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Improving HPV Vaccine Uptake
Navigating Challenges and Expanding Access: Practical Approaches for Improving HPV Vaccine Uptake

Released: November 07, 2024

Expiration: November 06, 2025

Rebekah Fenton
Rebekah Fenton, MD, MPH
Sharon G Humiston
Sharon G Humiston, MD, MPH
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Key Takeaways
  • To overcome barriers to HPV vaccination in underserved patient subpopulations, HCPs should encourage attendance at well-care visits, make effective vaccine recommendations, understand and address parents’ concerns about vaccination, and ensure consistent messaging on the importance of vaccination.

The following is a recap of key questions asked by healthcare professionals (HCPs) during a program featuring Rebekah Fenton, MD, MPH and Sharon G. Humiston, MD, MPH, discussing the burden of human papillomavirus (HPV)-related diseases, benefits of HPV vaccination, and strategies to overcome barriers to HPV vaccine uptake.

How can we improve HPV vaccination in underserved subgroups like those living in rural settings and LBGTQ+ adolescents?

Rebekah Fenton, MD, MPH:
Among underserved subgroups such as those in rural settings or LBGTQ+ adolescents, HCPs may be less likely to recommend HPV vaccination. This is our opportunity to provide education and change perceptions on someone being too young or old for the vaccine, the vaccine’s necessity, and other concerns such as safety. Understanding these barriers allows us to have targeted approaches that often look very similar in nature, but may be different in design to reach each population (eg, providing strategic messaging and patient education, addressing questions, improving medical visit attendance).

When addressing questions, avoid playing “fact tennis.” Also, to prevent reinforcing misinformation and ensure a consistent message is shared, respond to patients’ concern without repeating misbeliefs. This consistent messaging should be used across the entire healthcare team, so families are getting multiple reinforcements, even in that 1 visit.

What resources are available to help with HPV vaccine insurance coverage for adults?

Sharon G. Humiston, MD, MPH:
In the United States, for adults through 26 years of age, the HPV vaccine is recommended by the CDC Advisory Committee on Immunization Practices (ACIP). The Affordable Care Act (ACA) requires public and private insurance plans to cover ACIP-recommended immunizations without consumer cost-sharing, but not all insurance plans are subject to ACA requirements. 

Partially vaccinated or unvaccinated adults ages 27 through 45 years may decide to get the HPV vaccine based on discussion with their clinician. For this age group, HPV vaccination may be covered by insurance. If insurance does not cover the vaccine, reach out to your state immunization program, as sometimes state funds are available to support adult vaccination. This varies by state, but it is worth investigating whether state-level resources could help adults in your area.

Rebekah Fenton, MD, MPH:
I agree with that approach. In Illinois, for example, we have a program that covers vaccines for uninsured patients. This has been incredibly beneficial in ensuring that uninsured individuals still have access to necessary vaccinations, helping us reach populations who otherwise might not have access to these preventive measures.   

What is the recommended timing for the HPV vaccine in women?

Rebekah Fenton, MD, MPH:
Currently, the HPV vaccine is indicated in all individuals, regardless of gender. The American Academy of Pediatrics recommends routine HPV vaccination for all adolescents starting between age 9 and 12 years, at an age that the HCP deems optimal for acceptance and completion of the vaccination series. For those starting the series before their 15th birthday, the HPV vaccine series consists of 2 doses administered 6-12 months apart. For individuals who start the series at age 15 years and older (and for those who are immunocompromised), the recommended series consists of 3 doses. The second dose should be given 1-2 months after the first dose, and the third dose should be given 6 months after the first dose.

Sharon G. Humiston, MD, MPH:
I want to emphasize that if the vaccination series is initiated before the individual’s 15th birthday, only 2 doses are necessary. If the series starts on or after the 15th birthday, it's a 3-dose series. While there is discussion about possibly changing this schedule in the future, the current FDA approval and CDC recommendations maintain the 2-dose recommendation for those starting before the 15th birthday. 

If an adolescent is sexually active and potentially HPV positive, will the vaccine be effective? Should they be tested for HPV? 

Rebekah Fenton, MD, MPH:
The vaccine will prevent infection for any of the 9 vaccine HPV types that have not already infected the adolescent. The vaccine will not treat existing infections. So, yes, give the HPV vaccine to people who are already sexually active, if age appropriate. Ideally patients should be vaccinated before the onset of any sexual activity, but you do not need to test patients for HPV to see whether they are still eligible for vaccination. Also, HPV vaccination does not prevent infection with all high-risk HPV types so all people who have a cervix, regardless of vaccine status, should follow cervical cancer screening recommendations.

What is the downside of giving a 23-year-old male the HPV vaccine, even if he has had sex in the past? 

Rebekah Fenton, MD, MPH:
There is no downside. The main consideration is understanding that the amount of benefit may differ depending on prior exposure to HPV. With more than 200 subtypes of the virus, and no routine testing for HPV in males, we don't know exactly what a person has been exposed to. However, our goal remains to protect against any HPV type that the individual may encounter in the future. This is why we continue to recommend and offer vaccination, even in those who have already been sexually active. The vaccine’s role in HPV cancer prevention is critical, so it’s better to get it later than not at all. 

Sharon G. Humiston, MD, MPH:
I would add that, unfortunately, there is no comprehensive adult vaccine insurance program in the US comparable to the Vaccines for Children program. As we mentioned before, many insurers do cover HPV vaccination before age 27. This is another reason why it would be great to get this 23-year-old vaccinated as soon as possible.

Have antibody levels been evaluated in children vaccinated at a younger age vs older age?

Sharon G. Humiston, MD, MPH:
Yes. When we discuss younger vs older, it's hard to consider immune senescence so early in life, but that is essentially what we are seeing. Among vaccine recipients ages 9-14 years, a 2-dose HPV vaccine regimen (separated by 6 or 12 months) leads to antibody levels as high as after a 3-dose regimen in vaccine recipients ages 16-26 years.

In short, when HPV vaccine is administered at ages 11 or 12 years, there is a higher antibody response than when the vaccine is delayed until age 17 or 18. This early onset of immune senescence is the cause. Importantly, studies have shown that the immunity provided by the vaccine persists, so we can give HPV vaccine to younger adolescents with confidence that they will still be protected into adulthood.

Is there an increase in HPV vaccine hesitancy due to the polarization of COVID vaccines? 

Sharon G. Humiston, MD, MPH:
Yes, absolutely I’ve seen a notable increase in vaccine hesitancy. This influences many vaccines, particularly the HPV vaccine. Research from SUNY Upstate Medical University in Syracuse indicates that individuals living in Republican-leaning states are less likely to be vaccinated against HPV compared to Democratic-leaning states. This trend is concerning, as political factors should not influence access to cancer prevention.

Rebekah Fenton, MD, MPH:
Absolutely. There is also a broader skepticism regarding the safety of vaccines; people have concerns about them being produced quickly and many question what is in them. This skepticism has led to concerns about all vaccines, but especially those perceived as “newer” than others. These conversations are now prevalent both online and in clinical settings. It should be reassuring that the HPV vaccine has been in use in the United States for 18 years after extensive prelicensure testing.

What are the major adverse reactions to the HPV vaccine, and are there differences for age groups? 

Sharon G. Humiston, MD, MPH:
The primary adverse reaction associated with the HPV vaccine is injection-site pain, which is common with most vaccines. Adolescents often report discomfort. Immunize.org offers great materials highlighting strategies to improve the vaccination experience, such as distraction using cell phones during the injections. It’s important for HCPs to know how to decrease vaccine-related anxiety and pain, not just for children and adolescents, but for adult patients, too.

What are some administration strategies to reduce pain associated with the HPV vaccine?

Rebekah Fenton, MD, MPH:
False reassurances (eg, like saying, “This won’t hurt at all”) can make distress and pain worse, so I avoid that. Of course, the easiest way to avoid pain is to complete the series with just 2 injections, instead of 3, so start the series before the 15th birthday. Some patients want only 2 vaccines at a visit, which is one reason why some offices have started giving the HPV vaccine at age 9 or 10. In short, it’s very important to ask patients themselves how they prefer to manage their anxiety and to try to follow their preferences, as possible.

Sharon G. Humiston, MD, MPH:
Dr. Anna Taddio, a pharmacist at SickKids hospital in Toronto, specializes in vaccination pain management. She recommends that we administer the most painful vaccine last. For example, when both the Tdap (tetanus, diphtheria, pertussis) and HPV vaccines are given at the same visit, the HPV vaccine should be administered second. This is just one of the recommendations in the Canadian clinical practice guidelines to reduce pain during vaccine injections.

How should we approach the conversations with parents when their child expresses interest in receiving the HPV vaccine, but their parent hesitates or declines?

Rebekah Fenton, MD, MPH:
I would advise not mentioning the fact that the child has expressed interest to the parent, and instead guide the conversation toward a family decision. This approach prevents the child from feeling isolated or pressured by their parents. I advocate for adolescent autonomy in making their own healthcare decisions, but also want to protect their confidentiality of what the adolescent shares with me, including ideas or experiences their parent may not support, unless there are physical safety concerns. Instead, I prepare adolescents for potential parental opposition and reassure them that they can receive the vaccine at age 18 if they are unable to legally consent as minors. The goal is to promote autonomy without putting the child in a vulnerable position. 

Can HPV be transmitted at birth?

Sharon G. Humiston, MD, MPH:
Yes, it has been documented that HPV transmission can occur during pregnancy or birth, even during cesarean delivery. Children infected through vertical transmission may develop juvenile-onset recurrent respiratory papillomatosis (JoRRP). The papillomas mainly grow in the larynx and may cause stridor and respiratory distress. Treatment consists of repeated microlaryngoscopic procedures to remove the papillomas, but there is no cure. Fortunately, with the introduction of the HPV vaccine, the incidence of JoRRP has significantly decreased, and it is rarely seen today.

Why is the HPV vaccine not mandated for school entry across the US?

Sharon G. Humiston, MD, MPH:
Regarding school mandates, Texas attempted to make HPV vaccination mandatory but faced significant pushback. This opposition has caused many states to be hesitant to introduce the vaccine as a requirement for school entry. The concern is that legislation might ignite opposition from antivaccine groups, potentially causing setbacks in other school entry vaccination requirements. A lot of states prefer to avoid engaging in these conflicts, which leads to stagnation in expanding school vaccine mandates.

Your Thoughts?
In which patients do you recommend the HPV vaccine? How do you communicate your HPV vaccine recommendations? Join the discussion by posting a comment.