HPV Awareness and Willingness to HPV Vaccination among High-Risk Men attending an STI Clinic in Puerto Rico

Abstract

Objective

An HPV vaccine has been approved for men aged 9 to 26 in the US for the prevention of genital warts and anal cancer. The purpose of this study is to describe 1) HPV vaccine awareness, 2) willingness to get the HPV vaccine and 3) perceived susceptibility to HPV-related cancers and genital warts among men 18–26 years old who attend an STI clinic in San Juan, Puerto Rico (PR).

Methods

A cross-sectional pilot study consisting of 206 HIV+/HIV− men. For purpose of this analysis, only those participants aged ≤26 years old were included in this analysis (n=46).

Results

None of the study participants had been vaccinated against HPV. Fewer than a third knew about the HPV vaccine (28.3%). However, more than half (76.9%) were willing to be vaccinated against HPV. Information sources about the HPV vaccine included their female sexual partners (13.0%), a female sexual partner who received the vaccine (8.7%) and a male sexual partner (2.2%). Most participants reported that the main reason that would increase their willingness to get vaccinated was if a physician recommend the vaccine (95.7%). Perceived susceptibility was low, particularly for anal and oral cancer.

Conclusion

This pilot study shows poor awareness of the HPV vaccine, although willingness to getting the HPV vaccine was high among those who knew about the vaccine. Future studies should try to evaluate this paradox and study in depth willingness and barriers to vaccination among male sub-groups, such as men who have sex with men (MSM). These studies should also evaluate predictors of uptake of the HPV vaccine among men in this and other STI clinics in PR, in order to develop interventions to increase male vaccination.

Human papilloma virus (HPV) is a common sexually transmitted infection (1, 2). Studies have reported that oncogenic HPV types may be responsible for HPV-related cancers in men, such as oropharyngeal, anal, and penile cancer (3). Men are at risk for HPV infection and can benefit from vaccination, but vaccination rates remain low (4), with reports indicating only 1.4% of young men have received at least one dose in the US (5). The Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) recommends routine HPV vaccination for males at 11 or 12 years of age, or at 13 to 21 years of age if not previously vaccinated. Males 22 to 26 years of age may also be vaccinated (6, 7). Since this is not a live vaccine, it can be administered to immunocompromised persons through age 26 years not previously vaccinated. This vaccine is recommended for men who have sex with men (MSM) through age 26 years not previously vaccinated (7).

Given the burden of HPV-related malignancies and the availability of an effective vaccine to decrease the incidence of HPV-related external genital lesions (8, 9), as well as reducing the risk of anal cancer (10), understanding HPV vaccine awareness and willingness to receive the HPV vaccine is important for effective prevention programs with the objective of decreasing the burden of HPV (11). The objective of this pilot study was to describe 1) HPV vaccine awareness, 2) willingness to HPV vaccination and 3) the perceived susceptibility to HPV-related cancers and genital warts among men aged 18–26 years old who attend an STI clinic in Puerto Rico (PR).

Methods

We conducted a cross-sectional study of 206 men, 18 years and older, attending the Centro Latino Americano de Enfermedades de Transmisión Sexual (CLETS) in 2009–2010. This study was part of a parent study among men and women attending this STI clinic in San Juan, PR. The study design and methods have been described elsewhere (12). Briefly, the design of the parent study includes a consecutive selection of men and women, from the clinic waiting room. Following completion of the informed consent, subjects participated in a face-to face behavioral interview, and a supplemental survey that contained information related to HPV knowledge, including assessments of HPV transmission knowledge, susceptibility to HPV-related cancers (penile, anal, oral) and vaccine acceptability. Information from the surveys was gathered using the QDS system (Questionnaire Design System, Nova Research Co., Bethesda, Maryland). Both studies were previously approved by the University of Puerto Rico, Medical Sciences Campus Institutional Review Board (IRB).

HPV vaccine awareness and willingness to be vaccinated

Men were asked if they had ever heard about the HPV vaccine before the survey. Those men who reported having heard of the HPV vaccine were also asked questions regarding where they had heard of the HPV vaccine (information sources), factors that might influence vaccination willingness, and if they were interested in HPV vaccination in the future.

Perceived susceptibility to HPV-related morbidities

We assessed perceived susceptibility to HPV-related morbidities (cancer and genital warts) with the following question: ‘How do you describe your risk for anal, oral, penile and genital warts?’ by using a 4-item scale [0=Not sure how to assess my risk;1=Not at risk/low risk;2=At moderate risk;3=At high risk].

Statistical Analysis

From the total sample of 206 men who participated in our study, only 46 (22.3%) subjects aged 18–26 years were included in this analysis, given that this age groups are included within the recommended age for vaccine administration (4, 5). Frequency distributions and summary measures were used to describe the study sample using SPSS version 17 (Chicago, IL).

Results

Most participants had more than high school education (89.2%) and were employed at the time of the interview (78.3%). A third of the sample (34.8%) reported having used illegal or illicit drugs in the last 3 months, 32.6% reported being circumcised, and almost half (45.7%) attended the clinic for the first time at the time of the interview (Table 1).

Table 1.

Univariate analysis among a sample of men aged 18 to 26 years attending an STI clinic in PR, 2009–2010 (n=46).

Variables	N	%
Sociodemographic characteristics
Age (years)
mean ± SD: 21.70 ± 2.35
Educational Level
< High School	5	10.9%
≥ High School	41	89.2%
Employment
No	10	21.7%
Yes	36	78.3%
Individual Annual Income
None	10	21.7%
< $15,000	29	63.0%
≥ $15,000	7	15.2%
Place of Birth
Puerto Rico	42	91.3%
Other	4	8.7%
Health Insurance
None	13	28.3%
Public	13	28.3%
Private	20	43.5%
Behavioral Risk Factors
Tobacco Use (last 90 days)
No	23	50.0%
Yes	23	50.0%
Alcohol Use (last 90 days)
No	10	21.7%
Yes	36	78.3%
Drug Use (last 90 days)
No	30	65.2%
Yes	16	34.8%
Self-reported sexual Identity
Heterosexual	31	67.4%
MSM	15	32.6%
Lifetime Female Sexual Partners*
< 10 partners	13	41.9%
≥ 10 partners	17	54.8%
Female Sexual Partners (last 90 days)
None	18	39.1%
1 partner	19	41.3%
> 1 partner	9	19.6%
Lifetime MSM Sexual Partners†
< 10 partners	9	60.0%
≥ 10 partners	6	40.0%
Circumcised
No	36	78.3%
Yes	15	32.6%
Self-reported STIs (Lifetime)
Genital Warts
No	34	73.9%
Yes	12	26.1%
Chlamydia
No	35	76.1%
Yes	11	23.9%
HIV
No	43	93.5%
Yes	3	6.5%
First time at STI Clinic
No	25	54.3%
Yes	21	45.7%
HPV Vaccine
HPV vaccine awareness
No	33	71.7%
Yes	13	28.3%
HPV Vaccine Willingness**
No	3	23.1%
Yes	10	76.9%
Sources of Information about HPV vaccine**
Female sexual partner	6	13.0%
Female sexual partner who have received the vaccine	4	8.7%
Male sexual partner	1	2.2%

^*Only those who self-reported as heterosexual (n=30, 1 missing value);

^†Only who identified as (MSM) (n=15);

^**Only those who answered that knew about the HPV vaccine (n=13, 2 missing values)

A third of the study participants reported being MSM (32.6%) and more than half (54.8%) of the heterosexual men in this sample reported having sex with more than 10 female sexual partners in their lifetime. The lifetime self-reported prevalence of genital warts in the total sample was 26.1%, whereas 6.5% were HIV positive and 23.9% had ever had Chlamydia (Table 1).

HPV vaccine awareness and willingness

None of the study participants had been vaccinated against HPV and less than a third (28.3%) knew about the HPV vaccine. However, more than half of those who knew about the vaccine (76.9%) were willing to be vaccinated against HPV (Table 1). Sources of information of the HPV vaccine included their female sexual partners (13.0%), a female sexual partner who had received the vaccine (8.7%), and a male sexual partner (2.2%).

Table 2 shows factors influencing vaccination. In the overall sample, reported reasons that would lead study participants to be vaccinated included: if the physician recommended it (95.7%), if health insurance covers the vaccine (91.3%), and if the participants knew the vaccine’s importance for their health (91.3%) (Table 2). Among those who knew about the HPV vaccine but had not been vaccinated (28.3%), the majority reported that they would be willing to receive the vaccine if a physician recommends it and if they understand the vaccine’s importance for their health (data not shown). The principal reasons that men who knew about the vaccine indicated for not had been vaccinated against HPV were the lack of understanding of being at risk for HPV infection followed by the high cost of the vaccine.

Table 2.

Factors influencing vaccination among a sample of men aged 18 to 26 years attending an STI clinic in PR, 2009–2010 (n=46).

Would accept the HPV vaccine if…	N (%)
Doctor recommends it	44 (95.7%)
Other health professional recommends it	40 (87.0%)
Health insurance covers it	42 (91.3%)
Vaccine is free	41 (89.1)
Sexual partner recommends it	40 (87.0%)
Relative recommends it	37 (80.4%)
Friend recommends it	30 (65.2%)
Know the vaccine’s importance for his health	42 (91.3%)
It’s offered at school or college	37 (80.4%)
It protects a female sexual partner against genital warts and cervical cancer	38 (82.6%)
It protects a male sexual partner against genital warts	24 (52.2%)
It protects a male sexual partner against penile or anal cancer	23 (50.0%)

When contrasting heterosexual versus MSM, regarding the factors influencing vaccination, 82.6% of the heterosexual men interviewed reported that they would be willing to get vaccinated if they knew that the vaccine would protect their female sexual partners against genital warts and cervical cancer. However, only half of the MSM interviewed would be willing to be vaccinated against HPV if they knew that the vaccine would protect their male partners against genital warts (52.2%) or HPV-related cancers such as a penile or anal cancer (50.0%).

HPV Susceptibility

The majority of the study participants indicated that they perceived that they were at little or no risk for genital warts and HPV-related cancers (Figure 1). For anal cancer, approximately a third (32.6%) of the participants reported having low risk or no risk at all, followed by participants who indicated they were not sure how to assess their risk (30.4%). The majority (58.7%) also reported that they were at low risk or at no risk at all for oral cancer.

Figure 1.

Perceived susceptibility to HPV related morbidities among a sample of men aged 18 to 26 years attending an STI clinic in PR, 2009–2010 (n=46).

Discussion

This pilot study highlights the poor awareness of the HPV vaccine in a small sample of high-risk young men (18–26 years) attending an STI clinic in San Juan, PR. However, among those who knew about the vaccine, interest in getting vaccinated was high. High acceptability has also been reported previously in other male populations (4), including MSM (14). In this study, separate analysis showed that a higher proportion of MSM (53%) were aware of the HPV vaccine as compared to heterosexual men (16%, p=0.01), although acceptability was similarly high in both groups (77% and 80% respectively, p>0.05).

This study also showed that even though this population is at high-risk for HPV infection (given their high-risk sexual practices and high prevalence of genital warts), they had a low perceived susceptibility to HPV-related cancers and genital warts. Their reported perceived susceptibility is in alignment with findings regarding the low knowledge of HPV infection within men in this STI clinic, in which fewer than 15% had an adequate knowledge of HPV infection and its long-term consequences (15). Our study also showed that none of the study participants have been vaccinated against HPV. Given their high-risk sexual practices, this group and their sexual partners would benefit from HPV vaccination. However, given the small sample size, caution with the interpretation of the findings is warranted. Future studies with a larger and more representative population sample are needed to identify predictors of uptake of the HPV vaccine among different male sub-groups, including MSM and HIV positive men. This will assist in the development of tailored interventions to increase STI and cancer prevention efforts in Puerto Rican men.