For several years, there has been considerable, vigorous debate among members of the HPV sub-committee of the UK Joint Committee on Vaccination and Immunisation (JCVI) on whether to offer boys the HPV vaccine. Surprisingly, in July 2018, Ministers announced their intention to introduce gender-neutral HPV immunisation across the UK, which means that young men will have the opportunity to be offered the HPV vaccine. The JCVI recommends implementation of vaccine programmes based on the issue of cost-effectiveness within the publicly- funded NHS setting. Until July 2018, the main argument for not offering the vaccine to boys was that high uptake in girls (approximately 88% since 2008) confers significant herd protection to unvaccinated boys, and that offering vaccine to boys was therefore cost-ineffective. However, the argument not to have a gender-neutral programme is flawed several-fold.

Men can acquire HPV from sexual contact with women who have not been vaccinated. These are most likely to be women from countries with no or only a limited vaccination programme for girls. Men who have sex with men (MSM) are at a higher risk of exposure to HPV infection because they are completely unprotected by a girls-only vaccination programme. Rates of anal cancer are rising among men and women.1 However, the incidence of anal cancer in MSM is estimated to be similar to that of cervical cancer in an unscreened population of women. It is not truly effective to offer the HPV vaccine to MSM selectively because, to be most effective, the vaccine must be administered before sexual ‘debut’ and questioning boys of this age about their sexuality is both unethical and unreliable. The current policy in the UK is to offer HPV vaccine to MSM attending sexual health clinics but this approach may have little impact on prevention of infection: the average age of first attendance of an MSM at a clinic is 32 years by which time, HPV has already been acquired. A girls-only programme simply helps to perpetuate the belief that the primary responsibility for health, especially sexual health, should be borne by females. Promotion of good sexual health should be a responsibility shared equally by both sexes.

It should be noted that the JCVI HPV sub- committee did not include the most contemporary data available on the proportion of HPV-driven oropharyngeal cancers. A recent multicenter case-control study, which included UK data and harmonised analyses, found HPV-positive oropharyngeal cancer case proportions of 60% in US and 31% in Europe (for data collected between 2002-2004).2 Modelling assumptions must be fully tested, based on the most contemporary data available. Given that the epidemiological trend of oropharyngeal cancer in men has continued to increase, since the time of the European aetiological attributable fraction estimate of 31%, it would have been apposite to test the impact of a potential upper limit of an aetiological fraction towards that observed in the US of between 60%-70%.




In summary, the decision to add boys to an already successful vaccine programme in the UK is welcome and will result in accelerated reductions in HPV-driven cancers. This decision was based solely on equality and not on cost-effectiveness, a remarkable precedent for UK vaccine policy.

References

1. Islami F, Ferlay J, Lortet-Tieulent J, et al. International trends in anal can- cer incidence rates. Int J Epidemiol 2017;46:924–38. Available from:https://www.ncbi.nlm.nih.gov/pubmed/27789668
2. Anantharaman D, Abedi-Ardekani B, Beachler DC, et al. Geographic heterogeneity in the prevalence of human papillomavirus in head and neck cancer. Int. J. Cancer 2017;140:1968–75. Available from:https://www.ncbi.nlm.nih.gov/pubmed/28108990