HIV-Positive Gay Men's Knowledge and Perceptions of Human Papillomavirus (HPV) and HPV Vaccination: A Qualitative Study

"Public health policy and health promotion strategies in Canada have facilitated vaccine hesitancy among HIV-positive men at risk for HPV associated cancers."

Gay, bisexual, and other men who have sex with men (GBM) living with HIV are disproportionately impacted by human papillomavirus (HPV)-associated anal cancer. Only in 2016 did the province of Ontario in Canada expand its coverage of HPV vaccination to include boys aged 9 to 13 years and GBM up to 26 years of age. Qualitative research in North America and the United Kingdom has demonstrated that GBM often report a willingness to be vaccinated, despite limited awareness and understanding of HPV risks. This article explores HPV vaccination barriers and hesitancy among HIV-positive gay men in the city of Toronto, Ontario, by sharing the results of in-depth interviews conducted as part of the HPV Screening and Vaccine Evaluation (HPV-SAVE) Study.

Between November 2016 and July 2017, the researchers conducted 25 in-depth, semi-structured qualitative interviews with gay men living with HIV in Toronto. Almost all the participants said they were aware of the HPV vaccine before entering the HPV-SAVE study. There was also an emerging sense among many participants that HPV and anal cancer are serious health risks to HIV-positive men, as well as a reported interest by many to be vaccinated. However, before enrolling in the HPV-SAVE Study, only one-quarter of the participants reported being vaccinated for HPV (having received all or some of the 3 doses at the time of the interview).

The paper presents a review of the 2 overarching and multi-layered factors affecting the vaccine hesitancy of the participants:

1. The association of HPV with women and low levels of vaccination literacy - Many participants discussed having first heard about HPV and the HPV vaccine in the media. However, almost all participants reported initially believing HPV vaccination was predominately or exclusively an intervention designed for cisgender girls or women and that it was for the prevention of cervical cancer. Once informed by their primary care physicians and/or HPV-SAVE researchers about the risks posed by HPV to gay men in the form of anal cancer, most men explained that they could understand how this could be the case and were interested in learning more and becoming vaccinated. Yet many participants reported low levels of health literacy regarding HPV risks among GBM before entering HPV-SAVE; some explained that the association between HPV and women made it hard for them to locate health promotion material that was directly relevant for them. Not realising they could be at risk, they had never thought to initiate a conversation about HPV with their physician. Furthermore, none of the participants reported that the vaccine was strongly recommended by a physician; in the absence of such a recommendation, they said they would not actively pursue HPV vaccination.
2. The role of vaccine price including persistent financial barriers to vaccine access - Even when physicians were said to have made unambiguously clear recommendations for HPV vaccination, the perceived benefits and necessity of the vaccine were weighed against significant affordability concerns by some participants. Only a few participants reported being aware that the HPV vaccine is freely available to men in Ontario who are 26 years old and under.

For these reasons, notwithstanding their noted acceptability of vaccination (i.e., the idea/principle of getting vaccinated in general), reluctance remained in relation to HPV vaccination. Viewed in this way, the participants appeared to be closer to the "acceptance" end of the vaccine hesitancy continuum, with a number of interrelated obstacles preventing vaccination. The researchers' analysis points to a number of interrelated, structurally produced vaccine hesitancies. Rather than a property of individuals refusing vaccination, it is social systems - i.e., media, health promotion campaigns, public policy, physician recommendations - that together create environments and knowledge systems in which people are less likely to become vaccinated.

Given these structurally produced hesitancies, the study highlights that a clear and strong recommendation by a physician was a primary facilitator to be vaccinated. This poses challenges for physicians who have to balance communicating the possible benefits of vaccination with respecting how their patients' decision-making may be constrained by finances. However, according to the researchers, physicians should be mindful not to communicate the vaccine as being less essential because of the costs. Physicians serving HIV-positive patients should readdress the issue of vaccination annually to see if a patient's financial situation has changed, and to clarify the benefits of vaccination.

"Increasing HPV vaccination among HIV-positive GBM in Ontario and across Canada will require the commitment of well-informed health care providers who provide clear recommendations along with continued public health, governmental, and community efforts to remove barriers to access."