Disparities in human papillomavirus (HPV) vaccine initiation and completion based on sexual orientation among women in the United States

Exploration of individual socioeconomic and health-related characteristics associated with human papillomavirus vaccination initiation and vaccination series completion among adult females: A comprehensive systematic evidence review with meta-analysis

INTRODUCTION

Human papillomavirus (HPV) vaccination rates among females are lower than the World Health Organization target and vaccination rates specifically among adult females are even much lower.

METHODS

We systematically evaluated individual socioeconomic and health-related characteristics associated with HPV vaccination initiation and vaccination series completion among adult females (PROSPERO: CRD42023445721). We performed a literature search on December 14, 2022, and supplemented the search on August 1, 2023. We pooled appropriate multivariable-adjusted results using an inverse variance random-effects model and expressed the results as odds ratios with associated 95 % confidence intervals. A point pooled significantly increased/decreased odds of 30-69 % was regarded to be strongly associated, and ≥ 70 % was very strongly associated.

RESULTS

We included 63 cross-sectional studies. There were strongly increased odds of vaccination initiation among White women compared with Black or Asian women, and those with higher education, health insurance, a history of sexually transmitted infection (STI), receipt of influenza vaccination in the preceding year, not married/cohabiting, not smoking, using contraception, and having visited a healthcare provider in the preceding year. We observed very strongly increased odds of vaccination initiation among those younger and having been born in the country of study. Similarly, there were strongly increased odds of completing the vaccination series for the same variables as initiating vaccination, except for higher education, prior STI, smoking and contraception use. Additional variables associated with strongly increased odds of vaccination series completion not seen in initiation were higher annual household income, being lesbian/bisexual, and having a primary care physician. We observed very strongly increased odds of vaccination series completion similar to vaccination initiation but including for White compared with Black women, higher education, and prior cervical cancer screening.

CONCLUSIONS

These individual characteristics may be the key to identifying women at increased risk of not being vaccinated against HPV and could inform targeted messaging to drive HPV vaccination.

Understanding Sexual and Gender Minority Populations and Organ-Based Screening Recommendations for Human Papillomavirus-Related Cancers

OBJECTIVES

Sexual gender minority (SGM) populations are at risk for human papillomavirus (HPV)-related cancers of the anogenital tract and oropharynx and often face barriers to health care. The goals of this document are to clarify language to provide inclusive care for SGM populations and to provide recommendations for screening and prevention of HPV-related cancers in SGM populations.

MATERIALS AND METHODS

An expert committee convened by the American Society for Colposcopy and Cervical Pathology performed a narrative review of the literature through February 2023. A comprehensive MEDLINE database search was performed for relevant studies. The literature review was divided into categories by organ/topic and by SGM population. Given the variability in available data for several of the categories, recommendations were made based on national guidelines where appropriate or expert opinion where there were less data to support risk-based guidelines.

RESULTS

Definitions and terminology relevant to SGM populations are presented. The authors advocate the adoption of sexual orientation gender identity data collection and an organ-based screening approach, which is possible with knowledge of patient anatomy, sexual behaviors, and clinical history. This includes screening for cervical cancer per national recommendations, as well as screening for anal, vulvar, vaginal, penile, and oral cancers based on risk factors and shared clinical decision making. The authors recommend consideration of HPV vaccination in all SGM individuals up to age 45 years old who are at risk.

CONCLUSIONS

An organ-based screening approach is part of a global strategy to create an inclusive care environment and mitigate barriers to screening and prevention of HPV-mediated cancers in SGM populations.

Health inequities in human papillomavirus prevention, diagnostics and clinical care in the USA: a scoping review

BACKGROUND

Human papillomavirus (HPV) represents the most common STI in the USA. HPV inequities in prevention, diagnostics and clinical care persist. We define inequities as systematic, avoidable and unfair differences in health outcomes.

OBJECTIVES

The objectives of this scoping review are to chart existing data on HPV-related inequities, identify gaps in existing literature and guide future research to reduce these inequities.

METHODS

We completed a scoping review following guidelines from the Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping reviews extension. We performed a literature search on PubMed and Ovid Embase in July 2022 for articles pertaining to HPV and evaluating populations within the USA. We included English language publications from 2018 to 2022 evaluating at least one health inequity outlined by the National Institutes of Health. General publication characteristics and health inequity data were charted in a masked, duplicate fashion using a pilot-tested Google Form. We analysed frequencies of health inequities and summarised main findings from included studies.

RESULTS

Our final sample included 170 publications. The most common inequities examined were race/ethnicity (140 studies), sex or gender (97 studies), and income (69 studies). Many historically marginalised racial/ethnic groups had lower rates of HPV-related knowledge, vaccination and worse overall outcomes related to HPV. Compared with women, men had lower rates of HPV vaccination and provider recommendation, and higher rates of HPV-infection. Results regarding income were largely conflicting.

CONCLUSION

Findings from our review demonstrate clear gaps in HPV-related inequity research. Vaccine completion, provider recommendation and intersectionality should continue to be evaluated to implement targeted interventions.

Sexual Orientation and Gender Identity Differences in Influenza, Shingles, and Pneumococcal Vaccination Among U.S. Older Adults

Purpose: LGBT older adults face challenges accessing and receiving culturally competent health care and may be more vulnerable to serious outcomes from vaccine-preventable diseases. This study examines whether sexual orientation and gender identity are associated with older adult influenza, zoster ("shingles"), and pneumococcal vaccine uptake. Methods: Data come from the 2020 Behavioral Risk Factor Surveillance System. The sample included older adults aged 50+ (eligible for influenza and shingles vaccination; n = 136,528) and 65+ (eligible for pneumococcal vaccination; n = 74,779). We calculated rates of influenza, shingles, and pneumococcal vaccine uptake by gender-stratified sexual orientation groups and for transgender versus cisgender populations. Logistic regression models tested for associations between sexual orientation, gender identity, and vaccine uptake, controlling for key sociodemographic characteristics. Results: Transgender adults had the lowest rates of uptake across all three vaccines, including 46% lower odds of shingles vaccination and 61% lower odds of pneumococcal vaccination, when compared with cisgender adults. Gay (vs. straight) men had 1.5-1.9 times greater odds of flu and shingles vaccination. Bisexual (vs. straight) women had 32% lower odds of flu vaccination. Conclusion: Our findings indicate that vaccine uptake among LGBT older adults varies by sexual orientation, gender identity, and vaccine type. Bisexual women and transgender people are groups that tend to underutilize health care services and are at increased risk of nonvaccination, making them important targets for older adult vaccine promotion.

Human Papillomavirus Vaccination Initiation and Completion Among Heterosexual and Sexual Minority U.S. Adults

Purpose: The current study examined the relationship between sexual orientation and human papillomavirus (HPV) vaccination status (no vaccination vs. vaccination initiation [one to two doses] or completion [three or more doses]) among a nationally representative sample of U.S. adults. Methods: Pooled Integrated Public Use Microdata Series-National Health Interview Survey data from 2013 to 2017 were used. The analysis sample (N = 35,266) reported on HPV vaccination status, sexual orientation, and demographic covariates. Multinomial logistic regression, stratified by sex, was conducted to assess the relationship between sexual orientation and HPV vaccination status. Results: Most of the sample (80.37%) had not received any HPV vaccination dose, and only ∼10% reported vaccine completion (three or more doses). After adjusting for demographic covariates, gay and bisexual males were more likely than heterosexual males to initiate (gay: adjusted odds ratio [AOR] = 2.46, 95% confidence interval [CI] = 1.67-3.62; bisexual: AOR = 2.30, 95% CI = 1.28-4.12) and complete (gay: AOR = 2.59, 95% CI = 1.45-4.65; bisexual: AOR = 3.20, 95% CI = 1.56-6.55) HPV vaccination. Bisexual females were more likely than heterosexual females to initiate (AOR = 1.99, 95% CI = 1.55-2.54) and complete (AOR = 1.45, 95% CI = 1.23-1.86) HPV vaccination. Females of another sexual orientation were less likely than heterosexual females to complete HPV vaccination (AOR = 0.49, 95% CI = 0.26-0.92). Conclusions: HPV vaccination remains low across sexual orientation groups. Sexual minority status may be a promotive factor in HPV vaccination for specific subgroups.

Human papillomavirus-Inequalities in disease prevention and the impact on racial, ethnic, sexual, and gender minorities

HPV, a sexually transmitted viral infection, is the etiological agent of significant dermatologic disease including benign anogenital warts and invasive cancers. Sexual and gender minority individuals are particularly vulnerable to HPV-associated disease due to reduced vaccination rates in these cohorts, low awareness of HPV, lack of provider recommendation, and inadequate consensus guidelines on screening and prevention in these individuals. A targeted approach is needed with regards to vaccination in all children -especially those from racial, ethnic, sexual, and gender minorities; provider recommendation, especially from pediatric dermatologists, is crucial. Effort must also be made to use transgender and non-binary affirming language as dividing vaccination programs by anatomic sex and sexuality reinforces problematic notions of gender identity and sexuality, isolating the most vulnerable.

The COVID-19 Pandemic Seen from a Syndemic Perspective: The LGBTQIA2SP+ Community

An adverse condition or a disease can (either directly or indirectly) interact in a synergistic fashion with other adverse conditions or diseases/maladies, and co-cluster together with them: this fundamental observation is at the basis of the term "syndemic" (a portmanteau for "synergistic epidemic") [...].