A new study examined the rates of human papillomavirus (HPV) infection in a sample of young cisgender men who have sex with men and transgender women. They found that despite having come of age when a vaccine was available, less than a quarter of participants were fully vaccinated and more than half were infected with oral or anal HPV. The study also found high rates of coinfection with HIV, which makes HPV-related health issues such as anal cancer more likely. The results suggest a missed opportunity to improve health outcomes for sexual minority men and transgender women.
HPV in Young Sexual Minority Men and Transgender Women
While there has been a lot of research on HPV vaccination rates among young cisgender women, far fewer studies have focused on young sexual minority men and transgender women, despite the fact that both incidence and prevalence of HPV are higher among these groups. For this study, researchers at Rutgers School of Public Health in New Jersey wanted to document both vaccination rates and infection rates among these populations and determine whether either were associated with demographic variables.
They recruited a sample of 486 young men who have sex with men and transgender women in the greater New York metropolitan area. The average age of participants was 23, and 7% of participants identified as transgender women. One-third of the study participants identified as Hispanic or Latinx, and 26% identified as black. In addition, 74% of participants had incomes that put them near or below the poverty level.
Participants were asked whether they had ever received the HPV vaccine, and if so, how many shots they had been given. They also took self-administered tests for HPV infection -- using mouthwash samples for oral HPV and swabs for anal HPV.
Only 18% of participants said they had received all three doses of the HPV vaccine as recommended at the time. Another 24% had received one or two doses of the vaccine, but 45% were not vaccinated at all. Vaccine uptake was not associated with race/ethnicity, age, education, or poverty level. It was also not associated with sexual orientation, gender identity, or HIV status.
More than half of the participants tested positive for any type of HPV infection, with 56% testing positive for anal HPV and 9% testing positive for oral HPV. About a third of these infections (31%) were with one of the types of HPV that are covered by the newest vaccine. There were no differences in HPV rates associated with race/ethnicity, gender identity, income, sexual orientation, or age.
The research did find that having HIV was significantly associated with also having HPV; 88% of HIV-positive participants tested positive for HPV, compared to 59% of HIV-negative participants. HPV infection has been found to increase a person's susceptibility to HIV because it weakens the skin, causes inflammation, and "recruits HIV target cells." At the same time, having HIV can increase the likelihood of HPV-related health problems because the body is less able to clear the HPV virus, making long-term health consequences such as anal cancer more likely.
A Common but Preventable Sexually Transmitted Infection
HPV is a virus that is easily spread through skin-to-skin contact, including during vaginal, oral, or anal sex. The Centers for Disease Control and Prevention (CDC) notes: "HPV is so common that nearly all sexually active men and women get the virus at some point in their lives." Most HPV infections go away on their own without any health consequences, but if an infection does not go away, certain types of the virus can cause either genital warts or cancers of the genitals, anus, head, neck, and throat.
Though it is most widely associated with cervical cancer in cisgender women, approximately 12,100 men are affected by HPV-related cancers each year. Men with weakened immune systems -- including those living with HIV -- who contract HPV are more likely to have HPV-related health issues. And men who have receptive anal sex are more likely to contract anal HPV and develop anal cancer.
Since 2006, however, vaccines have been available to prevent HPV infection with high-risk types of the virus. The first version of the vaccine protected against four types of the virus -- two that were known to cause genital warts and two that caused most cases of cervical cancer. In 2014, a newer version of the vaccine was released that protects against nine types of HPV known to cause genital warts and cancers.
When the vaccine was originally released, it was recommended for girls and young women ages 9 to 26 and given as a series of three shots. Later, that recommendation was expanded to include young men. And, just last year, the vaccine was approved for both men and women up through age 45. The vaccine was originally given as a series of three shots, but now the series is considered complete with just two shots.
The vaccine is considered highly effective; since vaccinations started in this country, we've seen a reduction in HPV infections and genital warts. Unfortunately, vaccination rates have been low, for a variety of reasons. The HPV vaccine came out at a time when skepticism of all vaccines was high and inaccurate information -- such as the disproven idea that vaccines cause autism -- was rampant. And some parents and politicians seem to worry that vaccinating young people against a sexually transmitted infection is tantamount to giving them permission to have unprotected sex, though this fear has also been disproven by many research studies.
Missed Opportunities for Prevention
Uptake of the HPV vaccine for many young men and transgender women isn't about whether their parents approve. These findings suggest that uptake of the HPV vaccine is also not driven by access, like so many other health disparities which disproportionately affect racial/ethnic minorities and low-income families. Instead, the researchers found that vaccination rates are low across the board and HPV infection is distributed "along the continuum of race and income." They explain that this "closely resembles the infection distribution at the onset of the AIDS epidemic, in which there was little differentiation by socioeconomic status and race/ethnicity to HIV-related morbidity and mortality."
What seems to be at play is an overall lack of education about HPV and the available vaccines for young men and transgender women. This study adds to previous research that has found misunderstandings about whether the vaccine is available and appropriate for young men. The authors believe that their findings call for prevention efforts specific to sexual minority men and transgender women. Moreover, the high rate of coinfection with HPV and HIV suggests that health care providers need to do more to inform young men and transgender women living with HIV about the risk of HPV and the availability of a vaccine.
Perry Halkitis, Ph.D., the study's lead author and dean of Rutgers School of Public Health, said in a statement: "We are already witnessing higher rates of HPV-related cancers in older gay and sexual minority men, which is completely avoidable and preventable in more recent generations. Additionally, we know that those living with HIV are much more likely to be impacted by HPV infection and HPV-related cancers. Given that sexual minority men are also at highest risk for testing positive for HIV, there is an urgency in ensuring HPV vaccination before these young men engage in sexual behavior."