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. 2024 Dec 22;21(1):2440956. doi: 10.1080/21645515.2024.2440956

Uptake and service preferences of human papillomavirus vaccination in men who have sex with men

Rui Zhang a,b,c, Ngai Sze Wong a,b,c,✉, Sze Long Chung a,b, Chi Keung Kwan a, Tsz Ho Kwan a,b,c, Shui Shan Lee a,b
PMCID: PMC12934136  PMID: 39710883

ABSTRACT

Human papillomavirus (HPV) vaccination could reduce HPV infection in men who have sex with men (MSM), but the published statistics on HPV vaccination uptake in MSM were scarce globally. This study estimated the uptake and profiled the service preferences of HPV vaccination of Chinese MSM in Hong Kong. Adult MSM were recruited through non-governmental organizations (NGOs) and online channels for completing an online baseline survey. Factors associated with self-reported history of HPV vaccination were identified using multivariable stepwise logistic regression model. Totally 701 Chinese MSM completed the online baseline survey, with the median age of 30 y (interquartile range [IQR] 26–35, range 18–67), and 23% of them had received HPV vaccination. More than half of vaccinated MSM (72%) rated convenient or very convenient for local HPV vaccination services. Among unvaccinated MSM, 50% considered high cost of HPV vaccine as the barrier of vaccination, 67% expressed willingness to pay below USD 128 per vaccine dose, and 65% preferred receiving vaccination in private clinics. MSM who had taken HIV pre-exposure prophylaxis (PrEP) (p < .001), had been tested for HPV (p = .018), and had (p = .005) multiple regular sex partners in the past 6 months were more likely to be vaccinated. The HPV vaccination uptake of Chinese MSM in Hong Kong remains low (23%), and high HPV vaccine cost is the main barrier. Preventive behaviors (HIV PrEP use and HPV testing) and high-risk sexual behavior (multiple regular sex partners) are potential targets for intervention to increase the uptake of HPV vaccination in MSM.

KEYWORDS: Human papillomavirus, service preferences, vaccination, men who have sex with men, Asia

Introduction

Globally, the prevalence of human papillomavirus (HPV) infection at anal, penile, oral sites in men who have sex with men (MSM) were 78.4%, 36.2%, and 17.3%, respectively.1 And the prevalence of HPV infection in MSM living with HIV was much higher than MSM without HIV.1 It was estimated that 92.6% of MSM living with HIV and 63.9% of MSM without HIV had anal HPV infection.2 There has been a rapid increase in HPV infections in young MSM.3 Compared with the general population, the prevalence of anal cancers and genital warts was significantly higher in MSM.4,5 High-risk HPV types, including HPV 16, 18, 52 and 58, are responsible for most HPV-related cancers.6 Persistent infections of HPV 16 and 18 have been identified as the primary cause of over 90% of anal cancers.7 Low-risk HPV types, such as HPV 6 and 11, mainly cause the development of genital warts.5

As HPV is primarily transmitted through sexual contacts, HPV vaccination should be received before sexual debut to maximize its effectiveness.8 Given most MSM received the vaccines after their sexual debut and may have already been exposed to certain types of HPV, there are concerns about the effectiveness of HPV vaccination for MSM.9 Nevertheless, provided that MSM are at high risk of HPV infection, vaccination can still protect them from acquiring unexposed HPV types covered by the vaccine. Over the past decade, HPV vaccination has been proven to be highly effective in preventing genital warts and cancers in MSM.10,11 Although MSM are recommended to receive HPV vaccination,12 only several developed countries have included HPV vaccination for MSM in their national vaccination schemes. For instance, the United States (US) has included HPV vaccination for MSM under the age of 26 y in its national vaccination programme, with coverage provided by its national health insurance plans since 2021.13 The United Kingdom (UK) was one of the first countries to introduce a free national HPV vaccination programme for MSM aged up to 45 y.14 Australia launched a free time-limited catch-up HPV vaccination program for MSM aged less than 26 y in 2017.15 In places without free or subsidized HPV vaccination programme for MSM, self-financed HPV vaccination is crucial. Previous studies suggested that most MSM recognized the benefits and significance of HPV vaccination and were willing to receive it.16,17 However, studies for the uptake of HPV vaccination and service preferences in MSM in Asia were limited.

According to a meta-analysis conducted in 2020,18 18 studies reported uptake of HPV vaccination in MSM, mostly from the US, the average of which was 37%, with 29% in the US (13 studies), 63% in the UK (3 studies), 93% in Mexico (1 study), and 43% in Australia (1 study). After 2020, 6 studies on the uptake of HPV vaccination among MSM were conducted in the US,19–21 and Europe,22–24 and the uptake of at least one dose of HPV vaccine ranged from 8.6% to 52%. To our knowledge, in Asia, only one cohort study in Taiwan identified the influence of price and HPV diagnosis on vaccination behaviors in MSM.25, Additionally, no previous studies identified the service preferences of HPV vaccination in MSM. Understanding individual service preferences can inform decision-makers when developing guidelines and planning public health programs.26 To address the barriers to HPV vaccination uptake, it is essential to recognize these preferences to ensure the effective implementation of HPV vaccination programs.27

It was estimated that 59.9% of MSM in China had HPV infections.28 However, HPV vaccination programme for males has not been launched in mainland China.29 In Hong Kong, a Special Administrative Region (SAR) of China, the local government has been providing free HPV vaccines to female primary school students since 2019,30 but neither for boys nor high-risk populations, such as MSM. However, the HPV vaccine is commercially available in private clinics, and the cost of the 9-valent vaccine is approximately USD 591 for a three-dose regimen.31 Against this background, this study aims to estimate the uptake and profile the service preferences of HPV vaccination in MSM in Hong Kong.

Material and methods

Study design and participants

This study forms part of a community-based longitudinal study on sexually transmitted infections (STIs) burden in MSM in Hong Kong.32 MSM aged 18 y or above and normally living in Hong Kong were recruited from two non-governmental organizations (NGOs) which provide free HIV testing and counseling services for people with high risk of HIV infection, and through online channels frequented by MSM. From September 2021 to October 2022, MSM who were ethnic Chinese, provided e-consent, and completed the self-administrated baseline survey were included in this study.

The questionnaire for this study was structured, and all items are not in free text, except for a few questions that include an ‘other’ option, which allows for free text responses. Items including socio-demographics (age, marital status, education level, monthly income, and employment status), history of HPV vaccination, history of testing and diagnosis for STIs, HIV and HPV infection, history of HIV pre-exposure prophylaxis (PrEP) use, sexual behaviors in the past 6 months (history of sex, group sex, chemsex, condom use, and number of sex partners), preference for HPV vaccination services (cost and venue preference) were captured through the online self-administrated baseline survey. Ethical approval was obtained from the Joint Chinese University of Hong Kong-New Territories East Cluster Clinical Research Ethics Committee (approval number: CREC2020.436).

Data analysis

The outcome variable of this study was self-reported history of HPV vaccination. Factors (socio-demographic, histories of STIs/HIV/HPV testing and diagnosis, history of PrEP use, and sexual behaviors in the past 6 months) associated with the outcome variable were firstly examined in bivariate analysis (chi-square and Mann – Whitney U tests). The variables that showed statistical difference (p < .05) in the bivariate analysis were further examined in the multivariable binary backward stepwise logistic regression model. Complete-case analysis was performed. All statistical analyses were performed in SPSS 28.0.

Results

Characteristics of participants

Totally 701 Chinese MSM completed the survey, the median age was 30 y (interquartile range [IQR] 26–35, range 18–67). A majority were single/never married (97%), were in employment (83%), and had attained post-secondary education or above (85%). Additionally, almost half (47%) had a monthly income of USD 1927–3854. Some 23% (n = 158) self-reported a history of HPV vaccination. About four-fifths (81%) had ever tested for HIV, and 4% (n = 20/553) self-reported HIV positive (Table 1).

Table 1.

Characteristics of MSM by self-reported history of HPV vaccination.

  Total
(N = 701)
 Vaccinated
(N = 158)
 Unvaccinated
(N = 543)
 Chi-square/Mann–Whitney U test
  n % n % n % P values
Median age (IQR, range), years old 30 (26–35,
18–67)		 30 (27–35, 20–67) 30 (26–35,
18–64)		 0.587
Married status
Married/civil union 21 3 7 33 14 67 .170
Single/never married 680 97 151 22 529 78  
In employment
No 116 17 24 21 92 79 .720
Yes 585 83 134 23 451 77  
Educational level (N = 700)
Secondary or below 103 15 10 10 93 90 <.001
Post-secondary or above 597 85 148 25 449 75  
Monthly income (USD) (N = 636)
<1927 153 14 24 16 129 84 <.001
1927–3854 297 47 59 20 238 80  
3855–6424 109 17 26 24 83 76  
>6424 77 12 31 40 46 60  
History of HPV testing
No 620 88 123 20 497 80 <.001
Yes 81 12 35 43 46 57  
History of HIV testing (N = 694)
No 132 19 13 10 119 90 <.001
Yes 562 81 145 26 417 74  
History of STIs testing
No 265 38 31 12 234 88 <.001
Yes 436 62 127 29 309 71  
History of HIV PrEP use (N = 692)
No 536 77 79 15 457 85 <.001
Yes 156 23 79 51 77 49  
History of HPV diagnosis (N = 50)
No 40 80 22 55 18 45 .532
Yes 10 20 6 60 4 40  
History of HIV diagnosis (N = 553)
No 533 96 140 26 393 74 .620
Yes 20 4 4 20 16 80  
History of STIs diagnosis (N = 700)
No 454 65 72 16 382 84 <.001
Yes 246 35 86 35 160 65  
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IQR interquartile range, STIs sexually transmitted infections, PrEP pre-exposure prophylaxis.

Sexual behaviours of participants in the past 6 months

In the past 6 months, among sexually active MSM (n = 654, 93%), 34% and 9% of them had engaged in group sex and chemsex, respectively. One-third of MSM had at least five non-regular sex partners, 33% had one regular sex partner, while another 33% had 2–4 regular sex partners, and 8% had at least one commercial sex partners. More than one-third (35%) of MSM had never used condoms when having sex with regular partners, and 22% had never used condoms when having sex with commercial sex partners (Table 2).

Table 2.

Sexual behaviors in the past 6 months of MSM by self-reported history of HPV vaccination.

  Total
(N = 701)
 Vaccinated
(N = 158)
 Unvaccinated
(N = 543)
 Chi-square test
  n % n % n % P values
History of sex
No 47 7 5 11 42 89 .046
Yes 654 93 153 23 501 77  
Non-regular sex partner (N = 646)
0 193 30 35 18 158 82 .097
1 68 11 14 21 54 79  
2–4 174 27 42 24 132 76  
5 or more 211 33 60 28 151 72  
Regular sex partner (N = 646)
0 175 27 27 15 148 85 <.001
1 213 33 44 21 169 79  
2–4 216 33 60 28 156 72  
5 or more 42 7 20 48 22 52  
Commercial sex partner (N = 646)
0 596 92 142 24 454 76 .587
1 22 3 3 14 19 86  
2–4 18 3 3 17 15 83  
5 or more 10 2 3 30 7 70  
Group sex (N = 650)
No 431 66 81 19 350 81 <.001
Yes 219 34 72 33 147 67  
Chemsex engagement(N = 654)
No 596 91 127 21 469 79 <.001
Yes 58 9 26 45 32 55  
Condom use with regular sex partners (N = 509)
Always 150 29 23 15 127 85 .007
More than half 85 17 24 28 61 72  
Less than half 97 19 33 34 64 66  
Never 177 35 45 25 132 75  
Condom use with non-regular sex partners (N = 487)
Always 233 48 49 21 184 79 .006
More than half 119 24 35 29 84 71  
Less than half 79 16 29 37 50 63  
Never 56 11 8 14 48 86  
Condom use with commercial sex partners (N = 82)
Always 43 52 6 14 37 86 .336
More than half 10 12 3 30 7 70  
Less than half 11 13 4 36 7 64  
Never 18 22 4 22 14 78  
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Regular sex partner multiple sex acts without money exchange and emotional attachment or regular sext partner with emotional attachment. Non-regular sex partners one-night stand without money exchange.

HPV vaccination uptake and service preferences

Among 158 MSM who self-reported a history of HPV vaccination, most (80%) had received the 9-valent vaccine, followed by the 4-valent vaccine (10%). Some 72% of the vaccinated MSM rated the current HPV vaccination service in Hong Kong as convenient or very convenient (Table 3).

Table 3.

Uptake and service preferences of HPV vaccination in MSM.

Items   n %
Vaccinated (N = 158)
Type of the HPV vaccine 2-valent 1 1
4-valent 16 10
9-valent 126 80
Forget 15 9
Evaluation for Healthcare services regarding HPVvaccination (N = 155) Very convenient 34 22
Convenient 78 50
Inconvenient 22 14
Very inconvenient 16 10
Don’t know where this service is provided 5 3
Unvaccinated (N = 543)
Reasons against vaccination* (N = 517) Too expensive 261 50
Self-perceived low risk of HPV infection 127 25
HPV vaccines are only indicated for females 72 14
Be afraid of having injections 52 10
Concerned about the vaccine effectiveness 37 7
No idea 37 7
Worried about the safety 28 4
Have Infected with HPV 24 5
Self-perceived low risk of complication even if get infected with HPV 17 3
Plan to vaccinate 4 1
Beyond the age 4 1
Cost (USD) for one vaccine dose that MSM were willing to pay
(N = 526)		 Won’t join even it’s free 12 2
Won’t join if it requires payment 96 18
No more than 64 262 50
64.1 ~ 128 91 17
129 ~ 193 25 5
193 ~ 257 20 4
257.1–514 20 4
Cost (USD) for one vaccine dose that MSM were willing to pay among MSM who responded the vaccine was too expensive
(N = 255)		 Won’t join even it’s free 2 1
Won’t join if it requires payment 36 14
No more than 64 132 52
64.1 ~ 128 51 20
129 ~ 193 13 5
193 ~ 257 12 5
257.1–514 9 4
Preferred venue for HPV vaccination* (top three) (N = 526) Private clinics 340 65
NGOs 242 46
FPAHK 235 45
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NGOs non-governmental organizations, FPAHK Family Planning Association of Hong Kong, * multiple selections are allowed for these multiple choices questions.

Of those who did not receive HPV vaccination and reported the reasons (n = 517), the most common reason was the high cost of the HPV vaccine (50%). This was followed by a low self-perceived risk of HPV infection (25%), and a belief that HPV vaccines were only indicated for female (14%) (Table 3). In terms of HPV vaccination service preferences among unvaccinated MSM (n = 526), 67% reported that they were willing to pay no more than USD 128 per dose of HPV vaccine, and 18% expressed that they would not get vaccinated if it required payment. Among unvaccinated MSM who responded that the vaccine was too expensive as a reason against vaccination (N = 255), 72% reported that they were willing to pay no more than USD 128 per dose of HPV vaccine, and 14% expressed that they would not get vaccinated if it required payment. In terms of venue, private clinic (65%) was the most popular choice, followed by NGOs (46%) and the Family Planning Association of Hong Kong (FPAHK), a nonprofit making organization focusing on public sexual and reproductive health-related services (45%) (Table 3).

Factors associated with the uptake of HPV vaccination

MSM with self-reported histories of HPV testing (adjusted odds ratio (aOR) = 2.06, 95% CI = 1.03–4.10) and HIV PrEP use (aOR = 3.90, 95% CI = 2.22–6.86) were more likely to receive HPV vaccination. Compared with MSM without regular sex partner in the past 6 months, MSM with at least 5 (aOR = 8.93, 95% CI = 1.81–44.03) regular sex partners were more likely to receive vaccination (Table 4).

Table 4.

Bivariate and multivariable analyses for the factors associated with the uptake of HPV vaccination.

  Bivariate analysis Multivariable binary stepwise logistic regression model#
  OR (95%CI) aOR (95%CI)
History of HPV testing
No Reference Reference
Yes 3.07 (1.90–4.98)* 2.06(1.03–4.10)*
History of HIV PrEP use
No Reference Reference
Yes 5.94 (4.00–8.81)* 3.90 (2.22–6.86)*
Regular sex partner in the past 6 months
0 Reference Reference
1 2.36 (1.20–4.64)* 1.29 (0.59–2.81)
2–4 3.49 (1.75–6.96)* 1.47 (0.61–3.53)
5 or more 4.98 (2.40–10.36)* 8.93(1.81–44.03)*
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aOR adjusted odds ratio, CI confidence interval, PrEP pre-exposure prophylaxis. *p < .05. #Totally 13 variables were included at step1: educational level, monthly income, history of HPV testing, history of HIV testing, history of STIs testing, history of HIV PrEP use, history of STIs diagnosis, sexual behaviors in the past 6 months (history of sex, the number of regular sex, group sex, condom use with regular sex partners and non-regular sex partners, chemsex). Only three factors with statistical significance were selected in the final model.

Discussion

In this 2021/2022 study, 23% of Chinese MSM in Hong Kong had ever received HPV vaccination. Before the US Food and Drug Administration approval of the 9-valent HPV vaccine in 2014, the estimated vaccination uptake was almost zero in a local study in 2010/11.33 The increase in HPV vaccination uptake among MSM in Hong Kong may be attributed to several factors, including the availability of HPV vaccines in private clinics for MSM, and increasing awareness of HPV vaccination.31 The HPV vaccination uptake among MSM in Hong Kong was still lower than places with country-level HPV vaccination programme support, such as the US (37.6%),34 England (49.1%),35 Scotland (63.7%),36 and Australia (42.6%).15

Consistent with previous studies,25,37 our study findings showed that cost was the main barrier against vaccination, and most unvaccinated MSM accepted at most USD 128 per dose (currently about USD 193 per dose in Hong Kong). Hence, price reduction or subsidized HPV vaccination programmes could be useful to increase HPV vaccination uptake of MSM in Hong Kong. Previous studies conducted in Australia and the UK have reported that piloted free HPV vaccination programs contributed to a significant increase in HPV vaccination coverage among MSM.14,15,36 Additionally, most MSM in this study preferred private clinics and NGOs for HPV vaccination, indicating a preference for venues that provide services with privacy and a more gay-friendly health service environment. The results suggested that it is important to reduce stigma for MSM in developing vaccination strategies. Strengthening the accessibility of HPV vaccination for MSM can be achieved by improving the friendliness of the environment and the quality of vaccination services in private clinics as part of future vaccination program planning.

Our study findings revealed that the self-reported history of HPV testing was related to HPV vaccination. HPV testing is the primary screening strategy for HPV infection,38 and the HPV test results may stimulate negative emotional reactions and in turn increase the motivation to get vaccination.39 Consistent with previous studies conducted in France22 and Italy,23 this study also corroborated a higher odds of vaccination among MSM who had previously taken HIV PrEP. This may be attributed to the fact that HIV PrEP-experienced MSM, who are already aware of their increased risks for STIs, may be more motivated to seek preventive measures such as STIs vaccination.23 Additionally, this study showed that MSM who reported having multiple regular sex partners were more likely to be vaccinated. This may be due to the fact that individuals who reported having multiple sex partners perceived an increased risk of STIs,40 thereby exhibiting a greater intention to receive HPV vaccination. Different from previous studies conducted in other places, some behavioral risk factors, including recent condomless anal sex,20 diagnosis of HIV,41 and/or STIs,42 were not significantly associated with HPV vaccination history in this study. This may be because of the variation in the study region.

This study has a few limitations, and interpretation of results needs caution. First, 98 participants were recruited from an HIV PrEP research project, making a higher proportion of participants being PrEP-experienced as compared with the general MSM community. The influence of PrEP use in this study has been included in the multivariable regression model. Second, selection bias may exist as participants were recruited from NGOs and online channels, which may overrepresent individuals who were more engaged with health services or active in online communities, and affect the generalizability of the study findings. Additionally, we are unable to differentiate participants who came from NGOs from those recruited through online channels, making comparison of participants between the two channels difficult. Third, recall bias on reported survey items could exist. In this study, we limited the recall period of sexual behavior history to 6 months to minimize bias. Lastly, in the survey, we only asked about the type of HPV vaccination received, not the number of doses taken. We cannot confirm if all participants have completed the three-dose HPV vaccination regimen, but that they have received at least one dose.

Conclusions

The uptake of HPV vaccination in Chinese MSM in Hong Kong has increased remarkably in the past decade but is still lower than places with country-level vaccination programmes for MSM. This study highlighted that the main driver for being unvaccinated was the high cost of vaccination. A reduction of cost to below USD 128 per dose could be considered as a strategy to scale-up HPV vaccination coverage in MSM. Previous engagement in preventive behaviors, such as HIV PrEP use and HPV testing, along with previously engaged in high-risk sexual behavior such as multiple regular sex partners, are associated with the increased uptake of HPV vaccination in MSM.

Acknowledgments

We thank Ms Priscilla Wong, Ms Mandy Li, and Mr Alexander Chiu for project coordination and assistance. We thank C.H.O.I.C.E and Hong Kong AIDS Foundation for their kind support on subject recruitment.

Biography

Ngai Sze WONG is an assistant professor at the S.H. Ho Research Centre for Infectious Diseases, the JC School of Public Health and Primary Care, The Chinese University of Hong Kong. Her primary research interests include HIV/AIDS, STI, and viral hepatitis.

Funding Statement

This study is supported by the Health and Medical Research Fund Commissioned Research on Control of Infectious Diseases (Phase IV), Hong Kong Special Administrative Region Government [Reference number: CID-CUHK-E].

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethical approval

E-consent had been obtained before online baseline survey started. Ethical approval from the Joint Chinese University of Hong Kong-New Territories East Cluster Clinical Research Ethics Committee was obtained (approval number: CREC2020.436).

Data availability statement

The data presented in this study are available from the corresponding author upon request and approval from the ethics committee. The data are not publicly available due to privacy or ethical restrictions.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data presented in this study are available from the corresponding author upon request and approval from the ethics committee. The data are not publicly available due to privacy or ethical restrictions.

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