https://orcid.org/0000-0002-0452-0252
ABSTRACT
Gay, bisexual, and other men who have sex with men (GBM), in addition to transgender women who have sex with men (TW), are at disproportionate risk for anal cancer. Anal cancer can be prevented with HPV vaccination, but uptake among adult GBM/TW is low. Targeted HPV vaccination during the clinical management of pre-exposure prophylaxis (PrEP) is an unexplored strategy relevant to these populations. The purpose of this study was (1) to determine the need for HPV vaccination among GBM and transgender women PrEP users and (2) to identify correlates of HPV vaccination among PrEP users. Secondary analysis of the 2020 Pennsylvania LGBT Health Needs Assessment was conducted to estimate prevalence ratios of HPV vaccination among PrEP users. Overall, 43.8% of the sample had initiated HPV vaccination. Vaccine initiation was significantly lower among respondents 27 to 35 (PR = 0.64; 95% CI: 0.49–0.83) and 36 to 45 (PR = 0.38; 95% CI: 0.25–0.58). Respondents who had received Hepatitis A vaccination were significantly more likely to have had initiated HPV vaccination after adjusting for age (aPR = 2.60; 95% CI: 1.75–3.84). Overall, more than half of eligible GBM and TW engaged in PrEP care have not initiated HPV vaccination and represent potential missed opportunities for anal cancer prevention.
Gay, bisexual, and other men who have sex with men (GBM), in addition to transgender women who have sex with men (TW) are at disproportionate risk for anal cancer.Citation1 The necessary and sufficient cause of anal cancer is oncogenic anal HPV infection.Citation1 However, co-existing sexually transmitted infections (STIs), including human immunodeficiency virus (HIV), syphilis, and gonorrhea may amplify the risk of anal cancer in the presence of oncogenic HPV.Citation2 The synergistic relationship between HPV, concurrent STIs, and related behavioral factors (e.g., unprotected receptive anal intercourse [URAI]) is thought to contribute to a syndemic of anal cancer risk disproportionally impacting GBM and TW.Citation2
The 9-valent HPV vaccine is proven safe and effective at preventing oncogenic anal HPV infection in GBM up through age 26 and has shown to be highly immunogenic among mid-adult men aged 27 to 45.Citation3,Citation4 The 9-valent vaccine is currently licensed for adults up through age 45. Catchup vaccination is recommended for all adults up through age 26 and shared clinical decision-making (SCDM) for adults 27 to 45.Citation5 As of 2017, just 32.8% of GBM 18–26 had received at least 1 dose of HPV vaccine.Citation6 Coverage is even lower among mid-adult GBM: 22.2% for those aged 27 to 30 and 13.5% for those aged 31 to 40.Citation6 There is limited evidence for vaccine uptake among TW.Citation7
Acceptability is high for HPV vaccination among GBM and TW.Citation7,Citation8 Low uptake of HPV vaccination is likely a result of low awareness and missed opportunities during primary care.Citation9–11 Qualitative research has identified the need for alternative strategies for HPV vaccine delivery to increase convenience and availability for GBM and TW populations.Citation12,Citation13 Promoting HPV vaccination during the clinical management of pre-exposure prophylaxis (PrEP) is an unexplored strategy.
PrEP is the prevailing strategy for the prevention of HIV among GBM and TW, which involves frequent patient contacts that can be leveraged to promote HPV vaccination. HPV vaccination is not a part of the current screening guidelines for PrEP initiation despite the prevalence of STIs and URAI among PrEP patients.Citation14–16
The purpose of this exploratory study was to determine: What percentage of GBM and transgender women engaged in PrEP care have initiated HPV vaccination? What demographic, healthcare, and anal cancer risk factors are associated with HPV vaccine initiation among PrEP users?
This was a secondary analysis of the LGBT Health Needs Assessment collected by the Pennsylvania Department of Health in collaboration with the Bradbury-Sullivan LGBT Community Center and the Research & Evaluation Group at Public Health Management Corporation.Citation17 The survey was fielded between March and May of 2020. Participants were recruited through a non-probability community-based approach. Community-based organizations throughout the state disseminated information about the study through various communication platforms including e-mail, mailed postcards, websites, mobile phone applications, and social media. Recruitment materials were in English and Spanish. A lottery for one of nine $50 gift cards was used as an incentive. Inclusion criteria were any children or adults residing in the state of Pennsylvania who self-identified as lesbian, gay, bisexual, transgender, or queer (LGBTQ). Informed consent was obtained during primary data collection.
The brief questionnaire (15 minutes to complete) was available in either English or Spanish. A single item was used to identify PrEP users for this analysis: “Are you currently taking PrEP (Pre-Exposure Prophylaxis)?” Responses were recorded as either yes or no. Additional measures used in this analysis are described below.
HPV vaccination
A single item measured HPV vaccine uptake: “Have you received the HPV vaccine (sometimes called Gardasil or Cervarix)?” Responses were recorded as either yes, no, or I don’t know. Those who responded yes to this item were coded as having initiated HPV vaccination. Recall of HPV vaccination was high in a sensitivity analysis of adult GBM.Citation18
Sexual orientation and gender identity (SOGI)
Sexual orientation was operationalized as sexual identity. Due to low cell sizes gay/lesbian, bisexual/pansexual, and all other identities were collapsed into three categories. A two-step approach was used to assess gender identity.Citation19 Sex at birth and current gender identity were used to code participants as cisgender men (i.e., male sex at birth and current man) or transgender women (male sex at birth and current woman).
Healthcare utilization
Participants who responded yes to “Do you have one person you think of as your personal doctor or health care provider?” were coded as having a medical home. Additionally, receipt of the following three health services were assessed: Past year influenza vaccination (“flu shot” or “flu vaccine sprayed in nose”), hepatitis A vaccination, and past year treatment for a “sexually transmitted disease or infection” (STI).
Anal cancer risk factors
Two anal cancer risk factors were assessed: current cigarette smoking (i.e., currently smoked cigarettes some days or every day) and any past year occurence of unprotected receptive anal sex (i.e., “receptive anal sex [bottoming] without a condom).
Sociodemographic factors
Demographic factors included age, race, ethnicity, and educational attainment. Age was categorized to include participants in the catchup vaccine range (i.e., 18–26), those who were in the catchup age at some point since the vaccine was indicated for anal cancer in 2011 (i.e., those currently 27 to 35), and those who were never in the catchup age (i.e., 36–45). The 27 to 45 age cohorts represent adults who fall under the SCDM recommendation. Participants reported their county of residence, which was used to classify them as rural or urban based on The Center for Rural Pennsylvania’s definition of population density.Citation20 Financial insecurity was defined as participants with “Just enough money to make ends meet or not enough money to make ends meet” at the end of a month.
The sample for this study included GBM or TW between 18 and 45 years of age who were currently taking PrEP for HIV prevention (N = 284). This study focused on GBM and TW because these populations are at greatest risk for anal cancer and make up the highest percentage of PrEP patients.Citation21,Citation22 Out of this subsample, 10 cases had missing data on the independent variables. Thus, the analytic sample for the complete case analyses reported here was 274. Bivariate differences were examined using Chi-square test of independence. HPV vaccine initiation was regressed on the predictor variables using bivariate logistic regression (SAS Institute, Cary, NC). Crude and age-adjusted prevalence ratios were reported as the measures of association.
Sample characteristics are reported in . Overall, 43.8% of the sample had initiated HPV vaccination. Initiation of HPV vaccination was highest among those aged 18 to 26 and decreased among the older age cohorts (). Among PrEP users, 32.2% (aged 18–26), 56.5% (aged 27–35), and 74.0% (aged 36–45) had not initiated HPV vaccination.
Figure 1. Initiation of HPV vaccination overall and by age among gay and bisexual men and transgender women who current PrEP users (N = 274).
Table 1. Sample characteristics and correlates of HPV vaccine initiation among GBM and transgender women who are currently using pre-exposure prophylaxis for HIV prevention (PrEP), N = 274.
The prevalence of HPV vaccine initiation was significantly lower among respondents 27 to 35 (PR = 0.64; 95% CI: 0.49–0.83) and 36 to 45 (PR = 0.38; 95% CI: 0.25–0.58). Respondents who had received Hepatitis A vaccination were significantly more likely to have had initiated HPV vaccination after adjusting for age (aPR = 2.60; 95% CI: 1.75–3.84). No other factors were associated with HPV vaccine initiation.
More than half of GBM and TW engaged in PrEP care had not previously initiated HPV vaccination and represent potential missed opportunities for anal cancer prevention. Nearly a third of participants in the catchup age range and 60% in the mid-adult group were not vaccinated. It is unknown how many of these PrEP users were recommended to get vaccinated or engaged in SCDM. Previous research suggests that providers are not routinely engaging GBM in discussion about HPV vaccination and GBM have limited awareness of anal cancer.Citation10,Citation23 Future research should determine to what extent PrEP providers are discussing HPV, anal cancer, and/or HPV vaccinations with their PrEP patients.
HPV vaccination was not associated with known anal cancer risk factors suggesting that targeted promotion may not be routinely occuring. Nor was HPV vaccination associated with health-care utilization apart from Hepatitis A vaccination. Screening for Hepatitis A immunity is not currently apart from routine PrEP careCitation24; however, the strong correlation between Hepatitis A and HPV vaccination suggest that some PrEP patients are advocating for themselves or some PrEP providers are ensuring that their patients have received available vaccinations against STIs. These efforts should be expanded to include HPV vaccination.
The non-probability sample within one US state and the community-based recruitment strategies make it impossible to calculate a response rate and limit the generalizability of the findings. The small sample size may also have limited power to detect differences across predictor variables with limited distributions. In addition, the measures used self-report for vaccination status and did not allow for the differentiation of HPV vaccine initiation and completion. Further details regarding PrEP use, such as length of time on PrEP and adherence, were also not available in the dataset.
Provider recommendation is a major determinant of HPV vaccination among GBM and HPV vaccine acceptability is high among GBM and TW.Citation7,Citation8 Major barriers are availability and convenience.Citation6,Citation7,Citation11 PrEP management visits are a potential venue for targeted HPV vaccine promotion. Ensuring that all PrEP patients 18 to 26 are fully vaccinated against HPV and those 27 to 45 are engaged in SCDM will help to extend the reach of anal cancer prevention. Incorporating HPV vaccination into national PrEP guidelines would help promote equitable patient-centered care.
Disclaimer
These data were supplied by Pennsylvania Department of Health, Bureau of Health Promotion and Risk Reduction, Division of Tobacco Prevention and Control, Harrisburg, Pennsylvania. The Pennsylvania Department of Health specifically disclaims responsibility for any analyses, interpretations, or conclusions.
Disclosure statement
No potential conflict of interest was reported by the author(s).
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References
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