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ISSN: 2157-7560
Journal of Vaccines & Vaccination

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Literature Review of Sexual Risk Compensation Following Human Papillomavirus Immunization

Rebecca AG Christensenc1* and Jane M Heffernan2,3

1Department of Kinesiology and Health Science at York University, USA

2Department of Mathematics and Statistics at York University, USA

3Centre for Disease Modelling, York Institute for Health Research at York University, USA

*Corresponding Author:
Rebecca AG Christensenc
York University, Department of Mathematics and Statistics
Ross Building, Rm N520, 4700 Keele Street
Toronto, Ontario, M3J 1P3, USA
Tel: 87673937648
E-mail: [email protected]

Received date: June 10, 2016; Accepted date: June 29, 2016; Published date: July 04, 2016

Citation: Christensenc RAG, Heffernan JM (2016) Literature Review of Sexual Risk Compensation Following Human Papillomavirus Immunization. J Vaccines Vaccin 7:328. doi: 10.4172/2157-7560.1000328

Copyright: © 2016 Christensenc, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Objective: To examine existing literature on behavioural risk compensation/disinhibition following Human papillomavirus (HPV) immunization.
Methods: A systematic literature review was undertaken using the terms “behavioural risk compensation or disinhibition”, “HPV vaccination or immunization”, “in humans” on Google Scholar. A supplemental review was also undertaken to examine the themes “barriers and facilitators for HPV immunization” and “strategies to increase rates of vaccination”, which were identified in the original search.
Results and Discussion: Structural barriers to vaccination such as cost, and personal barriers such as concern about the safety of the vaccination, were identified. Approximately half of the literature suggests that individuals have similar sexual health practices regardless of vaccination status. Some literature also suggests that women who are vaccinated for HPV are more likely to use a condom than their counterparts. Strategies to increase immunization uptake primarily focus on education or recommendation from primary health practitioners.
Conclusion: Barriers and facilitators for HPV vaccination appear consistent with other vaccines. Individuals who are vaccinated for HPV may be less likely to engage in high risk sexual behaviours. Further, education and support from primary health practitioners are key for increased vaccine uptake.

Keywords

HPV; Vaccination; Risk compensation; Behavioural disinhibition

Introduction

Currently there are two approved Human papillomavirus (HPV)1 vaccines available in Canada: Cervarix and Gardasil. Cervarix, which is a multi-dose bivalent vaccine, protects against the two HPV serotypes, 16 and 18, that are responsible for 70% of all cervical cancers. Cervarix received approval in 2010 for use in females 10 to 25 years of age [1]. Gardasil is a multi-dose quadrivalent vaccine that protects against HPV serotypes2 6, 11, 16 and 18 [1]. In 2006, Gardasil was initially approved for use in Canada with females aged 9 to 26, which has since been expanded to for use in men of the same ages and then for women up to the age of 45 [1]. While both vaccines are available in Canada, Gardasil has been more heavily promoted by official sources due to its ability to protect against cervical cancer and genital warts. Currently, Gardasil is the vaccine used in all publicly funded immunization programs in Canada [1].

Gardasil has been proven to be safe, and 65-100% effective, in preventing new and reoccurring infections of HPV serotypes 16 and 18 in females 16 to 26 years old [2-4]. Gardasil was also added to Ontario’s routine immunization registry in 2007, and a program was instituted to provide all three doses of the vaccination free of charge to girls in grade 8 [5]. In 2012, a catch-up program was instituted which allowed girls in grades 9-12 who had not received, or had missed a dose of the vaccination to get it free of charge at local Public Health units [5]. In February 2015, a new nonavalent vaccine (Gardasil 9) was approved for use in Canada; however, the National Advisory Committee on Immunization has yet to issue a statement [6].

Currently, immunization rates for HPV in Ontario are approximately 55 percent among eligible females [7]. Considering the extensive availability of the vaccine, it remains unclear as to why such a large percentage of the population has not been vaccinated. Thus, this report will begin by examining reasons why individuals have or have not elected to be vaccinated for HPV, if there is any change in behaviour following vaccination, and conclude with strategies for increasing rates of vaccination among vulnerable populations. While this report is focused on HPV, given the promising results from ongoing vaccination trials for herpes simplex (HSV) and human immunodeficiency viruses (HIV), this review may also have future relevancy for other sexually transmitted infections (STIs).

Methods

A review was undertaken of the existing literature on behavioural risk compensation or disinhibition following HPV vaccination, from August 3rd to August 20, 2015. Google scholar was used as the search engine, with “behavioural risk compensation or disinhibition”, “HPV vaccination or immunization”, “in humans”, entered as search parameters. This returned 129 icles. Abstracts from these articles were then reviewed to ensure they met inclusion criteria (i.e. using human participants, with a portion of which have received at least one dose of the HPV vaccine). The reference lists of these papers were then reviewed for additional articles relating to HPV vaccination that may have been missed during the initial search. This provided 2 new references for a total of 7 references. We identified “barriers and facilitators for HPV immunization”, “behavioural changes following vaccination”, and “strategies to increase immunization” as themes from the literature. A supplemental review was undertaken to further explore the themes of barriers and facilitators for HPV immunization, and strategies to increase immunization.

Figure 1 contains a flow chart outline the inclusion and exclusion of articles while Table 1 (barriers and facilitators for HPV immunization), Table 2 (behavioural changes following vaccination), and Table 3 (strategies to increase immunization) summaries the articles by theme.

vaccines-vaccination-Article-Inclusion

Figure 1: Article Inclusion Flow Chart.

Author Study Design Sample Size (N) Age Sex Country
Abdelmuttiand Hoffman-Goetz [9] Newspaper Content Analysis 15* -- -- United States
Bednarczyk et al. [8] Retrospective Cohort 1398 Adolescents Female United States
Brewer andFazekas[11] Systematic Review 28* Adolescents, Young Adults, and Adults Female United States
Ferris et al. [15] Cross-sectional 322 Adults Female and Male United States
A. Forster, Wardle, Stephensonand Waller [10] Newspaper Content Analysis 92* -- -- United Kingdom
Griffoen et al. Cross-sectional 65 Adolescents and Adults Female United States
Guerry et al. [26] Cross-sectional 509 Adults Female and Male United States
Kahn et al. [18] Prospective cohort 99 Adolescents and Young Adults Female United States
Marlow, Forster, Wardle, and Waller [14] Cross-sectional 692 Adolescents and Adults Female United Kingdom
Sauvageau, Duval, Lavoie andOuakki[12] Cross-sectional 471 Adolescents, Young Adults and Adults Female Canada
Schuler, Reiter, Smith, Brewer and Hill [16] Cross-sectional 647 Adults Female and Male United States
Stretch et al. Cross-sectional 651 Adults Female and Male United Kingdom
Thomas and Goldstone [19] Cross-sectional 191 Adult Male United Kingdom
*=Sample size refers to number of articles/studies not participants
--=Information not provided
Adolescents=11 to 19 years of age
Young Adults=20 to 26 years of age

Table 1: Barriers and Facilitators to Vaccination Articles.

Author Study Design Sample Size (N) Age Sex Country
Bednarczyk et al.[8] Retrospective Cohort 1398 Adolescents Female United States
Cummings et al.[20] Case Control 225 Adolescents Female United States
Forster et al.[10] Prospective Cohort 407 Adolescents Female United Kingdom
Jena, Goldman, and Seabury [23] Case Control 2,08,111 Adolescents Female United States
Liddon et al.[21] Retrospective Cohort 1243 Adolescents and Young Adults Female United States
Rysavy et al.[22] Cross-sectional 203 Adolescents and Young Adults Female United States
Thomas and Goldstone [19] Cross-sectional 191 Adult Male United Kingdom
Adolescents=11 to 19 years of age
Young Adults=20 to 26 years of age
Adults=>26 years of age

Table 2: Behaviour Change Following Vaccination Articles.

Author Study Design Sample Size (N) Age Sex Country
Alexander et al.[30] Cross-sectional 42 Adolescents and Adults Female and Male United States
Askelson et al.[30] Cross-sectional 217 Adults Female United States
Brabin et al.[29] Cross-sectional 553 Adolescents Female United Kingdom
Brewer andFazekas [11] Systematic Review 28* Adolescents, Young Adults, and Adults Female United States
Griffoen et al. Cross-sectional 65 Adolescents and Adults Female United States
Guerry et al.[26] Cross-sectional 509 Adults Female and Male United States
Krawczyk et al.[24] Cross-sectional 447 Adolescents, Young Adults, and Adults Female Canada
McRee, Gottlieb, et al. Cross-sectional 900 Adults Female United States
McRee, Reiter and Brewer [28] Cross-sectional 888 Adults Female and Male United States
Zimet, Rosberger, Fisher, Perez, andStupiansky[27] Literature Review -- -- -- --
Zimet, Weiss, Rosenthal, Good andVichnin [25] Cross-sectional 185 Adolescents and Young Adults Female United States
*=Sample size refers to number of articles/studies not participants
--=Information not provided
Adolescents=11 to 19 years of age
Young Adults=20 to 26 years of age
Adults=>26 years of age

Table 3: Strategies to Increase Vaccination Articles.

Results and Discussion

Barriers and facilitators for HPV immunization

Research conducted on barriers and facilitators for HPV vaccination has primarily focused on mothers and a subpopulation of fathers, given the recommended young age of 11 to 12 years for HPV vaccination. Parents report structural barriers to immunization such as cost, and the multi-dose nature of the vaccine, as well as personal barriers such as concerns about how safe the vaccine is [8]. Additionally, various news reports throughout North America [9] and the United Kingdom [10] have suggested that girls may adopt risky sexual behaviours following vaccination. Concern for this risk compensation3 has been reported by 6-30% of parents surveyed in a variety of studies [11-16].

Research has been conducted on adolescent females that have reported no intention to change behaviours following vaccination [8], however, they do perceive themselves at a decreased risk for HPV as well as other STIs [17,18].

While research conducted on HPV has primarily focused on women being vaccinated, there has been a surge of research focusing on potential barriers and facilitators for men being vaccinated, given the potential health benefits of the vaccination for them. Overall, research showed that the reasons men would not, or did not get vaccinated for HPV were rather similar to women. Men reported the high cost associated with vaccination, as well a lack of adequate information regarding safety and effectiveness of the vaccine [19]. There was no concern about sexual risk compensation or disinhibition among men; however, this may be due to the fact that parents were not the respondents for these studies.

Behaviours following vaccination

Our literature review identified only seven studies to date the focus on behaviour change following vaccination. The small number of studies may be a result of the fact that the HPV vaccine has only been available for a short period of time. Six of the studies were conducted in the United States [8,20-23] and the United Kingdom [17] on females 11 to 24 years old. Study findings have been relatively consistent across all studies, with three reporting no difference in sexual behaviours, such as number of sexual partners and condom use [17,22,23], while the three other studies found no difference in the majority of sexual behaviours except that females who had been vaccinated had slightly increased rates of condom use [8,20,21]. These results were also consistent with the one study conducted on men, which showed there was no difference in frequency of anal sex, condom use, or sexual activity based on whether they had or had not received the HPV vaccine [19].

Overall, the consensus among existing literature appears to be that receiving the HPV vaccine does not contribute to increased risky sexual behaviour. Indeed, it appears as though being vaccinated may result in a greater likelihood of safe sex practices compared to same aged counterparts who had not been vaccinated.

Strategies to increase rates of vaccination

Consistent results across a variety of studies with both males and females have found that a lack of adequate information and education appear to be the primary barrier to HPV vaccine uptake. Physicians have been shown to be one of the most important determining factors in whether individuals accept vaccination [11,24-27] or not [21,25]. Therefore, HPV vaccine educational literature provision through medical offices may increase uptake in HPV immunization [19,27].

The manner of presentation of the risks of the HPV vaccine to children and their parents may also play an important role in determining whether or not vaccination will occur [27]. Therefore, physicians and other important role models, such as teachers, may want to focus on the risk associated with not getting vaccinated for HPV rather than how safe the vaccine is [27].

A percentage of parents also report concerns about sexual risk compensation or disinhibition following vaccination [11-16], which may make them less likely to have their child (ren) immunized for HPV. While research appears to contradict this concern, this research is not necessarily easily accessible for parents who are deciding if they should or should not have their child vaccinated. Further, research suggests that having accurate material accessible online for parents may improve vaccination uptake, given that parents are already accessing most of their medical resources online [28]. Therefore, providing quality information to parents may alleviate some of their concerns and aid in decision-making.

Lastly, openly discussing HPV vaccination may provide adolescents with an opportunity to actively participate in their health care practices [29,30] and an opportunity to discuss sexual health topics that build positive sexual health values [31]. This may be why research has shown that females who have received the HPV vaccination are more likely to participate in safe sexual practices compared to those who have not.

There is a limitation that warrants mentioning. This review used only one search engine to conduct the literature review which may have impacted the amount of articles retrieved. However, as Google Scholar aggregates articles from other search engines this is unlikely to have an impact on the overall findings presented.

Conclusion

Cost and sexual risk compensation are likely to be reported as reasons for not vaccinating adolescents against HPV, which is consistent with other vaccines. However, due to the public funding of Gardasil immunization for Ontario, and the findings of this review which suggest that that sexual disinhibition following vaccination does not occur, these are likely not the main reasons for poor immunization uptake. What may play a greater role is the lack of education and knowledge dissemination surrounding vaccination programs, as well as a lack of understanding of the benefits for safe sexual behaviour following HPV vaccination. Thus, recommendations from primary health care professional appear to be a key determining factor in vaccination. Further, providing a positive venue for parents and adolescents to speak openly about sex, and for adolescents to take responsibility for their health, are additional benefits from this program beyond the foundational proposition of decreased rates of HPV infection. This research also provides promise for the extended health benefits that may be seen following approval for HSV or HIV vaccinations in human, as well as provides strategies that might be employed to ensure the successful uptake of these new vaccinations on a population level.

Acknowledgements

RAGC and JMH conceived of the research question and were involved in the writing of the article. RAGC carried out the review. JMH had final approval of the article. Dr. Ève Dubé provided technical support regarding breadth of HPV literature reviewed.

Disclosure

None

1HPV is a sexually transmitted infection that has over 150 related viruses. HPV can cause genital warts in both men and women, and is responsible for all types of cervical cancer [32].

2Serotypes are distinct species or types of microorganisms like bacteria or viruses [33]. As they have differing surface structures they can cause different symptoms within the same bacteria. For example, HPV serotype 16 can cause cervical cancer while HPV serotype 6 can cause genital warts.

3Sexual risk compensation or disinhibition refers to individuals changing behaviours in response to vaccination, resulting in initiating in sex at a younger age, or adopting riskier sexual behaviours such as not using condoms.

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