Advancing evidence-based HPV vaccination & screening delivery for men who have sex with men and people living with HIV

In Progress

HIV/Sexually Transmitted and Blood-borne Infections

Three-quarters of all people in Canada will be exposed to the human papillomavirus (HPV) at least once in their lifetime. While some types of HPV are low risk, other strains cause cervical, anal, and oral cancers.

Vaccines and screening programs to prevent HPV-related cancers are available in Canada, but they’re not easy for everyone to access.

Two populations at particularly high risk of HPV are:

  • Gay, bisexual and other men who have sex with men (gbMSM). HPV is very common among gbMSM, impacting 78-98% of this population. Although several Canadian jurisdictions, including Ontario, have a targeted HPV vaccine policy for gbMSM aged 9-26, this requires a young man to be aware of his sexual orientation, and to be willing to disclose it to a provider.
  • Men and women living with HIV infection. Research shows that this group is not getting the HPV-related cancer screening they need. The rate of anal cancer among HIV+ gbMSM is 100 times higher than in the general population. Only half of women living with HIV in Ontario undergo regular cervical cancer screening.

How can we make it easier for high-risk groups to access HPV vaccination and screening for HPV-related cancers?

Using a community-based perspective, this project will generate solutions by gathering and integrating scientific as well as community knowledge:

  • Searching the scientific literature: We have synthesized findings and recommendations from eight recent research studies about HPV vaccine uptake and willingness, HPV awareness, and screening for HPV-related cancers.
  • Consulting with the community: We brought the evidence we gathered to health/service providers and people with lived expertise, to discuss, listen and acknowledge concerns. We then gathered ideas and advice from this community, looking for innovative ideas, alternatives and recommendations for policy and practice.

What we’ve learned so far

Three studies that were part of this grant explored vaccination among gbMSM:

  • Engage-HPV used respondent-driven sampling to recruit gbMSM aged 16+ years in Toronto, Montreal and Vancouver
  • #iCruise was an online-recruited sample of gbMSM aged 14+ years across Ontario
  • The HPV Provider Survey invited providers across the country to complete a questionnaire.

These studies found that:

  • The HPV vaccine is easier to access in urban areas. gbMSM living in cities are more likely to get the HPV vaccine, compared to the general gbMSM population in Ontario
  • The requirement to disclose sexual activity to a provider is preventing young gbMSM from getting the HPV vaccine. Older gbMSM (over the age of 26) are more willing to disclose sexual activity if the vaccine is free, compared to younger men (aged 26 and under).
  • Men who have been vaccinated are more likely to have looked for sexual health information online, suggesting that vaccinated men are more proactive about their health.
  • Most (59%) health-care providers support recommending the HPV vaccine to all men, regardless of age or sexual orientation. Health-care providers told us that when they don’t recommend the vaccine, it’s because of: vaccine cost; lack of time/resources; inability to identify appropriate candidates; and patient non-disclosure of sexual orientation.

The primary study in this grant examining women living with HIV is the Canadian HIV Women’s Sexual and Reproductive Health Cohort Study, a longitudinal cohort study for women aged 21-70 living in BC, ON or QC. This study found that among women with HIV:

  • Almost half are unfamiliar with or had never heard of HPV.
  • The most commonly cited reasons for not having a Pap test were, “Not thinking it was necessary,” “Not getting around to it,” and “Health-care provider never mentioning it.” Delays in getting Pap smears were also associated with: having a male health-care provider; being in a relationship; living in a smaller city; and not receiving HIV care.

The HPV-SAVE study surveyed men living with HIV as part of the Ontario HIV Treatment Network Cohort Study. The survey asked men about their knowledge, attitudes and experiences with HPV, and with HPV vaccination and anal cancer screening. This study found that among men with HIV:

  • Only 52% are familiar with HPV. Only two in five participants knew that HPV can cause anogenital warts and anal cancer; three in five knew that people living with HIV are at increased risk of getting cancers caused by HPV such as anal cancer; and only one in four knew that smoking also increases their risk.
  • Providing standardized information about HPV and its associated diseases didn’t work very well to help men understand the risk. After receiving the information, men continued to perceive themselves to be at no or low risk for getting HPV, anogenital warts and anal cancer.
  • Barriers also appeared at the provider level, including the high cost of the vaccine. HPV literacy efforts should focus on supporting conversations between men living with HIV and their healthcare providers.

Evidence to action: What’s next

Evidence from the studies included in the grant were synthesized and disseminated by community investigators through several presentations at partner organizations. A national symposium on the topic of HPV Vaccination in Young gbMSM was held in 2019 with invited researchers, health care practitioners, health promotion experts and community members. The goal of the symposium was to inform solutions to improve HPV vaccination among young gbMSM in the context of targeted vaccine policies. A brief report of the findings from this symposium is forthcoming.

The Engage-HPV study is now examining gbMSM in relation to a ‘vaccination cascade’, where men are divided into four stages: those who are unaware of the HPV vaccine, men who are undecided/unwilling to get the vaccine, men who are willing to be vaccinated and those who are vaccinated. This cascade approach will allow us to understand how men across these stages differ, which can help strategize efforts to improve vaccine uptake and identify subpopulations for vaccine promotion. More research is also needed to understand the significant gaps we identified in HPV literacy among people living with HIV.

HIV/Sexually Transmitted and Blood-borne Infections

Dr. Ann Burchell

A national leader in HIV/STI research and Canada Research Chair in Sexually Transmitted Infection Prevention, Dr. Ann Burchell generates evidence for effective and practical strategies to prevent STIs and related cancers in high-risk populations, including people living with or at risk for HIV.

Investigators

  • Dr. David Brennan (University of Toronto)
  • Dr. Alexandra de Pokomandy (McGill University)
  • Jennifer Gillis (University of Toronto)
  • Dr. Daniel Grace (University of Toronto)
  • Dr. Troy Grennan (BC Centre for Disease Control)
  • Dr. Trevor A. Hart (Ryerson University)
  • Dr. Claire Kendall (University of Ottawa)
  • Joanne Lindsay (St. Michael’s Hospital)
  • Dr. Mona Loutfy (Women’s College Hospital)
  • Dr. Paul MacPherson (The Ottawa Hospital)
  • Dr. Irving Salit (Toronto General Hospital)
  • Ramandip Grewal (St. Michael’s Hospital)
  • Dr. Anna Yeung (St. Michael’s Hospital)

Staff

  • Ashley Mah, Research Coordinator
  • Jayoti Rana, Research Coordinator
  • Lane Bonertz, Community Investigator

Funders

  • Canadian Institutes of Health Research (CIHR)

Collaborators

  • Jean Bacon (Ontario HIV Treatment Network)
  • Dr. Charlie B Guiang (St. Michael’s Hospital, Hassle Free Clinic)
  • Dr. Shelley Deeks (Public Health Ontario)
  • Ron Rosenes (Rosenes Consulting)

Contact Info

Dr. Ann Burchell