HIV-positive gay men's knowledge and perceptions of Human Papillomavirus (HPV) and HPV vaccination: A qualitative study

Barriers and facilitators in uptake of human papillomavirus vaccine across English Canada: A review

Human Papillomavirus (HPV) is a highly contagious sexually transmitted infection that leads to preventable cancers of the mouth, throat, cervix, and genitalia. Despite the wide availability of HPV Vaccine (HPVV) in Canada, its uptake remains suboptimal. This review aims to identify factors (barriers and facilitators) in HPV vaccine uptake across English Canada at three levels (provider, system, and patient). We explored academic and gray literature to examine factors involved in HPVV uptake and synthesized results based on interpretive content analysis. The review identified the following factors of prime significance in the uptake of the HPV vaccine (a) at the provider level, 'acceptability' of the HPV vaccine, and 'appropriateness' of an intervention (b) at the patient level, the 'ability to perceive' and 'knowledge sufficiency' (c) at the system level, 'attitudes' of different players in vaccine programming, planning and delivery. Further research is needed to conduct population health intervention research in this area.

An exploratory study of knowledge, attitudes, and practices toward HPV associated anal cancer among Pakistani population

Background

Anal cancer, mainly attributed to human papillomavirus (HPV) infection, is rising in prevalence among the general population in Pakistan. This study aimed to examine the knowledge, attitudes, and practices (KAP) towards anal cancer screening and HPV of the general population in Pakistan.

Method

We surveyed anal cancer KAP using social media and snowball sampling from December 2022 to May 2023. The questionnaire had 16 knowledge, 12 attitudes, 6 practice questions, and socio-demographic variables. We applied validity criteria for inclusion and exclusion and used cutoffs ≥50% for each KAP category. We analyzed data in R with Guttman's λ2 for reliability, did univariate and bivariate analysis, and reported frequencies, percentages, p-values, coefficients, odds ratios, and 95% confidence intervals.

Results

We surveyed 1620 people and discovered low awareness of HPV and anal cancer causes prevention, and screening (11%-24%), high stigma and embarrassment for screening (54%-70%), strong moral beliefs (89%), condom nonuse (91%), and low engagement in health services and programs (9.1%-14%). Knowledge (75.23%, OR = 1.0984, p = 0.05) was shaped by socio-demographic factors, attitude, and practice, with higher education enhancing knowledge (OR = 1.0984, p = 0.05). Attitude (78.45%, OR = 6.6052, p< 0.001) was influenced by socio-demographic factors, practice, and knowledge as well. Younger females, single, unemployed, students, living with more family members, earning more income, and residing in Islamabad had a more positive attitude (ORs from 1.0115 to 6.6052, p< 0.05), while religion did not affect attitude (p = 0.51). Practice (9.16%, OR = 0.1820, p< 0.001) was determined by socio-demographic factors, knowledge, and attitude. Older males, employed teachers, living with more family members, earning less income, and residing in Islamabad had better practice (ORs from 0.1323 to 3.8431, p< 0.05), but marital status and religion did not influence practice (p > 0.05).

Conclusion

Pakistani young adults need more education, awareness, health services, and programs on HPV and anal cancer, as they have low awareness, high stigma, and socio-cultural challenges. In addition, it is recommended for more research and policy initiatives are needed to address socio-cultural factors and increase anal Pap to overcome anal cancer.

Evaluation of the quality and reliability of anal cancer and its precancerous lesions-related content on YouTube: a cross-sectional study

OBJECTIVES

This research aims at evaluating the quality of anal cancer and its precancerous lesions-related videos on YouTube.

DESIGN

Cross-sectional survey design.

SETTING

USA.

PARTICIPANTS

The top 150 videos on YouTube were selected for analysis based on three search terms. The duplicate, irrelevant, commercial, operation-related and audio-free videos were excluded. Finally, 105 relevant videos were included.

METHODS

We assessed the completeness of video content from six dimensions and marked the men having sex with men (MSM)-related videos. To measure the video quality, DISCERN, Journal of the American Medical Association (JAMA) Benchmark Criteria, Patient Education Materials Assessment Tool (PEMAT) and Global Quality Scale (GQS) were used. The correlation between DISCERN classification and duration, JAMA, PEMAT and GQS scores were recorded.

RESULTS

The video content was mainly about the management of the disease (mean score 1.086). Overall, the quality of videos uploaded by the non-profit organisation was relatively high. A correlation existed between each other of the JAMA, DISCERN and GQS scores (p<0.001). Moreover, they were positively correlated with video duration and PEMAT scores (p<0.001).

CONCLUSIONS

Although the overall quality of information about anal cancer and its precancerous lesions videos on YouTube is acceptable, it might not fully meet the health information needs of patients. Therefore, they should exercise caution when using YouTube as a source of anal cancer-related information, especially the MSM population.

HPV vaccination for prevention of head and neck cancer among men

ABSTRACT

The incidence of human papillomavirus (HPV)-associated head and neck cancer (HNC) has been rapidly increasing in developed countries, with HPV-associated HNC now accounting for 70% of all HNC cases. An increased incidence has been noted particularly among males. The disparities in HPV vaccine uptake rates and the increasing number of individuals with HPV-associated HNC suggest a lack of public awareness of both HPV sequelae and prevention options. This review highlights the importance of prophylactic HPV vaccination for preventing HPV-associated HNC, particularly in males. Current evidence substantiates the need for gender-neutral HPV vaccination programs and reinforces the recommendations made by the CDC. This article raises awareness of the association between HPV and HNC as well as the effectiveness of HPV vaccination in HNC prevention.

Understanding Sexual and Gender Minority Populations and Organ-Based Screening Recommendations for Human Papillomavirus-Related Cancers

OBJECTIVES

Sexual gender minority (SGM) populations are at risk for human papillomavirus (HPV)-related cancers of the anogenital tract and oropharynx and often face barriers to health care. The goals of this document are to clarify language to provide inclusive care for SGM populations and to provide recommendations for screening and prevention of HPV-related cancers in SGM populations.

MATERIALS AND METHODS

An expert committee convened by the American Society for Colposcopy and Cervical Pathology performed a narrative review of the literature through February 2023. A comprehensive MEDLINE database search was performed for relevant studies. The literature review was divided into categories by organ/topic and by SGM population. Given the variability in available data for several of the categories, recommendations were made based on national guidelines where appropriate or expert opinion where there were less data to support risk-based guidelines.

RESULTS

Definitions and terminology relevant to SGM populations are presented. The authors advocate the adoption of sexual orientation gender identity data collection and an organ-based screening approach, which is possible with knowledge of patient anatomy, sexual behaviors, and clinical history. This includes screening for cervical cancer per national recommendations, as well as screening for anal, vulvar, vaginal, penile, and oral cancers based on risk factors and shared clinical decision making. The authors recommend consideration of HPV vaccination in all SGM individuals up to age 45 years old who are at risk.

CONCLUSIONS

An organ-based screening approach is part of a global strategy to create an inclusive care environment and mitigate barriers to screening and prevention of HPV-mediated cancers in SGM populations.

Perception about human papillomavirus vaccination among middle adolescent school girls in Addis Ababa, Ethiopia 2023: qualitative study

BACKGROUND

Human papillomavirus vaccine uptake among school girls in Ethiopia was still low and uptake was majorly related to perception regarding the vaccine. This study explored school girls' perceptions of Human papillomavirus vaccination in Addis Ababa, Ethiopia.

OBJECTIVES

The main aim of this study was to explore the perception of secondary school girls towards Human Papilloma Virus vaccine in Addis Ababa, Ethiopia 2023.

METHODS

A qualitative research using focused group discussions were used to explore middle adolescent school girls' perceptions of Human papillomavirus in Addis Ababa Ethiopia from March 2023-April 2023. A focus group discussion guide was employed with potential probes to achieve study objectives. A convenience sampling technique was performed to select study participants. The collected data were transcribed and translated into English and thematic analysis was done by using Atlas-Ti software version 7.5.16.

RESULT

Two dominant themes emerged from the study; perceived benefits and potential barriers to Human papillomavirus vaccine uptake. Poor awareness, lack of family support, perception of poor vaccine quality, fear of side effects, misconceptions, and myths are potential barriers to the Human papillomavirus vaccine. Some students perceive the vaccine as important in the prevention of cervical cancer, others are not sure about the importance of the vaccine and many students think that the vaccine can cause infertility and other beliefs it can cause diseases.

CONCLUSION

The perceived benefits of the Human papillomavirus vaccine was; it prevents cervical cancer enhance acceptability and can be an important motivation for Human papillomavirus vaccination among students. The main barriers to vaccine uptake and acceptance were; lack of awareness, misconceptions, and myths, lack of credible information sources of vaccines, perception of poor vaccine quality, Poor family support, and cultural and religious perspectives. We recommend the development of strong collaborations that work on identified challenges.

Identification of HPV oncogene and host cell differentiation associated cellular heterogeneity in cervical cancer via single-cell transcriptomic analysis

Human Papillomaviruses (HPVs) are associated with around 5-10% of human cancer, notably nearly 99% of cervical cancer. The mechanisms HPV interacts with stratified epithelium (differentiated layers) during the viral life cycle, and oncogenesis remain unclear. In this study, we used single-cell transcriptome analysis to study viral gene and host cell differentiation-associated heterogeneity of HPV-positive cervical cancer tissue. We examined the HPV16 genes - E1, E6, and E7, and found they expressed differently across nine epithelial clusters. We found that three epithelial clusters had the highest proportion of HPV-positive cells (33.6%, 37.5%, and 32.4%, respectively), while two exhibited the lowest proportions (7.21% and 5.63%, respectively). Notably, the cluster with the most HPV-positive cells deviated significantly from normal epithelial layer markers, exhibiting functional heterogeneity and altered epithelial structuring, indicating that significant molecular heterogeneity existed in cancer tissues and that these cells exhibited unique/different gene signatures compared with normal epithelial cells. These HPV-positive cells, compared to HPV-negative, showed different gene expressions related to the extracellular matrix, cell adhesion, proliferation, and apoptosis. Further, the viral oncogenes E6 and E7 appeared to modify epithelial function via distinct pathways, thus contributing to cervical cancer progression. We investigated the HPV and host transcripts from a novel viewpoint focusing on layer heterogeneity. Our results indicated varied HPV expression across epithelial clusters and epithelial heterogeneity associated with viral oncogenes, contributing biological insights to this critical field of study.

Identification of HPV oncogene and host cell differentiation associated cellular heterogeneity in cervical cancer via single-cell transcriptomic analysis

Human Papillomaviruses (HPVs) are associated with around 5%-10% of human cancer, notably nearly 99% of cervical cancer. The mechanisms HPV interacts with stratified epithelium (differentiated layers) during the viral life cycle, and oncogenesis remain unclear. In this study, we used single-cell transcriptome analysis to study viral gene and host cell differentiation-associated heterogeneity of HPV-positive cervical cancer tissue. We examined the HPV16 genes-E1, E6, and E7, and found they expressed differently across nine epithelial clusters. We found that three epithelial clusters had the highest proportion of HPV-positive cells (33.6%, 37.5%, and 32.4%, respectively), while two exhibited the lowest proportions (7.21% and 5.63%, respectively). Notably, the cluster with the most HPV-positive cells deviated significantly from normal epithelial layer markers, exhibiting functional heterogeneity and altered epithelial structuring, indicating that significant molecular heterogeneity existed in cancer tissues and that these cells exhibited unique/different gene signatures compared with normal epithelial cells. These HPV-positive cells, compared to HPV-negative, showed different gene expressions related to the extracellular matrix, cell adhesion, proliferation, and apoptosis. Further, the viral oncogenes E6 and E7 appeared to modify epithelial function via distinct pathways, thus contributing to cervical cancer progression. We investigated the HPV and host transcripts from a novel viewpoint focusing on layer heterogeneity. Our results indicated varied HPV expression across epithelial clusters and epithelial heterogeneity associated with viral oncogenes, contributing biological insights to this critical field of study.

Impact of Human Papillomavirus Vaccination on Male Disease: A Systematic Review

Human papillomavirus (HPV)-related diseases are highly prevalent in men worldwide, comprising external anogenital condyloma, anal intraepithelial neoplasia (AIN), penile intraepithelial neoplasia (PIN), and anogenital and oropharyngeal cancers. There is exceptionally low vaccine coverage in the male population. Only 4% of men were fully vaccinated, worldwide, as of 2019. The aim of this review is to assess the impact of HPV vaccination on male disease. Three databases (MEDLINE, Web of Science, Scopus) and Clinical Trials.gov were searched. We included thirteen studies, eight randomized controlled trials (RCTs), and five cohorts, comprising a total of 14,239 participants. Regarding anal disease, seven studies reported HPV vaccine efficacy ranging from 91.1% to 93.1% against AIN1, and ranging from 89.6% to 91.7% against AIN2|3 and anal cancer. Five studies showed an efficacy against genital condyloma of 89.9% in HPV-naïve males, varying between 66.7% and 67.2% in intention-to-treat populations. Studies reporting no efficacy have included older participants. These results support vaccination of young men previously infected, beyond HPV-naïve males. The evidence quality was moderate to low for most outcomes, namely genital diseases. RCTs are needed to assess the efficacy of HPV vaccination on male oropharyngeal cancer.

Barriers and facilitators to HPV and meningococcal vaccination among men who have sex with men: a qualitative study

BACKGROUND

Men who have sex with men (MSM) have suboptimal uptake of human papillomavirus (HPV) and meningococcal vaccines. This study examines barriers and facilitators to HPV and meningococcal vaccination among MSM in a large, racially/ethnically diverse, and medically underserved U.S. region.

METHODS

In 2020, we conducted five focus groups with MSM living in the Inland Empire, California. Participants discussed (1) their knowledge about and attitudes toward HPV, meningococcal disease, and related vaccines; and (2) factors that would encourage or discourage vaccine uptake. Data were systematically analyzed to identify salient barriers and facilitators to vaccination.

RESULTS

Participants (N = 25) had a median age of 29. Most were Hispanic (68%), self-identified as gay (84%), and had college degrees (64%). Key barriers to vaccination included: (1) limited awareness and knowledge about HPV and meningococcal disease, (2) reliance on mainstream healthcare providers for vaccine information, (3) stigma and reluctance to disclose sexual orientation, (4) uncertainty about health insurance coverage and vaccine costs, and (5) distance and time required to access vaccines. Key facilitators to vaccination were: (1) vaccine confidence, (2) perceived severity of HPV and meningococcal disease, (3) bundling vaccination into routine healthcare, and (4) pharmacies as vaccination sites.

CONCLUSIONS

Findings highlight opportunities for HPV and meningococcal vaccine promotion, including targeted education and awareness campaigns for MSM, LGBT inclusivity training for healthcare providers, and structural interventions to improve vaccine accessibility.

Promoting HPV Vaccination in People with HIV: Factors to Consider

People with HIV (PWH) and their sexual partners have increased risk of human papillomavirus (HPV) infection. Despite recommended HPV vaccination for PWH aged 18-26 years, vaccination rates among PWH remain low. This qualitative study used the Information-Motivation-Behavioral Skills (IMBS) model to identify factors influencing the decisions of PWH around promoting HPV vaccination to their sexual partners. Fourteen PWH with diverse sociodemographic characteristics participated in four focus-group discussions. Data were analyzed using thematic content analysis; codes and themes included IMBS constructs. For the information construct, the need for improved HPV education emerged as the driving factor for HPV vaccine uptake and discussing HPV vaccines with partners. Focal reasons for being unvaccinated included low knowledge of HPV risk, asymptomatic cancer-causing HPV, HPV vaccines, and vaccine eligibility. Salient factors in the motivation construct included the preventive benefits of HPV vaccination to both self and sexual partners. Salient factors in the behavioral skills construct included: accessing vaccine, low self-confidence and skills for promoting vaccination, relationships with sexual partners, partners' vaccine hesitancy, and stigma. Race/ethnicity impacted HPV vaccination promotion; important determinants included perceptions of HPV-related diseases as "White people's diseases" among Black people, and discrimination against those with HPV-related diseases among the Hispanic population.

Barriers and facilitators of adherence to treatment among women with vulvovaginal candidiasis: a qualitative study

BACKGROUND

Non-adherence of patients with vulvovaginal candidiasis (VVC) to treatment recommendations leads to treatment failure and recurrence of infection. Therefore, this qualitative study was conducted to identify barriers and facilitators of observance of treatment among women afflicted with vulvovaginal candidiasis.

METHODS

This qualitative study was conducted through 26 in-depth unstructured interviews with 24 patients and 2 gynecologists using purposeful sampling with maximum variation in Ahvaz, southwest Iran. Interviews were conducted in person at health centers and the gynecologist's offices. MAXQDA 10 software and conventional content analysis were used for data analysis.

RESULTS

The findings showed barriers and facilitator factors of adherence to treatment in women with VVC. Some of these factors lead to an increase in adherence to treatment, and others play the role of hindering factors. These factors were classified into two main categories: patients' beliefs and patients' fears and concerns.

CONCLUSION

The results of this study showed that many of the behaviors of patients from the acceptance of the diagnosis process to treatment are rooted in the patient's beliefs and fears. Therefore, it seems necessary to design and carry out interventions based on the findings of this study, which can be used in the development of appropriate solutions, treatment guidelines, and adopting a policy for treatment adherence.

AIB1 is a novel target of the high-risk HPV E6 protein and a biomarker of cervical cancer progression

The high-risk human papillomaviruses (HPV-16, -18) are critical etiologic agents in human malignancy, most importantly in cervical cancer. These oncogenic viruses encode the E6 and E7 proteins that are uniformly retained and expressed in cervical cancers and required for maintenance of the tumorigenic phenotype. The E6 and E7 proteins were first identified as targeting the p53 and pRB tumor suppressor pathways, respectively, in host cells, thereby leading to disruption of cell cycle controls. In addition to p53 degradation, a number of other functions and critical targets for E6 have been described, including telomerase, Myc, PDZ-containing proteins, Akt, Wnt, mTORC1, as well as others. In this study, we identified Amplified in Breast Cancer 1 (AIB1) as a new E6 target. We first found that E6 and hTERT altered similar profiling of gene expression in human foreskin keratinocytes (HFK), independent of telomerase activity. Importantly, AIB1 was a common transcriptional target of both E6 and hTERT. We then verified that high-risk E6 but not low-risk E6 expression led to increases in AIB1 transcript levels by real-time RT-PCR, suggesting that AIB1 upregulation may play an important role in cancer development. Western blots demonstrated that AIB1 expression increased in HPV-16 E6 and E7 expressing (E6E7) immortalized foreskin and cervical keratinocytes, and in three of four common cervical cancer cell lines as well. Then, we evaluated the expression of AIB1 in human cervical lesions and invasive carcinoma using immunohistochemical staining. Strikingly, AIB1 showed positivity in the nucleus of cells in the immediate suprabasal epithelium, while nuclei of the basal epithelium were negative, as evident in the Cervical Intraepithelial Neoplasia 1 (CIN1) samples. As the pathological grading of cervical lesions increased from CIN1, CIN2, CIN3 carcinoma in situ and invasive carcinoma, AIB1 staining increased progressively, suggesting that AIB1 may serve as a novel histological biomarker for cervical cancer development. For cases of invasive cervical carcinoma, AIB1 staining was specific to cancerous lesions. Increased expression of AIB1 was also observed in transgenic mouse cervical neoplasia and cancer models induced by E6E7 and estrogen. Knockdown of AIB1 expression in E6E7 immortalized human cervical cells significantly abolished cell proliferation. Taken together, these data support AIB1 as a novel target of HPV E6 and a biomarker of cervical cancer progression.

PrEP patient attitudes, beliefs and perceived barriers surrounding HPV vaccination: a qualitative study of semistructured interviews with PrEP patients in primary care clinics in Kansas and Missouri

OBJECTIVES

Men who have sex with men who use pre-exposure prophylaxis (PrEP) have not traditionally been targets for human papillomavirus (HPV) vaccine programmes, despite their high risk for HPV-related cancers and HPV vaccine being approved by the U.S. Food and Drug Administration (FDA) for people up to age 45. The objective of this study was to assess attitudes and barriers towards HPV vaccine for adult PrEP users in the primary care context.

METHODS

Semistructured phone interviews of 16 primary care patients taking PrEP in the Kansas City metropolitan area were conducted, with interviews assessing HPV vaccination status, and attitudes, beliefs and perceived barriers surrounding HPV vaccine. Interview notes were open-coded by student authors, and themes were generated through code review and consensus. Data were then analysed using thematic analysis.

RESULTS

The results showed that most patients believed that preventative health was important and felt the HPV vaccine was important. Most patients were open to vaccination if recommended by their primary care physician and covered by insurance. Most participants believed HPV infection to be far worse in women, and there were gaps in knowledge surrounding HPV and its effects in men.

CONCLUSIONS

While more research is needed to better understand facilitators of a linkage between PrEP and HPV vaccine in clinical settings for groups at high risk for HPV-related cancers, getting primary care providers involved in educating high-risk patients about the importance of HPV vaccination and actively recommending the vaccine to those patients has the potential to prevent HPV-related cancers.

Human Papillomavirus Prevalence and Vaccination Rates Among Users of Pre-Exposure Prophylaxis for Human Immunodeficiency Virus Prevention

INTRODUCTION

Our study provides data on the prevalence of human papillomavirus (HPV) related disease and vaccination rates among users of pre-exposure prophylaxis (PrEP) in a primary care clinic. Results highlight an opportunity to partner HIV and HPV prevention efforts.

METHODS

This is a retrospective chart review of PrEP patients in an urban Midwestern Family Medicine clinic. We conducted univariate analyses for HPV vaccination status and the prevalence of any HPV-related disease. We then examined bivariate relationships between vaccination status and insurance coverage, provider type, and age.

RESULTS

Of all 78 PrEP patients identified, 21.8% (n = 17) were vaccinated. Of the 59 patients 45 years or younger, 28.8% (n = 17) were vaccinated. There was no association between insurance or provider type and vaccination status. Patients 26 years or younger were 3 times more likely to be vaccinated than those ages 27 to 45 (56.3% vs 18.6%, P = .0011). Three unvaccinated patients had HPV-related disease.

CONCLUSIONS

Despite ongoing risk of HPV infection and frequent interaction with the medical system, this study found most PrEP users continue to be unvaccinated. This is a significant missed opportunity for HPV prevention. With the FDA approval of the HPV vaccine for individuals age 9 to 45, PrEP patients in this age range would benefit from clinicians partnering HPV vaccination with PrEP prescribing.

COVID-19 Vaccination in People Living with HIV (PLWH) in China: A Cross Sectional Study of Vaccine Hesitancy, Safety, and Immunogenicity

The administration of COVID-19 vaccines is the primary strategy used to prevent further infections by COVID-19, especially in people living with HIV (PLWH), who are at increased risk for severe symptoms and mortality. However, the vaccine hesitancy, safety, and immunogenicity of COVID-19 vaccines among PLWH have not been fully characterized. We estimated vaccine hesitancy and status of COVID-19 vaccination in Chinese PLWH, explored the safety and impact on antiviral therapy (ART) efficacy and compared the immunogenicity of an inactivated vaccine between PLWH and healthy controls (HC). In total, 27.5% (104/378) of PLWH hesitated to take the vaccine. The barriers included concerns about safety and efficacy, and physician counselling might help patients overcome this vaccine hesitancy. A COVID-19 vaccination did not cause severe side effects and had no negative impact on CD4+ T cell counts and HIV RNA viral load. Comparable spike receptor binding domain IgG titer were elicited in PLWH and HC after a second dose of the CoronaVac vaccine, but antibody responses were lower in poor immunological responders (CD4+ T cell counts < 350 cells/µL) compared with immunological responders (CD4+ T cell counts ≥ 350 cells/µL). These data showed that PLWH have comparable safety and immune response following inactivated COVID-19 vaccination compared with HC, but the poor immunological response in PLWH is associated with impaired humoral response.

Human papillomavirus (HPV) vaccination across a cascade of knowledge, willingness, and uptake among gay, bisexual, and other men who have sex with men in Canada's three largest cities

BACKGROUND

Some Canadian jurisdictions offer publicly funded HPV vaccine to gay, bisexual, and other men who have sex with men (GBM) aged ≤26 years. We characterized factors associated with being in different stages of HPV vaccination.

METHODS

Engage is a sexual health study of GBM in the three largest Canadian cities recruited via respondent driven sampling (RDS). We categorized participants as: (1) unaware of HPV vaccine, (2) undecided/unwilling to get vaccinated, (3) willing to get vaccinated, (4) vaccinated with one or more doses. Our RDS-II weighted analyses used multinomial logistic regression to identify factors associated with being in earlier stages of the cascade compared to Stage 4.

RESULTS

Across the cities, 26-40%, 7-14%, 33-39%, and 13-28% were in Stages 1 to 4, respectively. Compared to Stage 4, being in earlier stages of the cascade was associated with bisexual-identification (Stage 1: adjusted odds ratio[aOR] = 2.84, 95% confidence interval[CI] = 1.06-7.62; Stage 2: aOR = 3.09, 95%CI = 1.19-8.05), having immigrated to Canada (Stage 1: aOR = 1.79, 95%CI 1.07-2.99), preference to keep same-sex romantic relationships private (Stage 1: aOR = 1.25, 95% CI = 1.05-1.48; Stage 2: aOR = 1.24, 95%CI = 1.05-1.46), not receiving sexual health information (Stage 1: aOR = 0.31, 95% CI = 0.13-0.71; Stage 2: aOR = 0.27, 95%CI = 0.12-0.64), not accessing a health-care provider (Stage 2: aOR = 0.36, 95%CI = 0.15-0.83), and no past hepatitis A/B vaccination (Stage 1: aOR = 0.16, 95% CI = 0.09-0.30; Stage 2: aOR = 0.18, 95%CI = 0.09-0.35; Stage 3: aOR = 0.38, 95%CI = 0.21-0.61).

DISCUSSION

Interventions are needed to reduce social and financial barriers, increase sexual health knowledge, and improve GBM-competent health-care access to increase vaccine uptake among GBM.

Knowledge of prevention and treatment of human papillomavirus (HPV) infections among young men

Background: Today, human papillomavirus (HPV) infection has become the most common sexually transmitted disease worldwide. Major consequences of contracting the virus include both mild skin lesions and a range of cancers, the most frequent of which are cervical cancer, penile cancer, oral cavity cancer, throat cancer, and anal cancer, undoubtedly demonstrating its high oncogenic potential. Aim of the study: The objective of this study is to determine the level of knowledge among men aged 18–26 years with regard to HPV prevention and treatment. Materials and methods: An online survey was conducted using a questionnaire developed by the authors. The questionnaire was comprised of 16 closed-ended questions and 5 questions pertaining to demographics. Chi-squared tests or Spearman’s rank correlation coefficients were used for the statistical analysis. Results: Only 27.5% of the respondents correctly answered a question regarding the number of types of the virus, and 33% correctly determined the percentage of the cases where an active infection turns into a chronic state. However, a high level of awareness of the routes of infection was demonstrated, with more than half of the respondents (63%) answering this question correctly. Additionally, more than two-thirds (67.9%) of the men indicated correctly that one of the factors facilitating infection is a young age at the time of the first contact with the virus. Nearly all respondents (90%) indicated that using condoms is an effective form of prevention. Conclusions: The results expressly indicate an insufficient level of knowledge regarding HPV among young men. Due to the high level of sexual activity in this age group, increased education with regard to the prevention of sexually transmitted diseases is needed.

Administering the HPV Vaccine to People Living with HIV: Providers' Perspectives

HIV-positive patients suffer disproportionate burden of anal cancer, a disease which is primarily caused by persistent infection with human papillomavirus (HPV) and is potentially preventable with the completion of the HPV vaccine series. Past research qualitatively explored HIV-positive patients' perspectives about the HPV vaccine. However, little is known about their healthcare practitioners' vaccine recommendation behaviors, the strongest influence on vaccine uptake. This study reports on in-depth interviews conducted with 25 healthcare practitioners who provide care for HIV-positive patients. Qualitative themes that emerged from the study included clinicians' HPV vaccination behaviors, HIV patient's willingness to get the HPV vaccine, the role of HIV-positive patients' immune functioning in terms of timing of HPV vaccine administration, and vaccinating HIV-positive patients over age 26. The majority of providers offered the vaccine at their healthcare facility. Participants varied in their opinions related to the importance of patients' CD4 count in terms of timing of HPV vaccine administration; some believed that patients' immune functioning should first be stabilized to receive the most benefit from the vaccine series. They also differed in the perceived benefit of offering the vaccine to patients over age 26. In light of the U.S. Food and Drug Administration's recent approval to extend HPV vaccination to adults up to age 45 years, more HIV-positive adults may benefit by receiving this vaccine series. Future efforts should ensure that providers regularly promote the HPV vaccine to their adult HIV-positive patients. Vaccinating HIV-positive patients may help reduce the burden of HPV-related cancers, particularly anal cancer.

Human papillomavirus (HPV) vaccine uptake among a community-recruited sample of gay, bisexual, and other men who have sex with men in the three largest cities in Canada from 2017 to 2019

INTRODUCTION

In 2015/2016, Canada's largest provinces implemented publicly-funded human papillomavirus (HPV) vaccination programs for gay, bisexual, and other men who have sex with men (GBM) ≤ 26 years old. We sought to describe HPV vaccine uptake among GBM and determine barriers and facilitators to vaccine initiation with a focus on healthcare access and utilization.

METHODS

Engage is a cohort study among GBM aged 16 + years in three Canadian cities recruited from 2017 to 2019 via respondent driven sampling (RDS). Men completed a comprehensive questionnaire at baseline. By publicly-funded vaccine eligibility (≤26 years old = eligible for vaccination, ≥27 years old = ineligible), we described HPV vaccine uptake (initiation = 1 + dose, completion = 3 doses) and explored factors associated with vaccine initiation using Poisson regression. All analyses were weighted with the RDS-II Volz-Heckathorn estimator.

RESULTS

Across the three cities, 26-35% and 14-21% of men ≤ 26 years and 7-26% and 2-9% of men ≥ 27 years initiated and completed HPV vaccination, respectively. Vaccine initiation was significantly associated with STI/HIV testing or visiting a HIV care specialist in the past six months (≤26: prevalence ratio[PR] = 2.15, 95% confidence interval[CI] 1.06-4.36; ≥27: PR = 2.73, 95%CI 1.14-6.51) and past hepatitis A or B vaccination (≤26: PR = 2.88, 95%CI 1.64-5.05; ≥27: PR = 2.03, 95%CI 1.07-3.86). Among men ≥ 27 years old, vaccine initiation was also positively associated with accessing PrEP, living in Vancouver or Toronto, but negatively associated with identifying as Latin American and increasing age. Vaccine initiation was twice as likely among men ≥ 27 years with private insurance versus no insurance.

CONCLUSIONS

Sixty-five to 74% of men eligible for publicly-funded vaccine across the three cities remained unvaccinated against HPV by 2019. High vaccine cost may partly explain even lower uptake among men ≥ 27 years old. Men seeking sexual health care were more likely to initiate vaccination; bundling vaccination with these services may help improve HPV vaccine uptake.

Low human papillomavirus (HPV) vaccine uptake among men living with human immunodeficiency virus (HIV): Cross-sectional findings from a clinical cohort

Men living with human immunodeficiency virus (HIV) are internationally recognized as a priority population for human papillomavirus (HPV) vaccination. Our objective was to explore HPV vaccine uptake among men living with HIV in Ontario, Canada, and investigate differences between vaccinated and unvaccinated men. We used data from a cross-sectional questionnaire administered between 2016 and 2017 among men living with HIV and participating in the Ontario HIV Treatment Network Cohort Study. We calculated the proportion vaccinated against HPV, described vaccination experiences, and HPV vaccine knowledge, and calculated differences in characteristics between vaccinated and unvaccinated men. Among 1651 men (mean age = 51 years, 72% identified as gay), 7% were vaccinated (95% confidence interval[CI] 5.5-7.9%); 85% received their first dose at a primary care or HIV clinic. Among unvaccinated men, 40% were unaware of the HPV vaccine, 65% reported low perceived risk for HPV, and 8% discussed HPV vaccination with a physician. Compared to unvaccinated men, vaccinated men were younger, most identified as gay, had a higher education/income, reported a higher number of recent sex partners, and had a history of bacterial sexually transmitted infections (STIs), HPV, anogenital warts, and/or anal cancer. Our findings reveal that few men living with HIV were vaccinated against HPV. This may be influenced by low HPV awareness, prohibitive cost, and lack of physician recommendation. Several men reporting lower socio-economic status, older men, and heterosexual, bisexual, and other men who have sex with men were missed for vaccination. Primary care and HIV clinics may be ideal locations to increase uptake.

Racial Disparities in Anal Cancer Screening Among Men Living With HIV: Findings From a Clinical Cohort Study

BACKGROUND

Our objective was to quantify the extent of anal cancer screening among men receiving HIV specialty care in Ontario, Canada, and evaluate factors associated with screening.

SETTING

Cross-sectional questionnaire within a multisite clinical HIV cohort.

METHODS

A questionnaire assessing knowledge and experience with human papillomavirus-associated diseases and their prevention was administered in 2016-2017 to 1677 men in the Ontario HIV Treatment Network Cohort Study. We used logistic regression to identify factors associated with having discussed screening with a health care provider and self-reported receipt of screening [digital anal rectal examinations (DARE); anal cytology or anoscopy]. Results reported as adjusted odds ratios (aORs) with 95% confidence intervals (CIs).

RESULTS

Forty percent of men reported ever having had anal cytology/anoscopy, and 70% had ever had DARE. After accounting for differences in age, sexual orientation, years since HIV diagnosis, previous diagnosis with AIDS, knowing someone with human papillomavirus-associated cancer, comfort discussing anal health, education, and income, the proportion screened differed by self-identified race. Compared with white men, Asian men were less likely to have discussed screening with a health care provider (aOR = 0.48; 95% CI: 0.29 to 0.80) or to have been screened by DARE (aOR = 0.27; 95% CI: 0.17 to 0.44) or anal cytology/anoscopy (aOR = 0.51; 95% CI: 0.31 to 0.83), and African, Caribbean, or black men (aOR = 0.47; 95% CI: 0.31 to 0.70) were less likely to have had DARE. Results were consistent when restricting the analyses to gay, bisexual, and other men who have sex with men.

CONCLUSION

Our findings highlight the potential for disparities in anal cancer screening that need to be considered when developing guidelines and screening programs to reduce the burden of anal cancer among men living with HIV and ensure health equity.

"That's Only for Women": The Importance of Educating HIV-Positive Sexual Minority Men on HPV and High Resolution Anoscopy (HRA)

Gay, bisexual, and other men who have sex with men (MSM) experience disproportionately high burdens of Human Papilloma Virus (HPV)-associated anal cancers. Recent focus has shifted to anorectal cancer prevention through high-resolution anoscopy (HRA); however, little is known about sexual minority men's perceptions, attitudes, or beliefs regarding HRA. We conducted 4 qualitative Focus Group Discussions (FGDs) (n = 15) with sexual minority men, focusing on their beliefs, attitudes, and perceptions of undergoing HRA. Participants discussed their experiences of HPV/HRA as influenced by both their gender and sexuality, including unawareness of HPV disease as a male health issue, challenges relating to female-oriented HPV/HRA language, conception of HPV/HRA as related to prostate health, and connecting their sexual behavior identification as "bottoms" to their need for HRA. As efforts to improve HRA knowledge, access, and uptake among sexual and gender minority communities increase, special attention should be paid to language and messaging choices around HRA.

Low human papillomavirus (HPV) knowledge related to low risk perception among men living with HIV: Implications for HPV-associated disease prevention

Human papillomavirus (HPV)-associated anal cancer is orders of magnitude higher among men living with HIV than the general male population. Our objective was to examine factors associated with HPV awareness and self-perceived risk for HPV-associated anal cancer among men living with HIV, which may influence uptake of cancer prevention strategies. A cross-sectional questionnaire on HPV was administered from 2016 to 2017 to 1677 men in a multisite, HIV clinical cohort in Ontario, Canada. We used logistic regression and proportional odds models to identify factors associated with being familiar with HPV and increasing self-perceived risk for anal cancer, respectively. We used correspondence analysis to examine associations of specific HPV-related knowledge with self-perceived risk. Only 52% were familiar with HPV, and 72% felt they had no or low risk for anal cancer. Familiarity with HPV was more common among men who have sex with men than heterosexual men (58% vs. 21%). Older men were less likely to be familiar with HPV (adjusted odds ratio [aOR] per 10 years = 0.77; 95% confidence interval [CI]: 0.69, 0.85). Familiarity with HPV was associated with increasing self-perceived risk (aOR = 2.39; 95% CI: 1.87, 3.04). After accounting for differences in HPV awareness and sexual orientation, racialized men had lower self-perceived risk (aOR = 0.68; 95% CI: 0.52, 0.88). In the correspondence analysis, risk-focused HPV-related knowledge (e.g., knowing smoking increases risk) was associated with highest risk perception. Efforts are needed to improve HPV-related health literacy in this population. Our findings suggest specific HPV-related knowledge may differentially influence self-perceived risk for anal cancer.

Individual, interpersonal, and situational factors influencing HIV and other STI risk perception among gay, bisexual, and other men who have sex with men: a qualitative study

Gay, bisexual, and other men who have sex with men (GBMSM) are disproportionately affected by HIV and other sexually transmitted infections (STI). While levels of self-perceived risk of HIV or other STI acquisition has been well-established as a factor that is positively associated with HIV or other STI testing, less effort has been made to identify the processes through which GBMSM assess their perceived risk of HIV or other STI acquisition. We conducted a qualitative study exploring the factors influencing self-perceived risk of HIV or other STI among GBMSM. Semi-structured interviews were conducted with 35 self-identified GBMSM in Singapore from October 2017 to June 2018, and the data were analyzed through inductive thematic analysis. Participants reported drawing on individual factors including their own sexual health knowledge and past experiences of risk, interpersonal factors including their sexual partners' attributes or characteristics and perceived trust and familiarity with their sexual partners, and situational factors including the venue and familiarity with such venues where sexual activity took place, in determining their self-perceived risk of HIV or other STI acquisition. The results of this study have implications for HIV and other STI risk education.

Diagnosing uncertainty: The challenges of implementing medical screening programs for minority sub-populations in Canada

The social science literature on medical screening has documented a notable disjuncture between the promises of population-based screening programs and the complex realities of their rollout in everyday practice. We contribute to this scholarship by examining how healthcare providers confront numerous uncertainties associated with the implementation of anal cancer screening programs in Canada given the absence of standardized national evidence-based guidelines. The data was derived from in-depth interviews conducted with 13 physicians and 2 clinical researchers about anal cancer screening for gay, bisexual and other men who have sex with men living with HIV, the minority sub-population at the highest risk for HPV-associated anal cancer. Despite having unknown utility and low specificity, an initial anal Pap test was used to triage patients into anal dysplasia clinics for high-resolution anoscopy. This process led to technological scepticism toward the Pap's accuracy, diagnostic ambiguity related to the interpretation of the cytology results and increased patient anxiety regarding abnormal results. Physicians navigated a tension between wanting to avoid exposing their patients to additional uncertainties caused by screening and pre-cancer treatment and wanting to ensure that their patients did not develop anal cancer under their care. A high number of abnormal anal Pap results paradoxically reintroduced some of the capacity issues that the Pap was meant to resolve, as the existing dysplasia clinics were incapable of seeing all patients with abnormal results. We define this sequence as the epistemic-capacity paradox, a dynamic whereby seeking evidence to improve healthcare capacity simultaneously produces evidence that introduces capacity challenges and generates additional uncertainty. The epistemic-capacity paradox demonstrates the limitations of evidence-based medicine frameworks at determining best practices in the context of rarer health conditions affecting minority sub-populations, where smaller population numbers and limited institutional support pose systemic challenges to the acquisition of sufficient evidence.

Economic barriers, evidentiary gaps, and ethical conundrums: a qualitative study of physicians' challenges recommending HPV vaccination to older gay, bisexual, and other men who have sex with men

BACKGROUND

The human papillomavirus (HPV) is the most common sexually transmitted infection (STI) worldwide. Gay, bisexual, and other men who have sex with men (GBM), and GBM living with HIV in particular, are disproportionately impacted by HPV-associated cancers. The HPV vaccine, given early enough in life, may markedly reduce the likelihood of such cancers. In Canada, most provincial insurance programs only cover HPV vaccination for GBM up to the age of 26. Our objective was to understand physicians' everyday experiences and challenges in recommending HPV vaccination to older GBM patients.

METHODS

As part of the HPV Screening and Vaccine Evaluation (HPV-SAVE) Study, we conducted semi-structured interviews with 25 HIV-positive GBM patients who had received anal cancer screening and 15 service providers, including 13 physicians, who had arranged for anal cancer screening in the Canadian provinces of Ontario and British Columbia. In this analysis, we draw upon the 13 physician interviews, which were coded following Grounded Theory.

RESULTS

Physicians strongly supported the HPV vaccine for all GBM and considered it to be important for the management of HIV-related care. However, the overall support for HPV vaccination among physicians did not translate into consistent recommendation practices. There were two overarching factors that limited the strength/frequency of physicians' vaccine recommendation practices. First, cost/insurance coverage for some older patients impacted if and how the HPV vaccine was discussed. Second, physicians had diverse perspectives on both the prevention and therapeutic benefits of vaccinating older GBM and the reality that national guidelines are incongruent with publicly funded vaccine programs for vaccinating patients over 26 years old. These two interrelated factors have co-produced an apparent economic-evidentiary conundrum for many physicians regarding how and for whom to offer HPV vaccination.

CONCLUSION

Economic barriers coupled with evidentiary and guideline gaps have created clinical practice challenges for physicians and has resulted in different messages being communicated to some older GBM patients about how important HPV vaccination is for their health.

A tale of two epidemics: gay men's mental health and the biomedicalisation of HIV prevention and care in Toronto

There is mounting urgency regarding the mental health of gay, bisexual and other men who have sex with men (GBM). We examined how GBM are understanding the relationship between HIV and their mental health given the increasing biomedicalisation of HIV prevention and care. Our Grounded Theory analysis derived from qualitative interviews with 24 GBM living in Toronto, Canada, including both HIV-negative and HIV-positive men. Participants understood biomedical advances, such as undetectable viral load and pre-exposure prophylaxis (PrEP), as providing some relief from HIV-related distress. However, they offered ambivalent perspectives on the biomedicalisation of HIV. Some considered non-HIV-specific stressors (e.g. unemployment, racial discrimination) more significant than HIV-related concerns. These men expressed HIV-related distress as being under control due to biomedical advances or as always negligible when compared to non-HIV-specific stressors. Others emphasised the ongoing mental health implications of HIV (e.g. enduring risk and stigma). We describe a tension between optimistic responses to biomedicine's ability to ease the psychosocial burdens associated with HIV and the inability for biomedicine to address the social and economic determinants driving the dual epidemics of HIV and mental distress amongst GBM. We argue for more socio-material analysis over further sexual behavioural analysis of GBM mental health disparities.