Cost-effectiveness and health impact of gender-neutral and single-dose HPV vaccination in Hong Kong: a modeling analysis

Horace Cheuk Wai Choi; Kathy Leung; Mark Jit; Joseph T Wu

doi:10.1016/j.lanwpc.2026.101892

. 2026 Jun 17;71:101892. doi: 10.1016/j.lanwpc.2026.101892

Cost-effectiveness and health impact of gender-neutral and single-dose HPV vaccination in Hong Kong: a modeling analysis

Horace Cheuk Wai Choi ^a,^b,^∗, Kathy Leung ^a,^b,^c,^d,^e, Mark Jit ^a,^b,^c,^f,^g,^h, Joseph T Wu ^a,^b,^c,^d

PMCID: PMC13311331 PMID: 42376243

Summary

Background

Since 2019, Hong Kong has implemented a routine nonavalent human papillomavirus (HPV) vaccination program for schoolgirls aged 10–12 years with two-dose uptake of over 85%. However, Hong Kong is one of the high-income populations in Asia that lacks an assessment of the impacts of gender-neutral vaccination (GNV) with a single-dose schedule. This study evaluates the cost-effectiveness of expanding the two-dose female-only vaccination (2dFOV) to GNV and reducing the schedule to one dose.

Methods

We modeled the impacts of 2dFOV and GNV (a single- or two-dose schedule) on the burden of HPV-related cancers and genital warts in both genders. We estimated the associated costs and health outcomes over a time horizon of 100 years with a 3% annual discount rate. We compared the incremental cost-effectiveness ratio (ICER) of expanding 2dFOV to GNV to a threshold of one gross domestic product per capita (US$52,120).

Findings

Assuming a base case vaccination cost of US$177 per dose and 85% uptake for both genders, two-dose GNV (2F2M) has an ICER of US$71,105 (90% prediction interval: (US$44,085, US$153,197)) compared to 2dFOV and is not cost-effective. Compared to 2dFOV, giving one dose to both genders (1F1M) is cost-effective or dominant in all simulations, if boys’ uptake is more than 50% and if the single-dose schedule provides 30 years of protection. If the single-dose schedule gives only 20 years of protection, 1F1M is cost-effective or dominant in 92% and 73% of simulations if boys’ uptake is 85% and 50%, respectively.

Interpretation

Expanding the current 2dFOV to GNV with a one-dose schedule for males (1F1M or 2F1M) could be a cost-effective strategy if the uptake among boys is sufficiently high.

Funding

Health and Medical Research Fund, AIR@InnoHK.

Keywords: Gender-neutral vaccination, Cost-effectiveness analysis, Single-dose schedule, Nonavalent HPV vaccines, Population-based HPV vaccination

Research in context.

Evidence before this study

Human papillomavirus (HPV) vaccination has proven effective in reducing persistent HPV infections and HPV-related cancers, including cervical, anal, and oropharyngeal cancers, in both females and males. Hong Kong implemented a female-only vaccination (FOV) program with a two-dose schedule for schoolgirls in primary 5–6 starting in 2019. Globally, recent clinical trial data and the World Health Organization recommendations (December 2022) support the use of either one-dose or two-dose HPV vaccination schedules, highlighting potential cost savings and increased coverage with simplified schedules. Cost-effectiveness analyses are critical for informing policy decisions regarding the expansion of HPV vaccination to gender-neutral vaccination (GNV) programs that include males. We searched PubMed on 26 March 2026 using the terms “cost-effectiveness”, “HPV vaccine∗”, and (“gender-neutral vaccination” OR “universal vaccination”) with no language or date restrictions. Existing literature has primarily compared two-dose GNV versus two-dose FOV programs, with limited data on single-dose strategies, especially within the Hong Kong context. In Hong Kong, only one modeling study published in 2023 has examined the cost effectiveness of expanding the existing school-based program from two-dose FOV to two dose GNV. This published study assumed vaccine uptake of 70–80%, substantially lower than the >85% uptake now achieved among girls. Another local study evaluated targeted HPV vaccination for men who have sex with men. However, there remains a paucity of evidence assessing the cost-effectiveness of implementing a single-dose HPV vaccination schedule for GNV among the general population in Hong Kong.

Added value of this study

This is the first health economic evaluation for Hong Kong that incorporates the latest evidence on single-dose HPV vaccine efficacy and uses real-world female uptake (>85%). We modeled multiple policy options: expansion to two-dose GNV; transition to single-dose GNV; and single-dose supplementation of boys alongside the existing two-dose FOV program. Under base case vaccination cost, two-dose GNV was unlikely to be cost-effective compared to two-dose FOV. In contrast, a switch to single-dose GNV became highly cost effective (and potentially dominant) when male uptake reached 50% or above and single-dose protection lasted 20 years or more. Even at modest male uptake of 25% and assuming only 20-year vaccine protection, adding one dose for boys to the current two-dose FOV program was cost-effective. These findings suggest that implementing a single-dose GNV program is likely to be a cost-effective strategy in the Hong Kong setting.

Implications of all the available evidence

In settings achieving high female uptake (85%), such as Hong Kong, our findings indicate that single-dose GNV is likely to be cost-effective, and may even be dominant, compared to FOV. This strategy aligns with emerging global practices, optimizes resource utilization, and is expected to strengthen herd effect and further reduce HPV-related disease burden across genders. Adoption of a single-dose schedule for both sexes therefore represents a pragmatic and economically efficient pathway for high-income jurisdictions with established FOV programs to transition to GNV.

Introduction

Persistent high-risk oncogenic human papillomavirus (HPV) infection is a necessary cause of cervical cancer and can also lead to non-cervical cancers including anal, oropharyngeal, vaginal/vulvar, and penile cancers.¹^,² Hence, both females and males can directly benefit from receiving HPV vaccines for preventing HPV infection and the subsequent development of HPV-related cancers.³^,⁴

In its position paper updated in 2022, the World Health Organization (WHO) reviewed the use of HPV vaccination with a primary focus on accelerating the elimination of cervical cancer (i.e., bringing incidence below 4 per 100,000 women-years).⁵^,⁶ The WHO recommended a two-dose or single-dose schedule for girls aged 9–14 years who are the primary target population of HPV vaccination. Older females and boys are the secondary target populations if such vaccinations are feasible and affordable. As of February 2026, over 160 countries/regions have initiated population-based HPV vaccination programs for female adolescents, and 90 countries have implemented the single-dose schedule.⁷ Moreover, more than 80 countries have extended female-only vaccination (FOV) to gender-neutral vaccination (GNV) in their population-based HPV vaccination programs for adolescents. Some of these countries, such as Australia and the United Kingdom, have moved to a single-dose schedule for both genders since 2023.⁸^,⁹

Since 2019, Hong Kong has implemented a population-based HPV vaccination program for schoolgirls in primary five and six (aged 10–12 years).¹⁰ The program achieved uptake of over 85% among targeted schoolgirls for the two-dose nonavalent HPV (9vHPV) vaccine in the first and subsequent years of program implementation.¹¹ In response to recent global developments in HPV vaccination strategies, we evaluated the cost-effectiveness of potentially updating the current HPV vaccination program in Hong Kong by expanding FOV to GNV and adopting a single-dose schedule.

Methods

Models

HPV transmission and cervical cancer

To estimate the change in HPV infection prevalence and the impacts associated with large-scale GNV, we adapted our previous model that was used to assess the cost-effectiveness of schoolgirl 9vHPV vaccination in Hong Kong.¹² The model included an HPV transmission model with four groups of HPV types (namely, HPV-16, HPV-18, HPV-31/33/45/52/58, and other non-vaccine high-risk HPV types) that simulates HPV transmission between heterosexual females and males in the population, and an individual-based model to account for the effect of cervical screening. The model was calibrated to (i) the local age- and type-specific genital HPV prevalence among females and age-specific cervical cancer incidence, (ii) the distribution of HPV types in local cervical cancer cases, and (iii) the cumulative proportions of progression and regression from HPV infection/cervical intraepithelial neoplasia grade 1 (CIN1)/CIN2 from non-Hong Kong studies due to the lack of local data. Appendix A (Section S1.1) provides more details of the model.

Other HPV-related cancers

We expanded this model by considering oropharyngeal cancers (OPCs), anal cancers, penile cancers, and vaginal/vulvar cancers when evaluating the health impacts of GNV. Data on the incidence of these cancers (stratified by age and sex) were obtained from the Hong Kong Cancer Registry (HKCaR).¹³ A local study reported that high-risk HPV infection was present in 42% (95% confidence interval [CI]: 35%–49%) of 179 OPC cases diagnosed in 2016–2020.¹⁴ However, more detailed local data on high-risk HPV prevalence by age and HPV attributable fraction (i.e., the proportion of cancer cases that are associated with high-risk HPV infection) at non-cervical sites are limited. In the absence of such data, to estimate the impacts of HPV vaccination on non-cervical HPV-related cancers, we assumed that for each gender, age-specific incidence of each of these cancers is statistically associated with age-specific genital HPV infection incidence.¹⁵^,¹⁶ Specifically, we used a three-component link function to estimate the incidence of non-cervical HPV-related cancer at a particular age based on the genital HPV infection incidence at earlier ages. This combines a time-lagged function and an age-specific scaling function that statistically model the time difference between genital HPV infection and its attributable cancer incidence. These functions were used to reproduce the observed incidence of non-cervical HPV-related cancers due to the lack of Hong Kong-specific data about precancerous states. The functions should not be interpreted as mechanistic representations of biological processes.¹⁵ Our simulations indicate that the reduction in cervical cancer incidence estimated using this approach was similar to that produced by our transmission model in the absence of screening, thereby supporting the validity of applying this approach to non-cervical cancers (Appendix A, Figure S5).

We inferred model parameters by fitting the model to empirical cancer incidence from HKCaR and the reported relative prevalence of high-risk HPV types among HPV-positive cancer cases in the literature.²^,¹³^,¹⁴ Using the fitted model, we projected the changes in non-cervical HPV-related cancer incidence following different strategies of HPV vaccination. See Appendix A (Sections S1.2–S1.3) for more details on model calibration and estimation of non-cervical HPV-related cancer incidence.

Genital warts

The 9vHPV vaccine also covers low-risk HPV types 6/11, which cause approximately 90% of genital warts.¹⁷ The lack of age-specific local data on the incidence of genital warts and HPV6/11 infection limited our ability to explicitly model the transmission of genital warts. Integrating the approach in Kim et al. with local low-risk HPV epidemiology, we considered the relative reduction of the incidence of HPV-16/18 infection as the surrogate for the incidence of HPV-6/11 infection.¹⁸^,¹⁹ We applied the respective estimated relative reduction following HPV vaccination to the overall gender-specific incidence rate of genital warts reported in a local study.²⁰ See Appendix A (Section S1.4) for details on the corresponding calculation.

HPV vaccination

We used the current two-dose FOV program (2dFOV) in Hong Kong as the comparator.¹⁰ We then considered GNV scenarios that extend 2dFOV to vaccinating schoolboys in primary five/six using 9vHPV vaccines. We assumed that 9vHPV vaccines provide the same HPV type-specific efficacy of 95% in preventing vaccine-targeted HPV infection (HPV-16/18/31/33/45/52/58) in both genders,¹²^,²¹^,²² but no efficacy against non-vaccine HPV types.

We assumed that vaccine uptake of primary five/six schoolgirls would remain at 85% in all scenarios based on the most recent coverage data of the program.¹¹ We considered three scenarios of vaccine uptake among schoolboys of 85%, 50%, and 25% based on the observed uptake among schoolgirls and local surveys of acceptability of male adolescent HPV vaccination.²³^,²⁴ We evaluated three GNV strategies: (a) two doses for both schoolgirls and schoolboys (2F2M), (b) one dose for both genders (1F1M), and (c) two doses for schoolgirls and one dose for schoolboys (2F1M). To reflect conservative scenarios regarding the effectiveness of one-dose vaccination, we referred to the findings of the latest clinical trials. The International Agency for Research on Cancer (IARC) India trial reported similar vaccine efficacy (>90%), with no evidence of waning, among females who received one, two or three doses post-randomization based on an average of 12 years of follow-up.²⁵ The Costa Rica HPV Vaccine Trial (CVT) observed a similar seropositive rate (>98%) with no sign of a sudden drop of antibody concentration against vaccine-targeted HPV types among individuals who received one or three doses at the 16th year of follow-up visits.²⁶ Based on these results, we assumed that the two-dose schedule provided lifelong protection while the one-dose schedule provided only 20 or 30 years of protection. These assumptions were consistent with the settings in many overseas CEAs of GNV.²⁷^,²⁸

Cost-effectiveness analysis (CEA)

We conducted the CEA using a societal perspective. Based on the procurement expenditure of HPV vaccines for the vaccination program for female adolescents in Hong Kong and the administrative charges of running the vaccination program,²⁹^,³⁰ we estimated that the vaccination cost (vaccine cost plus administration expenses) was US$177 per dose. We used this as the base case vaccination cost.

We estimated the costs of cancer treatment and diagnosis based on the corresponding charges for private care in the Government’s Gazette by the Hospital Authority, which covers approximately 90% of hospitalization services in Hong Kong.¹²^,³¹ We applied the same approach to the costs for treatment and diagnostic procedures for HPV-related cancers and genital warts.³² For cervical cancer, we included costs of cervical screening for females, considering the population-based cervical screening program which was started in Hong Kong in 2004. We considered a 50% screening uptake among women aged 25–64 years, based on the Population Health Survey 2020–2022.³³ Referring to the latest screening recommendations, HPV testing and cytology are used as the primary modality for women aged 30–64 and 25–29 years, respectively.³⁴^,³⁵ Abnormal cytology results and HPV-positive cases are managed according to the local guidelines.³⁶ For example, HPV-16/18 genotyping is used for HPV-positive cases, with referral to colposcopy for HPV-16/18-positive cases. Follow-up procedures and non-adherence were also incorporated in the model (Section S2 of the Appendix A presents more details). Currently, there is no standard screening protocol for HPV-related cancers other than cervical cancer. We also considered individuals’ time costs and transportation costs to attend clinical treatments and visits.

We quantified health outcomes using quality-adjusted life years (QALYs).³⁷ We estimated the changes in the associated costs and QALYs across the lifetime of all cohorts of both genders over a time horizon of 100 years with a 3% annual discount rate, as considered in other local health economic evaluations on HPV vaccination.¹²^,³²^,³⁸

We assessed cost-effectiveness by estimating the incremental cost-effectiveness ratio (ICER) of GNV, defined as the incremental cost divided by the incremental QALYs gained from expanding FOV to GNV. We considered one gross domestic product per capita (GDPpc; US$52,120) per QALY gained as the willingness to pay (WTP) threshold, as done in previous health technology assessments of HPV vaccination in Hong Kong.¹²^,³²^,³⁸^,³⁹ This WTP threshold is similar to the estimated cost-effectiveness thresholds in high-income countries (US$46,181 on average) that have a similar life expectancy and GDPpc to Hong Kong.⁴⁰ The WTP threshold of one GDPpc was also close to the average of the thresholds considered among 36 high-income settings that were investigated in a recent study (GBP$33,400/US$45,200).⁴¹ We acknowledged that the WHO Commission for Macroeconomics and Health proposed a threshold of 1–3 times GDPpc in 2003,⁴² but more recent guidance from WHO has moved away from this,⁴³ and further commentary as well as econometric analyses suggest that thresholds are well below 3 times GDPpc and may even be below 1 times GDPpc.⁴⁰^,⁴⁴^,⁴⁵ We also evaluated the threshold vaccination cost (TVC) for expanding FOV to GNV, defined as the cost per dose of vaccination at which GNV and FOV would be equally cost-effective at the WTP threshold of one GDPpc. TVC provides information on the cost needed to vaccinate each individual, which helps policymakers justify the procurement price with consideration of administration expenses. We assumed that the vaccination cost was the same for both genders.

We used probabilistic sensitivity analysis to account for parametric uncertainty in the natural history of cervical cancer and HPV transmission dynamics, the statistical linkages between genital HPV infections and non-cervical HPV-related cancers, as well as costs and health utilities. Outcomes in terms of ICERs and TVCs are summarized using medians and 90% prediction intervals (PIs; 5th to 95th percentiles).

To avoid overestimating the health benefits of GNV, we assumed in the base case that all HPV-related cancers in males were equally avertable by FOV via indirect herd protection. In the sensitivity analysis, we considered an alternative scenario in which a proportion of HPV-related cancers in males occurred in men who have sex with men (MSM) and would not benefit from herd protection conferred by FOV; these cancers in MSM were assumed to be unaffected by FOV. Because local data were unavailable, we used overseas studies to estimate the proportion of cases occurring in MSM. Specifically, we assumed that 40% of male anal cancers occurred in MSM, based on a study from the United States.⁴⁶ We further assumed that 18% of HPV-related male OPC and 4.6% of HPV-related penile cancers occurred in MSM, assuming that site-specific cancer risk is proportional to the risk of HPV infection at the corresponding sites while accounting for the estimated prevalence of MSM in the Hong Kong population.47, 48, 49, 50 The corresponding assumptions in the base case and the sensitivity analysis indicate the potential range of the cost-effectiveness of GNV, taking into account the uncertainty in the proportion of MSM in local male HPV-related cancers. See Section S2 in Appendix A for details of the CEA.

In view of WHO’s cervical cancer elimination initiative, we estimated the time it takes for the age-standardized incidence rate (ASIR) for cervical cancer to fall below 4 per 100,000 women-years following the implementation of the population-based HPV vaccination program.⁶^,¹³

Model simulations were performed using Matlab, C++, and R. We followed the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 statement and HPV-FRAME checklist for reporting health economic and HPV-related cancer control evaluations, respectively (Appendix B).⁵¹^,⁵²

Ethics approval

This is a modeling study. No ethics approval is required.

Role of the funding source

The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Results

CEA

2F2M

Compared to 2dFOV, 2F2M was not cost-effective. The ICER increased with higher vaccine uptake among boys (Fig. 1). In the base case, assuming vaccine uptake among boys mirrors the current uptake among girls (85%), the ICER of 2F2M was US$71,105 (US$44,085, US$153,197) and the TVC was US$135 (US$66, US$204) (Table S3). At this uptake, 2F2M was not cost-effective in 82% of simulations at the base case vaccination cost. At 85% uptake, 2F2M remained not cost-effective in 54% of simulations at the base case vaccination cost even if we assumed that some of the HPV-related cancer cases in males were not avertable by FOV (e.g., cases among MSM).

1F1M

The impact of 1F1M was sensitive to vaccine uptake in boys and the protection duration of the one-dose schedule. If the one-dose schedule provided only 20 years of protection, 1F1M may incur QALY losses compared to 2dFOV. In the base case, 1F1M generated fewer QALYs than 2dFOV in 75% and 27% of simulations if vaccine uptake among boys was 25% and 50%, respectively (Fig. 2A(i)). If vaccine uptake among boys was 85%, 1F1M was cost-effective or dominant in 37% or 54% of simulations, respectively, with fewer QALYs in only 3% of simulations, compared to 2dFOV. Notwithstanding, if the one-dose schedule provided 30-year protection, 1F1M generated more QALYs than 2dFOV in most simulations regardless of vaccine uptake in boys (Fig. 2B). In the base case, if schoolboys’ uptake was 85%, 1F1M generated QALY gains in all simulations and was either cost-effective (25%) or dominant (75%) (Fig. 2B(i)).

Fig. 2 — **Cost-effectiveness planes for 1F1M vs 2dFOV if the one-dose schedule was assumed to provide (A) 20-year and (B) 30-year protection.** The two-dose schedule was assumed to provide lifelong protection. The duration of vaccine-induced protection of the one-dose schedule was assumed to be 20 years in panel (A) and 30 years in panel (B). Vaccine uptake among girls was 85% in all GNV and FOV schedules. The green lines present the willingness to pay (WTP) threshold at US$52,120/QALY. The orange triangles denote the mean of the differences in discounted cost and QALY. On the density heatmaps (2-D histograms), grey/lighter blue represents fewer simulations and darker blue represents more simulations. In each subplot, the percentage of simulations in each quadrant (i.e., Q1–Q4) is presented. Quadrant Q1 (North-east, higher costs and more QALYs) includes the percentage of simulations that were cost-effective at the WTP threshold. All percentages are based on the total number of simulations. The base case scenario considered costs and QALYs associated with genital warts and assumed that all HPV-related cancers in males were equally avertable by FOV. The alternative scenario assumed that 40%, 18%, and 4.6% of HPV-related anal, oropharyngeal, and penile cancer cases in males occurred in MSM, respectively, and were not avertable by FOV. Abbreviations: CE, cost-effective; MSM, men who have sex with men; QALY, quality-adjusted life year; Q1 to Q4, quadrant 1 to quadrant 4 of the cost-effectiveness plane; 1F1M, one-dose schedule for both schoolgirls and schoolboys; 2dFOV, two-dose schedule for female-only vaccination.

2F1M

Although dose schedules are typically agnostic to gender in routine immunization programs, we explored the potential impact of adopting 2F1M as an alternative to 2dFOV or 1F1M. The ICER of 2F1M compared to 2dFOV increased as vaccine uptake among boys increased (Fig. 3/Figure S6). The cost-effectiveness outcomes of 2F1M were not sensitive to the duration of protection provided by the one-dose schedule as long as the protection was between 20 and 30 years (Table S4). 2F1M was a cost-effective alternative to 2dFOV at the base case vaccination cost. In the base case scenario with 85% uptake among boys, 2F1M was cost-effective in 85% of simulations at the base case vaccination cost compared to 2dFOV, if the one-dose schedule provided 20 years of protection (Table S4). In contrast, compared to 1F1M, 2F1M was not cost-effective in most simulations across almost all considered scenarios of vaccine uptake among boys. However, if the one-dose schedule provided only 20 years of protection and boys’ uptake was 25%, then 2F1M was cost-effective in 62% of simulations compared to 1F1M (Fig. 3, Figure S6 and Table S5).

Fig. 3 — Incremental cost-effectiveness ratios (ICERs) and threshold vaccination costs (TVCs) of the 2F1M schedule for (A) 2F1M vs 2dFOV and (B) 2F1M vs 1F1M if the one-dose schedule provided 20-year protection to vaccinees. The two-dose and one-dose schedules were assumed to provide lifelong and 20-year protection to vaccinees, respectively. Vaccine uptake among girls was 85% in all GNV and FOV strategies. For panel (A), the willingness to pay (WTP) threshold was US$52,120 per QALY gain. For panel (B), the base case vaccination cost (vaccine cost plus administration expenses) was US$177 per dose. The WTP threshold and base case vaccination cost were presented by grey dashed lines on respective panels. The violin plots present the smoothed kernel density of the values of ICERs/TVCs. The box plots present the medians (the horizontal lines), the 25th/75th percentiles (the boxes), and the 5th/95th percentiles (the whiskers). The base case scenario considered costs and QALYs associated with genital warts and assumed that all HPV-related cancers in males were equally avertable by FOV. The alternative scenario assumed that 40%, 18%, and 4.6% of HPV-related anal, oropharyngeal, and penile cancer cases in males occurred in MSM, respectively, and were not avertable by FOV. Abbreviations: FOV, female-only vaccination; GNV, gender-neutral vaccination; MSM, men who have sex with men; 1F1M, one-dose schedule for both schoolgirls and schoolboys; 2F1M, two-dose schedule for schoolgirls and one-dose schedule for schoolboys; 2dFOV, two-dose schedule for female-only vaccination.

Projected timeline for the elimination of cervical cancer

We estimated that under the status quo 2dFOV (85% vaccine uptake in schoolgirls) and cervical screening program (50% screening uptake among women aged 25–64 years), Hong Kong would reach the elimination target (lowering the ASIR of cervical cancer to below 4/100,000 women) in 2067 (90% PI: (2064, 2070)) (Fig. 4). 2F2M with 85% vaccine uptake among boys would eliminate cervical cancer 2 years sooner in 2065 (2062, 2068). The time to cervical cancer elimination is similar between 1F1M and 2F1M if vaccine uptake among boys reached 85% and the one-dose schedule provided 20-year protection. However, if only 25% of males were vaccinated under 1F1M, then the time to cervical cancer elimination would be delayed by 1 year to 2068 (2065, 2072) compared to 2dFOV.

Fig. 4 — **Estimated age-standardized rate of cervical cancer incidence across time horizon.** Lifelong vaccine protection was assumed for a two-dose schedule of 2dFOV and 2F2M. The age-standardized incidence rate (ASIR) of cervical cancer was calculated based on Segi’s 1960 world standard population.¹³ Empirical ASIR (the black line) from the Hong Kong Cancer Registry was available up to 2023.¹³ The lines present the medians of the estimated ASIR for the vaccination schedules specified in the legend. The legend includes vaccine uptake among females (F) and males (M), whenever appropriate, and the medians (90% prediction intervals [PIs], 5th to 95th percentiles) of the projected time to cervical cancer elimination. The medians were obtained based on probabilistic sensitivity analysis. The grey dashed line presents the reference of cervical cancer elimination for ASIR at 4 per 100,000 women-years. The median of the estimated ASIR for 2F1M (cyan) were very close to that for 2F2M (orange), with small difference in after calendar years 2075. The one-dose schedule was assumed to provide 20-year protection. Abbreviations: ASIR, age-standardized rate; CSP, Cervical Screening Programme; HKCaR, Hong Kong Cancer Registry; 1F1M, one-dose schedule for both genders; 2dFOV, female-only HPV vaccination with a two-dose schedule for schoolgirls; 2F1M, two-dose schedule for schoolgirls and one-dose schedule for schoolboys; 2F2M, gender-neutral HPV vaccination with a two-dose schedule for both schoolgirls and schoolboys.

Section S3 of Appendix A presents more findings on comparing GNV to 2dFOV. Considering the distribution of the difference in costs and QALYs gained associated with treatments of HPV-related cancers and genital warts, the greatest proportion of health impacts conferred by GNV were attributed to the prevention of cervical cancer, followed by male HPV-related OPC and anal cancer, and genital warts in males (Figure S7). Regarding the impacts on HPV infection, if the vaccination schedule was changed from 2dFOV to 1F1M with 20- or 30-year protection from a one-dose schedule, a rebound in the incidence of vaccine-targeted HPV types was seen at older ages when vaccine-induced protection wanes (Figure S11–Figure S12). The rebound of incidence occurred in later ages among males, and in scenarios of higher uptake among boys. This suggests that the one-dose schedule with limited duration of protection may delay HPV infection only rather than eliminate it, further supporting the importance of long-term monitoring of the duration of vaccine protection.

Discussion

In this study, we evaluated the cost-effectiveness of expanding the current routine adolescent 9vHPV vaccination program in Hong Kong from FOV to GNV, accounting for the benefits of GNV in reducing cervical cancer incidence in women (due to herd effects) and non-cervical HPV-related cancer incidence in both genders.

At the current vaccine uptake (over 85%) of the FOV program,¹¹ our study suggested that 2F2M would not be a cost-effective alternative to 2dFOV at the base case vaccination cost (US$177 per dose) under a WTP threshold of one GDPpc. In the base case scenario, the TVC was 24% (median) lower than the base case vaccination cost. That is, 2F2M was not cost-effective compared to 2dFOV unless the vaccination cost (vaccine cost plus administration expenses) was reduced by 24% from the base case vaccination cost. This finding aligned with the results reported in other high-income settings in Europe and Asia, such as Spain, the United Kingdom, Japan, Singapore and China, which found that 2F2M with 9vHPV vaccines was not cost-effective compared to 2dFOV.53, 54, 55, 56, 57, 58 For example, the United Kingdom study found that the vaccination cost needed to be reduced by 51% for 2F2M using 9vHPV vaccines to be cost-effective.⁵⁴ In Singapore, a study found that 2F2M using 9vHPV vaccines would only be cost-effective compared to 2dFOV if the vaccination cost is reduced by 67% from the base case vaccination cost at US$149, assuming vaccine uptake was 80% in both genders.⁵⁶ The Singaporean study used a static model to consider vaccine impacts on HPV-related cancers, with results from a meta-analysis to approximate the magnitude of herd effects from high vaccine uptake. A study from China that used a discrete-time, dynamic transmission Markov model suggested that the 2F2M strategy could be cost-effective relative to 2dFOV in the economically developed cities of Beijing, Shanghai and Guangzhou, if the price of the 9vHPV vaccine were reduced by 90%, from US$185 to approximately US$20 per dose.⁵⁷ In contrast, a manufacturer-sponsored study for Taiwan, China, using a lower vaccination cost of US$63 per dose, reported that the ICER of 2F2M was approximately US$20,000/QALY (∼68% of one times GDPpc in Taiwan, China) if vaccine uptake was 85% for females and 80% for males.⁵⁸ This study adapted the transmission dynamic model developed by the manufacturer for the US settings, but recalibrated it to the local disease incidence. Differences in vaccination cost, model design, and disease patterns across these studies led to the divergent cost-effectiveness outcomes of 2F2M, suggesting the importance of carefully examining model assumptions and conducting local-specific studies to address the issue.

A recent manufacturer-sponsored local study assessed the cost-effectiveness of 2F2M with 9vHPV vaccines using the manufacturer’s model re-calibrated to the overall crude incidence rate of HPV-related cancers in Hong Kong.³² Assuming 80% vaccine uptake and accounting for genital warts, the study reported that 2F2M was cost-effective compared to 2dFOV with an ICER of US$40,500/QALY from a healthcare payer perspective at a vaccination cost of US$178 per dose. Compared to our study, their study considered 3-year cytology for cervical screening with lower coverage (13%), in which case the impact of HPV vaccination on reducing cervical cancer would be more pronounced. If we adopted their assumptions in our model, the ICER would be US$41,100/QALY (median) for 2F2M vs 2dFOV.

Besides the two-dose schedule, we also considered the single-dose schedule, in line with WHO’s updated recommendation in 2022.⁵ Compared to 2dFOV with lifelong protection, a one-dose schedule with shorter protection duration may result in a rebound of incidence of vaccine-targeted HPV types, by delaying HPV infection from the age of peak sexual activity to older ages. Nevertheless, this delay may still reduce the risk of HPV-related cancers.²⁸ The genital prevalence of high-risk HPV types among females in Hong Kong showed a major peak (approximately 10%) at ages 19–30 years, followed by a smaller peak of approximately 5% and a gradual decline across ages 36–55 years.¹⁹^,⁵⁹ For a vaccination program targeting adolescents aged 10–12 years old, a one-dose schedule giving 20-year protection would cover the major peak of HPV infection. A longer protection duration of 30 years could also cover half of the age range corresponding to the smaller, later peak. These findings highlight the importance of protection duration (20 vs 30 years) in determining the impact and cost-effectiveness of a one-dose schedule. Nevertheless, switching from 2dFOV to 1F1M is likely to be cost-effective under either scenario of protection duration, provided that vaccine uptake among boys reaches at least 50%.

In contrast to 1F1M, 2F1M was less sensitive to the protection duration of the one-dose schedule, as its cost-effectiveness compared to 2dFOV was similar under both the 20-year and 30-year protection assumptions. If a gender-specific vaccination schedule is deemed acceptable, 2F1M would be more cost-effective and incur more health benefits compared to 2dFOV, although it would remain less cost-effective than 1F1M. Given the uncertainty in vaccine uptake among boys and the protection duration conferred by a one-dose schedule, our analysis highlights the potential benefits and trade-offs of various vaccination strategies (summarized in Table 1). At the base case vaccination cost, 1F1M was the most cost-effective strategy although the uncertainty in this conclusion increased if the one-dose schedule provided only 20 years of protection and uptake among boys was low. By contrast, 2F1M consistently provided greater health benefits than 2dFOV and remained more cost-effective than 2dFOV regardless of the uptake in boys. These findings support the potential value of 1F1M vaccination, while also highlighting the need to monitor vaccine uptake among boys in the program and the duration of protection for one-dose vaccination.

Table 1.

The cost-effective vaccination strategy at the base case vaccination cost.^a^,^b

Duration of vaccine-induced protection by the one-dose schedule	Vaccine uptake among boys^c
	25%	50%	85%
20 years	2F1M^d	1F1M	1F1M
30 years	1F1M	1F1M	1F1M

Open in a new tab

Abbreviations: FOV, female-only vaccination; GNV, gender-neutral vaccination; QALY, quality-adjusted life year; 1F1M, one-dose schedule for both schoolgirls and schoolboys; 2dFOV, two-dose schedule for FOV; 2F1M, two-dose schedule for schoolgirls and one-dose schedule for schoolboys.

We considered a GNV strategy effective if it incurred more QALYs (mean and median) than the status quo 2dFOV.

The findings were based on the base case scenario that considered the impacts of HPV vaccination on genital warts and assumed all HPV-related cancers in males are equally avertable by FOV via indirect protection.

Vaccine uptake among schoolgirls was assumed to be 85% in all strategies.

The two-dose schedule was assumed to provide lifelong protection.

The duration of protection provided by the one-dose schedule critically influences its expected health benefits. Two post-randomization cohorts from trial participants that received a single HPV vaccine dose showed that the single-dose schedule conferred protection comparable to the two-dose schedule. With a median 12-year follow-up, there was no significant difference in vaccine efficacy among participants in the IARC India trial who received one, two or three doses post-randomization.²⁵ At the 16th year follow-up visits of one-dose recipients, the CVT study reported that the seropositive rate remained high (over 98%), with no sign of a sudden drop of antibody concentration for vaccine-targeted HPV types.²⁶ Findings from these cohorts are further strengthened by recent trial evidence. The ESCUDDO trial reported that the single-dose schedule resulted in non-inferior vaccine efficacy compared to the two-dose schedule over a 5-year period.⁶⁰ The KEN SHE trial found that the single-dose schedule was highly efficacious, demonstrated high immunogenicity, and conferred durable protection, based on the findings of 3-year follow-up.⁶¹^,⁶² Taken together, these results suggest non-inferior vaccine efficacy with no evidence of waning within 12–16 years for the single-dose schedule. However, some modeling studies have used other assumptions when estimating vaccine impacts. For example, Daniels et al. assumed that the protection from the single-dose schedule waned substantially faster than that of a two-dose schedule.⁶³ Long-term monitoring of the vaccine protection of the one-dose as well as two-dose schedules should be continued to confirm the outcomes.

Our model illustrated that 1F1M could provide comparable effectiveness as 2dFOV in reducing cervical cancer incidence and other HPV-related diseases, if uptake among boys was high (85%) and the one-dose schedule provided 20-year protection or more. However, in terms of cervical cancer elimination, some forms of cervical screening should be maintained for providing complete protection, given that the 9vHPV vaccines do not cover all high-risk HPV types attributing to cervical cancer. Moreover, in the era of large-scale HPV vaccination, screening algorithms incorporating individuals’ vaccination status could be explored.⁶⁴

Limitations

Our study has several limitations. First, there are no published local data on HPV prevalence and HPV type distribution for sites other than the cervix and oral cavity.¹⁴^,¹⁹^,⁵⁰ As such, we used the HPV type distribution among HPV-positive cancer cases in Asia and Oceania in model calibration.² Second, our statistical models that link genital HPV prevalence to the incidence of non-cervical HPV-related cancers did not include precancerous lesions such as anal or penile intraepithelial neoplasia.⁶⁵ Without data for the intermediate precancerous lesions, the non-cervical HPV-related cancer model specification and calibration cannot be fully validated.⁶⁶ Third, we did not explicitly include MSM in the model structure. Local data on the share of HPV-related cancer cases in MSM was unavailable. This limited our ability to perform a thorough evaluation of the effects of HPV vaccination in the MSM subgroup and the general population. A model excluding the MSM subgroup would typically overestimate the benefit of FOV, since MSM would benefit much less from herd protection from FOV compared to heterosexual males. In turn, this could underestimate the incremental benefit of extending vaccination to boys. Although local studies conducted in 1999–2001 among men aged 18–60 years estimated that 4% and 2% of them had same-sex sexual activity in their lifetime and in the last 6 months, respectively,⁴⁹^,⁶⁷ these data do not indicate the proportion of HPV-related cancer cases occurring in MSM. Nevertheless, the MSM subgroup may contribute to a considerable burden of HPV-related diseases. To evaluate the potential impacts of the exclusion of the MSM subgroup in the transmission dynamic model, we ran a scenario analysis assuming that 40%, 18% and 4.6% of male anal, oropharyngeal and penile HPV-related cancers, respectively, occurred in MSM and would not benefit from herd protection conferred by FOV. In this scenario, 2F2M remained not cost-effective compared to 2dFOV regardless of vaccine uptake among boys. Nevertheless, besides health economics, equity arguments should be considered when deliberating the potential extension of vaccination to all boys on grounds of equity in view of the significant burden of HPV-related cancers in MSM.⁶⁸

Conclusions

Our findings suggested that 2F2M was not cost-effective compared to 2dFOV unless the current vaccination cost is modestly reduced. In contrast, 1F1M was likely cost-effective compared to 2dFOV but its health impact was sensitive to the protection duration of the one-dose schedule and uptake among boys. 2F1M would be a cost-effective alternative to 2dFOV if the one-dose schedule provides 20 years or longer protection but not lifetime protection. Expanding the current 2dFOV to GNV with a one-dose schedule for males (1F1M or 2F1M) could be a cost-effective strategy if the uptake among boys is sufficiently high.

Contributors

All authors meet the ICMJE criteria for authorship. HC, KL, MJ, and JTW designed and conceptualized the study. HC conducted formal data analysis and acquired research funding. HC, KL, and JTW have directly accessed and verified the data reported in the manuscript. All authors drafted, edited and reviewed the manuscript. All authors had read and approved the final manuscript.

Data sharing statement

The data generating the findings of this article are included within the article and its additional files.

Editor note

The Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.

Declaration of interests

We declare no competing interests.

Acknowledgements

This work was supported by grants from the Health and Medical Research Fund (CID-HKU-2-20) of the Government of the Hong Kong Special Administrative Region, China. This research was supported by the Hong Kong Jockey Club Global Health Institute (HKJCGHI), Hong Kong Special Administrative Region, China. This work was supported by AIR@InnoHK administered by the Innovation and Technology Commission, Hong Kong Special Administrative Region, China. The computations were performed using research computing facilities offered by Information Technology Services at the University of Hong Kong, Hong Kong Special Administrative Region, China. MJ was supported by the Gates Foundation (INV-067155).

Footnotes

^{Appendix A}

Supplementary data related to this article can be found at https://doi.org/10.1016/j.lanwpc.2026.101892.

Appendix A. Supplementary data

Supplementary Material

mmc1.pdf^{(3.8MB, pdf)}

AppendixB

mmc2.pdf^{(72.9KB, pdf)}

References

1.Bosch F.X., Lorincz A., Munoz N., Meijer C.J.L.M., Shah K.V. The causal relation between human papillomavirus and cervical cancer. J Clin Pathol. 2002;55(4):244–265. doi: 10.1136/jcp.55.4.244. [DOI] [PMC free article] [PubMed] [Google Scholar]
2.de Sanjose S., Serrano B., Tous S., et al. Burden of human papillomavirus (HPV)-related cancers attributable to HPVs 6/11/16/18/31/33/45/52 and 58. JNCI Cancer Spectr. 2019;2(4) doi: 10.1093/jncics/pky045. [DOI] [PMC free article] [PubMed] [Google Scholar]
3.Cheng L., Wang Y., Du J. Human papillomavirus vaccines: an updated review. Vaccines. 2020;8(3) doi: 10.3390/vaccines8030391. [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Zhang J., Qin Z., Lou C., Huang J., Xiong Y. The efficacy of vaccination to prevent human papilloma viruses infection at anal and oral: a systematic review and meta-analysis. Public Health. 2021;196:165–171. doi: 10.1016/j.puhe.2021.05.012. [DOI] [PubMed] [Google Scholar]
5.World Health Organization Human papillomavirus vaccines WHO position paper. Wkly Epidemiol Rec. 2022;97(50):645–672. https://iris.who.int/handle/10665/365351 [Google Scholar]
6.World Health Organization Cervical cancer elimination initiative. 2020. https://www.who.int/initiatives/cervical-cancer-elimination-initiative Available at:
7.World Health Organization HPV dashboard. 2026. https://www.who.int/teams/immunization-vaccines-and-biologicals/diseases/human-papillomavirus-vaccines-(HPV)/hpv-clearing-house/hpv-dashboard Available at:
8.UK Health Security Agency HPV vaccination programme moves to single dose from September 2023. 2023. https://www.gov.uk/government/news/hpv-vaccination-programme-moves-to-single-dose-from-september-2023 Available at:
9.Department of Health and Ageing, Australian Government Change to single dose HPV vaccine. 2023. https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/change-to-single-dose-hpv-vaccine Available at:
10.Centre for Health Protection, Department of Health Human papillomavirus (HPV) vaccination. 2025. https://www.chp.gov.hk/en/features/102146.html Available at:
11.Legislative Council LCQ12: Human papillomavirus vaccination. 2023. https://www.info.gov.hk/gia/general/202307/05/P2023070500270.htm Available at:
12.Choi H.C.W., Jit M., Leung G.M., Tsui K.-L., Wu J.T. Simultaneously characterizing the comparative economics of routine female adolescent nonavalent human papillomavirus (HPV) vaccination and assortativity of sexual mixing in Hong Kong Chinese: a modeling analysis. BMC Med. 2018;16:127. doi: 10.1186/s12916-018-1118-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
13.Hong Kong Cancer Registry. http://www3.ha.org.hk/cancereg/ Available at:
14.Chen Z., Chan A.B.W., Kam L.S., et al. Changes in the incidence and human papillomavirus-positive portion of oropharyngeal squamous cell carcinoma in Hong Kong. Cancers. 2024;16(1) doi: 10.3390/cancers16010226. [DOI] [PMC free article] [PubMed] [Google Scholar]
15.Brisson M., Laprise J.-F., Chesson H.W., et al. Health and economic impact of switching from a 4-valent to a 9-valent HPV vaccination program in the United States. J Natl Cancer Inst. 2016;108(1) doi: 10.1093/jnci/djv282. [DOI] [PMC free article] [PubMed] [Google Scholar]
16.Cody P., Tobe K., Abe M., Elbasha E.H. Public health impact and cost effectiveness of routine and catch-up vaccination of girls and women with a nine-valent HPV vaccine in Japan: a model-based study. BMC Infect Dis. 2021;21(1) doi: 10.1186/s12879-020-05632-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
17.Chan P.K.S., Luk A.C.S., Luk T.N.M., et al. Distribution of human papillomavirus types in anogenital warts of men. J Clin Virol. 2009;44:111–114. doi: 10.1016/j.jcv.2008.11.001. [DOI] [PubMed] [Google Scholar]
18.Kim J.J., Simms K.T., Killen J., et al. Human papillomavirus vaccination for adults aged 30 to 45 years in the United States: a cost-effectiveness analysis. PLoS Med. 2021;18(3) doi: 10.1371/journal.pmed.1003534. [DOI] [PMC free article] [PubMed] [Google Scholar]
19.Chan P.K.S., Ho W.C.S., Wong M.C.S., Chang A.R., Chor J.S.Y., Yu M.-Y. Epidemiologic risk profile of infection with different groups of human papillomaviruses. J Med Virol. 2009;81:1635–1644. doi: 10.1002/jmv.21575. [DOI] [PubMed] [Google Scholar]
20.Lin C., Lau J.T.F., Ho K.-M., Lau M.-C., Tsui H.-Y., Lo K.-K. Incidence of genital warts among the Hong Kong general adult population. BMC Infect Dis. 2010;10:272. doi: 10.1186/1471-2334-10-272. [DOI] [PMC free article] [PubMed] [Google Scholar]
21.Joura E.A., Giuliano A.R., Iversen O.-E., et al. A 9-valent HPV vaccine against infection and intraepithelial neoplasia in women. N Engl J Med. 2015;372(8):711–723. doi: 10.1056/NEJMoa1405044. [DOI] [PubMed] [Google Scholar]
22.Malagon T., Drolet M., Boily M.-C., et al. Cross-protective efficacy of two human papillomavirus vaccines: a systematic review and meta-analysis. Lancet Infect Dis. 2012;12(10):781–789. doi: 10.1016/S1473-3099(12)70187-1. [DOI] [PubMed] [Google Scholar]
23.Wang Z., Wang J., Fang Y., et al. Parental acceptability of HPV vaccination for boys and girls aged 9-13 years in China - a population-based study. Vaccine. 2018;36(19):2657–2665. doi: 10.1016/j.vaccine.2018.03.057. [DOI] [PubMed] [Google Scholar]
24.Cheung T., Lau J.T.F., Wang J.Z., Mo P.K.H., Ho Y.S. Acceptability of HPV vaccines and associations with perceptions related to HPV and HPV vaccines among male baccalaureate students in Hong Kong. PLoS One. 2018;13(6) doi: 10.1371/journal.pone.0198615. [DOI] [PMC free article] [PubMed] [Google Scholar]
25.Malvi S.G., Esmy P.O., Muwonge R., et al. A prospective cohort study comparing efficacy of 1 dose of quadrivalent human papillomavirus vaccine to 2 and 3 doses at an average follow up of 12 years postvaccination. J Natl Cancer Inst Monogr. 2024;2024(67):317–328. doi: 10.1093/jncimonographs/lgae042. [DOI] [PMC free article] [PubMed] [Google Scholar]
26.Porras C., Romero B., Kemp T., et al. HPV16/18 antibodies 16-years after single dose of bivalent HPV vaccination: costa Rica HPV vaccine trial. J Natl Cancer Inst Monogr. 2024;2024(67):329–336. doi: 10.1093/jncimonographs/lgae032. [DOI] [PMC free article] [PubMed] [Google Scholar]
27.Prem K., Choi Y.H., Benard E., et al. Global impact and cost-effectiveness of one-dose versus two-dose human papillomavirus vaccination schedules: a comparative modelling analysis. BMC Med. 2023;21(1) doi: 10.1186/s12916-023-02988-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
28.Brisson M., Laprise J.F., Drolet M., et al. Population-level impact of switching to 1-dose human papillomavirus vaccination in high-income countries: examining uncertainties using mathematical modeling. J Natl Cancer Inst Monogr. 2024;2024(67):387–399. doi: 10.1093/jncimonographs/lgae038. [DOI] [PMC free article] [PubMed] [Google Scholar]
29.Department of Health The budget. Replies to written questions raised by Finance Committee Members in examining the Estimates of Expenditure (2025-26) 2025. https://www.dh.gov.hk/english/budget/budget.html Available at:
30.Centre for Health Protection Human papillomavirus (HPV) vaccination catch-up programme. 2026. https://www.chp.gov.hk/en/features/108084.html Available at:
31.Hospital Authority Revisions to list of charges: Gazette No. 3884. 2017. https://www.gld.gov.hk/egazette/pdf/20172124/egn201721243884.pdf Available at:
32.Cheung T.H., Cheng S.S.Y., Hsu D., et al. Health impact and cost-effectiveness of implementing gender-neutral vaccination with the 9-valent HPV vaccine in Hong Kong. Hum Vaccin Immunother. 2023;19(2) doi: 10.1080/21645515.2023.2184605. [DOI] [PMC free article] [PubMed] [Google Scholar]
33.Centre for Health Protection, Department of Health Report of Population Health Survey 2020-2022. 2022. https://www.chp.gov.hk/en/features/37474.html Available at:
34.Cervical Screening Programme, Department of health. https://www.cervicalscreening.gov.hk/en/index.html Available at:
35.Choi H.C.W., Leung K., Wu J.T. Cervical screening among Chinese females in the era of HPV vaccination: a population-based survey on screening uptake and regular screening following an 18-year organized screening program. J Gynecol Oncol. 2024;35(2):e20. doi: 10.3802/jgo.2024.35.e20. [DOI] [PMC free article] [PubMed] [Google Scholar]
36.The Hong Kong College of Obstetricians and Gynaecologists Guidelines for cervical cancer prevention and screening. 2024. https://www.hkcog.org.hk/hkcog/Download/Guidelines_for_Cervical_Cancer_Prevention_and_Screening.pdf Available at: [DOI] [PubMed]
37.Choi H.C.W., Leung K., Chan K.K.L., Bai Y., Jit M., Wu J.T. Maximizing the cost-effectiveness of cervical screening in the context of routine HPV vaccination by optimizing screening strategies with respect to vaccine uptake: a modeling analysis. BMC Med. 2023;21(1) doi: 10.1186/s12916-023-02748-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
38.You D., Quan J., Bishai D., et al. Evaluating cost-effectiveness of 9-valent HPV vaccination for men who have sex with men by HIV status in Hong Kong. Vaccine. 2025;63 doi: 10.1016/j.vaccine.2025.127625. [DOI] [PubMed] [Google Scholar]
39.Census and Statistics Department Table 31: gross domestic product (GDP), implicit price deflator of GDP and per capita GDP. https://www.censtatd.gov.hk/en/web_table.html?id=31 Available at:
40.Pichon-Riviere A., Drummond M., Palacios A., Garcia-Marti S., Augustovski F. Determining the efficiency path to universal health coverage: cost-effectiveness thresholds for 174 countries based on growth in life expectancy and health expenditures. Lancet Glob Health. 2023;11(6):e833–e842. doi: 10.1016/S2214-109X(23)00162-6. [DOI] [PubMed] [Google Scholar]
41.Charles River Associates Benchmarking the UK’s cost-effectiveness threshold: findings from international comparison. 2026. https://www.abpi.org.uk/publications/benchmarking-the-uk-s-cost-effectiveness-threshold-findings-from-international-comparison/ Available at:
42.World Health Organization Making choices in health: WHO guide to cost-effectiveness analysis, ed. T. Tan-Torres Edejer, R.M.P.M. Baltussen, T. Adam et.al Geneva, Switzerland. 2003. http://www.who.int/choice/publications/p_2003_generalised_cea.pdf Available at:
43.Bertram M.Y., Lauer J.A., De Joncheere K., et al. Cost-effectiveness thresholds: pros and cons. Bull World Health Organ. 2016;94(12):925–930. doi: 10.2471/BLT.15.164418. [DOI] [PMC free article] [PubMed] [Google Scholar]
44.Marseille E., Larson B., Kazi D.S., Kahn J.G., Rosen S. Thresholds for the cost–effectiveness of interventions: alternative approaches. Bull World Health Organ. 2015;93:118–124. doi: 10.2471/BLT.14.138206. [DOI] [PMC free article] [PubMed] [Google Scholar]
45.Ochalek J., Claxton K., Lomas J., Thompson K.M. Valuing health outcomes: developing better defaults based on health opportunity costs. Expert Rev Pharmacoecon Outcomes Res. 2021;21(4):729–736. doi: 10.1080/14737167.2020.1812387. [DOI] [PubMed] [Google Scholar]
46.Deshmukh A.A., Damgacioglu H., Georges D., Sonawane K., Clifford G.M. Human papillomavirus-associated anal cancer incidence and burden among US men, according to sexual orientation, human immunodeficiency virus status, and age. Clin Infect Dis. 2023;77(3):419–424. doi: 10.1093/cid/ciad205. [DOI] [PMC free article] [PubMed] [Google Scholar]
47.Sonawane K., Shyu S.S., Damgacioglu H., Li R., Nyitray A.G., Deshmukh A.A. Prevalence and concordance of oral and genital HPV by sexual orientation among US men. JNCI Cancer Spectr. 2023;7(1) doi: 10.1093/jncics/pkac088. [DOI] [PMC free article] [PubMed] [Google Scholar]
48.Deshmukh A.A., Tanner R.J., Luetke M.C., Hong Y.R., Sonawane Deshmukh K., Mainous A.G. 3rd. Prevalence and risk of penile human papillomavirus infection: evidence from The National Health and Nutrition Examination Survey 2013-2014. Clin Infect Dis. 2017;64(10):1360–1366. doi: 10.1093/cid/cix159. [DOI] [PubMed] [Google Scholar]
49.Lau J.T., Kim J.H., Lau M., Tsui H.Y. HIV related behaviours and attitudes among Chinese men who have sex with men in Hong Kong: a population based study. Sex Transm Infect. 2004;80(6):459–465. doi: 10.1136/sti.2003.008854. [DOI] [PMC free article] [PubMed] [Google Scholar]
50.Ho W.C.S., Boon S.S., Chong K.C., et al. Prevalence of oral human papillomavirus infection among the general adult population in Hong Kong. J Med Virol. 2024;96(2) doi: 10.1002/jmv.29460. [DOI] [PubMed] [Google Scholar]
51.Husereau D., Drummond M., Augustovski F., et al. Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) statement: updated reporting guidance for health economic evaluations. BMC Health Serv Res. 2022;22(1) doi: 10.1186/s12913-021-07460-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
52.Canfell K., Kim J.J., Kulasingam S., et al. HPV-FRAME: a consensus statement and quality framework for modelled evaluations of HPV-related cancer control. Papillomavirus Res. 2019;8 doi: 10.1016/j.pvr.2019.100184. [DOI] [PMC free article] [PubMed] [Google Scholar]
53.Linertova R., Guirado-Fuentes C., Mar Medina J., Imaz-Iglesia I., Rodriguez-Rodriguez L., Carmona-Rodriguez M. Cost-effectiveness of extending the HPV vaccination to boys: a systematic review. J Epidemiol Community Health. 2021;75(9):910–916. doi: 10.1136/jech-2020-216305. [DOI] [PubMed] [Google Scholar]
54.Datta S., Pink J., Medley G.F., et al. Assessing the cost-effectiveness of HPV vaccination strategies for adolescent girls and boys in the UK. BMC Infect Dis. 2019;19:552. doi: 10.1186/s12879-019-4108-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
55.Palmer C., Tobe K., Negishi Y., You X., Chen Y.T., Abe M. Health impact and cost effectiveness of implementing gender-neutral HPV vaccination in Japan. J Med Econ. 2023;26(1):1546–1554. doi: 10.1080/13696998.2023.2282912. [DOI] [PubMed] [Google Scholar]
56.Wahab M.T., Tan R.K.J., Cook A.R., Prem K. Impact of including boys in the national school-based human papillomavirus vaccination programme in Singapore: a modelling-based cost-effectiveness analysis. Vaccine. 2023;41(12):1934–1942. doi: 10.1016/j.vaccine.2023.02.025. [DOI] [PubMed] [Google Scholar]
57.Fu X., Zhang Q., Wagner A.L., Zhou W., Xia Y., Lu Y. Cost-effectiveness and epidemiological impact of gender-neutral vaccination against human papillomavirus in economically developed metropolises of Beijing, Shanghai, and Guangzhou, China. Hum Vaccin Immunother. 2025;21(1) doi: 10.1080/21645515.2025.2557092. [DOI] [PMC free article] [PubMed] [Google Scholar]
58.Chou H.H., Chu P.Y., Wu Y.H., et al. Health impact and cost-effectiveness analysis of gender-neutral versus female-only 9-valent human papillomavirus vaccination in Taiwan. PLoS One. 2025;20(10) doi: 10.1371/journal.pone.0333757. [DOI] [PMC free article] [PubMed] [Google Scholar]
59.Liu S.S., Chan K.Y.K., Leung R.C.Y., et al. Prevalence and risk factors of human papillomavirus (HPV) infection in southern Chinese women - a population-based study. PLoS One. 2011;6(5) doi: 10.1371/journal.pone.0019244. [DOI] [PMC free article] [PubMed] [Google Scholar]
60.Kreimer A.R., Porras C., Liu D., et al. Noninferiority of one HPV vaccine dose to two doses. N Engl J Med. 2025;393:2421–2433. doi: 10.1056/NEJMoa2506765. [DOI] [PubMed] [Google Scholar]
61.Barnabas R.V., Brown E.R., Onono M.A., et al. Durability of single-dose HPV vaccination in young Kenyan women: randomized controlled trial 3-year results. Nat Med. 2023;29(12):3224–3232. doi: 10.1038/s41591-023-02658-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
62.Baisley K., Kemp T.J., Mugo N.R., et al. Comparing one dose of HPV vaccine in girls aged 9-14 years in Tanzania (DoRIS) with one dose in young women aged 15-20 years in Kenya (KEN SHE): an immunobridging analysis of randomised controlled trials. Lancet Glob Health. 2024;12(3):e491–e499. doi: 10.1016/S2214-109X(23)00586-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
63.Daniels V., Saxena K., Patterson-Lomba O., et al. Modeling the health and economic implications of adopting a 1-dose 9-valent human papillomavirus vaccination regimen in a high-income country setting: an analysis in the United Kingdom. Vaccine. 2022;40(14):2173–2183. doi: 10.1016/j.vaccine.2022.02.067. [DOI] [PubMed] [Google Scholar]
64.Galani A., Zikopoulos A., Moustakli E., et al. Cervical cancer screening in the HPV-vaccinated and digital era: reassessing strategies in light of artificial intelligence and evolving risk. Cancers. 2025;17(19) doi: 10.3390/cancers17193179. [DOI] [PMC free article] [PubMed] [Google Scholar]
65.Elbasha E.H., Dasbach E.J. Impact of vaccinating boys and men against HPV in the United States. Vaccine. 2010;28(42):6858–6867. doi: 10.1016/j.vaccine.2010.08.030. [DOI] [PubMed] [Google Scholar]
66.Alarid-Escudero F., MacLehose R.F., Peralta Y., Kuntz K.M., Enns E.A. Nonidentifiability in model calibration and implications for medical decision making. Med Decis Mak. 2018;38(7):810–821. doi: 10.1177/0272989X18792283. [DOI] [PMC free article] [PubMed] [Google Scholar]
67.Lau J.T., Siah P.C., Tsui H.Y. A study of the STD/AIDS related attitudes and behaviors of men who have sex with men in Hong Kong. Arch Sex Behav. 2002;31(4):367–373. doi: 10.1023/a:1016280411280. [DOI] [PubMed] [Google Scholar]
68.Wei F., Gaisa M.M., D'Souza G., et al. Epidemiology of anal human papillomavirus infection and high-grade squamous intraepithelial lesions in 29 900 men according to HIV status, sexuality, and age: a collaborative pooled analysis of 64 studies. Lancet HIV. 2021;8(9):e531–e543. doi: 10.1016/S2352-3018(21)00108-9. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

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

Supplementary Materials

Supplementary Material

mmc1.pdf^{(3.8MB, pdf)}

AppendixB

mmc2.pdf^{(72.9KB, pdf)}

[bib1] 1.Bosch F.X., Lorincz A., Munoz N., Meijer C.J.L.M., Shah K.V. The causal relation between human papillomavirus and cervical cancer. J Clin Pathol. 2002;55(4):244–265. doi: 10.1136/jcp.55.4.244. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib2] 2.de Sanjose S., Serrano B., Tous S., et al. Burden of human papillomavirus (HPV)-related cancers attributable to HPVs 6/11/16/18/31/33/45/52 and 58. JNCI Cancer Spectr. 2019;2(4) doi: 10.1093/jncics/pky045. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib3] 3.Cheng L., Wang Y., Du J. Human papillomavirus vaccines: an updated review. Vaccines. 2020;8(3) doi: 10.3390/vaccines8030391. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib4] 4.Zhang J., Qin Z., Lou C., Huang J., Xiong Y. The efficacy of vaccination to prevent human papilloma viruses infection at anal and oral: a systematic review and meta-analysis. Public Health. 2021;196:165–171. doi: 10.1016/j.puhe.2021.05.012. [DOI] [PubMed] [Google Scholar]

[bib5] 5.World Health Organization Human papillomavirus vaccines WHO position paper. Wkly Epidemiol Rec. 2022;97(50):645–672. https://iris.who.int/handle/10665/365351 [Google Scholar]

[bib6] 6.World Health Organization Cervical cancer elimination initiative. 2020. https://www.who.int/initiatives/cervical-cancer-elimination-initiative Available at:

[bib7] 7.World Health Organization HPV dashboard. 2026. https://www.who.int/teams/immunization-vaccines-and-biologicals/diseases/human-papillomavirus-vaccines-(HPV)/hpv-clearing-house/hpv-dashboard Available at:

[bib8] 8.UK Health Security Agency HPV vaccination programme moves to single dose from September 2023. 2023. https://www.gov.uk/government/news/hpv-vaccination-programme-moves-to-single-dose-from-september-2023 Available at:

[bib9] 9.Department of Health and Ageing, Australian Government Change to single dose HPV vaccine. 2023. https://www.health.gov.au/ministers/the-hon-mark-butler-mp/media/change-to-single-dose-hpv-vaccine Available at:

[bib10] 10.Centre for Health Protection, Department of Health Human papillomavirus (HPV) vaccination. 2025. https://www.chp.gov.hk/en/features/102146.html Available at:

[bib11] 11.Legislative Council LCQ12: Human papillomavirus vaccination. 2023. https://www.info.gov.hk/gia/general/202307/05/P2023070500270.htm Available at:

[bib12] 12.Choi H.C.W., Jit M., Leung G.M., Tsui K.-L., Wu J.T. Simultaneously characterizing the comparative economics of routine female adolescent nonavalent human papillomavirus (HPV) vaccination and assortativity of sexual mixing in Hong Kong Chinese: a modeling analysis. BMC Med. 2018;16:127. doi: 10.1186/s12916-018-1118-3. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib13] 13.Hong Kong Cancer Registry. http://www3.ha.org.hk/cancereg/ Available at:

[bib14] 14.Chen Z., Chan A.B.W., Kam L.S., et al. Changes in the incidence and human papillomavirus-positive portion of oropharyngeal squamous cell carcinoma in Hong Kong. Cancers. 2024;16(1) doi: 10.3390/cancers16010226. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib15] 15.Brisson M., Laprise J.-F., Chesson H.W., et al. Health and economic impact of switching from a 4-valent to a 9-valent HPV vaccination program in the United States. J Natl Cancer Inst. 2016;108(1) doi: 10.1093/jnci/djv282. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib16] 16.Cody P., Tobe K., Abe M., Elbasha E.H. Public health impact and cost effectiveness of routine and catch-up vaccination of girls and women with a nine-valent HPV vaccine in Japan: a model-based study. BMC Infect Dis. 2021;21(1) doi: 10.1186/s12879-020-05632-0. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib17] 17.Chan P.K.S., Luk A.C.S., Luk T.N.M., et al. Distribution of human papillomavirus types in anogenital warts of men. J Clin Virol. 2009;44:111–114. doi: 10.1016/j.jcv.2008.11.001. [DOI] [PubMed] [Google Scholar]

[bib18] 18.Kim J.J., Simms K.T., Killen J., et al. Human papillomavirus vaccination for adults aged 30 to 45 years in the United States: a cost-effectiveness analysis. PLoS Med. 2021;18(3) doi: 10.1371/journal.pmed.1003534. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib19] 19.Chan P.K.S., Ho W.C.S., Wong M.C.S., Chang A.R., Chor J.S.Y., Yu M.-Y. Epidemiologic risk profile of infection with different groups of human papillomaviruses. J Med Virol. 2009;81:1635–1644. doi: 10.1002/jmv.21575. [DOI] [PubMed] [Google Scholar]

[bib20] 20.Lin C., Lau J.T.F., Ho K.-M., Lau M.-C., Tsui H.-Y., Lo K.-K. Incidence of genital warts among the Hong Kong general adult population. BMC Infect Dis. 2010;10:272. doi: 10.1186/1471-2334-10-272. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib21] 21.Joura E.A., Giuliano A.R., Iversen O.-E., et al. A 9-valent HPV vaccine against infection and intraepithelial neoplasia in women. N Engl J Med. 2015;372(8):711–723. doi: 10.1056/NEJMoa1405044. [DOI] [PubMed] [Google Scholar]

[bib22] 22.Malagon T., Drolet M., Boily M.-C., et al. Cross-protective efficacy of two human papillomavirus vaccines: a systematic review and meta-analysis. Lancet Infect Dis. 2012;12(10):781–789. doi: 10.1016/S1473-3099(12)70187-1. [DOI] [PubMed] [Google Scholar]

[bib23] 23.Wang Z., Wang J., Fang Y., et al. Parental acceptability of HPV vaccination for boys and girls aged 9-13 years in China - a population-based study. Vaccine. 2018;36(19):2657–2665. doi: 10.1016/j.vaccine.2018.03.057. [DOI] [PubMed] [Google Scholar]

[bib24] 24.Cheung T., Lau J.T.F., Wang J.Z., Mo P.K.H., Ho Y.S. Acceptability of HPV vaccines and associations with perceptions related to HPV and HPV vaccines among male baccalaureate students in Hong Kong. PLoS One. 2018;13(6) doi: 10.1371/journal.pone.0198615. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib25] 25.Malvi S.G., Esmy P.O., Muwonge R., et al. A prospective cohort study comparing efficacy of 1 dose of quadrivalent human papillomavirus vaccine to 2 and 3 doses at an average follow up of 12 years postvaccination. J Natl Cancer Inst Monogr. 2024;2024(67):317–328. doi: 10.1093/jncimonographs/lgae042. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib26] 26.Porras C., Romero B., Kemp T., et al. HPV16/18 antibodies 16-years after single dose of bivalent HPV vaccination: costa Rica HPV vaccine trial. J Natl Cancer Inst Monogr. 2024;2024(67):329–336. doi: 10.1093/jncimonographs/lgae032. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib27] 27.Prem K., Choi Y.H., Benard E., et al. Global impact and cost-effectiveness of one-dose versus two-dose human papillomavirus vaccination schedules: a comparative modelling analysis. BMC Med. 2023;21(1) doi: 10.1186/s12916-023-02988-3. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib28] 28.Brisson M., Laprise J.F., Drolet M., et al. Population-level impact of switching to 1-dose human papillomavirus vaccination in high-income countries: examining uncertainties using mathematical modeling. J Natl Cancer Inst Monogr. 2024;2024(67):387–399. doi: 10.1093/jncimonographs/lgae038. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib29] 29.Department of Health The budget. Replies to written questions raised by Finance Committee Members in examining the Estimates of Expenditure (2025-26) 2025. https://www.dh.gov.hk/english/budget/budget.html Available at:

[bib30] 30.Centre for Health Protection Human papillomavirus (HPV) vaccination catch-up programme. 2026. https://www.chp.gov.hk/en/features/108084.html Available at:

[bib31] 31.Hospital Authority Revisions to list of charges: Gazette No. 3884. 2017. https://www.gld.gov.hk/egazette/pdf/20172124/egn201721243884.pdf Available at:

[bib32] 32.Cheung T.H., Cheng S.S.Y., Hsu D., et al. Health impact and cost-effectiveness of implementing gender-neutral vaccination with the 9-valent HPV vaccine in Hong Kong. Hum Vaccin Immunother. 2023;19(2) doi: 10.1080/21645515.2023.2184605. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib33] 33.Centre for Health Protection, Department of Health Report of Population Health Survey 2020-2022. 2022. https://www.chp.gov.hk/en/features/37474.html Available at:

[bib34] 34.Cervical Screening Programme, Department of health. https://www.cervicalscreening.gov.hk/en/index.html Available at:

[bib35] 35.Choi H.C.W., Leung K., Wu J.T. Cervical screening among Chinese females in the era of HPV vaccination: a population-based survey on screening uptake and regular screening following an 18-year organized screening program. J Gynecol Oncol. 2024;35(2):e20. doi: 10.3802/jgo.2024.35.e20. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib36] 36.The Hong Kong College of Obstetricians and Gynaecologists Guidelines for cervical cancer prevention and screening. 2024. https://www.hkcog.org.hk/hkcog/Download/Guidelines_for_Cervical_Cancer_Prevention_and_Screening.pdf Available at: [DOI] [PubMed]

[bib37] 37.Choi H.C.W., Leung K., Chan K.K.L., Bai Y., Jit M., Wu J.T. Maximizing the cost-effectiveness of cervical screening in the context of routine HPV vaccination by optimizing screening strategies with respect to vaccine uptake: a modeling analysis. BMC Med. 2023;21(1) doi: 10.1186/s12916-023-02748-3. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib38] 38.You D., Quan J., Bishai D., et al. Evaluating cost-effectiveness of 9-valent HPV vaccination for men who have sex with men by HIV status in Hong Kong. Vaccine. 2025;63 doi: 10.1016/j.vaccine.2025.127625. [DOI] [PubMed] [Google Scholar]

[bib39] 39.Census and Statistics Department Table 31: gross domestic product (GDP), implicit price deflator of GDP and per capita GDP. https://www.censtatd.gov.hk/en/web_table.html?id=31 Available at:

[bib40] 40.Pichon-Riviere A., Drummond M., Palacios A., Garcia-Marti S., Augustovski F. Determining the efficiency path to universal health coverage: cost-effectiveness thresholds for 174 countries based on growth in life expectancy and health expenditures. Lancet Glob Health. 2023;11(6):e833–e842. doi: 10.1016/S2214-109X(23)00162-6. [DOI] [PubMed] [Google Scholar]

[bib41] 41.Charles River Associates Benchmarking the UK’s cost-effectiveness threshold: findings from international comparison. 2026. https://www.abpi.org.uk/publications/benchmarking-the-uk-s-cost-effectiveness-threshold-findings-from-international-comparison/ Available at:

[bib42] 42.World Health Organization Making choices in health: WHO guide to cost-effectiveness analysis, ed. T. Tan-Torres Edejer, R.M.P.M. Baltussen, T. Adam et.al Geneva, Switzerland. 2003. http://www.who.int/choice/publications/p_2003_generalised_cea.pdf Available at:

[bib43] 43.Bertram M.Y., Lauer J.A., De Joncheere K., et al. Cost-effectiveness thresholds: pros and cons. Bull World Health Organ. 2016;94(12):925–930. doi: 10.2471/BLT.15.164418. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib44] 44.Marseille E., Larson B., Kazi D.S., Kahn J.G., Rosen S. Thresholds for the cost–effectiveness of interventions: alternative approaches. Bull World Health Organ. 2015;93:118–124. doi: 10.2471/BLT.14.138206. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib45] 45.Ochalek J., Claxton K., Lomas J., Thompson K.M. Valuing health outcomes: developing better defaults based on health opportunity costs. Expert Rev Pharmacoecon Outcomes Res. 2021;21(4):729–736. doi: 10.1080/14737167.2020.1812387. [DOI] [PubMed] [Google Scholar]

[bib46] 46.Deshmukh A.A., Damgacioglu H., Georges D., Sonawane K., Clifford G.M. Human papillomavirus-associated anal cancer incidence and burden among US men, according to sexual orientation, human immunodeficiency virus status, and age. Clin Infect Dis. 2023;77(3):419–424. doi: 10.1093/cid/ciad205. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib47] 47.Sonawane K., Shyu S.S., Damgacioglu H., Li R., Nyitray A.G., Deshmukh A.A. Prevalence and concordance of oral and genital HPV by sexual orientation among US men. JNCI Cancer Spectr. 2023;7(1) doi: 10.1093/jncics/pkac088. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib48] 48.Deshmukh A.A., Tanner R.J., Luetke M.C., Hong Y.R., Sonawane Deshmukh K., Mainous A.G. 3rd. Prevalence and risk of penile human papillomavirus infection: evidence from The National Health and Nutrition Examination Survey 2013-2014. Clin Infect Dis. 2017;64(10):1360–1366. doi: 10.1093/cid/cix159. [DOI] [PubMed] [Google Scholar]

[bib49] 49.Lau J.T., Kim J.H., Lau M., Tsui H.Y. HIV related behaviours and attitudes among Chinese men who have sex with men in Hong Kong: a population based study. Sex Transm Infect. 2004;80(6):459–465. doi: 10.1136/sti.2003.008854. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib50] 50.Ho W.C.S., Boon S.S., Chong K.C., et al. Prevalence of oral human papillomavirus infection among the general adult population in Hong Kong. J Med Virol. 2024;96(2) doi: 10.1002/jmv.29460. [DOI] [PubMed] [Google Scholar]

[bib51] 51.Husereau D., Drummond M., Augustovski F., et al. Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) statement: updated reporting guidance for health economic evaluations. BMC Health Serv Res. 2022;22(1) doi: 10.1186/s12913-021-07460-7. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib52] 52.Canfell K., Kim J.J., Kulasingam S., et al. HPV-FRAME: a consensus statement and quality framework for modelled evaluations of HPV-related cancer control. Papillomavirus Res. 2019;8 doi: 10.1016/j.pvr.2019.100184. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib53] 53.Linertova R., Guirado-Fuentes C., Mar Medina J., Imaz-Iglesia I., Rodriguez-Rodriguez L., Carmona-Rodriguez M. Cost-effectiveness of extending the HPV vaccination to boys: a systematic review. J Epidemiol Community Health. 2021;75(9):910–916. doi: 10.1136/jech-2020-216305. [DOI] [PubMed] [Google Scholar]

[bib54] 54.Datta S., Pink J., Medley G.F., et al. Assessing the cost-effectiveness of HPV vaccination strategies for adolescent girls and boys in the UK. BMC Infect Dis. 2019;19:552. doi: 10.1186/s12879-019-4108-y. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib55] 55.Palmer C., Tobe K., Negishi Y., You X., Chen Y.T., Abe M. Health impact and cost effectiveness of implementing gender-neutral HPV vaccination in Japan. J Med Econ. 2023;26(1):1546–1554. doi: 10.1080/13696998.2023.2282912. [DOI] [PubMed] [Google Scholar]

[bib56] 56.Wahab M.T., Tan R.K.J., Cook A.R., Prem K. Impact of including boys in the national school-based human papillomavirus vaccination programme in Singapore: a modelling-based cost-effectiveness analysis. Vaccine. 2023;41(12):1934–1942. doi: 10.1016/j.vaccine.2023.02.025. [DOI] [PubMed] [Google Scholar]

[bib57] 57.Fu X., Zhang Q., Wagner A.L., Zhou W., Xia Y., Lu Y. Cost-effectiveness and epidemiological impact of gender-neutral vaccination against human papillomavirus in economically developed metropolises of Beijing, Shanghai, and Guangzhou, China. Hum Vaccin Immunother. 2025;21(1) doi: 10.1080/21645515.2025.2557092. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib58] 58.Chou H.H., Chu P.Y., Wu Y.H., et al. Health impact and cost-effectiveness analysis of gender-neutral versus female-only 9-valent human papillomavirus vaccination in Taiwan. PLoS One. 2025;20(10) doi: 10.1371/journal.pone.0333757. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib59] 59.Liu S.S., Chan K.Y.K., Leung R.C.Y., et al. Prevalence and risk factors of human papillomavirus (HPV) infection in southern Chinese women - a population-based study. PLoS One. 2011;6(5) doi: 10.1371/journal.pone.0019244. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib60] 60.Kreimer A.R., Porras C., Liu D., et al. Noninferiority of one HPV vaccine dose to two doses. N Engl J Med. 2025;393:2421–2433. doi: 10.1056/NEJMoa2506765. [DOI] [PubMed] [Google Scholar]

[bib61] 61.Barnabas R.V., Brown E.R., Onono M.A., et al. Durability of single-dose HPV vaccination in young Kenyan women: randomized controlled trial 3-year results. Nat Med. 2023;29(12):3224–3232. doi: 10.1038/s41591-023-02658-0. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib62] 62.Baisley K., Kemp T.J., Mugo N.R., et al. Comparing one dose of HPV vaccine in girls aged 9-14 years in Tanzania (DoRIS) with one dose in young women aged 15-20 years in Kenya (KEN SHE): an immunobridging analysis of randomised controlled trials. Lancet Glob Health. 2024;12(3):e491–e499. doi: 10.1016/S2214-109X(23)00586-7. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib63] 63.Daniels V., Saxena K., Patterson-Lomba O., et al. Modeling the health and economic implications of adopting a 1-dose 9-valent human papillomavirus vaccination regimen in a high-income country setting: an analysis in the United Kingdom. Vaccine. 2022;40(14):2173–2183. doi: 10.1016/j.vaccine.2022.02.067. [DOI] [PubMed] [Google Scholar]

[bib64] 64.Galani A., Zikopoulos A., Moustakli E., et al. Cervical cancer screening in the HPV-vaccinated and digital era: reassessing strategies in light of artificial intelligence and evolving risk. Cancers. 2025;17(19) doi: 10.3390/cancers17193179. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib65] 65.Elbasha E.H., Dasbach E.J. Impact of vaccinating boys and men against HPV in the United States. Vaccine. 2010;28(42):6858–6867. doi: 10.1016/j.vaccine.2010.08.030. [DOI] [PubMed] [Google Scholar]

[bib66] 66.Alarid-Escudero F., MacLehose R.F., Peralta Y., Kuntz K.M., Enns E.A. Nonidentifiability in model calibration and implications for medical decision making. Med Decis Mak. 2018;38(7):810–821. doi: 10.1177/0272989X18792283. [DOI] [PMC free article] [PubMed] [Google Scholar]

[bib67] 67.Lau J.T., Siah P.C., Tsui H.Y. A study of the STD/AIDS related attitudes and behaviors of men who have sex with men in Hong Kong. Arch Sex Behav. 2002;31(4):367–373. doi: 10.1023/a:1016280411280. [DOI] [PubMed] [Google Scholar]

[bib68] 68.Wei F., Gaisa M.M., D'Souza G., et al. Epidemiology of anal human papillomavirus infection and high-grade squamous intraepithelial lesions in 29 900 men according to HIV status, sexuality, and age: a collaborative pooled analysis of 64 studies. Lancet HIV. 2021;8(9):e531–e543. doi: 10.1016/S2352-3018(21)00108-9. [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

Cost-effectiveness and health impact of gender-neutral and single-dose HPV vaccination in Hong Kong: a modeling analysis

Horace Cheuk Wai Choi

Kathy Leung

Mark Jit

Joseph T Wu

Summary

Background

Methods

Findings

Interpretation

Funding

Research in context.

Evidence before this study

Added value of this study

Implications of all the available evidence

Introduction

Methods

Models

HPV transmission and cervical cancer

Other HPV-related cancers

Genital warts

HPV vaccination

Cost-effectiveness analysis (CEA)

Ethics approval

Role of the funding source

Results

CEA

2F2M

Fig. 1.

1F1M

Fig. 2.

2F1M

Fig. 3.

Projected timeline for the elimination of cervical cancer

Fig. 4.

Discussion

Table 1.

Limitations

Conclusions

Contributors

Data sharing statement

Editor note

Declaration of interests

Acknowledgements

Footnotes

Appendix A. Supplementary data

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

Similar articles

Cited by other articles

Links to NCBI Databases