Research Article: Potential effectiveness of prophylactic HPV immunization for men who have sex with men in the Netherlands: A multi-model approach

Date Published: March 4, 2019

Publisher: Public Library of Science

Author(s): Johannes A. Bogaards, Sofie H. Mooij, Maria Xiridou, Maarten F. Schim van der Loeff, Silvia de Sanjosé

Abstract: BackgroundMen who have sex with men (MSM) are at high risk for anal cancer, primarily related to human papillomavirus genotype 16 (HPV16) infections. At 8.5 per 100,000 per year, the incidence rate of anal cancer among MSM is similar to that of cervical cancer among adult women in the Netherlands. However, MSM are not included in most HPV vaccination programs. We explored the potential effectiveness of prophylactic immunization in reducing anogenital HPV16 transmission among MSM in the Netherlands.Methods and findingsWe developed a range of mathematical models for penile–anal HPV16 transmission, varying in sexual contact structure and natural history of infection, to provide robust and plausible predictions about the effectiveness of targeted vaccination. Models were informed by an observational cohort study among MSM in Amsterdam, 2010–2013. Parameters on sexual behavior and HPV16 infections were obtained by fitting the models to data from 461 HIV-negative study participants, considered representative of the local MSM population. We assumed 85% efficacy of vaccination against future HPV16 infections as reported for HIV-negative MSM, and age-specific uptake rates similar to those for hepatitis B vaccination among MSM in the Netherlands. Targeted vaccination was contrasted with vaccination of 12-year-old boys at 40% uptake in base-case scenarios, and we also considered the effectiveness of a combined strategy. Offering vaccine to MSM without age restrictions resulted in a model-averaged 27.3% reduction (90% prediction interval [PI] 11.9%–37.5%) in prevalence of anal HPV16 infections, assuming similar uptake among MSM as achieved for hepatitis B vaccination. The predicted reduction improved to 46.1% (90% PI 21.8%–62.4%) if uptake rates among MSM were doubled. The reductions in HPV16 infection prevalence were mostly achieved within 30 years of a targeted immunization campaign, during which they exceeded those induced by vaccinating 40% of preadolescent boys, if started simultaneously. The reduction in anal HPV16 prevalence amounted to 74.8% (90% PI 59.8%–93.0%) under a combined vaccination strategy. HPV16 prevalence reductions mostly exceeded vaccine coverage projections among MSM, illustrating the efficiency of prophylactic immunization even when the HPV vaccine is given after sexual debut. Mode of protection was identified as the key limitation to potential effectiveness of targeted vaccination, as the projected reductions were strongly reduced if we assumed no protection against future infections in recipients with prevalent infection or infection-derived immunity at the time of immunization. Unverified limitations of our study include the sparsity of data to inform the models, the omission of oral sex in transmission to the penile or anal site, and the restriction that our modeling results apply primarily to HIV-negative MSM.ConclusionsOur findings suggest that targeted vaccination may generate considerable reductions in anogenital HPV16 infections among MSM, and has the potential to accelerate anal cancer prevention, especially when combined with sex-neutral vaccination in preadolescence.

Partial Text: Sexually transmitted oncogenic types of human papillomavirus (HPV) are known as the causative agents of cervical cancer [1–3]. They may also cause cancers in males, notably penile cancer, anal cancer, and a subset of head and neck cancers [2]. Relative to heterosexual males, men who have sex with men (MSM) are at increased risk for HPV-related cancers, especially for anal cancer [3]. With an estimated incidence of 8.5 per 100,000 per year, the incidence rate of anal cancer among MSM is similar to that of cervical cancer among adult women in the Netherlands [4].

We developed a range of mathematical models for penile–anal HPV16 transmission to assess the potential effectiveness of selective vaccination of MSM. Throughout we assumed that MSM acquire penile infections via insertive anal intercourse, whereas anal infections are acquired through receptive anal intercourse. The models differed in terms of sexual contact structure of the MSM population and assumptions regarding the natural history of HPV16 infection. Sexual contact parameters were estimated, whenever possible, from self-administered questionnaire data regarding sociodemographic characteristics and recent sexual behavior among 778 MSM (median age: 40 years, 5th–95th percentile 28–61 years) participating in the H2M study [19]. This is an observational cohort study on HIV and HPV infections in MSM recruited in Amsterdam in 2010–2011 and followed every 3–6 months for at least 2 years.

Patterns of site-specific HPV16 infection prevalence and clearance among HIV-negative H2M study participants were compatible with a range of mathematical models for penile–anal HPV16 transmission (Fig 1). Site-specific transmission probabilities varied widely across the models (Table 2), but penile-to-anal transmissibility almost invariably exceeded anal-to-penile transmissibility. Models that assumed a higher degree of natural immunity generally required increased transmissibility to reproduce the observed prevalence of penile and anal HPV16 infections. In addition, penile-to-anal transmissibility was higher when presuming a stronger degree of assortative mixing with respect to sexual activity (S7 Fig).

This study explored the potential effectiveness of HPV vaccination for MSM in the Netherlands. Based on predictions from a range of penile–anal HPV16 transmission models, we estimated that around 30% of anogenital infections might be prevented after 40 years if uptake similar to that of HepB vaccine among MSM throughout the Netherlands were realized. This figure increased to 75% after 60 years when targeted vaccination was combined with sex-neutral vaccination in preadolescence, assuming 40% uptake among 12-year-old boys. HPV16 prevalence reductions among MSM mostly exceeded vaccine coverage projections, illustrating the efficiency of prophylactic immunization even when HPV vaccine is given after sexual debut.



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