Challenging Dogma

...Using social sciences to improve the practice of public health

Friday, April 20, 2007

HPV Immunization Policy: A Critique of the Campaign to Implement HPV Immunizations Among Young Girls and Women-Alana Wooley

Recently two pharmaceutical companies began manufacturing Human papillomavirus (HPV) vaccines designed to prevent type-specific HPV infections. Gardasil, which is manufactured by Merck Pharmaceutical, received Federal Drug Administration (FDA) approval in July, 2006 (1). GlaxoSmithKline’s HPV vaccine, Cervarix, is pending FDA approval. Since the approval of Gardasil, many state governments recommend that the vaccination become compulsory for girls ages 11-12 in an effort to decrease the incidence of HPV, the most common sexually transmitted infection (STI). The prophylactic HPV vaccination is a cost-effective technique designed to protect against type-specific HPV infections and complement Papanicolaou (Pap) tests in preventing cervical cancer cases originating from HPV infections (2). Administered in three doses (0, 2, and 6 months), the vaccine costs $360 for the series (3,4). The purpose of this paper is to demonstrate that efforts of the public health community to implement mandatory HPV vaccinations will fail to decrease the incidence of STIs because this effort ignores social factors.

Human Papillomavirus
Cervical cancer, predominantly caused by HPV infections, is the second highest cause of cancer mortality among women worldwide (3, 5, 6). In the United States alone, 4,000 women die each year due to cervical cancer and 12,000 new cases of cervical cancer are reported (7). The Center for Disease Control (CDC) estimates that 20 million people in the United States have HPV and each year 5.5 million people in the United States become infected, increasing the possibility of transmitting the virus (8). Currently, 15% of people between the ages of 15 and 49 have HPV. A 3-year study of college-aged American women indicated that 14% of the women became infected with HPV, with a total of 43% of women infected with HPV during the course of the study (8). This transient virus is transmitted via sexual intercourse and skin-to-skin contact (7). HPV has few symptoms; however, if the virus persists undetected it can develop into cancerous lesions, making this STI an important public health issue.

There are more than 100 types of HPV (4) and approximately 40 oncogenic types that can infect the genitalia of both men and women, some of which cause genital warts, others of which manifest themselves in cervical intraepithelial neoplasia (CIN) and can lead to cervical, anal, or penile cancer (3). HPV type 16 is responsible for 50% of cervical cancer cases. Types 16, 18, 31, and 35 combined account for 80% of cervical cancer cases (3, 5).

For the most efficacious use of the vaccine, the CDC Advisory Committee on Immunization Practices (ACIP) recommends that girls get inoculated before becoming sexually active, and therefore before exposure to HPV (3). The ACIP recommends inoculating girls at age 11-12; however, girls as young as 9 can receive the vaccine (9). Girls and women ages 13-26 who do not receive the vaccine at the recommended age can also get inoculated (3). The vaccine will not protect against a strain of HPV carried by the recipients if they already have an HPV infection (3).

Health Education: The Inadequacy of Abstinence-only Sex Education
Health education and awareness programs are cost-effective and realistic approaches to reducing the incidence of deaths due to cervical cancer by empowering people with knowledge of safe sex techniques to prevent the transmission of STIs, including HPV (5). However, many schools lack programs which offer comprehensive information about STIs. Abstinence-only education (AOE) programs focus on the benefits of abstaining from sex, promote abstinence as the only guaranteed method of preventing pregnancy, and teach students about STIs. AOE programs do not fully educate and prepare adolescents for safe-sex practices when they decide to have intercourse. Instead, these programs often censor textbooks, lead to the cancellation of health education classes, and misinform students about contraceptives and pregnancy options (2). A 2004 congressional examination of AOE curricula revealed that information regarding efficacy of contraceptives and risks associated with abortions were was false, subjective, misleading or distorted in 11 out of 13 AOE curricula (10, 11). In addition, AOE curricula carry the message that sex outside of marriage is not a social norm and, therefore, can lead to psychological and physical problems for the individual engaging in out-of-wedlock sex as well as for a child conceived out of wedlock (12). Such methodology shames sexual activity outside of marriage, perhaps giving people a sense that they can be ostracized if others knew they engaged in sexual intercourse. This reaction to AOE curricula may prevent adolescents from accessing resources pertaining to safe sex practices as well as obtaining contraceptives and protection.

Twenty-three states and Washington D.C. have proposed legislation to mandate the HPV vaccine for school entrance, with allowances for exceptions. Colorado, Florida, Georgia, Hawaii, Illinois, Kansas, Kentucky, Massachusetts, Michigan, Missouri, Mississippi, New Jersey, New Mexico, Ohio, South Carolina, Texas, Virginia, and Washington D.C. are among states enacting legislation to incorporate the HPV vaccine into school entrance requirements. These states receive federal funding ranging from $1.5 million to $16 million for AOE programs (13, 14). Adolescents in these states are doubly challenged. This combination of states requiring the vaccination and sex education programs that are heavily supported by federal AOE funds will create a generation ignorant of safe sex practices.

An examination of the virginity pledge movement by Bearman et al found that teens pledging to remain abstinent until marriage through their AOE curricula reported STI rates close to students who did not take the pledge (15). With inadequate education about contraception and protection, adolescents are less likely to practice safe sex. Furthermore, many adolescents and adults are unaware of HPV and fewer understand the pathology of this virus. An American Association of Cancer Research study revealed that only 40% of women ages 18-75 have heard of HPV and less than 20% of these women understand that an HPV infection can develop into cervical cancer (4).

Abstinence-only education and pledges are not practical means of reducing the risk of STI transmission because abstinence until marriage is difficult to practice (16). Some teens pledging to remain abstinent until marriage forego the pledge and are less equipped to experience sexual activity, thereby demonstrating higher STI rates than those with comprehensive sex education. Furthermore, some teens maintaining their abstinence pledge consider their pledge to include vaginal intercourse and thereby engage in other forms of sex such as oral, anal, or homosexual sex. Perhaps unaware, these forms of intercourse also put young people at risk for receiving or transmitting STIs (11). It is plausible that adolescents who receive the vaccine as they begin to learn about sexuality will not understand the protection the HPV vaccine offers. Instead, due to inadequate sex education adolescents may misinterpret coverage of the vaccine or replace other forms of contraceptives.

Failure to Account for Psychological Factors
The vaccination is intended to reduce the risk of HPV for women. Risk compensation (17), a behavior pattern that occurs when animals or people alter their behaviors to compensate for a change in the risk-level of specific behaviors, may occur after receiving the vaccination. Compulsory seat belt regulations can best explain this behavior pattern. The seat belt was intended to reduce injuries and fatalities associated with car accidents. Studies indicate that despite the intervention, injuries and fatalities as a result of car accidents have not declined (18). Drivers feel protected by the seatbelt and compensate by driving faster (17). Risk compensation in the case of the HPV vaccine would manifest itself in a situation where young people are not fully informed. Women who engage in safe sex practices might feel safer and more protected against HPV after receiving the vaccination. In response, they may use contraceptives less often, which would offset the protection obtained through the HPV vaccine. A study regarding risk-taking behavior in adolescents by Mathew and colleagues revealed that adolescents engaging in risky behavior often do not utilize safety devices such as seatbelts (19). Current health campaigns do nothing to counteract this psychological phenomenon of risk compensation. Comprehensive sex education and information regarding the HPV vaccine are useful tools when adolescents begin to explore their sexuality.

Adolescence is characterized by cognitive, social, and biological development as teens mature into adulthood. Due to their heightened interest in novelty and sensation-seeking activities or subjects, adolescents are more susceptible to engaging in risky behaviors. Adolescents do not develop a mature decision-making process that understands risks until early adulthood (20). Comprehensive education about STIs may reduce risky sexual behavior. Health professionals and educators should disseminate this information during adolescence, when students begin to explore their sexuality.

Potential to Consider HPV as a Less Serious STI
The large-scale political and media publicity about the states’ responses to implement the vaccine may cause people to think HPV is a less serious STI. Pubic health officials should consider the influence of HIV drug advertisements and publicity on sexual behaviors which changed consumers understanding of the severity of the disease. A survey designed to evaluate the influence of direct-to-consumer antiretroviral HIV medication advertisements showed that HIV-positive men who have sex with men (MSM) were frequently exposed to these advertisements. Frequent exposure influenced attitudes and behavior towards safe sex. When viewed frequently, the ads facilitated a sense of optimism in medical advancements in HIV treatment and influenced consumers’ perception that HIV is a curable disease. Among HIV-positive MSM, those with high exposure to the ads were six-times more likely to believe HIV was a curable disease than men with low exposure. Fifty-eight percent of HIV-positive men with high-exposure, compared with 13% of HIV-positive men with low exposure, reported that ads influenced their decisions (21). This response, in turn, could contribute to a rise in unsafe sex practices among the MSM population. Likewise, the political and media hype about the vaccination and compulsory vaccination laws may inundate young girls and women with a new or more popular term in sexual health, “Human papillomavirus,” but adolescents may not understand the virus or its pathology. Lack of a comprehensive discussion about HPV susceptibility and severity may cause recipients of the vaccine to consider the it as a panacea for all HPV types or to believe that coverage may extend to protection against other STIs. In response, this lack of information may lead adolescents to perceive HPV as a less severe virus and may compromise their understanding of the importance of safe-sex practices.

While many developments surrounding the politics of the HPV vaccine are still incipient, it is important to consider HPV vaccination combined with inadequate and incorrect sexual health information taught in the American school system. Analogous problems of adolescent development, risk compensation, and the potential to consider HPV as a less serious STI due to hype surrounding the vaccine can also offset the intentions of the HPV vaccine. It is imperative that public health officials account for current sex education programs and these psychological phenomena when considering compulsory HPV vaccinations.

1. The Henry J. Kaiser Family Foundation. State Politics and Policy: Lawmakers Should Not Make HPV Vaccination Mandatory, CDC Advisory Panel Chair Says.. Melno Park, CA: The Henry J. Kaiser Family Foundation.
2. Goldie SJ, Kohli M, Grima D et al. Projected Clinical Benefits and Cost-effectiveness of a Human Papillomavirus 16/18 vaccine. Journal of the National Cancer Institute 2004; 96 (8):604-615.
3. Center for Disease Control and Prevention. HPV (Human papillomavirus) Vaccine: What You Need to Know. Atlanta, GA: Center for Disease Control and Prevention, 2007.
4. The Henry J. Kaiser Family Foundation. Fact Sheet: HPV Vaccine: Implementation and Financing Policy. Melno Park, CA: The Henry J. Kaiser Family Foundation.
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13. Sexuality Information and Education Council of the United States (SIECUS). Federal Abstinence-Only-Until-Marriage Funding by State. Washington, DC: Sexuality Information and Education Council of the United States, 2007.
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