Preventing anal cancer: The importance of HPV vaccination for gay, bisexual and other men who have sex with men

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A common sexually transmitted infection (STI) called human papillomavirus (HPV) is the leading cause of anal cancer. Gay, bisexual and other men who have sex with men (gbMSM) are much more likely than the general population to develop anal cancer. While there are vaccines that can prevent cancer-causing HPV infections, most gbMSM in Canada are not vaccinated. Service providers can support increased vaccination among gbMSM by providing accurate and complete information about HPV and vaccination, linking clients to appropriate healthcare services and helping them address practical barriers to vaccination.

HPV and cancer 

HPV can be passed through vaginal, front hole, anal and oral sex. HPV is one of the most common sexually transmitted infections worldwide.1 It is estimated that over 70% of sexually active people in Canada will get HPV at some point in their lifetime.2

While most HPV infections are cleared by the body without causing any health problems, some infections persist, which can sometimes lead to cancer.3 HPV is a leading cause of anal, cervical, oropharyngeal (back of the throat or tongue), penile, vaginal and vulvar cancer.4

The link between HPV and cancer is strongest for cervical cancer and anal cancer. Almost all cases of cervical cancer and anal cancer are caused by persistent HPV infections in these areas of the body.4 

There are many types of HPV. HPV types 16 and 18 account for most cases of HPV-caused cancers.4

HPV-related anal cancer among gbMSM 

Anal cancer is relatively rare in the general population, occurring at a rate of approximately two cases per 100,000 people per year. Women are at higher risk than the general male population, with two to three cases per 100,000 per year (compared to approximately one to two cases among men).5,6

GbMSM have a much higher risk of anal cancer than women or men who have sex only with women (MSW). HIV-negative gbMSM have rates of about 19 cases per 100,000 per year.7 GbMSM living with HIV have particularly high rates, at approximately 85 cases per 100, 000 per year. GbMSM living with HIV who are also 45 years or older have the highest rates of all at-risk populations, at approximately 100 cases per 100,000 per year.8 

One probable reason for higher rates of anal cancer among gbMSM is that anal infections with cancer-causing HPV types are more common in this population (about 40% of HIV-negative gbMSM vs. 7% of HIV-negative MSW).9 

Effectiveness of HPV vaccines among gbMSM 

Highly effective vaccines are available to prevent infection with the types of HPV most often linked to cancer. There are two HPV vaccines used in Canada, sold under the brand names Cervarix and Gardasil 9. Both of these protect against HPV types 16 and 18. Gardasil 9 also protects against an additional five cancer-causing HPV types. Vaccines are given in either a two-dose or three-dose schedule.10

In a clinical trial with gbMSM, HPV vaccines were found to prevent 93.8% of persistent anal infections with HPV type 16 and to completely (100%) prevent persistent anal infections with type 18.11 Although there is limited research on the prevention of HPV-related cancer specifically among gbMSM, a long-term study that included gbMSM showed that the vaccine provided lasting protection against anal precancer and cancer over a 10-year period.12 

HPV vaccines are more effective in people who get them when they are young, ideally before becoming sexually active.13 This is because older individuals tend to be more sexually experienced and thus are more likely to already have one or more types of vaccine-preventable HPV. For this reason, all Canadian provinces and territories now offer free school-based vaccination for boys and girls between grades four and six. All provinces and territories also fund vaccines for gbMSM through 26 years of age. However, only two provinces, Nova Scotia and Prince Edward Island (PEI), provide funding for people older than 26 years.14,15

Despite this age restriction on publicly funded vaccination for gbMSM, HPV vaccines can also benefit older individuals. One reason for this is that vaccines cover multiple HPV types and can prevent new and persistent infections with any HPV types a person does not yet have.16,17Another reason is that not all gbMSM follow the same trajectory of sexual experience. Some may not become sexually active, or start having sex with men, until later in life.

How many gbMSM in Canada are vaccinated? 

Despite the health risks associated with HPV and the proven benefits of the HPV vaccine, most gbMSM in Canada are still not vaccinated. A study conducted between 2017 and 2019 in three major cities, Vancouver, Toronto and Montreal, found that only 26% to 35% of gbMSM aged 26 years and younger had been vaccinated, depending on the city. Importantly, the percentage was much lower among men aged 27 years and older, ranging from 7% to 26%, depending on the city.18

Factors that influence HPV vaccination uptake among gbMSM

Understanding the factors that influence HPV vaccination among gbMSM can support targeted strategies to increase vaccination, thereby reducing the risk of HPV-related cancer within this community.

Knowledge about HPV among gbMSM

To make the decision to get vaccinated, gbMSM need to know the risks of HPV and the benefits of vaccination. There are significant gaps in this knowledge among gbMSM. 

At the most basic level, many gbMSM are simply unaware of HPV19 or that there is a vaccine to prevent it.20 Some are aware of HPV but mistakenly believe they have little to no chance of getting it or are unaware that it can lead to serious health problems. Some believe HPV to be a women’s health issue only.21,22 It is important to address these misconceptions because perceived susceptibility to HPV and perceived health consequences of HPV infection are both associated with accepting and receiving the vaccine among gbMSM.19,23–26 

Similarly, some gbMSM are broadly aware that there is an HPV vaccine but lack knowledge about its benefits. This is important because research shows that men who have concerns about vaccine efficacy are less likely to accept the HPV vaccine,26 while those who perceive the vaccine as beneficial are more likely to accept it.25

Communication by healthcare providers

Healthcare providers can have a strong influence on individuals' attitudes toward HPV vaccines and their willingness to get vaccinated. Research has shown that gbMSM who receive a healthcare provider’s recommendation are more likely to get vaccinated for HPV than those who do not receive a recommendation.25As such, it is important to understand why some providers may not recommend the vaccine. 

Providers, even those who specialize in sexual health or infectious disease or who care for gbMSM, can be reluctant to bring up the subject of HPV vaccination. In one Canadian study, physicians involved in anal cancer screening for gbMSM often avoided recommending the vaccine even though they endorsed it in principle. The main reasons they cited were concerns about the cost for uninsured gbMSM too old to receive the publicly funded vaccine and uncertainty about the vaccine’s clinical indications for this age group.27 

Compared with sexual healthcare providers, primary care practitioners have been found to be less confident recommending and discussing the HPV vaccine with their patients because of factors like lower awareness of HPV and HPV vaccination, less confidence in identifying gbMSM who could benefit from it and discomfort discussing patients’ sexual orientation.28 

Additionally, stigma in healthcare settings can make some gbMSM hesitant to disclose their sexual identity and activities to healthcare providers.28,29 Healthcare providers need to be knowledgeable about and prepared to discuss these topics, because these discussions will determine whether a patient meets the clinical recommendations for the vaccine. This may help to explain studies showing that gbMSM who disclose their sexual identity to a healthcare provider are more likely to accept and receive the HPV vaccine.28,30,31

Engagement with health services

GbMSM who access health services, particularly sexual health services, are more likely to be vaccinated than those who do not. Studies have shown that vaccination and vaccine acceptance are more likely among gbMSM who:

  • recently tested for sexually transmitted infections32 
  • recently accessed an HIV care specialist18 
  • are vaccinated against hepatitis A and B18,33,34 
  • are aware of, use or attempt to access biomedical HIV prevention tools18,32,35,36
  • recently accessed primary care, or healthcare in general30,33 

Vaccine cost

Studies have shown that gbMSM are more likely to accept and get the HPV vaccine when they can access it for free, through public funding, private insurance or other means.18,30 

At around $600 for all three doses in Canada,14 cost is a significant barrier to HPV vaccination for low-income gbMSM who do not have coverage.21,29 The large out-of-pocket expense may explain the associations found in some studies between income level and vaccination among gbMSM.30,35,37 

Across Canada, school-based programs and adult “catch-up” programs together provide publicly funded vaccination for gbMSM through 26 years of age. However, in most provinces and territories, gbMSM older than 26 years are left without publicly funded vaccination, one probable reason for lower vaccination rates among older gbMSM in Canada.17,18,35 

Implications for service providers

HPV infection is a very common sexually transmitted infection that poses serious health risks for gbMSM. Effective vaccines are available to help prevent the kinds of HPV that cause most cases of anal cancer and other HPV-related cancers. Despite this, only a minority of gbMSM are vaccinated. Community-based service providers can support efforts to increase vaccination by ensuring their own knowledge of HPV is up to date, including their knowledge of the current recommendations for vaccinating gbMSM. Service providers also need to work with gbMSM to address the obstacles preventing them from getting vaccinated. 

Some key findings from this review can help to inform approaches to promoting vaccine uptake:

Lack of awareness and inaccurate information prevent some gbMSM from seeking out vaccination and accepting it if recommended. By including accurate and complete HPV information in their sexual health outreach and counselling, service providers can help motivate gbMSM to get vaccinated and dispel myths keeping them from getting vaccinated. This should include basic information about HPV, its high prevalence among gbMSM, the risk of cancer from HPV infection and the effectiveness and safety of HPV vaccines. Offering information tailored to specific communities is crucial, particularly for older men, sexual and gender minorities, immigrants and members of racialized communities.

GbMSM who get vaccinated are more likely to also be engaged with other health services, particularly sexual health care. Whenever possible, efforts to promote and increase vaccination should be bundled with efforts to promote clients’ overall sexual health. Vaccination may be facilitated by simply encouraging clients to establish and maintain contact with sexual health services. Clients should also be encouraged to see HPV as an important aspect of their sexual health and overall wellness and to make sure it is on the agenda when they access other health services. 

Healthcare providers are not all well equipped to identify gbMSM’s HPV-related needs and risks. Linking clients to healthcare providers experienced with and comfortable discussing sexual health and same-sex relationships is one way to make sure the important conversations about HPV risk and recommendations can happen. Helping clients to understand the importance of vaccination and helping them to develop strategies to convey this to their healthcare providers (e.g., giving clients language or terms to self-advocate) may also support them to broach the topic when their providers do not.

The cost of vaccination is prohibitive for gbMSM who are not covered by public or private insurance. The age cut-off for publicly funded vaccination is an obstacle for gbMSM older than 26 years of age who have a low income or unstable employment. These clients may benefit from help exploring other options for paying for the vaccine, such as patient assistance programs, which subsidize vaccination for some low-income individuals. 

References

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Externally reviewed by: Dr. Ann Burchell & Darren Ho

About the author(s)

Dan Miller is CATIE’s knowledge specialist, HIV care and STI. He completed a master’s degree in public health at the University of Toronto and is an experienced health services researcher and communicator.