The Department of Health and Social Care will this year start rolling out a national HPV vaccination programme aimed at men who have sex with men (MSM). This will bring England into line with Scotland, Wales and Northern Ireland which already have national programmes for MSM. This decision follows the publication of an evaluation of a pilot programme in England.
The rationale for a separate programme for MSM is that, unlike heterosexual men, MSM derive no benefit from the vaccination of girls and are therefore at particular risk. There is some truth in this, which is why the rollout is welcome, but there are also serious doubts about whether the MSM programme is an effective response.
- The programme is delivered opportunistically to MSM aged up to 45 years via sexual health clinics. These clinics are now under huge pressure, however. The Local Government Association (LGA) has stated that sexual health services are at ‘a tipping point’ after demand increased by a quarter in the past five years while funding has been cut. Total local authority spending on GUM services fell by 3.5% between 2014/15 and 2015/16. The King’s Fund has found clear evidence that pressure on GUM services has increased over the past few years and that patient care in some parts of the country has suffered as a result. Sexual health services may therefore lack the capacity to offer an effective HPV vaccination service to MSM.
- The average age of first attendance for MSM is 32 years and a recent study of MSM attending a London sexual health clinic found that 45% had a current HPV infection with type that can cause cancer or anogenital warts, suggesting that a significant proportion of MSM will already have been infected before they are offered HPV vaccination. The immune response to vaccination is also known to be stronger at a younger age.
- A proportion of MSM attending clinics will also be unable to access the programme because they will choose not to disclose their sexual identity.
- The proportion of men who have sex with other men is almost certainly increasing as a result of what has become known as ‘sexual fluidity’. Men who define themselves as heterosexual may have sex with other men occasionally or regularly, behaviour that increases their risk of exposure to HPV infection. A survey of British adults published by YouGov in 2015 found that while 85% of men described themselves as heterosexual, a significantly lower proportion (68%) defined themselves as ‘completely heterosexual’ and 20% disclosed a sexual experience with another man.
- The evaluation of the pilot programme showed that, out of almost 19,000 MSM attending a clinic, just 46% were recorded as actually receiving the first of three vaccine doses. There is no good data on the numbers who went on to receive the second or third doses (because the pilot did not run for long enough). 50% of those recorded as receiving the first dose were aged 31-45. The evaluation did not look at the impact of vaccination of health outcomes. It is therefore difficult to agree with the DHSC’s statement that the pilot was ‘a success’
The best way to protect MSM is to vaccinate in adolescence, before sexual contact (and therefore before exposure to HPV), and when the immune response is greatest. But questioning boys in this age group about their sexual orientation would be impractical (because orientation for many will not yet be firmly established) as well as unethical and it would almost certainly be opposed by parents and boys themselves. The only effective solution is therefore to vaccinate all boys in order to reduce the risks to men whatever their sexual orientation.