ABSTRACT
When considering what the scientific evidence is for the potential added value to offer HPV vaccines to sex workers, not only its potential role for female sex workers should be examined, but its role for all those who conduct sex work. Our initial paper looked at the evidence in terms of HPV vaccine immunogenicity, efficacy, effect on transmission, induction of mucosal immunity, and not at implementation. Brown and Cabral considered our omission to address the aspects of implementation an ‘academic mistake’. We disagree; implementation aspects are complex and require analyses of multiple barriers, and how to address these. It only makes sense to discuss these if there is scientific evidence for its implementation; otherwise offering the vaccine is not useful.
Dear Editor,
The comments raised by Brown and CabralCitation1 are valuable ones, and we would like to address these here-under. In our contribution, we focused on the scientific evidence for the potential added value to offer HPV vaccines to female sex workers (see title),Citation2 based on the existing literature, which is mostly referring to vaccination of women. Increasingly, data become available on male HPV vaccination, and we fully agree with Brown and Cabral that it is important to collate the evidence on HPV vaccination in other than female sex workers only, so extending to all those who conduct sex work.
Our paper looked at the evidence in terms of HPV vaccine immunogenicity, efficacy, effect on transmission, induction of mucosal immunity, and not at implementation, for the simple reason that if there was no scientific evidence at all, we should not offer the vaccine. Brown and Cabral considered our omission to address the aspects of implementation an ‘academic mistake’, but this is missing the point: we went for a step-by-step approach. The evidence related to the potential added value of the HPV vaccination was addressed in our paper, and the implementation aspects can be discussed in a separate paper; the authors can appreciate our earlier work,Citation3–Citation7 where we addressed many issues on how to include sex workers, and in general the target group, in the decision-making processes on implementation of health interventions in general and immunization in particular. Several of our co-authors have been working for more than 15 y with sex workers on earlier hepatitis B vaccination projects and are well aware of including their visions directly or through street workers and experience experts (www.violett.be; www.ghapro.be).
So, in our paper, we did not discuss the aspects of the implementation of an HPV program, nor the consequences of a mandatory or voluntary HPV immunization program in sex workers, as this would clearly require a separate paper. We agree with Brown and Cabral that offering a vaccine in a systematic program requires analyses of multiple barriers, and how to address these, along with interviews and qualitative research with sex workers to understand the position of and input from sex workers, as we did in our earlier programmatic work. But we do not agree with the observation that not discussing those issues in our paper is a ‘critical mistake’, for the reasons mentioned above.
Disclosure of potential conflicts of interest
The institution of MFSvdL received study funding from Sanofi Pasteur MSD and Janssen Infectious Diseases and Vaccines; he was a coinvestigator in a Merck-funded investigator-initiated study; he was an investigator on a Sanofi Pasteur MSD-sponsored trial; he served on a vaccine advisory board of GSK; his institution received in-kind contribution for an HPV study from Stichting Pathologie Onderzoek en Ontwikkeling (SPOO).
The institute of AV and PVD received unrestricted education grants from Sanofi Pasteur MSD, Merck, and GSK. AV and PVD participated in advisory board meetings of Merck.
The other authors have no conflicts of interest.
References
- Brown B, Cabral A. Female sex workers and HPV vaccine (Letter to the Editor). Hum Vaccin Immunother. 2019;1–2. doi:10.1080/21645515.2019.1633880.
- Schim van der Loeff MF, Vorsters A, Marra E, Van Damme P, Hogewoning A. Should female sex workers be offered HPV vaccination? Hum Vaccin Immunother. 2019 May 7:1–5. [Epub ahead of print]. doi:10.1080/21645515.2019.1602432.
- Van Damme P, Leuridan E, Wouters K, Mak R, Prévost C. Can health programmes lead to mistreatment of sex workers? Lancet. 2003;26:328–29. doi:10.1016/S0140-6736(03)13979-7.
- Van Ardenne N, Roelofs I, Leuridan E, Wouters K, Van Damme P. Audit on offering hepatitis B vaccine and accepting it in sex workers. Intern J STD AIDS. 2004;15(7):493–494. IF 1, 086. doi:10.1258/0956462041211298.
- Van Herck K, Leuridan E and Van Damme P. Schedules for hepatitis B vaccination of risk groups: balancing immunogenicity and compliance. Sex Transm Inf. 2007;83:426–32. doi:10.1136/sti.2006.022111.
- Wouters K, Leuridan E, Van Herck K, Van Ardenne N, Roelofs I, Mak R, Prévost C, Guérin P, Denis B, Van Damme P. Compliance and immunogenicity of two hepatitis B vaccination schedules in sex workers in Belgium. Vaccine. 2007;25:1893–900. doi:10.1016/j.vaccine.2006.09.073.
- Leuridan E, Vercauteren A, Cornelissen T, Bilcke A, van Damme P. Sex workers and HIV: missed opportunities. Lancet. 2012;380(9849):1230–1230. doi:10.1016/S0140-6736(12)61716-4.