Should the HPV vaccine be given to boys?

Beth wrote, “I plan on having my daughter vaccinated against HPV when she’s the right age (which is what by the way?). Recently, some friends were saying they were planning to have their sons receive the vaccine as well because although males obviously don’t get cervical cancer, they can spread HPV and put their future partners at risk. Is this true?”

Yes, men can catch HPV infections, and spread them to women. But that might not be reason enough to have your son vaccinated.

First, background: HPV (human papilloma virus) is by far the most common sexually-transmitted infection. About 50% of all men and women will be infected by at least one strain of HPV at least once in their lives; about 20 million Americans are infected (and infectious) right now, and 6 million new cases of HPV infection occur each year in the United States. There is a lot of virus going around.

HPV is the direct cause of genital warts. It also causes cervical cancer (12,000 new cases a year in the United States), vulvar and vaginal cancers (4,000 per year), as well as cancers of the anus, head, and neck in men and women. From a pediatric perspective, it can also cause warts in the airways of young babies exposed during childbirth, which can be lethal or very difficult to treat. However, most people infected with HPV do not develop any of these long term problems—the virus is cleared by the immune system.

Most cancers are caused by two specific strains of HPV, and those strains are included in both brands of HPV vaccine (Gardasil and Cervarix.) About 70-80% of cervical cancers could be prevented by widespread use of these vaccines. Gardasil also protects against  two other HPV strains that cause genital warts. Though Cervarix doesn’t include these two wart-causing types, there is some evidence for cross protection these and other strains from the vaccine.

Both HPV vaccines are very safe. Despite media scaremongering and a hysterical anti-vaccine movement eager to encourage the spread of disease, there have been very few serious reactions to these vaccines. The most common reaction is pain at the injection site (these vaccines do seem more painful than others). There have also been reports of fainting after HPV vaccine, which isn’t unexpected among teenagers after any injection or medical procedure.

So why wouldn’t you want to give these vaccines to boys?

  1. The diseases they prevent in men are quite rare, far rarer than cervical cancer. For instance, penile cancer affects about 1,000 men each year, compared to 16,000 women who get cancer of their reproductive organs. Though HPV can contribute to cancers of the head and neck in both men and women, smoking accounts for far more cases of these diseases.
  2. It’s difficult to prove that this vaccine actually works in men. The point of the vaccine is to 1. prevent HPV infection, which 2. prevents HPV from causing cancer. In women, early HPV infections can be demonstrated by pap smear—there is no similar way to show that men have caught HPV. Blood tests in both men and women can serve as “surrogate markers” of infection, but aren’t really accurate for specific patients to predict disease. Cancers develop rarely, even in infected people, and they may take years or decades to develop. Penis cancer is primarily a disease of elderly, uncircumcised men. Following boys for 50 years to see how many of them develop penis cancer is nearly impossible. So whether HPV vaccination prevents cancer in men will be difficult to prove. Not only that, but we can’t even be sure that vaccination prevents men from spreading HPV to their partners—again, it’s very difficult to know what men are even infected, so correlating new infections in their partners would be logistically impossible. That doesn’t mean that the vaccine doesn’t work, just that it’s hard to prove that it works to the same degree that we require proof of effectiveness of other vaccines.
  3. It’s very, very expensive. A three-dose course of HPV vaccine costs me about $400, plus administration and storage and other associated costs. Is that worth it?

There are some high risks groups of boys who ought to be more-strongly considered for HPV vaccinations. Men who have sex with men are at especially high risk for HPV-associated cancers, probably about 17 times the population risk. And men with immune-compromising disorders, like HIV infections, are at a very high risk both for cancers from HPV infections, but also for extensive warts that are more-difficult to treat.

A legitimate question: how would most parents know that their son might be engaging, or might later engage, in higher-risk sexual activities? Since you might not know, perhaps it would be best to vaccinate all boys. I can see both sides of that argument.

At this point I would confidently say that all girls ought to be vaccinated—both the safety and effectiveness have been well demonstrated. The FDA has approved HPV vaccines from age 9-26, and the AAP recommends girls begin the three dose series at age 11 or 12. All three doses (which are typically given over six months) need to be received prior to the first sexual encounter to work best. In my clinic, most of my patients have stable homes with good health insurance, so I think it’s reasonable to begin vaccinations a few years older than the AAP recommends, but if you’re not sure you’ll still have health insurance next year, start the vaccines when they’re covered.

Currently, the AAP and CDC take a “permissive” stance on HPV vaccines for boys, and I agree with that. It’s a vaccine that parents ought to consider, but because of the shortcomings discussed here, it’s not “recommended” for all boys. It may also not be covered by health insurance, so you might want to ask about that and the retail charge before your son is vaccinated.

Roy Benaroch is a pediatrician who blogs at The Pediatric Insider. He is also the author of Solving Health and Behavioral Problems from Birth through Preschool: A Parent’s Guide and A Guide to Getting the Best Health Care for Your Child.

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  • http://www.sinestetoscopio.com Giordano

    Nice article,
    Do you have any conflict of interest about this topic?

    Thank you.

  • http://natickpediatrics.net Rob Lindeman

    Dr. Benaroch is persuasive that HPV vaccine shouldn’t be given to boys. There are two caveats, however, that he neglected to mention about HPV in GIRLS: First, regarding cancer-prevention. Gardasil doesn’t prevent invasive cancer of the cervix, PAP SMEARS DO. Physicians ought to be careful to avoid lulling their female charges into a (false) sense of security that might dissuade them from routine Pap smears when they begin having intercourse. Second, related to the first, Gardasil provides SOME protection against SOME, but not all strains of HPV linked to cancer of the cervix. Again, this needs to be emphasized to the kids and their parents. The last point is a persnickety one, but needs to be made in any case: Merck and others “sold” this vaccine as ‘the first anti-cancer’ vaccine. That is not correct. The hepatitis B vaccine was the first vaccine that promised to reduce the incidence of (liver) cancer.

    Finally, regarding sexually-transmitted diseases, could the expression “permissive stance” be any more poorly chosen?

    • http://pediatricinsider.com Roy Benaroch, MD

      I agree wholeheartedly re: the continued importance of pap smears. I hadn’t seen the promotional material re: this as the “first anti-cancer vaccine,” but you’re certainly correct that hep B vaccination deserves that title.

      RE: “permissive stance”, ha! But I deserve no credit for that: http://www.pediatricsupersite.com/view.aspx?rid=44776

  • Frank in L.A.

    Dr Benaroch said:
    “Despite media scaremongering and a hysterical anti-vaccine movement eager to encourage the spread of disease, there have been very few serious reactions to these vaccines.”

    There is a lot wrong with the “hysterical anti-vaccine movement.” Their grossly misguided advocacy of an untenable position is good reason to condemn their irrational actions. But they are not doing it because they are “eager to encourage the spread of disease.” They think they are doing the right thing. People who are terribly wrong but convinced they are right can be the most dangerous.

  • doc99

    The author doesn’t consider throat cancer. More cases are linked to HPV now than those linked to smoking.

    • http://pediatricinsider.com Roy Benaroch, MD

      Throat cancer can be caused by HPV infection– though I cannot confirm your statement that more of these are caused by HPV than smoking. In any case, no study has shown that HPV vaccination prevents throat cancer in boys, or girls for that matter. It might– in fact, I believe it probably does– but it is dishonest of us to claim that we have substantial evidence supporting this.

  • Sideways Shrink

    Though the risks of specific cancers to males receiving the vaccine may be low, vaccines are part of public health efforts. Therefore, the positive population effects of a vaccine are studied epidemiologically. So every case of cancer prevented in a woman by vaccinating a young man, must be factored into the risk/benefit/cost ratio discussion of vaccinating young men. Young women are not contracting HPV from other young women, with some rare exceptions. Regular pap smears do not prevent invasive cancers of the cervix, they detect the precursor conditions that can lead to it. While not complete in the strains it prevents, these vaccines can stop some of the conditions that prevent the precursor conditions. I can’t imagine a physician
    who would in any way “lull” or discourage a patient from getting pap smear! That is a statement made by someone unfamiliar with women’s health care or actual public health practices.
    Vaccinating young men makes sense. I know it steps out of the model in which all “family planning” falls on women, but population based vaccination strategies can be implemented if they will primarily save women’s lives. It’s OK. Somebody run the $ numbers. I’m sure it goes beyond justice and will save money.

  • http://pediatricinsider.com Roy Benaroch, MD

    Update: Feb 2011 NEJM published http://www.nejm.org/doi/full/10.1056/NEJMoa0909537, the first study (to my knowledge) that actually demonstrates clinical effectiveness of HPV vaccination in males. In this industry-sponsored study, 4000 males were followed for 3 years, half of whom received the three-dose series of Gardasil. They were examined for appearance of genital warts. In the vaccinated group, 36 warts were observed, compared to 89 in the placebo group (a 60% lower risk).

    This study wasn’t designed to look for other potential benefits of HPV vaccination in males, including decreaased HPV transmission to partners, and decreased anorectal, penile, and oropharyngeal cancer. These outcomes seem likely, but can’t be said to have been demonstrated by current research.

  • http://pediatricinsider.com Roy Benaroch, MD

    Giordano, I have no conflicts of interest in that I have no industry relationship with any vaccine (or any pharmaceutical) manufacturer. I’m a pediatrician in private practice, and I do stock and administer HPV vaccines.

  • http://pediatricinsider.com Roy Benaroch, MD

    Update re: insurance coverage for HPV vaccination: in my state (Georgia) most major carriers including Blue Cross/Blue Shield, Aetna, and Cigna DO cover HPV vaccines for young men, and the state VFC program for underinsured children and people with medicaid coverage also includes this vaccine, at least thru age 18. Among the larger carriers, to my knowledge only UnitedHealthCare provides no coverage.

  • buzzkillersmith

    It is an elementary fact of human nature that most people will not engage in an irksome activity if almost all the benefit from that activity goes to other people who are not their kin. Next case.

  • Sideways Shrink

    buzzkillersmith

    It is hard to tell if you want to be taken seriously, but unless the logic is that it is only in young men’s interest to get the vaccine it they have sex with “kin” as in blood relatives. However, the very point of the vaccine is that it will protect their new potential kin, their sexual partners. For most young people having sexual partners is somewhat like a cake walk: they never know which one they will end up will for a long period of time, hence establishing a family relationship with. If this is not immediately intuitive to them, that is OK. These individuals have health care providers to explain this to them. In medicine, nursing and public health we help people think in the big picture when we have the evidence to prove that an initial expenditure of money/discomfort up front will often sometimes save exponential amounts of money and suffering in the future. Science is great.

    • buzzkillersmith

      Most women exposed to HPV get from their first few sexual partners, in their teens or early 20s, way way before their young partners are thinking about marriage. By the time these guys think about protecting their potential wives, the horse has been out of the barn for a decade.
      So, in my office, I should explain to a young guy and his parents that he should get this expensive vaccine not because it will do him any good, but because if all young men did the same, then a very few women, most of whom he will never meet (cervical cancer death risk is extremely low) might be ultimately saved . Exponential amounts of money and suffering?!? You’re way off base. Please do some reading on this disease.
      This idea makes no sense to persons who understand human nature and the statistics of cervical cancer and exponential functions. Next case.

  • Sarah

    As a parent, I would explain to my son that he should get this expensive vaccine** in order to protect his sexual partners, and that if he’s going to have sex with a woman, regardless of whether he intends to marry her, he’d better have an interest in her well-being.

    Why would I vaccinate my son against rubella? I do it to protect the fetuses of women I’ve never met.

    ** That is, IF the vaccine is effective enough to be worth giving, which is what I’m trying to find out by reading posts like this one.

  • Sideways Shrink

    The efficacy of the vaccine has been proven in multiple studies. HPV is not only a risk for cervical cancer and throat cancer but the treatments on the cervix for aggressive HPV also can impair a woman’s fertility. It is rank cynicism to declare that young men will not get the vaccine if it does not directly interest them. If they were vaccinated in high school along with routine care at their doctor and mother’s urging, resistance would be nullified.
    Public health requires education of patients, not merely going along with the initial resistance of the patient. I will here resist saying “next case”. If only HPV would disappear so quickly as a public health problem ….

  • http://Shouldhpvvaccinebegiventoboys gagirl

    Buzzkillersmith…yes there must be a higher risk of cervical cancer than u or someone told u, because I have my pap smear every year. I was told in march of this year I have the HPV virus, stage III, and if I don’t have a hysterectomy within weeks it could be cancerious by then. I am worried sick & I have two daughters 23&18, that I’m worried about also. Women go to the dr more as far as for paps & ect, but men do not. They need to be taught about what risk they are putting these females in. there needs to be something to prevent the males from getting it too. Its not fair the females have to go thru all the suffering, surgeries, treatments, shots &ect and they guys just sleep with everyone & don’t worry because they will not have symptoms. Everyone needs to talk to their sons also for future babies & families. Its going to get more costly for all this cancer even in babies if we don’t try to get the word out more….

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