News Sexual Health

Study: Low-Income Girls Less Likely to Get HPV Vaccine, Reasons Vary

Martha Kempner

New research found that low-income parents do not get their daughters vaccinated with the HPV vaccine for a variety of reasons, including inadequate explanations by health-care providers, distrust of the government and medicine, and beliefs about pre-marital sex.

The human papillomavirus (HPV) vaccine is recommended as part of routine vaccinations for girls ages 11 and 12, but research has shown that few young people actually get all three of the required doses. The Centers for Disease Control and Prevention (CDC) has found that only 54 percent of girls initiated the vaccine and only 33 percent received all three doses in 2012. The completion rate is even lower—28 percent—for girls under the poverty line.

New research released last week looked into the reasons why low-income parents do not get their daughters vaccinated and found that they include inadequate explanations by health-care providers, distrust of the government and medicine, and beliefs about pre-marital sex. Moreover, the research found that these reasons varied based on whether parents spoke primarily English or Spanish.

Researchers conducted phone interviews and focus groups with 41 low-income parents of girls ages 12 to 15 in the Denver area. Approximately half of the parents spoke English, and the other half spoke Spanish. Within each language group, half of the parents had initiated HPV vaccines for their daughters but not completed them, and the other half had not initiated them at all. The results were presented at IDWeek 2013, the annual meeting of four professional groups dedicated to infectious diseases.

The results found that English-speaking parents were more likely to note safety concerns about the vaccine and distrust of the government or medicine in general. They were also more likely to perceive their daughters’ risk of HPV infection as low. In contrast, Spanish-speaking parents were more concerned that the vaccine would undermine their messages of “no sex before marriage.” Spanish-speaking parents also said that their health-care providers did not encourage the vaccine or had not adequately explained that the vaccine required three shots over the course of six months.

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“The reasons low-income girls did not initiate or complete HPV vaccination were strikingly different depending on whether their parents spoke English or Spanish,” Dr. Sean O’Leary, one of the researchers, said in a statement. “This insight should be helpful to health educators and policymakers as they seek ways to improve vaccination rates.”

Specifically, O’Leary suggests that information about the vaccine and the need to get all shots written in Spanish might help Spanish-speaking parents, whereas more information about the vaccine’s safety might be what English-speaking parents need.

HPV is very common, with about 79 million Americans currently infected and some 14 million new infections each year. Moreover, about 17,400 women in the United States get cancer caused by the virus each year, with cervical cancer being the most common type. HPV-related cancers of the neck, throat, and penis also affect almost 8,800 men each year. There are two vaccines on the market—Gardasil and Cervarix—that have been shown to prevent infection with the strains of HPV that are most likely to cause cervical cancer.

Commentary Science

HPV Vaccines Are Working, So It’s Time to Stop Arguing About Them

Martha Kempner

A new study finds that HPV rates have plummeted in the last six years. Yet HPV vaccination rates continue to lag behind those of other vaccines, in part because of the stigma surrounding sexually transmitted infections.

According to a new study, human papilloma virus (HPV) rates have plummeted in the first six years vaccines against the virus have been available. Unfortunately, HPV vaccination rates lag behind those of other recommended inoculations, in part because of the stigma that stifles conversations around sexually transmitted infections.

Perhaps these new success rates—coupled with additional new research that reminds us of the possibility of non-sexual HPV transmission—will convince more parents to take advantage of this potentially life-saving vaccine.

HPV is actually a group of more than 150 related viruses, 40 of which are known to be sexually transmitted. Most types of the virus are thought of as low-risk, because they are unlikely to cause health problems. Nine types, however, have been identified as high-risk and are thought to be responsible for 99 percent of cervical cancers and a large portion of vulvar, vaginal, penile, anal, and oropharyngeal (a part of the throat) cancers.

Since 2006, there have been three vaccines against HPV developed and released on the market. The most recent, made available last year, was the most wide-ranging; it protects against the nine high-risk types of the virus.

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The vaccine is given as a series of three shots over eight months. The Centers for Disease Control and Prevention (CDC) recommends that boys and girls begin the series at age 11 or 12 in order to be sure that they are fully vaccinated before they become sexually active, but those who do not get the shots at that time can get them at any point before age 26. Experts estimate that widespread vaccination could prevent up to 90 percent of cases of cervical, anal, and genital cancer.

Though the research released last month uses data collected before the latest vaccine was available, the success of the original vaccine supports an optimistic outlook for the future prevention of HPV.

For the new study, which was published in the journal Pediatrics, researchers used data from the CDC’s National Health and Nutrition Examinations Survey (NHANES). They compared cervical and vaginal specimens from individuals ages 14-to-34 collected between 2003 and 2006—before the vaccine was available—with samples collected between 2009 and 2012, after the first vaccine was in use. They also used vaccination records from the latter group.

They found that 11.5 percent of young women ages 14-to-19 in the pre-vaccine group had one of the four types of HPV covered by the original vaccine. This dropped to about 4 percent in the group examined after the vaccine was available. Among those ages 20-to-24, the prevalence rate dropped from 18.5 percent to roughly 12 percent. There was no change among the oldest age group.

Overall, the study concludes, within six years of the vaccine’s introduction, HPV rates were down 64 percent among teen girls and 34 percent among women in their 20s.

Dr. Laurie E. Markowitz, lead author of the study, told the Guardian that results were better than expected.“The fact that we are seeing a larger decrease overall than what we expect given our coverage rates does suggest there may be some herd protection,” which occurs when a large enough portion of the population is vaccinated to slow the spread of the virus, she said. “There also may be effectiveness from less than a complete three dose series,” Markowitz continued.

Researchers anticipate that more people will continue to benefit from the vaccines. Markowitz told the Guardian, “As women who got the vaccine when they were younger age move into these older age groups, we should continue to see a continued decrease,” because they will not transmit the strains to anyone else as they become sexually active.

In addition, vaccination rates have improved since this data was collected. In 2009, only about 44 percent of girls had received one dose of the vaccine and only about 27 percent had received all three. By 2014, two-thirds of teenage girls ages 17 and under had received at least one of the three recommended doses of the HPV vaccine, and about 40 percent had received all three doses.

The CDC recommends that boys get the HPV vaccine as well, but vaccinations rates among boys have always been lower than those among young women—perhaps because when the vaccine was originally introduced, it was only suggested for girls, or perhaps because it is best known for preventing cervical cancer. But vaccination rates for boys have been on the rise as well. In 2014, roughly 42 percent of teenage boys ages 17 and under had received at least one dose of the vaccine: about 8 percentage points higher than the year prior.

Unfortunately, HPV vaccination rates still lag behind those of other recommended vaccines. For comparison, in 2014, about eight in ten teens ages 17 and under had received the quadrivalent meningococcal conjugate vaccines and roughly 87 percent had received the Tdap vaccine, which covers tetanus, diphtheria, and pertussis.

There are a number of reasons that HPV vaccination rates might be lower than others, including the fact that only two states and Washington, D.C. require the vaccine for school-aged children. By contrast, the Tdap vaccine is required in most states; meningitis vaccines are required in about half. Additionally, some parents may not have the resources or time to take their children to get a series of three vaccinations.

Not surprisingly, there still exists a discomfort with the sexually transmitted nature of HPV. Since, the HPV vaccine was introduced, there have been those who argue that vaccination will be seen by teenage recipients as permission to have sex, thereby increasing their risky behavior. This faction also argues that it is not necessary to inoculate young people against HPV because they can easily avoid it by just not having sex.

Numerous studies have found that HPV vaccines do not, in fact, turn young people into sex machines. A study last year from the United Kingdom, for example, found girls who have been vaccinated are less likely to engage in risky sexual behavior than those who have not. An earlier study in the United States found that teen girls who had been vaccinated were more likely to use condoms than their non-vaccinated peers. Other studies have found that young people’s perception of sexual risk and risk behaviors do not change after vaccination.

Perhaps a new article will take the wind out of the sails of the argument that teens should “just say no” to prevent HPV. The paper, cleverly titled “Penises Not Required,” reviewed 51 studies that found evidence of transmission through means other than penile-vaginal or penile-anal intercourse. Some of the studies reviewed found HPV DNA in the genital tract of female “virgins”—though the definitions of “virgin” varied widely among studies, and were based on respondents’ self-reported sexual activity. Other studies found HPV DNA in children who had not been sexually abused. Some studies focused on evidence of HPV DNA on medical equipment, toilet seats, and sex toys, and questioned whether this would be sufficient to transmit the virus. And others suggested the possibility of finger-to-genital transmission either from a partner or even from one’s own hands.

The researchers told Rewire in an email that their results have to be interpreted cautiously, as they do not provide proof of non-penetrative or non-sexual transmission. Nonetheless, the possibility that this virus can be transmitted without sex should help us rid the HPV vaccine debate of moralizing. As the researcher concludes in the article, “The distribution of HPV vaccines has been hindered, in part, by societal discomfort with the role of HPV in human sexuality. A fuller appreciation of the potential for non-sexual HPV transmission could help increase vaccine acceptance.”

The facts are simple. We have a vaccine that prevents cancer, it’s working, and that’s a major public health victory. It’s time to stop arguing about whether vaccinating kids against an STD is a good idea and start protecting everyone.

News Family

Study: Girls With HPV Vaccine Take Fewer Sexual Risks

Martha Kempner

Since HPV vaccines were introduced almost a decade ago, there has been a fear that vaccinating young girls against sexually transmitted infections will give them license to have sex and increase promiscuity. A new study suggests that the opposite may in fact be true—girls who have been vaccinated are less likely to engage in risky sexual behavior than those who have not.

Since HPV vaccines were introduced almost a decade ago, there has been a fear that vaccinating young girls against a sexually transmitted infection (STI) would lead to increased promiscuity.

There is a large and growing body of evidence that this fear is unfounded, and now a study out of the United Kingdom suggests that the opposite may in fact be true—girls who have been vaccinated are less likely to engage in risky sexual behavior than those who have not.

The UK since 2008 has offered HPV vaccines to all girls ages 12-to-13 as well as a catch-up program that provides vaccines to any woman born after 1990. For this study, researchers reviewed medical records of 363 young women who attended clinics in Northwest England and compared markers of sexual behaviorsuch as pregnancy tests or sexually transmitted disease (STD) diagnoses—among those who had been vaccinated to those of their unvaccinated peers.

Sixty-three percent of those studied had received one of the three recommended doses of the vaccine.

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Researchers found five variables showing significant differences between women who had been vaccinated and those who had not, but all five showed that the vaccinated had lower levels of sexual risk. Those who were not vaccinated were more likely to have had three or more sex partners in the past six months, had anal sex during their last sexual encounter, have gone to the clinic with symptoms of an STD, and have tested positive for chlamydia at their last clinic visit.

In contrast, women who had been vaccinated were more likely to use condoms.

The authors and other public health experts have given a number of possible explanations for these behavioral differences. In the UK, where the government offers vaccinations to everyone, vaccination rates are high. Failure to vaccinate, therefore, may be a marker of other high risk sexual behavior, according to the authors.

On the flip side, the report’s authors explain that “vaccination was taken up by those demonstrating other types of prevention or less risky behaviors.” This does not surprise those in the public health field.

Dr. Jessica Kahn, a professor of pediatrics at Cincinnati Children’s Hospital Medical Center, told Reuters: “Preventive health behaviors tend to cluster, so it makes sense that girls who practice safer behaviors are more likely to be vaccinated.”

Of course, the correlation could go the other way as well. “One explanation for the findings is that girls who are vaccinated receive education about sexual health and prevention which decreases riskier behaviors,” Kahn said.

Either way, the study should be seen as good news to those who are worried that providing vaccines to girls and young women will somehow lead to riskier sexual behavior. And these results echo those of many other studies, including a December study that reviewed the records of 260,000 young women in Ontario and found no evidence that receiving the vaccine led to increased risk of either an unintended pregnancy or an STD.

“These results suggest that concerns over increased promiscuity following HPV vaccination are unwarranted and should not deter from vaccinating at a young age,” the authors of that study concluded.

HPV is a very common STI. The Centers for Disease Control and Prevention estimates that 79 million people in the United States are infected with HPV and 14 million new infections occur annually. Though most people will suffer no long-term health consequences and may never know they have HPV, others may develop cervical cancer or cancers of the head, neck, throat, penis, or anus.

About 12,000 women develop cervical cancer in the United States each year and 4,000 die from it.

The HPV vaccine was approved in by the U.S. Food and Drug Administration in 2006, but uptake has been relatively slow due in part to skepticism about vaccines in general and to the unfounded fear that providing the vaccine will lead to promiscuity.