Research

JAMA Oncology | Original Investigation

Prevalence of Genital Human Papillomavirus Infection

and Human Papillomavirus Vaccination Rates
Among US Adult Men
National Health and Nutrition Examination Survey (NHANES)
2013-2014
Jasmine J. Han, MD; Thomas H. Beltran, BS; John W. Song, MD; John Klaric, PhD; Y. Sammy Choi, MD

Supplemental content
IMPORTANCE Human papillomavirus (HPV) is a common sexually transmitted infection that is
a major cause of noncervical anogenital and oropharyngeal cancers. Prophylactic HPV
vaccine is available for primary prevention. However, the population prevalence data for male
genital HPV infection is not well known, while the HPV vaccination coverage is low in the
United States.

OBJECTIVES To estimate the prevalence of genital HPV infection and the HPV vaccination
rate in the United States among adult men and to examine potential risk factors for HPV
infection.

DESIGN, SETTING, AND PARTICIPANTS The National Health and Nutrition Examination Survey
(NHANES) samples a representative cross-section of the US population. Men aged 18 to 59
years were examined in mobile examination centers during the NHANES 2013-2014. DNA was
extracted from self-collected penile swab specimens, and HPV genotyping was performed by
polymerase chain reaction amplification. Demographic and vaccination information was
gathered via self-report during home-based standardized interviews. Binary multivariable
logistic regression was used to estimate the odds of HPV infection.

MAIN OUTCOMES AND MEASURES The prevalence of genital HPV infection and the HPV
vaccination coverage rate among adult men.

RESULTS During the NHANES 2013-2014, a total of 1868 men aged 18 to 59 years were
examined. The overall genital HPV infection prevalence was 45.2% (95% CI, 41.3%-49.3%).
The infection prevalence with at least 1 high-risk HPV subtype defined by DNA testing was
25.1% (95% CI, 23.0%-27.3%). In vaccine-eligible men, the prevalence of infection with at
least 1 HPV strain targeted by the HPV 4-valent vaccine and HPV 9-valent vaccine was 7.1%
(95% CI, 5.1%-9.5%) and 15.4% (95% CI, 11.7%-19.6%), respectively. Among vaccine-eligible
Author Affiliations: Division of
men, the HPV vaccination coverage was 10.7% (95% CI, 7.8%-14.6%). Gynecologic Oncology, Department
of Obstetrics and Gynecology,
CONCLUSIONS AND RELEVANCE Among men aged 18 to 59 years in the United States, the Womack Army Medical Center, Fort
Bragg, North Carolina (Han);
overall prevalence of genital HPV infection was 45.2% (95% CI, 41.3%-49.3%). The overall Department of Clinical Investigation,
genital HPV infection prevalence appears to be widespread among all age groups of men, and Womack Army Medical Center, Fort
the HPV vaccination coverage is low. Bragg, North Carolina (Beltran,
Klaric); Department of Medicine,
Womack Army Medical Center, Fort
Bragg, North Carolina (Song, Choi);
Department of Pediatrics, Womack
Army Medical Center, Fort Bragg,
North Carolina (Choi).
Corresponding Author: Jasmine J.
Han, MD, Division of Gynecologic
Oncology, Department of Obstetrics
and Gynecology, Womack Army
Medical Center, 2817 Reilly Rd,
JAMA Oncol. 2017;3(6):810-816. doi:10.1001/jamaoncol.2016.6192 Fort Bragg, NC 28307
Published online January 19, 2017. (jasmine.j.han.mil@mail.mil).

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 Prevalence of Genital HPV Infection and Vaccination Rates Among US Men
H
uman papillomavirus (HPV) infection is the most com-
mon sexually transmitted infection in the United
States.1 Epidemiological studies2-5 have established
HPV infection as the central cause of various cancers. In the
United States alone, 79 million persons are estimated to be in-
fected with some type of HPV, with approximately half of new
infections occurring before age 24 years.6 It is estimated that
more than 9000 cases of HPV-related cancers occur in men an-
nually, responsible for 63% of penile, 91% of anal, and 72% of
oropharyngeal cancers, in addition to being an indirect causal
factor for cervical cancer via men serving as reservoirs for HPV
transmission.7 Low-risk HPV infection is not without conse-
quence, with HPV-6 and HPV-11 responsible for 90% of geni-
tal warts, and 160 000 men are affected annually with low-
risk HPV.8 In addition, HPV infection may lead to recurrent
respiratory papillomatosis.9,10
Since 2006, the Advisory Committee on Immunization
Practices (ACIP) of the Centers for Disease Control and Pre-
vention (CDC) has recommended HPV vaccination for adoles-
cent girls at age 11 years, with catch-up vaccination to age 26
years.11 However, male vaccination was not approved by the
US Food and Drug Administration until 2009, and the ACIP pro-
vided guidance on male HPV vaccination for genital warts
prevention.12 This guidance was further expanded in 2011 to
include routine HPV vaccination to decrease HPV transmis-
sion and cancer prevention in male individuals aged 11 to 26
years.13 Recently, a 9-valent HPV vaccine has been approved
for HPV-related cancers that includes high-risk HPV subtypes
31, 33, 45, 52, and 58, in addition to strains 6, 11, 16, and 18 of
HPV.14 Furthermore, only 2 doses of HPV vaccine are recom-
mended for young adolescents instead of the traditional 3-shot
series.14 Although male HPV vaccination programs have been
available to the public since 2009, the male genital HPV in-
fection prevalence is still not clear epidemiologically, and the
vaccination rate remains low in the United States.
The prevalence of oral HPV infection is low compared with
genital infections, occurring in 10.1% of men and 3.6% of
women, although HPV-associated oropharyngeal cancers have
significantly increased over time.15 With the current trend, the
annual incidence of HPV-related oropharyngeal cancers is ex-
pected to surpass the annual number of cervical cancers by
2020 despite the availability of an efficacious prophylactic vac-
cine against HPV.3
While the prevalence of female genital HPV infection and
the female HPV vaccination coverage in the United States are
well known, there are limited population data regarding geni-
tal HPV infection in male individuals. In this study, we report
the first population-based study to date of the genital HPV in-
fection prevalence among US male adults.
Methods
Study Population and Design
The National Health and Nutrition Examination Survey
(NHANES) is a series of ongoing cross-sectional surveys con-
ducted by the National Center for Health Statistics (NCHS)
of the CDC. The NHANES sampling procedure oversampled
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Original Investigation Research
Key Points
Question What are the prevalence of both genital human
papillomavirus (HPV) infection and the HPV vaccination rate
among adult men in the United States?
Findings In this cross-sectional study of the National Health and
Nutrition Examination Survey (NHANES) 2013-2014, the overall
genital HPV infection prevalence among 1868 men was 45.2%,
which appears to be widespread among all age groups, with a low
HPV vaccination rate of 10.7%.
Meaning Male HPV vaccination may have a greater effect on HPV
transmission and cancer prevention in men and women than
previously estimated.
targeted populations, such as Hispanics, non-Hispanic
blacks, non-Hispanic Asians, older adults, and low-income
persons, to obtain adequate samples for meaningful sub-
group analyses and more reliable variable estimates. 16
Demographic information, including race/ethnicity, educa-
tional level, household income, and sexual history, was
obtained during the home-based interview via self-report.
A total of 1868 men aged 18 to 59 years participated in both
the NHANES 2013-2014 interview and the mobile examina-
tion center component. Of these individuals, 111 men had
inadequate laboratory samples and were excluded from the
HPV infection analysis, but they were retained for analyses
of the self-reported vaccination rate. To account for unequal
selection probabilities among participants and adjustments
for nonresponse, all estimates were weighted as provided
by the NCHS. The protocol was approved by the NCHS insti-
tutional review board, and written informed consent was
obtained from all participants. The design and weighting
methods have been previously described.17
Specimen Collection and Processing
During examinations, participants self-collected a penile swab
sample from the glans. These swabs were stored under refrig-
erated conditions (2°C-8°C) before shipment to the CDC for HPV
genotyping.18
HPV Risk
We used the established classification of high-risk and low-
risk HPV to categorize those that cause or are associated with
various cancers.19 The following HPV types were labeled as low-
risk HPV: types 6, 11, 40, 42, 54, 55, 61, 62, 64, 67, 69, 70, 71,
72, 81, 83, 84, 89, and IS39. High-risk subtypes included 16,
18, 26, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59, 66, 68, 73, and
82. In addition, participants positive for at least 1 of the 14 high-
risk HPV subtypes assessed in DNA testing (subtypes 16, 18,
31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68) were grouped
for separate analysis. Low risk is classified as the presence of
at least 1 low-risk type without a high-risk subtype. Partici-
pants with no detected HPV infections but with valid positive
β-globin control were considered negative for genital HPV in-
fection. Samples negative for HPV with negative β-globin con-
trol were considered inadequate for interpretation.
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 Research Original Investigation Prevalence of Genital HPV Infection and Vaccination Rates Among US Men

Figure. Prevalence of HPV Strains Among Men Aged 18 to 59 Years in the NHANES 2013-2014

Low risk
10

8
Prevalance, %

0
64 69 11 IS39 71 67 40 72 70 81 6 55 42 83 54 61 89 84 62
HPV Type

High risk
10

8
Prevalance, %

0 Error bars show 95% CIs. HPV

26 56 31 33 82 58 68 18 73 45 35 52 39 59 66 16 53 51 indicates human papillomavirus;
HPV Type NHANES, National Health and
Nutrition Examination Survey.

Statistical Analysis
All analyses were conducted using mobile examination cen-
ter sample weights to account for the complex survey design
and provide accurate estimates of the HPV prevalence among
the noninstitutionalized US population. The prevalence esti-
mates are reported as percentages with 95% CIs. Rao-Scott χ2
tests of independence were performed in accord with CDC ana-
lytic guidelines.20 Odds ratios (ORs) with 95% Wald CIs were
estimated using binary multivariable logistic regression mod-
els to assess potential associations between the genital HPV
infection prevalence and respondent characteristics. Covari-
ates in the reduced model included age, race/ethnicity, edu-
cational level, marital status, circumcision, and age at first
sexual intercourse. Men aged 18 to 32 years were considered
eligible for vaccination, while the remainder (aged 33-59 years)
were not eligible.
Univariate statistical analyses were weighted and con-
ducted using statistical software (SPSS Complex Samples, ver-
sion 21; IBM). Multivariable analyses were conducted with an-
other software program (SAS, version 9.4; SAS Institute Inc).
Variances were adjusted by Taylor series linearization. Two-
tailed P < .05 was considered statistically significant. An in-
stitutional review board waiver was obtained in accord with
the use of publicly available deidentified data.
Results
Demographic characteristics of 1757 male participants (age
range, 18-59 years) in the NHANES 2013-2014 with valid HPV
genotyping are listed in eTable 1 in the Supplement. Charac-
teristics of these participants were similar to those with non-
interpretable HPV genotyping results.
Prevalence
The overall genital HPV infection prevalence for men aged 18
to 59 years was 45.2% (95% CI, 41.3%-49.3%), and the high-
risk HPV prevalence defined by DNA testing was 25.1% (95%
CI, 23.0%-27.3%). The genital HPV infection prevalence ap-
peared to follow a bimodal pattern, with a peak in infection
among men aged 28 to 32 years and a second higher peak
among men aged 58 to 59 years (eTable 1 in the Supplement).
Prevalence rates of specific high-risk and low-risk HPV are
shown in the Figure. The most prevalent high-risk HPV sub-
type detected was 51 (5.5%; 95% CI, 4.2%-7.2%). The overall
prevalence of HPV 6, 11, 16, and 18 found in the 4-valent vac-
cine was 2.7% (95% CI, 2.0%-3.6%), 0.2% (95% CI, 0.1%-
0.4%), 4.3% (95% CI, 3.2%-5.6%), and 1.7% (95% CI, 1.1%-
2.5%), respectively. The overall prevalence of the additional

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 Prevalence of Genital HPV Infection and Vaccination Rates Among US Men
5 HPV subtypes 31, 33, 45, 52, and 58 found in the 9-valent vac-
cine was 1.3% (95% CI, 0.8%-1.9%), 1.3% (95% CI, 0.7%-
2.4%), 2.1% (95% CI, 1.5%-3.0%), 2.7% (95% CI, 2.0%-3.7%),
and 1.3% (95% CI, 0.7%-2.4%), respectively.
The HPV prevalence with at least 1 of the 4-valent HPV
types among adults aged 18 to 59 years was 8.5% (95% CI, 7.1%-
10.0%), representing more than 6.5 million men in the United
States. The overall prevalence of infection with at least 1 of the
9-valent HPV subtypes was 15.1% (95% CI, 13.7%-16.6%) (eTable
2 in the Supplement). Among those aged 18 to 32 years who
are or would have been eligible for the vaccine, the preva-
lence of infection with at least one 4-valent HPV type or 9-
valent HPV subtype was 7.1% (95% CI, 5.1%-9.5%) and 15.4%
(95% CI, 11.7%-19.6%), respectively. The prevalence of 9-
valent HPV was similarly elevated among the vaccine-
ineligible group at 14.6% (95% CI, 12.5%-16.9%). Bivariate
analysis indicated no difference in prevalence based on vac-
cine age eligibility among 4-valent HPV types (P = .17 for com-
parison) and 9-valent HPV subtypes (P = .73 for comparison).
We found that the overall HPV-16 prevalence was 4.3%
(95% CI, 3.2%-5.6%), which represents 3.3 million men in the
United States. The HPV-18 prevalence was 1.7% (95% CI, 1.1%-
2.5%), which reflects 1.3 million men. The infection preva-
lence solely among those aged 18 to 32 years was 3.3% (95%
CI, 2.2%-5.0%) for HPV-16 and 1.3% (95% CI, 0.6%-2.6%) for
HPV-18. There was no difference between vaccine-eligible and
vaccine-ineligible groups (P = .27 for comparison for HPV-16
and P = .25 for comparison for HPV-18).
The distribution and prevalence of genital high-risk HPV
infection were similar between vaccine-eligible and vaccine-
ineligible groups at 29.5% (95% CI, 25.0%-34.3%) and 29.1%
(95% CI, 26.4%-33.0%), respectively (eTable 2 in the Supple-
ment). The overall prevalence of HPV infection was lowest
among men aged 18 to 22 years at 28.9% (95% CI, 22.2%-
36.8%). Most men infected with only low-risk HPV (79.1%; 95%
CI, 73.0%-84.2%) showed single-strain infection compared
with the high-risk group, who showed single-strain infection
at 36.4% (95% CI, 31.1%-42.1%) (Table 1).
Factors Associated With HPV Infection
Demographic characteristics associated with genital HPV in-
fection in univariate analysis included age (P < .001), race/
ethnicity (P < .001), marital status (P < .001), educational level
(P < .002), and age at first sexual intercourse (P < .001) (P value
for trend). Annual household income (P = .05) and smoking sta-
tus (P = .05) were marginally associated with genital HPV in-
fection. Circumcision was also marginally associated with such
infection (P = .03). The results were similar in the high-risk HPV
DNA testing group except for circumcision (P = .01) and smok-
ing status (P = .35). The genital HPV infection prevalence was
highest among non-Hispanic black men (65.0%; 95% CI, 59.7%-
70.0%) and lowest among non-Hispanic Asian men (24.4%;
95% CI, 18.4%-31.5%).
In multivariable analyses, men in older age groups were
approximately twice as likely to have genital HPV infection
compared with those aged 18 to 22 years. This increased risk
was apparent in those aged 23 to 32 years only when the analy-
sis was limited to the 14 high-risk HPV subtypes (Table 2). Com-
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Original Investigation Research
Table 1. HPV Infections by Classified Risk
HPV Infection, % (95% CI)
No. of HPV Strains
Detected Low Risk High Risk
1 79.1 (73.0-84.2) 36.4 (31.1-42.1)
2 16.3 (11.1-23.2) 26.3 (22.6-30.3)
3 3.0 (1.2-7.4) 16.9 (13.0-21.7)
4 1.6 (0.5-5.1) 9.7 (6.7-13.9)
≥5 0.0 (0.0-0.0) 10.7 (7.7-14.5)
Abbreviation: HPV, human papillomavirus.
pared with those with less than a high school education, those
with a high school diploma or general equivalency diploma
were approximately 40% more likely to have these infections
(OR, 1.4; 95% CI, 1.0-2.1) in the high-risk group. Compared with
married men, men who reported never having been married,
living with a partner, or being widowed, divorced, or sepa-
rated from a spouse were twice as likely to have genital HPV
infections. In the high-risk group, this prevalence increased
to 2.8 times (OR, 2.8; 95% CI, 1.7-4.7) if widowed, divorced,
or separated from a spouse.
Vaccination
The overall rate of HPV vaccination among men who are or were
vaccine eligible was 10.7% (95% CI, 7.8%-14.6%) among an un-
weighted sample of 729 participants. This sample represents
3 million men aged 18 to 32 years in the noninstitutionalized
US population. Among men aged 18 to 22 years, 22.0% (95%
CI, 15.5%-30.3%) reported having received an HPV vaccina-
tion, and 48.1% (95% CI, 26.0%-71.0%) completed the series,
with a mean age at HPV vaccination of 17 years (95% CI, 16.4-
17.8 years).
Discussion
In this nationally representative sample of men aged 18 to 59
years, the prevalence of overall genital HPV infection in the
United States was 45.2% (95% CI, 41.3%-49.3%), represent-
ing 34.8 million men, with the high-risk HPV prevalence at
25.1% (95% CI, 23.0%-27.3%). The lowest prevalence was 28.9%
(95% CI, 22.2%-36.8%) among men aged 18 to 22 years, which
increased to 46.5% (95% CI, 38.4%-54.7%) in the next age group
(23-27 years) and then remained high and constant in older age
groups (P < .001 for trend). This finding may reflect the cur-
rent practice of providing HPV vaccination to younger male age
groups. This result is in contrast to the female HPV preva-
lence, which was higher among the age group younger than
20 years and then decreased in later years.21
The prevalence of genital HPV infection followed a
bimodal pattern, with a peak in prevalence among men aged
28 to 32 years and a second higher peak among men aged 58
to 59 years. This pattern of infection is similar to the preva-
lence of oral HPV infection from the NHANES 2009-2010
previously reported.15 The overall HPV prevalence is similar
to recent research from Denmark, which reported a 41.8%
overall HPV prevalence, with the same high-risk HPV sub-
type 51 as the most prevalent.22 In female individuals, the
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 Research Original Investigation Prevalence of Genital HPV Infection and Vaccination Rates Among US Men

Table 2. Multivariable Analysis of Characteristics Associated With All HPV and High-Risk Only HPV Infections
Among Men Aged 18-59 Yearsa

Any HPV High Risk by DNA Testingb

Characteristic OR (95% CI) P Value OR (95% CI) P Value
Age, y
8-22 1 [Reference] 1 [Reference]
23-32 2.3 (1.3-3.9) 2.0 (0.9-4.5)
.01 .04
33-42 1.8 (1.0-3.1) 1.5 (0.8-2.9)
43-59 2.6 (1.4-4.6) 0.9 (1.0-4.4)
Race/ethnicity
Non-Hispanic white 1 [Reference] 1 [Reference]
Hispanic 0.8 (0.5-1.3) 1.1 (0.8-1.6)
Non-Hispanic black 1.6 (1.1-2.4) .93 1.7 (1.2-2.5) .76
Non-Hispanic Asian 0.7 (0.5-1.2) 0.9 (0.4-1.7)
Other, including multiracial 0.7 (0.3-1.7) 0.6 (0.3-1.5)
Educational level
<High school 1 [Reference] 1 [Reference]
High school or general equivalency diploma 1.5 (0.9-2.3) .09 1.4 (1.0-2.1) .01
>High school 0.9 (0.6-1.3) 0.8 (0.6-1.0)
Marital status
Married 1 [Reference] 1 [Reference]
Never married 1.9 (1.2-3.0) 2.7 (1.9-4.0)
<.001 <.001
Living with partner 1.8 (1.2-2.7) 2.3 (1.4-3.7)
Abbreviations: HPV, human
Widowed, divorced, or separated 2.3 (1.4-4.0) 2.8 (1.7-4.7) papillomavirus; NHANES, National
Circumcision Health and Nutrition Examination
Circumcised 1 [Reference] 1 [Reference] Survey; OR, odds ratio.
.14 .05 a
Includes 1430 participants with
Uncircumcised 0.8 (0.6-1.1) 0.7 (0.5-1.1)
complete information.
Age at first sexual intercourse, y b
High-risk HPV defined by DNA
<16 1 [Reference] 1 [Reference] testing. Participants were positive
16-18 0.7 (0.6-1.1) <.001 0.8 (0.6-1.2) .02 for at least 1 of the following HPV
subtypes: 16, 18, 31, 33, 35, 39, 45,
>18 0.5 (0.4-0.7) 0.5 (0.3-1.0)
51, 52, 56, 58, 59, 66, and 68.

most prevalent HPV subtype was 53, and subtype 51 was the
fourth most common.21 Furthermore, the most prevalent
HPV subtype may not reflect the putative potency of carci-
nogenesis. This inconsistency of the most prevalent high-
risk HPV subtype in infection and in cancer may reflect dif-
ferent aggressiveness of HPV subtypes because common
HPV subtypes in cancer are 16 and 18, which are responsible
for 70% of all anogenital cancers.2 This overall HPV preva-
lence was found to be lower than that among the multina-
tional population study23 that combined Mexico, Brazil, and
the United States, which reported a prevalence of 65.2%.
The prevalence difference may also be owing to the types of
tests that were used, the location of the male genital area
swabbed, or the study population.
In addition, the Denmark study22 showed the highest HPV
infection prevalence among men aged 20 to 29 years in con-
trast to our study, which demonstrated a lower prevalence
among younger groups, with a higher and persistent preva-
lence among older age groups. It may be that the cumulative
prevalence of persistent infections would be expected to in-
crease with age, as was shown in oral HPV infection.15 It is
thought that the lower immune response to natural infection
in male individuals may explain the higher prevalence of HPV
infections, with a wide age range in boys and men.24,25
Clearance of genital HPV infection in men has been re-
ported to occur between 6 and 18 months, which is comparable
to that in female individuals.26 However, male individuals have
lower circulating HPV antibodies than female individuals de-
spite a higher genital HPV infection prevalence.27,28 This find-
ing may explain the difference in HPV immune responses be-
tween the sexes. The HPV Infection in Men (HIM) cohort study26
reported that the number of partners and new partners in the
last 3 months was similar for all age groups, hence potentially
providing continued exposure to HPV throughout life in male
individuals. Therefore, if men generate a lower and weaker HPV
immune response in the setting of remaining at high risk of ac-
quiring new HPV infections throughout their lives, then vacci-
nation programs for older men might be warranted.
Our study revealed independent risk factors for high-risk
genital HPV infection, including demographic characteristics
of age, educational level, marital status, and sexual behavior
at an early age. An analysis of the number of lifetime sex part-
ners was not possible because of a low response rate, suggest-
ing that the self-reported sexual history may not be accurate.
In addition, current tobacco use was not associated with male
genital HPV infection, although it is a known risk for female
genital and oropharyngeal infection. Educational level was in-
dependently associated with the high-risk HPV group, but the

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 Prevalence of Genital HPV Infection and Vaccination Rates Among US Men Original Investigation Research

increased risk decreased to baseline in the group with higher
education, with a 95% CI close to 1.0. With the high preva-
lence of HPV among the general population, sexually active
male individuals are at risk of transmission. Therefore, edu-
cational level may not lower the risk of HPV infection as seen
in other sexually transmitted infections.
Historically, circumcision is known to lower HPV infec-
tion risk.29 Our analysis revealed a higher risk of HPV infec-
tion with circumcision, although statistical significance was
not met in multivariable analysis. This finding may be due to
increased exposure of the mucosal surface of the glans in cir-
cumcised male individuals, which is the area obtained for
genital HPV swab specimens in this study. In general, cir-
cumcision is known to lower the risk of sexually transmitted
infections, which may not be as clear in HPV secondary to
subclinical relevance with a high prevalence rate. When
high-risk and low-risk HPV strains are classified separately,
most low-risk HPV represented infection of a single type
(79.1%; 95% CI, 73.0%-84.2%) compared with high-risk HPV
infection, which frequently involved multiple strains
(63.6%; 95% CI, 57.9%-68.9%). High-risk HPV subtypes may
be more aggressive secondary to concurrent infections of
multiple strains.
The 9-valent HPV vaccine was approved by the US Food
and Drug Administration in late 2014 for male and female in-
dividuals up to age 26 years to cover 90% of HPV types re-
sponsible for cervical cancer, with recent requirement of only
2 vaccines for young adolescents.14 The present investigation
is the first population-based study to date in the United States
to examine the prevalence of the 9-valent HPV subtypes (15.1%;
95% CI, 13.7%-16.6%) among men, which remained elevated
throughout all ages. To our knowledge, we are also the first to
report the national HPV vaccination coverage among US adult
men (10.7%; 95% CI, 7.8%-14.6%), which is significantly lower
than the current female vaccination rate.
Only 5.6% (95% CI, 3.2%-8.2%) of the adult male popula-
tion reported completing the HPV vaccine series. This vacci-
nation rate may reflect low public awareness and the stigma
of a sexually transmitted infection vaccine, with concerns
about the vaccine’s effect on sexual behavior.30 The initial HPV
vaccine approval for male individuals was obtained for geni-
tal warts only, which was expanded later.
The principal strength of this study is that the data come
from the NHANES database, which represents 76.9 million male
Americans. Limitations include that vaccination history and
sexual history were obtained from self-reports, which can lead
to underreporting or overreporting. In addition, HPV samples
were self-collected. However, there is evidence to suggest that
self-collected specimens provide sensitivity and specificity
comparable to clinician-collected samples.31
Using the NHANES 2013-2014 data, we estimated that more
than 25 million eligible male Americans did not receive HPV
vaccination. The high HPV prevalence among male individu-
als suggests that there is opportunity for increased vaccine ef-
fectiveness as the HPV vaccination coverage in the popula-
tion increases. Human papillomavirus vaccination may have
a profound effect on the prevention of HPV-related cancers in
male and female individuals because one serves as host for the
other, in addition to being a direct cause of anogenital and oro-
pharyngeal cancers. Only when vaccination rates are signifi-
cantly increased will progress be made in eradicating most HPV-
related cancers in the United States.
Conclusions
Our study provides the first national estimate to date of the
genital HPV infection prevalence among men aged 18 to 59
years in the United States. The overall genital HPV infection
prevalence was 45.2% (95% CI, 41.3%-49.3%), and the onco-
genic high-risk HPV prevalence was 29.5% (95% CI, 25.0%-
34.3%) among the vaccine-eligible group. The overall vacci-
nation rate was only 10.7% (95% CI, 7.8%-14.6%). Our study
indicates that male HPV vaccination may have a greater
effect on HPV infection transmission and cancer prevention
in men and women than previously estimated. Further
studies may be warranted to evaluate the rationale regard-
ing the current male vaccination age cutoff.

ARTICLE INFORMATION
Accepted for Publication: November 8, 2016.
Published Online: January 19, 2017.
doi:10.1001/jamaoncol.2016.6192
Author Contributions: Mr Beltran and Dr Klaric had
full access to all the data in the study and take
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Han, Beltran, Song.
Acquisition, analysis, or interpretation of data: Han,
Beltran, Klaric, Choi.
Drafting of the manuscript: Han, Beltran, Klaric,
Choi.
Critical revision of the manuscript for important
intellectual content: Han, Beltran, Song, Choi.
Statistical analysis: Beltran, Klaric.
Administrative, technical, or material support: Han,
Song, Choi.
Study supervision: Han.
Conflict of Interest Disclosures: None reported.
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