Information for health professionals
Human papillomavirus (HPV) is the name for a group of viruses that affect the skin and moist membranes lining the body (ref: Cancer Research UK).
Vulnerable areas for HPV infection in males include the penis, anus, mouth and throat.
There are around 200 types of HPV (ref: Viarisio et al.). Many are harmless. But some types can cause cancer or genital warts.
The high-risk types of HPV include HPV 16 and 18. These types can cause cancer. Genital warts are caused by HPV 6 and 11. The cancer-causing and wart-causing types are different. This means that genital warts are not an early-warning sign of cancer.
HPV infection is very common – it is spread by sexual and skin-to-skin contact. It can also be spread by sex toys (ref: Anderson et al.). Condoms reduce the risk of infection but do not eliminate it because HPV can infect areas not protected by a condom (ref: CDC). Some studies suggest that deep kissing spreads HPV but this has not been definitely proven (ref: CDC).
High-risk HPV types cannot be caught from toilet seats, hugging, holding hands, swimming pools or hot tubs or sharing food or cutlery (ref: American Cancer Society).
Nearly all (an estimated 70-80%) sexually active people get HPV at some point in their lives (ref: Luyten et al.). Because the infection is so common, many people are infected shortly after becoming sexually active for the first time. A person who has had only one sexual partner can get HPV although people who have many partners, or who have sex with someone who has had many partners, are more at risk. There is a 50-80% chance of HPV transmission following unprotected sexual intercourse with someone with a current HPV infection (ref: NCIRS).
The epidemiology of genital HPV infection among men is similar to that among women (ref: Moreira et al.). However, HPV infection rates seem to stay constant in men, independent of age, as opposed to women, among whom the HPV prevalence is highest during 18–24 years of age and then decreases until middle age, after which it generally remains steady (ref: Smith at al.).
Most people with HPV are unaware that they are infected and never develop a health problem as a result. HPV usually clears on its own: approximately 70% of men clear an HPV infection within 12 months (ref: Anic et al.). Having HPV does not therefore mean someone will automatically get cancer or genital warts. But HPV infection can persist in some people and cause health problems, sometimes years later.
It is not possible to predict which people with HPV will go to develop health problems but people with weak immune systems are thought to be more at risk as are smokers. People with HIV/AIDS are among those at greater risk (ref: Konopnicki et al.).
HPV vaccination is by far the best way of preventing infection and the diseases caused by the virus.
Head and Neck Cancer
The clinical evidence shows that HPV causes cancer in different parts of the head and neck, especially the oropharynx. (The oropharynx includes the back third of the tongue, the soft area at the back of the roof of the mouth, the tonsils and the back wall of the throat.) Up to three quarters (73%) of oropharyngeal cancer cases are caused by HPV (ref: Cancer Research UK). This cancer mostly affects men– they are twice as likely to be affected as women (ref: Cancer Research UK). Mouth and throat cancers caused by HPV have become far more common over the past 30 years, a trend that is expected to continue over the next 20 years (ref: Mehanna et al.).
For more information on head and neck cancers:
- Throat Cancer Foundation
- Mouth Cancer Foundation
- Oral Health Foundation
- Mouth Cancer Awareness Month
- Cancer Research UK
- The Swallows
- Oral Cancer Foundation (USA)
HPV causes the vast majority (90%) of anal cancer cases (ref: Cancer Research UK). This cancer is relatively rare in the UK with around 430 new cases in men in the UK in 2014 (it is about twice as common in women). But the number of cases in men is expected to more than double in the period 1993 to 2035 (ref: Smittenaar et al.).
Anal cancer is much more common in men who have sex with other men; in fact, rates of anal cancer are 15 times higher in men who have sex with men compared to heterosexual men (ref: BASHH). Over 140 men in the UK died from anal cancer in 2014.
For more information on anal cancer:
Clinical studies suggest that HPV infection causes up to half (48%) of penile cancer cases (ref: CDC). This cancer is relatively rare in the UK: there were around 630 new cases in the UK in 2014, an average of two new cases every day (ref: Cancer Research UK). However, penile cancer is becoming more common with 25% more cases now being diagnosed each year than in the early 1990s. There were 130 penile cancer deaths in 2014.
For more information on penile cancer:
HPV causes genital warts, the second most common sexually transmitted infection. In men, warts can develop on the penis, scrotum, urethra (the tube which urine goes through from the bladder to the penis), the upper thighs and on, or inside, the anus. Both men and women are affected but the problem is much more common in men and particularly in men who have sex with men. UK-wide data on the number of cases of warts is not available but HPV Action estimates that about 40,000 cases are diagnosed in men each year.
For more information on genital warts:
Recurrent respiratory papillomatosis (RRP)
People with RRP have wart-like growths on their airways caused by HPV, according to clinical studies. These can seriously affect breathing.
RRP affects both children and adults. Children are infected while still in the womb or at birth. Males and females are about equally affected.
Fortunately, RRP is rare but it can be very distressing and is often difficult to treat.
For more information on RRP:
Boys cannot currently be vaccinated free of charge by the NHS, unlike girls who covered by a national vaccination programme. Girls are offered the vaccine, usually at school, when they are 12/13 (in school year 8).
The government’s vaccination advisory committee, JCVI (Joint Committee on Vaccination and Immunisation) has considered whether boys should be included in the national programme and, in July 2018, it issued its final statement on the issue. It concluded that boys should be vaccinated and its advice has now been accepted by the Department of Health and Social Care for England and by the health departments in Scotland and Wales. (No announcement has yet been made for Northern Ireland.)
Vaccination for boys aged 12/13 is expected to start in England, Scotland and Wales, and possibly Northern Ireland, in the 2019/20 school year. This timescale has not yet been finally confirmed, however.
The government has announced that it will not be introducing a catch-up HPV vaccination programme for older boys.
A growing number of boys are now being vaccinated privately and the vaccine is becoming more widely and easily available.
Like boys currently, most adult males cannot be vaccinated free of charge by the NHS. The only men eligible for free HPV vaccination in the UK are men who have sex with men (MSM) aged up to 45 (there is no lower age limit) who present at a sexual health clinic for another reason (e.g. STI diagnosis or treatment). MSM who present specifically for HPV vaccination are not eligible, although some clinics may use their discretion. Doctors in these clinics can also offer HPV vaccination to transgender people.
MSM who are in prison are also eligible for free HPV vaccinations from prison health services.
These are the main arguments for and against opting for a private vaccination for a boy or man:
Arguments for private vaccination
- Boys and men are as susceptible to HPV infection as girls and women and vaccination provides a high level of protection against the most dangerous HPV types that cause cancer, genital warts or RRP.
- Vaccination offers protection against infection for at least 10 years and probably for much longer (ref: Public Health England).
- Vaccination is most effective when a boy is aged under 15. This is because he is unlikely to have been exposed to HPV yet and because younger people have a stronger immune response (which is why two doses of the vaccine are effective for younger people while those aged over 15 require three doses) (ref: CDC).
- Although men cannot get HPV from a woman who has been vaccinated, 15% of girls are not currently vaccinated in the UK. There is evidence that women in the UK who did not take up the offer of vaccination in adolescence may be disproportionately likely to acquire or transmit HPV because being unvaccinated is a marker for high-risk sexual behaviours (ref: Sadler et al.). Also, men can get HPV from a woman who was too old to be vaccinated by the NHS (vaccination started for girls in the UK in 2008).
- HPV can also be acquired from a woman from another country where there is no vaccination programme for girls or a programme with a low uptake. It is significant that there are no programmes in Poland or Romania, two of the five countries with the highest recent levels of migration to the UK, and only about a quarter of girls in France are vaccinated. Around one in 10 men report forming a new sexual partnership while overseas in the past five years (ref: Tanton et al.). The proportion among younger men is far higher: 13% of 16-24 year olds and 15% of 25-34 year olds. Men who had partners who lived outside the UK were also more likely to pay for sex and female sex workers are known to have a high prevalence of infection with high-risk HPV types (ref: Soohoo et al.).
- There is no screening programme for men that can detect cancers caused by HPV at an early stage (there is no male equivalent of the cervical cancer screening programme).
- The vaccine available in many private clinics is Gardasil-9. This offers protection against a wider range of cancer-causing HPV types than the vaccine currently used by the NHS.
- HPV vaccination is now recommended for boys in an increasing number of countries including Australia, Austria, Bermuda, Brazil, Canada, Israel, Italy, New Zealand, Norway, Switzerland and the USA.
- Vaccination for boys is supported by many health organisations and doctors. The BMA (British Medical Association), British Dental Association, Oral Health Foundation, Faculty of General Dental Practice of the Royal College of Surgeons, Faculty of Public Health, Royal College of Obstetricians and Gynaecologists and Royal Society for Public Health are among those backing the vaccination of boys. Cancer Research UK states: ‘As HPV is linked to cancers in men as well as women, offering HPV vaccination to men would help reduce the risk of disease’ (ref: Cancer Research UK). A recent HPV Action survey of almost 1,700 GPs and dentists found that 95% thought that boys should be vaccinated (ref: HPV Action).
- Vaccination is socially responsible – the more people who are protected, the less easily HPV can circulate in the whole population and affect unvaccinated men and women.
For men who have sex with men specifically:
- Men who have sex with men derive no benefit from the girls’-only national vaccination programme. Men can acquire HPV through sexual contact with other men and men who have sex with men are at much greater risk of infection than heterosexual men.
- HPV vaccinations are only available to MSM who are attending sexual health clinics for another reason (e.g. STI diagnosis or treatment).
- The average age of first attendance at a sexual health clinic is 32 years for MSM (ref: Bayley et al.). By then, HPV infection may well already have occurred.
- Many MSM may not wish to disclose their sexual identity to sexual health clinics and some MSM who present to sexual health clinics may not self-identify as MSM. They will therefore not be offered the vaccine.
- Sexual identity does not need to be disclosed to obtain the vaccine privately.
- There is no need to wait until there is an ‘valid’ reason to attend a NHS sexual health clinic.
Arguments against private vaccination
- Private HPV vaccination for boys is expensive. Typically, it costs about £150 per dose. Adolescents need two doses; older boys (16 years and over) and men need three doses.
- HPV vaccination can sometimes cause side-effects, although these are almost always mild and short-lived such as soreness, swelling and redness in the arm. There is more information on the safety of the HPV vaccine here.
- Most HPV infections do not lead to a health problem – only a small proportion of people with HPV go on to develop cancer or another disease caused by HPV.
- Men who have sex with women who have been vaccinated will not be exposed to HPV. Most women born after 1995, who were living in the UK when they were 12/13 years old, have been vaccinated through the national vaccination programme that began in 2008. A lower proportion of women born between 1990 and 1995 have also been vaccinated through a catch-up programme that ran from 2008-11. It should be noted, however, that the make of vaccine (Cervarix) used in the UK until 2012 does not protect against the HPV types that cause genital warts.
There is overwhelming evidence from scientific and medical studies that HPV vaccinations are very safe.
The NHS says that the most common side effects of the HPV vaccine include swelling, redness and pain at the site of the injection, and headaches (ref: NHS).
A much smaller group of people might experience fever, nausea (feeling sick) and painful arms, hands, legs or feet. More rarely still, some people develop an itchy red rash. Very rarely, in about one in 10,000 cases, there may be a restriction of the airways and breathing problems. One person in a million may have a severe allergic reaction.
These problems, which may be unpleasant and even distressing, are treatable through self-help (e.g. painkillers) or by healthcare staff. They are also short-lived and people make a full recovery. The staff who give the vaccines are trained to spot and deal with any allergic reactions.
The small risk of having one of these side-effects must be balanced against the risk of developing a disease caused by HPV (e.g. cancer).
There have, however, been occasional stories in the media and also campaigns led by parents of girls who they believe have been seriously harmed by HPV vaccination. It has been suggested by some parents’ groups that HPV vaccination can cause serious long-term health problems such CRPS (complex regional pain syndrome) and POTS (postural tachycardia syndrome). CRPS produces long-lasting pain affecting a limb while POTS is associated with an increase in heart rate on standing up, together with various symptoms including dizziness, weakness, pain, feeling sick, and fatigue.
There is no good scientific evidence that HPV vaccination causes these (or other) long-term problems. An assessment by the European Medicines Agency (EMA) concluded that the occurrence of CRPS and POTS in vaccinated girls is no higher than would be expected in girls in the general population (around 150 cases of CRPS and at least 150 of POTS per million each year), and that there is no evidence that the vaccines can trigger these syndromes. The EMA saw no reason to change the way in which HPV vaccines are used (ref: EMA). The World Health Organisation has also not found any safety issue that alters its recommendations for the use of the vaccine (ref: WHO).
Most (85%) 12/13 year-old girls in the UK are vaccinated each year. It is a very common procedure that for the vast majority of people is quick, painless and uneventful.
Boys who wish to be vaccinated may choose to wait until the NHS offers this, probably in the 2019/20 school year (the date is still subject to final confirmation). However, there will not be a catch-up programme for boys older than 12/13. When advising boys and their parents/carers about the best course of action, it should be borne in mind that vaccination is most effective when given before the start of sexual activity and that, below the age of 16, just two doses are required.
Currently, NHS GPs are very unlikely to be able to provide HPV vaccination for boys or men. If it is available, it would be on a private basis which means that there would be a charge.
The vaccination is also available from a number of private health centres and travel clinics. An online search along the lines of “Where can I get HPV vaccination privately in [insert nearest town/city] UK” should be helpful.
It should be noted that there are sometimes temporary interruptions in the supply of vaccines to private sector providers.
Men who have sex with men aged up to 45 who attend a sexual health or HIV clinic for another problem should be offered HPV vaccination. Doctors in these clinics can also offer HPV vaccination to transgender people. This vaccination service is currently available in all clinics in Northern Ireland, Scotland and Wales. It is also currently available in about 40 clinics across England. It is not yet available more widely in England because the programme is being run on a trial basis; HPV Action hopes that the scheme will be extended to all clinics in 2018/19.
The vaccination service for men who have sex with men was set up because they are at greater risk of HPV infection and the diseases it causes.
Three types of vaccine are available (ref: National Cancer Institute):
- Cervarix. This vaccine was used by the NHS in the early years of the girls’ vaccination programme. It protects against two HPV types (16 and 18) that can cause pre-cancers and cancers of the cervix, vulva, vagina and anus. Cervarix does not offer protection against the HPV types (6 and 11) that cause genital warts. It can be given from the age of 9.
- Gardasil. This is the vaccine currently used for girls by the NHS for the national HPV vaccination programme. It can be given from the age of 9 and protects against infection by the four most significant HPV types, 16 and 18 that can cause cancer and 6 and 11 that can cause genital warts. It is used to prevent pre-cancers and cancers of the cervix, vulva, vagina and anus as well as genital warts.
- Gardasil 9. This is the newest HPV vaccine available. It protects against 9 HPV types, 16,18 and five others that can cause cancer and 6 and 11 that can cause genital warts. It can be given from the age of 9 years to prevent pre-cancers and cancers of the cervix, vulva, vagina and anus as well as genital warts
The vaccine manufacturers do not claim that their products protect against the development of HPV-caused penile, head and neck cancers. However, most scientists, doctors and dentists believe that, due to the similarities in the diseases, the vaccines do offer protection against these cancers as well as penile and anal cancers. The UK government’s vaccination advisory committee (known as JCVI) is among those sharing this view.
Boys aged 15 or under will need two injections, with the second between six and 12 months after the first (although it can be given up to 24 months later). The second injection is important as, without it, the boy will not be fully protected. The youngest age for an HPV vaccination is nine years. Males aged 16 or over will need three injections over a 4-12 month period. The second dose is given at least one month after the first. The third is at least three months after the second dose (and ideally within 12 months of the first dose).