus, organizational and policy-level changes may be the most practical steps to increasing HPV vaccination rates among adolescents.” – by Alexandra Todak

Reference:

Wigfall LT, et al. Abstract 3327. Presented at: AACR Annual Meeting; March 29-April 3, 2019; Atlanta.

Disclosures: NCI supported this study. The authors report no relevant financial disclosures.

Photo of Lisa Wigfall
Lisa T. Wigfall

ATLANTA — Adults at high risk for HIV infection based on injectable drug use or high-risk sexual behavior showed low rates of HPV vaccination, according to study results presented at American Association of Cancer Research Annual Meeting.

Adults with HIV may be less able to fight off HPV infection — which is associated with anal, cervical and oral cancer, among others — due to their compromised immune systems. Given that HIV/AIDS and HPV often occur among racial/ethnic and sexual/gender minority populations, increasing HPV vaccination rates among HIV high-risk adults should be a public health priority, according to the researchers.

“I am very interested in reducing HPV-associated cancers among vulnerable populations, such as people living with HIV and men who have sex with men,” Lisa T. Wigfall, PhD, MCHES, assistant professor in the division of health education in the department of health and kinesiology in the College of Education and Human Development at Texas A&M University, told HemOnc Today. “Cost is a major barrier [to HPV vaccination] for those who are uninsured. Beyond cost, low knowledge about HPV and lack of provider recommendations about the HPV vaccine are also barriers.”

The CDC recommends adolescent boys and girls aged up to age 15 years receive two doses of the HPV vaccine beginning at age 11 or 12 years. They recommend three doses for those who initiate the series at age 15 to 26 years.

In October, the FDA expanded the approval of the HPV 9-valent vaccine (Gardasil 9, Merck) to include adults aged 27 to 45 years. However, current adult HPV vaccination recommendations are for females and gay/bisexual males aged 18 to 26 years, and heterosexual males aged 18 to 21 years.

The CDC also has recommended routine HIV testing since 2006.

Despite a goal to reach 80% HPV vaccination rates by 2020, as of 2017 only 49% of U.S. adolescents had received the series, and only 66% received the first dose.

Wigfall and colleagues evaluated data from the 2016 Behavioral Risk Factor Surveillance System survey (n = 486,303) to evaluate HPV vaccination rates among individuals who reported engaging in high-risk behaviors in the last year, defined as having used IV drugs, been diagnosed with a sexually transmitted infection, exchanged sex for money, had unprotected anal sex, or had four or more sexual partners.

Based on recommendations for HPV vaccination, researchers included all females aged 18 to 36 years, heterosexual males aged 18 to 28 years, and gay or bisexual males aged 18 to 33 years.

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Overall, 16,507 survey respondents (3.39%) were classified as high risk for HIV infection. Of them, 416 (2.52%) had complete data and were included in the analysis.

Wigfall and colleagues found that only about a quarter (25.68%) of gay or bisexual males aged 18 to 33 years initiated the three-dose HPV vaccine series — with only 6.2% completing the series — and only 10.91% of heterosexual males aged 18 to 29 years initiated the series.

“The Advisory Committee on Immunization Practices considers people living with HIV infection a special population of interest because of their increased HPV-associated cancer risk,” the researchers wrote. “That said, it was alarming that HPV vaccination rates were low among HIV infection high-risk adults in our study, including gay/bisexual males who have the highest HPV-associated cancer risk.”

Only 25.01% of heterosexual females aged 18 to 36 years completed the three-dose series.

“It’s important to note that the vaccination rates among women compared with gay/bisexual men are similar, so there has been a lot of progress in that area [for men],” Wigfall said during a press conference. “However, more females have completed the vaccine, whereas a large number of gay/bisexual males have just reported that they initiated the vaccine.”

Further, all the transgender men and women and gender-nonconforming individuals were unvaccinated, although Wigfall noted that this was a very small proportion of the study population.

Also, almost all (96.09%) non-Hispanic black individuals were unvaccinated.

“When you take into consideration that regardless of age, gender and sexual orientation, African-Americans disproportionately are affected by HIV/AIDS, and given the length [of time] between HIV and HPV co-infection, we thought this was a very important result to take note of,” Wigfall said.

Age, sex and sexual orientation were significantly associated with HPV vaccination rates (P = .0047).

Researchers observed higher HPV vaccine initiation (11.91%) and completion (15.72%) rates among high-risk adults who had been tested for HIV, but this association did not reach statistical significance.

To increase HPV vaccination in these high-risk populations, “a necessary first step would be the wide adoption of routine HIV testing for all adolescents and adults, regardless of perceived risk,” Wigfall said in a press release.

It remains to be determined how the FDA’s recent approval expansion will impact this group of patients, Wigfall told HemOnc Today.

Research shows the HPV vaccine is still recommended for sexually experienced individuals because it is unlikely that they have been exposed to all nine HPV types covered by the 9-valent HPV vaccine, Wigfall said.

“The best way to maximize effectiveness of the HPV vaccine is for it to administered before sexual debut, which means getting more parents/caregivers to vaccinate their adolescent children,” she said. “Thus, organizational and policy-level changes may be the most practical steps to increasing HPV vaccination rates among adolescents.” – by Alexandra Todak

Reference:

Wigfall LT, et al. Abstract 3327. Presented at: AACR Annual Meeting; March 29-April 3, 2019; Atlanta.

Disclosures: NCI supported this study. The authors report no relevant financial disclosures.

    Perspective
    Kimlin Tam Ashing

    Kimlin Tam Ashing

    Increasing HPV vaccination is not just a U.S. problem — it’s a global problem.

    Given our collaborative work with the African-Caribbean Cancer Consortium, or AC3, we have noted that countries in the Caribbean and Africa — regions heavily hit with HIV and HPV cancers — also have disappointing HPV vaccination rates. HPV vaccination is highly effective, even among people who are immunocompromised, such as those who are HIV infected, and so it needs to be a priority as part of their clinical care.

    We have an even greater opportunity — which comes with a greater challenge — given that the FDA in November expanded approval of HPV vaccination for adults aged up to 45 years. We know that the uptake has been very slow even among those for whom the vaccine has been approved — since 2006 for girls and 2009 for boys. HPV vaccination of adults is not part of the U.S. Preventive Services Task Force guidelines, but clinically, providers could recommend it based on the FDA approval.

    We are hoping that we will see a dramatic uptake, both in terms of recommendations from clinicians as well as uptake from patients, compared with what we’ve seen since the vaccine was approved. Clinicians are not recommending HPV vaccination at the rate that they ought to, although it should be standard. The safety and efficacy have been clearly established from the rigorous research that’s been done. Now the challenge is upon clinicians for routine vaccine protocol. The slow uptake is deeply concerning because this is a cancer-preventing vaccine, the opportunity of a lifetime, so we’re hoping that, in the next phase of the vaccine rollout, we will not see the barriers that we’ve seen in the first decade.

    Wigfall and colleagues evaluated populations that are disproportionately burdened by both HPV-related cancers as well as HIV, so it’s even more troubling that vaccination rates in these vulnerable populations are critically low. Medically underserved populations should be prioritized in a culturally responsive and socioeconomically thoughtful way. Reaching out to HIV-positive and ethnic minority groups, and even cancer survivors, for HPV vaccination may seem that it is stigmatizing these groups. We should engage advocates from these communities to create ads that are presented by CDC and other national organizations, including the American Cancer Society, to be responsive and not create a sense of targeting or stigmatizing these groups. The goal of the ads should be to promote that HPV vaccination is cancer-preventive without branding our vulnerable populations — to improve HPV vaccination acceptability among young adults and their clinicians.

    It also will be important to have private-sector partnership for cost coverage. We can work with popular personalities in the entertainment, media and sports industries, especially from the African-American community, to spread the message of the importance of HPV vaccination. Often, the community listens to these influential people. This is not a new idea — it has worked before, specifically in HIV. Going back to some of those strategies, as well as utilizing social media, may improve the responsiveness and acceptability of the HPV vaccine.

    • Kimlin Tam Ashing, PhD
    • City of Hope

    Disclosures: Ashing reports no relevant financial disclosures.

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