“[HPV] only targets woman, even if a man got it, it wouldn’t affect them,” a male participant in a Rutgers University study told lead researcher Perry Halkitis, PhD, MPH. “It’s just like if you’re gay, are you gonna sleep with women? If you’re not, then you don’t have to worry,” said another.

There’s a common misconception that human papillomavirus (HPV) only causes cancer in women, but that’s far from the case. While most gay men don’t have cervixes, they’re not immune to the negative health effects of HPV, and gay and bisexual men with HPV are at a higher risk for genital warts along with penile, oropharyngeal (throat), and anal cancers.

In fact, gay and bisexual men are 17 times more likely to develop anal cancer that men who only have sex with women. This is due to similar biology between the anus and cervix; just like in the cervix, HPV can mutate normal healthy cells into cancerous ones.

Human papilloma virus.

That’s why in 2010, the Advisory Committee of Immunization Practices recommended routine vaccination, Gardasil, for all men 26 years old and younger who have sex with men (MSM). Shortly after, the CDC quickly adopted those guidelines. Last year, the FDA approved of Gardasil shots for men and women until the age of 45, citing that the vaccine was still 88% effective in older adults. Initially, researchers thought that the vaccine would only be effective in younger people, assuming they had limited amounts of sexual interactions. However, once the FDA learned of the research, the agency extended the age range to include older adults.

Affordable access to the vaccine remains in murky territory for those over 26. The vast majority of insurances cover Gardasil for men [and women] under 26, as it’s deemed preventive care. However, it’s not yet deemed preventative care in the older age range, which is why most insurance companies do not cover it. And even though Gardasil is listed under the “immunization vaccines” on Healthcare.gov, which means it’s a part of a group of vaccines that “all Marketplace health plans and many other plans cover,” it still comes with the disclaimer: “Doses, recommended ages, and recommended populations vary.”

The Rutgers study, published in a April 2019 issue of AIDS Patient Care and STDs, specifically looked at the younger age group of MSM, which has affordable access to the vaccine. The study revealed that less than one-fifth of gay/bi men 26 and under had been fully vaccinated for HPV.

While there are over 100 strains of HPV, there are roughly 14 that are thought to be “high risk,” meaning they increase the likelihood of causing cancer, whereas the others are thought to be low risk. The current nonavalent Gardasil 9, protects against nine high risk strains, including 16 and 18, the two most highly implicated in cancer. Gardasil 9 is administered three times, with a mandatory waiting period of at least two months in between doses.

The Rutgers study asked 486 MSM between 22 and 25 years old if they had been vaccinated, and then tested the young men for detectable HPV strains. The researchers also collected data on a number of baseline demographics to see if race, education, HIV status, socio-economic status, and neighborhood impacted the likelihood of testing positive for HPV and receiving the full number of Gardasil shots.

More than half of the participants (58.6%) tested positive for anal HPV infection, and 8.8% tested for oral infection. Very few men showed any symptoms whatsoever of infection. Nearly 9 out of 10 men living with HIV (87.9%) tested positive for any form of HPV; while this figure is high, HIV is known to increase the susceptibility of contracting HPV.

A number of the strains diagnosed in the study were preventable with Gardasil. Three out of 10 HIV-negative men had a strain of HPV that was vaccine-preventable, whereas nearly double the number of HIV-positive men (53.1%) tested positive for a vaccine-preventable strain.

The major issue, in conjunction with the high rates of HPV in gay/bi men, were the lack of gay/bi men who received the full number of Gardasil doses. Only 18.1% received all three shots and 24.3% of men received partial vaccination.

“Receiving one or two of the three recommended doses may provide some protection, but the efficacy of incomplete vaccination is not well known, and especially are not studied among MSM,” explains Tsvetelina Velikova, MD, PhD, who works with MedAlertHelp.org.

Dr. Halkitis was asked if the study analyzed the efficacy of partial vaccinations, he noted a secondary paper would be out shortly that would look at how effective getting only one or two of the Gardasil shots could be in preventing HPV. He did, however, confirm that receiving all three doses does inhibit acquiring the preventable strains.

“If a young man has the full vaccination prior to the onset of sexual activity he will be protected from the preventable HPV strains,” Dr. Halkitis says.

Their findings did not show any significant differences in HPV vaccination and infection by race/ethnicity or income. But, as Dr. Halkitis noted, many other health conditions, including HIV, didn’t show any racial or income disparities at first.

“Nowadays, there are very clear [HIV] disparities in gay men, with poorer and black men more likely to become infected. Those with power and privilege began to access more effective prevention and care. As a result, these types of health challenges tend to burden those with low income and access, often people of color, who also have a higher level of medical mistrust—and for good reason.”

Dr. Halkitis found the low rate of full vaccination both “surprising and disturbing.” He believes the CDC is largely at fault here. “When the vaccine was rolled out, it was not marketed to [men], leading to misinformation.”

Dr. Halkitis believes there needs to be full-on educational campaigns that specifically target gay men to help address the epidemic. “We need vaccination fairs in gay community centers; we need to educate parents, and we need to be clear that HPV is the main cause of anal cancer in gay men.” (Note: anal cancer is different than colorectal cancer, which is common in all men regardless of HPV infection.)

“Even in the most gay centric regions like the New York and New Jersey metropolitan area,” Dr. Halkitis continues, “the situation is less than ideal, as our study has shown.”

Lastly, Dr. Halkitis wants doctors to understand that gay men’s health is not just about HIV. “It is 2019, not 1985, and gay men’s well-being and lives are defined by more than just HIV.”