It’s time to vaccinate boys against HPV

Monday, April 13th, 2015 |

It’s time boys were included in HPV vaccination programmes, most of which currently target girls only. A start has been made – gender-neutral vaccination is already happening in Austria, Australia, the United States and parts of Canada. The vaccination of boys will also start soon in Israel and is now recommended in Switzerland. But HPV does not respect national borders. The European Men’s Health Forum (EMHF) believes this very common but also nasty and dangerous sexually transmitted infection can only be tamed, and hopefully ultimately eliminated altogether, by comprehensive and international action to immunise both sexes.

HPV is still too often thought of as the cause of just cervical cancer – and it does lead to around 23,250 new cases of cervical cancer each year in Europe. But HPV also causes vaginal and vulval cancer in women (3,850 cases), several head and neck (15,230 cases) as well as anal cancers (4,630 cases) in both sexes, and penile cancer (1,090 cases). Overall, HPV causes 5% of all cancers worldwide and is heavily implicated in the recent rapid rise in anal and head and neck cancers. HPV is also the cause of genital warts, the commonest sexually transmitted viral infection (614,700 cases).

In Europe each year, there are an estimated 15,490 new cases of HPV-related cancer in men and 325,700 new cases of genital warts.

Of course, more needs to be done to protect girls. In some European countries vaccination rates for girls are low – less than one-third of girls are vaccinated in France, for example, and around two-thirds in Norway. Even in the UK, which has a high national rate (almost 90%), there are parts of the country, especially in London, where uptake is much lower. It therefore makes good sense to take action to raise vaccination uptake in girls. More girls would also be protected, especially in countries where many don’t receive the vaccine, if boys were also vaccinated.

It’s often argued that it’s not worth vaccinating boys because, if enough girls are vaccinated (the proportion most often mentioned is 80%), then boys will be protected by default. 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 boys too, suggesting that boys are no longer being infected by the girls.

There are several major problems with this argument, however. The first is that it completely overlooks a group of men – men who have sex with men (MSM) – who are, for obvious reasons, completely unprotected by a girls-only vaccination programme, however effective that might be. MSM are in fact 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 is no sure way of reaching enough of the MSM population. It is best practice to vaccinate before people become sexually active and are infected by HPV; the immune response to the vaccine is also greater if it is administered at a younger age. But it would neither be ethical nor practical to try to identify and vaccinate adolescent boys who might later become MSM. Offering HPV vaccinations to adult MSM would also be ineffective – many will already have been infected with HPV, will have a lower immune response and relatively few will be reached. The best way of protecting all MSM is to vaccinate all boys.

Many heterosexual boys will also remain at risk from a girls-only vaccination programme, even if it reaches 90% of girls. The ‘missing’ 10% of girls is a significant absolute number and research suggests that these girls are those most likely to go on to adopt high-risk sexual behaviours, such as having a large number of partners, not using condoms and practising anal sex. Many men will also have sex with women from countries where there is no HPV vaccination programme for girls, or one 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 sex (in this case, male). It would be unacceptable, of course, to suggest that only white people should receive the HPV vaccine because that would protect black people by default; or that people with red hair should be denied the vaccine because they would be protected by the vaccination of people with other hair colours.

The final issue concerns cost. Is it simply unaffordable to vaccinate boys as well as girls? The Australian government certainly doesn’t think so – its Pharmaceutical Benefits Advisory Committee judged that vaccinating boys is cost-effective. In Europe, it’s known that the vaccine price per dose can be as low as €33. Just two doses of the vaccine are needed, making the vaccine cost per person under €66. There will be additional costs for administration and delivery, of course, but these are unlikely to be substantial.

These costs have to set against the costs 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; a similar study of the economic burden of HPV-related cancers in France estimated the cost to be about €240 million.  The estimated costs of HPV-related anal cancer treatment, rehabilitation and sick leave in Germany are about €29 million annually.  The cost of treating genital warts was over €71 million in the UK in 2010. The human costs of HPV-related diseases are self-evident.

EMHF does not believe the decision to introduce gender-neutral vaccination should 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.

During European Immunization Week 2015, EMHF is hosting a Symposium in London on HPV: Prevention and Early Diagnosis. This will include a session on vaccinating boys. EMHF plans to hold a similar event in mainland Europe in 2016.

EMHF is a member of HPV Action, a collaboration of 36 patient and professional organisations in the UK, which makes the case for vaccinating boys as well as girls.

This blog was first published by European Immunization Week 2015 on 13 April 2015.

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