Human papillomavirus (HPV) is a group of viruses affecting the skin and other moist membranes. Although there are over 200 types of HPV, around 40 are sexually transmitted and affect the genital areas of both men and women.

Certain strains within these 40 can cause unpleasant genital warts, but, more concerning, there are 13 strains of high-risk HPV that are linked to cervical cancer. Teenage Cancer Trust head of policy and public affairs Ben Sundell says: “HPV has been closely linked to cervical cancer, with nearly all cervical cancers being caused by HPV infection.”

Due to asymptomatic nature of genital HPV infection, healthcare providers across the world have sought to protect populations from cancer and other complications of HPV through broad vaccination programmes, which have been very successful to date at reducing the prevalence of high-risk strains of the virus, genital warts and pre-cancerous cervical cancer lesions.

The UK first launched its programme in 2008 with a focus only on girls – with limited provisions for men who have sex with men and trans women. More than a decade later, the country has followed in the footsteps of Australia and others to include boys in the highly successful HPV vaccination programme from this school year. This is due to due to growing evidence that high-risk HPV strains are also important in could cause more types of cancer than cervical tumours.

However, the UK’s Department of Health and Social Care (DHSC) has followed the Joint Committee on Vaccination and Immunisation’s (JCVI) advice to only expand the HPV vaccine to include boys in Year 8 aged between 12 and 13 who were born after 1 September 2006.

Despite this important break-through to better protect boys, HPV and cancer charities argue this move does not go far enough and they are calling for older boys to also be included in the UK’s HPV vaccination programme.

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Explaining the initial focus on girls

Based on advice from JCVI, a routine HPV immunisation programme was introduced across the UK in 2008 to girls aged 12 and 13 in year 8, but older girls have also been able to access catch-up vaccination until the age of 25.

The vaccine used in the programme protects against four types of HPV – two which cause most cervical, anal, genital and head and neck cancers, and two that cause the majority of genital warts cases.

Girls were prioritised because “up until this year, the vaccination programme has focused on the prevention of cervical cancers, which are caused by HPVs 99.7%of the time,” Sundell explains. HPV Action campaign director Peter Baker adds that the evidence about the risks of HPV to boys was not there in 2008.

Sundell notes more than 10 million doses of HPV vaccine have been administered to women in the past decade. There has been a n 83% uptake of the vaccination in the UK, which, Baker explains, is significantly higher than some other countries, for example France. This has caused an 86% reduction in infections of HPV types linked with cervical cancers in England, according to Sundell.

Why should boys be included in the programme?

The answer is simple. “HPV causes cancer and genital warts in both sexes” notes Baker. Evidence now shows that high-risk types of HPV are also linked to other forms of cancer, including anal, head and neck and penis cancers – the viruses could potentially be involved in causing up to 5% of all cancers globally, Sundell says.

Although there is herd immunity from vaccinating one sex only, Baker argues “this is not sufficient” to fully protect boys and men from HPV-related cancers and genital warts. As Baker argues, this is because “there are always going to be some girls who are not vaccinated who can continue to be infected and pass on the infection” and “’men who have sex with men are completely unprotected by a vaccination programme only for girls”.

Sundell adds that vaccinating boys can contribute further to herd immunity as “vaccinated boys will help to further reduce the spread of the HPV virus, which in turn will help to limit the number of cervical cancers in women”. Vaccinating boys will also help to increase herd immunity among the excluded men who have sex with men group.

In addition, HPV Action argues that vaccinating girls only simply perpetuates the belief that primary responsibility for population health, and particularly sexual health, should be with females; whereas in a modern society it should be shared between everyone of all ages, genders and sexual orientations.

What more needs to be done to protect boys against HPV?

JCVI’s decision to only introduce the vaccine for boys aged 12 and 13 means “boys and young men currently over the age of 13 (born after 01/09/2006), are not eligible to receive a free HPV vaccine. This means if you’re a male who’s older than 13 this year…you aren’t currently able to have this jab unless you can pay for it,” explains Sundell.

Therefore, HPV Action is currently calling for a catch-up programme for boys until the age of 18. Teenage Cancer Trust is going further to call for it to be available to boys up to the age of 25, like it is for girls, in its Jabs For Lads campaign.

Although DHSC claims that the “extending the vaccine to boys aged over 13 would only have a limited benefit as older boys and young men are already protected by herd immunity – built up by 10 years of the girls’ successful vaccination programme”, Sundell argues this “contradicts the NHS’ own message that universal vaccines are for the common good.”

Baker agrees, saying this contradicts the DHSC’s decision to include Year 8 boys in the programme, as it means “they have accepted that boys are not sufficiently protected by the vaccination of girls [and] boys who are 14, 15, 16 or 17, are at exactly the same risk of HPV and the diseases it causes as boys who are 12 to 13.”

Baker adds: “It is particularly galling because JCVI took so long to make a decision. If they made that decision in 2015, as they said they would originally, rather than three years later, then most of the boys, who we would now like to see in a catch-up programme, would have been vaccinated anyway.”

“More than a million teenage boys [and young men], currently aged 13 to 25, in the UK will miss out on potentially life-saving vaccinations,” Sundell adds. “This leaves them at risk of HPV-related cancers in adulthood that could be prevented. Teenage Cancer Trust thinks this is unfair.”

“Not vaccinating older teenage boys puts them at risk, as it relies on the false presumption that they will only have sexual partners who don’t have HPV.”

Preventing exclusion based upon sexual orientation

A particular at-risk group are men or trans women who have sex with men, who are largely unprotected by herd immunity. Although men who have sex with men and trans women are eligible to receive a HPV vaccine for free at any age at a sexual health clinic, Baker explains the flaws in this programme.

Rather than being able to show up at a sexual health clinic and ask for the vaccine, a man who has sex with men or a trans woman has to turn up at the clinic for another reason and then be offered the HPV vaccine, meaning the situation is “a bit hit and miss” in Baker’s words.

Another issue with the men who have sex with men programme is “the average of first attendance [for this group to a sexual health clinic] is 32 years,” which is almost two decades after the recommended age for the HPV jab of 12 to 13 years as the vaccine is most effective if administered before sexual debut.

Although they may still get value from being vaccinated, most of the cellular damage from infection with HPV has already been done. “It is really the case of shutting the stable door after the horse has bolted” says Baker.

“If you want to protect men who have sex with men effectively, you have to have a vaccination programme for all boys; there’s no escaping that.”