Prevalence of human papillomavirus in teenage heterosexual males following the implementation of female and male school-based vaccination in Australia: 2014-2017

Real-world impact and effectiveness of the quadrivalent HPV vaccine: an updated systematic literature review

INTRODUCTION

Human papillomavirus (HPV) infection, which poses significant disease burden, is decreasing following implementation of vaccination programs. Synthesized evidence on HPV vaccine real-world benefit was published in 2016. However, long-term impact of vaccination, and how vaccination programs influence infection rates and disease outcomes, requires further examination.

AREAS COVERED

We systematically reviewed observational studies on HPV vaccination within MEDLINE, EMBASE, and Google Scholar from 2016 to 2020, involving 14 years of follow-up data. We identified 138 peer-reviewed publications reporting HPV vaccine impact or effectiveness. Outcomes of interest included rates of infection at different anatomical sites and incidence of several HPV-related disease endpoints.

EXPERT OPINION

The expansion of HPV vaccination programs worldwide has led to a reduction in genital infection and significant decreases in incidence of HPV-related disease outcomes. Therefore, the WHO has set goals for the elimination of cervical cancer as a public health concern. To track progress toward this requires an understanding of the effectiveness of different vaccination initiatives. However, the impact on males, and potential benefit of gender-neutral vaccination programs have not been fully explored. To present an accurate commentary on the current outlook of vaccination and to help shape policy therefore requires a systematic review of available data.

PROM SSCOL-Impact of a Papillomavirus Vaccination Promotion Program in Middle Schools to Raise the Vaccinal Coverage on Reunion Island

Introduction: On Reunion Island, cervical cancer is the third most common cause of cancer in women. Primary prevention is based on the HPV vaccination, yet coverage rate is low (8.1%). The objective of the study was to evaluate the impact of a health promotion program on the proportion of middle school girls who have completed the HPV vaccination schedule. Material and methods: In this prospective, controlled intervention study of superiority, 12 classes were randomly selected in an intervention school where the promotion program took place, and in a control school where no specific intervention was planned. The program combined: information to students during school classes, information to parents by letter and phone calls, information to general practitioners by letter and video conference call, and the free school-based vaccination (in a “health bus” parked in the schoolyard) with the nonavalent HPV vaccine. Results: In the intervention group, the completion was achieved for 26 girls, which was significantly higher than in the control group (three girls, p < 10−3). The initiated vaccination was also higher in the intervention group (31 girls vs. 6 girls in the control group, p < 10−3). The same results were obtained for the boys as for the full or partial scheme (seven boys vs. 0, p = 0.01; 16 boys vs. 1, p < 10−3, respectively). Conclusions: Implementing a health promotion program and offering the free, school-based vaccination raised the vaccination coverage. These results are promising and may be a stepping stone to expanding this program to the whole Reunion Island and hopefully someday decrease the burden of cervical cancer.

Human papillomavirus vaccine coverage in male-male partnerships attending a sexual health clinic in Melbourne, Australia

We aimed to investigate the sexual mixing by human papillomavirus (HPV) vaccination status in male-male partnerships and estimate the proportion of male-male partnerships protected against HPV. We analyzed male-male partnerships attending the Melbourne Sexual Health Center between 2018 and 2019. Data on self-reported HPV vaccination status were collected. Newman’s assortativity coefficient was used to examine the sexual mixing by HPV vaccination status. Assortativity refers to the tendency of individuals to have partners with similar characteristics (i.e. same vaccination status). Of 321 male-male partnerships where both men reported their HPV vaccination status, 52.6% (95% CI: 47.0–58.2%) partnerships had both men vaccinated, 32.1% (95% CI: 27.0–37.5%) partnerships had only one man vaccinated, and 15.3% (95% CI: 11.5–19.7%) had both men unvaccinated. The assortativity on HPV vaccination status was moderate (assortativity coefficient = 0.265, 95% CI: 0.196–0.335). There were about 15% of male-male partnerships where both men were not protected against HPV. Interventions targeting vaccinated individuals to encourage their unvaccinated partners to be vaccinated might increase the HPV vaccine coverage.

Update on the Epidemiological Features and Clinical Implications of Human Papillomavirus Infection (HPV) and Human Immunodeficiency Virus (HIV) Coinfection

Human papillomavirus (HPV) infection is the most common sexually transmitted infection (STI) worldwide. Although most HPV infections will spontaneously resolve, a considerable proportion of them will persist, increasing the risk of anogenital dysplasia, especially within certain populations, such as patients infected with human immunodeficiency virus (HIV). Furthermore, high-risk oncogenic HPV types (HR-HPV) are the main cause of cervix and other anogenital cancers, such as cancer of the vagina, vulva, penis, or anus. HIV and HPV coinfection is common among people living with HIV (PLWH) but disproportionally affects men who have sex with men (MSM) for whom the rate of persistent HPV infection and reinfection is noteworthy. The molecular interactions between HIV and HPV, as well as the interplay between both viruses and the immune system, are increasingly being understood. The immune dysfunction induced by HIV infection impairs the rate of HPV clearance and increases its oncogenic risk. Despite the availability of effective antiretroviral therapy (ART), the incidence of several HPV-related cancers is higher in PLWH, and the burden of persistent HPV-related disease has become a significant concern in an aging HIV population. Several public health strategies have been developed to reduce the transmission of HIV and HPV and mitigate the consequences of this type of coinfection. Universal HPV vaccination is the most effective preventive tool to reduce the incidence of HPV disease. In addition, screening programs for HPV-related cervical and vulvovaginal diseases in women are well-recognized strategies to prevent cervical cancer. Similarly, anal dysplasia screening programs are being implemented worldwide for the prevention of anal cancer among PLWH. Herein, the main epidemiological features and clinical implications of HIV and HPV coinfection are reviewed, focusing mainly on the relationship between HIV immune status and HPV-related diseases and the current strategies used to reduce the burden of HPV-related disease.

Natural History of Anal Papillomavirus Infection in HIV-Negative Men Who Have Sex With Men Based on a Markov Model: A 5-Year Prospective Cohort Study

Objective

Men who have sex with men (MSM) are at increased risk for Human papillomavirus (HPV) infection compared to women and heterosexual men. We aimed to assess the incidence, clearance and duration of anal human papillomavirus (HPV) infection in HIV-negative MSM and the influencing factors in a 5-year prospective cohort study.

Methods

From April 2016 to April 2021, HIV-negative MSM were recruited and followed every 6 months in Urumqi, Xinjiang, China. Questionnaires and anal swabs were collected at baseline and every 6 months. We detected 37 anal HPV genotypes using the HPV Geno Array Diagnostic Kit Test. Incidence and clearance rates of anal HPV infection and the influencing factors were estimated using a two-state Markov model.

Results

A total of 585 MSM were included with a median age of 37 years [interquartile range (IQR): 31–43 years] and were followed for a median 2.8 years (IQR: 1.8–3.6 years). Incidence rates for any HPV and high-risk HPV (Hr-HPV) were 53.4 [95% confidence interval (CI): 49.1–58.0] and 39.0 (95% CI: 35.7–42.5)/1,000 person-months. Median duration of infection was 9.67 (95% CI: 8.67–10.86) and 8.51 (95% CI: 7.57–9.50) months, respectively. Clearance rates for any HPV and Hr-HPV were 50.9 (95% CI: 46.7–55.3) and 62.1 (95% CI: 56.8–66.7)/1,000 person-months, respectively. HPV16 and HPV6 had the highest incidence, lowest clearance rate and longest duration of infection among Hr-HPV and low-risk HPV (Lr-HPV) types, respectively. Receptive anal sex is a risk factor for any HPV [hazard ratio (HR) = 1.66, 95% CI: 1.16–2.38] and Hr-HPV infection (HR = 1.99, 95% CI:1.39–2.85). Recent anal sex without condom use was significantly associated with any HPV (HR = 1.80, 95% CI: 1.10–2.94) and Hr-HPV infection (HR = 2.60, 95% CI: 1.42–4.77). Age ≥35 years was significantly associated with Lr-HPV HPV infection only (HR = 1.40, 95% CI: 1.02–1.93). Both inserted and receptive anal sex (HR = 0.60, 95% CI: 0.40–0.89) and anal sex ≥2 times per week (HR = 0.61, 95% CI: 0.43–0.87) were associated with reduced Hr-HPV clearance. Six of the nine-valent vaccine types (HPV6, 11, 16, 18, 52 and 58) occurred most frequently, which indicates the need for high vaccination coverage in MSM.

Conclusions

In this cohort study, high incidence and low clearance of any HPV, Hr-HPV and individual HPV infections emphasize the importance of MSM vaccination. Modifiable behavioral factors such as condoms and drug use should be incorporated into HPV prevention strategies.

PROM SSCOL – Impact of a Papillomavirus vaccination promotion program in middle school: a study protocol for a cluster controlled trial (Preprint)

Background

On Reunion Island, incidence and mortality for uterine cervical cancer is high, yet coverage rate for human papillomavirus (HPV) vaccination is low.

Objective

The main objective of the study is to evaluate the impact of a health promotion program promoting HPV vaccination on the proportion of middle school girls who complete the full HPV vaccination schedule (2 or 3 doses) by the end of school year.

Methods

This study is a cluster controlled intervention study using a superiority design. A combined health promotion program will be offered containing information to students and parents, training of general practitioners, and free school-based vaccination (in a “health bus”). Children who attend this program will constitute the intervention group and will be compared to children from another middle school who will not attend the program constituting the control group.

Results

Recruitment began in October 2020. In the intervention school, of 780 students, 245 were randomly selected in the 12 classes. In the control school, 259 students out of 834 were randomly selected.

Conclusions

In this study, we explore the impact of a health promotion program combining information toward students, parents, and general practitioners with free school-based vaccination. We expect a significantly higher HPV vaccination coverage in the intervention school as compared to the control school, whether it be among girls or boys. The final implication would be an extension of this program in all middle schools on the Island and thus an increase in HPV vaccination coverage.

Trial Registration

ClinicalTrials.gov NCT04459221; https://clinicaltrials.gov/ct2/show/NCT04459221

International Registered Report Identifier (IRRID)

DERR1-10.2196/35695

Real-world impact and effectiveness assessment of the quadrivalent HPV vaccine: a systematic review of study designs and data sources

INTRODUCTION

Vaccine effectiveness and impact studies are typically observational, generating evidence after vaccine launch in a real-world setting. For human papillomavirus (HPV) vaccination studies, the variety of data sources and methods used is pronounced. Careful selection of study design, data capture and analytical methods can mitigate potential bias in such studies.

AREAS COVERED

We systematically reviewed the different study designs, methods, and data sources in published evidence (1/2007-3/2020), which assessed the quadrivalent HPV vaccine effectiveness and impact on cervical/cervicovaginal, anal, and oral HPV infections, anogenital warts, lesions in anus, cervix, oropharynx, penis, vagina or vulva, and recurrent respiratory papillomatosis.

EXPERT OPINION

The rapid growth in access to real-world data allows global monitoring of effects of different public health interventions, including HPV vaccination programs. But the use of data which are not collected or organized to support research also underscore a need to develop robust methodology that provides insight of vaccine effects and consequences of different health policy decisions. To achieve the WHO elimination goal, we foresee a growing need to evaluate HPV vaccination programs globally. A critical appraisal summary of methodology used will provide timely guidance to researchers who want to initiate research activities in various settings.

Human Papilloma Virus Vaccination: Focus on the Italian Situation

Human papilloma virus (HPV) is a viral agent whose transmission occurs mainly by sexual means. It causes different pathological conditions in both males and females, ranging from benign pathologies up to cancers. The introduction of vaccination has certainly had a major impact in terms of reducing the incidence of both HPV infections and diseases but in the European Union and the European Economic Area (EU/EEA) there are still about more than 13,000 deaths due to cervical cancer each year. To date in Europe and in Italy there are three vaccines available (bi-, tetra-, and nonvalent vaccines). The vaccination campaign started irregularly in Europe and Italy in 2007, with pre-adolescent girls as the primary target. Later, other cohorts were introduced such as 12-year-old boys, additional cohorts of >25-year-old women, women who already underwent cervical surgery and other subjects entitled to free vaccination. The COVID-19 pandemic has strongly impacted on public health services, particularly on vaccinations that, especially during the first pandemic phase, have been often delayed and/or canceled. The most affected vaccinations by the pandemic have been the non-mandatory ones, particularly those addressing the adolescent and adult population, such as immunization against papillomavirus. To date the achievement of the coverage target set by the Italian National Immunization Plan (NIP) has not yet been achieved. The aim of this work is to summarize the current situation in Italy and to discuss the strategies that have been implemented to increase overall vaccination coverage rates.

Intra-Anal Imiquimod Cream against Human Papillomavirus Infection in Men Who Have Sex with Men Living with HIV: A Single-Arm, Open-Label Pilot Study

Men who have sex with men (MSM) living with HIV have a high prevalence and incidence of anal high-risk human papillomavirus (hrHPV) and anal cancer. We conducted an open-label, single-arm pilot study to examine the tolerability of imiquimod cream among MSM aged ≥18 years, living with HIV, who tested positive for anal hrHPV at Melbourne Sexual Health Centre between April 2018 and June 2020. We instructed men to apply 6.25 mg imiquimod intra-anally and peri-anally 3 doses per week for 16 weeks (period 1) and then one dose per week for a further 48 weeks (period 2). Twenty-seven MSM enrolled in period 1 and 24 (86%) applied at least 50% of doses. All men reported adverse events (AEs), including 39.5% grade 1, 39.5% grade 2, and 21% grade 3 AEs on at least one occasion. Eighteen MSM (67%) temporarily stopped using imiquimod during period 1, most commonly due to local AEs (n = 11) such as irritation and itching. Eighteen MSM continued in period 2 and all applied at least 50% of doses with no treatment-limiting AEs reported. Imiquimod 3 doses per week caused local AEs in most men and was not well tolerated. In contrast, once-a-week application was well tolerated over 48-weeks with no treatment-limiting AEs.

Prevention and Screening of HPV Malignancies

It is estimated that 5% of the global cancer burden, or approximately 690,000 cancer cases annually, is attributable to human papillomavirus (HPV). Primary prevention through prophylactic vaccination is the best option for reducing the burden of HPV-related cancers. Most high-income countries (HICs) have introduced the HPV vaccine and are routinely vaccinating adolescent boys and girls. Unfortunately, although they suffer the greatest morbidity and mortality due to HPV-related cancers, many lower- and middle-income countries (LMICs) have been unable to initiate and sustain vaccination programs. Secondary prevention in the form of screening has led to substantial declines in cervical cancer incidence in areas with established screening programs, but LMICs with absent or inadequate screening programs have high incidence rates. Meanwhile, HICs have seen incidence rates of anal and oropharyngeal cancers rise owing to the limited availability of organized screening for anal cancer and no validated screening options for oropharyngeal cancer. The implementation of screening programs for individuals at high risk of these cancers has the potential to reduce the burden of cervical cancer in LMICs, of anal and oropharyngeal cancers in HICs, and of anal cancer for highly selected HIV+ populations in LMICs. This review will discuss primary prevention of HPV-related cancers through vaccination and secondary prevention through screening of cervical, anal, and oropharyngeal cancers. Areas of concern and highlights of successes already achieved are included.

Effect on genital warts in Australian female and heterosexual male individuals after introduction of the national human papillomavirus gender-neutral vaccination programme: an analysis of national sentinel surveillance data from 2004-18

BACKGROUND

In Australia, the government-funded human papillomavirus (HPV) vaccination programme was introduced in April, 2007, for girls and young women, and in February, 2013, for boys. As of Dec 31, 2018, all Australian-born female individuals younger than 38 years and male individuals younger than 21 years have been eligible for the free quadrivalent or nonavalent HPV vaccine. We aimed to examine the trends in genital wart diagnoses among Australian-born female and heterosexual male individuals who attended sexual health clinics throughout Australia before and after the introduction of the gender-neutral HPV vaccination programme in February, 2013.

METHODS

We did a serial cross-sectional analysis of genital wart diagnoses among Australian-born female and heterosexual male individuals attending a national surveillance network of 35 clinics between Jan 1, 2004, and Dec 31, 2018. We calculated prevalence ratios of genital warts, using log-binomial regression models, for the female-only vaccination period (July 1, 2007, to Feb 28, 2013), gender-neutral vaccination period (March 1, 2013, to Dec 31, 2018), and the whole vaccination period (July 1, 2007, to Dec 31, 2018) compared with the pre-vaccination period (Jan 1, 2004, to June 30, 2007).

FINDINGS

We included 121 038 men and 116 341 women in the analysis. Overall, we observed a 58% reduction (prevalence ratio 0·42, 95% CI 0·40-0·44) in genital wart diagnoses in female individuals and a 45% reduction (0·55, 0·53-0·57) in genital wart diagnoses in heterosexual male individuals after the introduction of the vaccination programme in 2007. The largest reduction in genital warts was observed in younger individuals, and there was a decreasing magnitude of reduction with increasing age (80%, 72%, 61%, 41%, and 16% reductions in female individuals aged 15-20 years, 21-25 years, 26-30 years, 31-35 years, and ≥36 years, respectively; 70%, 61%, 49%, 37%, and 29% reductions in male individuals aged 15-20 years, 21-25 years, 26-30 years, 31-35 years, and ≥36 years, respectively). Significant reductions observed in female individuals (0·32, 0·28-0·36) and male individuals (0·51, 0·43-0·61) aged 15-20 years in the female-only vaccination period were followed by a more substantial reduction in female individuals (0·07, 0·06-0·09) and male individuals (0·11, 0·08-0·15) aged 15-20 years in the gender-neutral vaccination period.

INTERPRETATION

The national gender-neutral HPV vaccination programme has led to substantial and ongoing reduction in genital warts among Australian female and heterosexual male individuals, with a marked reduction in young individuals who received the vaccine at school.

FUNDING

Seqirus Australia and the Australian Government Department of Health.

Prevalence of human papillomavirus in young men who have sex with men after the implementation of gender-neutral HPV vaccination: a repeated cross-sectional study

BACKGROUND

Anal infection with high-risk human papillomavirus (HPV) genotypes 16 and 18 and anal cancer are overrepresented in men who have sex with men (MSM). This study investigated HPV prevalence in young MSM before and after the implementation of a school-based quadrivalent HPV (genotypes 6, 11, 16, and 18) vaccination programme for boys in Australia in 2013.

METHODS

In this repeated cross-sectional study, MSM aged 16-20 years were recruited from two successive birth cohorts via sexual health clinics and the community in Melbourne, Australia. The first cohort was before the implementation of gender-neutral vaccination (HYPER1 study, done in 2010-12, NCT01422356), and the second was the post-vaccination cohort (HYPER2 study, done in 2017-18, NCT03000933). Men who self-identified as being same-sex attracted were enrolled, and those recruited via the HYPER2 study had to be resident in Australia since 2013 to ensure eligibility. Study procedures were done in the Melbourne Sexual Health Centre. A clinician-collected anal swab and self-collected penile swab and oral rinse were tested for 28 HPV genotypes, and data on demographics and sexual health practices were collected via questionnaires. Only assessable samples were included in the analyses. We compared anatomical site-specific prevalence of HPV genotypes between cohorts by calculating the prevalence ratio, adjusting for age, circumcision, and sex with women. Herd protection was also assessed, by calculating the adjusted prevalence ratios by vaccination status.

FINDINGS

400 MSM, 200 per cohort, were included in the study. In both cohorts, the median number of lifetime male partners was ten (IQR 5-25). The prevalence of any anal quadrivalent vaccine-preventable HPV genotype was higher in the pre-vaccination cohort (54 [28%] of 193) than in the post-vaccination cohort (14 [7%] of 193; adjusted prevalence ratio [PR] 0·24, 95% CI 0·14-0·42), largely driven by decreases in HPV6, followed by HPV11, 16, and 18. Nevertheless, there was also a significant reduction in anal HPV16 and 18 in the post-vaccination cohort from the pre-vaccination cohort (0·31, 0·14-0·68). The prevalence of any penile quadrivalent vaccine-preventable HPV genotype was also higher in the pre-vaccination cohort (21 [12%] of 177) than in the post-vaccination cohort (11 [6%] of 179; 0·48, 0·24-0·97), driven by decreases in HPV 6 and 11, but not by 16 and 18. The prevalence of any oral quadrivalent vaccine-preventable HPV genotype was higher in the pre-vaccination cohort (seven [4%] of 200) than in the post-vaccination cohort (one [1%] of 199; 0·10, 0·01-0·97); there were no cases of oral HPV6 or 11 detected in HYPER2. Comparing the pre-vaccinated cohort with the 149 confirmed vaccinated men from HYPER2 showed a reduction in any quadrivalent vaccine-preventable HPV genotype for anal (0·09, 0·03-0·25) and penile (0·18, 0·05-0·59) infection but not for oral infection (0·17, 0·03-1·08).

INTERPRETATION

A reduction in anal, penile, and oral quadrivalent vaccine-targeted genotypes occurred in young MSM following the implementation of a school-based gender-neutral HPV vaccination programme. The fall in anal HPV16 and 18 may lead to a reduction in the incidence of anal cancer.

FUNDING

Merck and the Australian Government Department of Health.

Human papillomavirus vaccination and sexual practices among men who have sex with men in Melbourne, Australia: a cross-sectional study

The aim of this study was to explore the factors associated with self-reported receipt of human papillomavirus (HPV) vaccine among men who have sex with men (MSM). MSM aged 16–40 years attending the Melbourne Sexual Health Centre, Australia, for their first visit in 2016 were included in the analysis. Multivariable logistic regression analyses were performed to examine the association between self-reported HPV vaccination and sexual practices: one examining the sexual practices. A total of 1332 MSM with a mean age of 27.6 (standard error [SE] = 0.1) were included in the analysis. The mean number of reported male partners in the last 3 and 12 months was 4.0 (SE = 0.1) and 8.9 (SE = 0.4), respectively. Six percent ( n =  81) of MSM reported receiving the HPV vaccine. There was no significant association between sexual practices (the number of partners or condomless anal sex) and self-reported HPV vaccine receipt after adjusting for confounding factors such as human immunodeficiency virus (HIV) status and pre-exposure prophylaxis (PrEP). HIV-negative MSM taking PrEP were three times more likely to be vaccinated against HPV compared with HIV-negative MSM not taking PrEP in both multivariable analyses. Our findings suggest that there is no association between HPV vaccination and sexual risk practices in MSM.

Men having sex with men and the HPV vaccine in France: A low vaccine coverage that may be due to its infrequent proposal by physicians

INTRODUCTION

In France, the human papilloma (HPV) vaccine is recommended to all female adolescents, and since 2016 to men having sex with men (MSM) under the age of 27. Here, we aimed to explore HPV vaccine coverage in adult MSM living in France.

METHODS

We elaborated an anonymous online questionnaire targeting MSM and disseminated it between October 7, 2018 and January 15, 2019 by various means, including a Facebook® discussion forum for pre-exposure prophylaxis (PrEP) users.

RESULTS

Overall, 2094 participants completed the questionnaire (mean age 35.4 ± 11 years); 25.8% were in the age class targeted by the HPV vaccine recommendation; 16.1% were in a PrEP program. On a 1-10 scale, they evaluated being "in favor of vaccination" at a median of 10, and general vaccine usefulness and harmfulness at medians of 10 and 2, respectively; 62.4% considered that the HPV vaccine was rather not or not at all dangerous. Those using PrEP had better perceptions of vaccination in general and of the HPV vaccine in particular. For the 1728 participants with a family physician, he/she had proposed the HPV vaccine in 9.9% of cases (9.1% of those in the targeted age class [<27 years]). Overall, 1994 knew their HPV vaccine status; 8.0% had received at least 1 dose of the vaccine, including 17.9% of those in the targeted age class (and 52.2% among the 40 participants in this age group who received PrEP). When the 1935 participants who declared to be unvaccinated against HPV were asked whether they would accept to be vaccinated, 34.4% answered "rather yes" and 45.5% "definitely yes".

CONCLUSION

HPV vaccine coverage is low among French MSM. Our results suggest that this trend has more to do with the infrequent proposals made by clinicians than with negative vaccine perceptions.