Gynecologic Oncology 117 (2010) S26–S31

Contents lists available at ScienceDirect

Gynecologic Oncology
j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / y g y n o

Review

HPV vaccine and males: Issues and challenges

Gregory D. Zimet ⁎, Susan L. Rosenthal
Section of Adolescent Medicine, Indiana University School of Medicine, Health Information & Translational Sciences, 410 W. 10th Street, HS 1001, Indianapolis, IN 46202, USA

a r t i c l e i n f o a b s t r a c t

Article history: The quadrivalent vaccine has been shown to be safe and efficacious against HPV infection in men. It is
Received 19 January 2010 expected, though, that male vaccination rates will remain low. Therefore this literature review examines the
Available online 2 February 2010 attitudes of parents, young men, and HCPs toward HPV vaccination and other sexually transmitted infections
(STI). It appears that parents are interested in vaccinating their sons against HPV and other (STI). In addition,
Keywords:
adolescent and adult males are interested in receipt of HPV vaccine and other vaccines for prevention of STI.
Vaccination acceptance
HPV vaccine
Health care providers have a general preference for vaccinating females, but they indicate a willingness to
Male vaccination recommend HPV vaccine for their male patients. This is important given the “permissive” recommendation
Parental attitude for male HPV vaccination issued by the US Advisory Committee on Immunization Practices (ACIP).
Cost Cost effectiveness studies have shown that vaccinating males and females is less cost effective than
vaccinating females alone. With low female vaccination rates, both cost effectiveness and health benefits
increase. It is clear that males have poor knowledge of HPV infection, morbidity, transmission and
prevention. Regardless of vaccination strategies adopted, efforts should be made to educate males about HPV
and its health implications. In addition, there are more challenges to overcome before male vaccination can
be successfully implemented.
© 2010 Published by Elsevier Inc.

Introduction with the recommendation of routine vaccination of females, national

Research has demonstrated that both the quadrivalent and
bivalent human papillomavirus (HPV) vaccines stimulate immuno-
genicity in males and females [1,2]. More recently, evidence has
shown that the quadrivalent vaccine is safe and efficacious against
HPV infection and external genital lesions in young men [3,4]. There is
a reasonable expectation that it will also be protective against HPV-
related cancers in males and will help to prevent transmission of the
virus. On October 16, 2009, the US Food and Drug Administration
(FDA) approved the use of the quadrivalent vaccine in males 9–26
years old, for the prevention of genital warts [5]. Subsequently, the
Advisory Committee on Immunization Practices (ACIP) declined to
recommend the quadrivalent vaccine for routine immunization of
males, instead issuing a permissive recommendation, which leaves
the decision to the discretion of health care providers (HCPs) [see:
http://www.cdc.gov/vaccines/recs/provisional/downloads/hpv-
vac-dec2009-508.pdf]. The ACIP did recommend that the costs of male
HPV vaccination be covered by the Vaccine for Children (VFC)
program, which will largely remove vaccine cost as an obstacle to
vaccination. This recommendation for male vaccination is in contrast
to the recommendation issued in 2006 for routine, universal
vaccination of females 9–26 years of age [6]. It is of note that even
⁎ Corresponding author. Fax: +1 317 274 0133.
E-mail address: gzimet@iupui.edu (G.D. Zimet).
data from 2008 indicate that only about 35% of 13- to 17-year-old girls
in the United States have received one or more doses of vaccine [7].
These data suggest strongly that male vaccination rates will likely
remain quite low unless parents and physicians decide that
vaccinating adolescent boys is an important way to protect their
health and contribute to public health. For this reason, it is particularly
important to examine the attitudes of parents, young men, and HCPs
toward HPV vaccination.
In this paper, we review attitudinal research about male HPV
vaccination and vaccination against other sexually transmitted
infections (STIs). Three sets of literature are discussed: parental
views about vaccinating sons, adolescent and adult male attitudes
about receipt of vaccine, and HCPs' willingness to recommend vaccine
for their male patients. Finally, we address some of the controversies
and challenges associated with provision of HPV vaccine to males.
Vaccine acceptability research
Over the past several years much of the focus of information
provision regarding HPV infection and HPV-associated diseases has
been directed at young women and parents of girls. As a result, many
men are quite ill-informed about HPV infection and unaware of its
consequences for male health [8–11]. It is important, therefore, to
interpret the acceptability findings in the context of this overall poor
knowledge about HPV infection, disease, and transmission related to
males.

0090-8258/$ – see front matter © 2010 Published by Elsevier Inc.

doi:10.1016/j.ygyno.2010.01.028
 G.D. Zimet, S.L. Rosenthal / Gynecologic Oncology 117 (2010) S26–S31 S27

Parental attitudes
We identified 18 articles that involved evaluation of parental
attitudes about vaccinating their sons against HPV or other STIs (see
Table 1). One set of studies, all carried out in the United States,
examined parental intentions regarding STI vaccination in general
[12–15]. In a qualitative study of 34 parents of 8- to 17-year-old
children, individual interviews addressed attitudes about vaccines for
the prevention of genital herpes, HIV, HPV, and gonorrhea [12]. Of the
18 parents of sons, 11 indicated that they would vaccinate their sons
against all four infections. Most parents who opposed vaccination
perceived their child at low behavioral risk of infection. Three papers
report quantitative research with parents accompanying their 12- to
17-year-old children to health care appointments [13–15]. All of these
articles report high parental support for vaccination against STI, with
no difference in intention to vaccinate daughters compared to sons.
Fourteen articles looked specifically at parental attitudes about
HPV vaccination [16–29]. These studies were carried out in the United
States, United Kingdom (UK), Australia, Canada, Finland, the
Netherlands, Turkey, and El Salvador. Methodologies differed, with
two of the studies using qualitative approaches [16,18]. Further, some
studies asked parents about a specific child (their own son or
daughter) [19,23,26,28,29], whereas others principally asked parents
about children in general (boys and girls) [16–18,20–22,24,25,27].
Despite these and other variations in methodology, HPV vaccination
for sons was typically endorsed by more than 65% of parents and most
studies found little difference between attitudes about vaccinating
daughters versus sons. Two notable exceptions include a study of
women from Turkey [27] and a study of Latino parents attending a US
medical center for health care [28], both of which reported that only
59% of parents endorsed male vaccination.
Attitudes among males
We identified 16 papers reporting on 17 studies that assessed
intention to accept HPV/STI vaccination among males (see Table 2).
The research is quite diverse, with multiple countries represented
(though all are industrialized nations), wide age ranges (12–71 years
of age), different methodologies, and different participant samples
(e.g. national data, college students, clinic patients, men who have sex
with men). In three studies from the United States that examined
attitudes about genital herpes vaccination among college students,
40–74% of respondents endorsed vaccination [30–32]. Rates of
endorsement did not substantially differ between males and females
with respect to receipt of vaccine for oneself, but one article reported
different sets of predictors of acceptability for males compared to
females [32]. In contrast, a study of adolescents, 12–17 years old,
recruited from clinical settings, found that over 80% strongly endorsed
vaccination for themselves against gonorrhea, genital herpes, and HIV
[14]. Results again did not vary on the basis of respondent gender.
HPV-vaccine-specific studies have focused principally on adult
males [9,20,21,31,33–40], with only one study, based in Finland,
including adolescent respondents [22]. In this national survey study,
83% of the 14- to 15-year-old respondents indicated that they would
be willing to receive HPV vaccine. Across all studies, endorsement of
vaccination ranged from a low of 33% in a sample from the state of
Georgia in the United States [34] to a high of 88% in a telephone survey
of adults in the Quebec City area of Canada [21]. Some studies found
no differences between male and female respondents with respect to
intention to receive vaccine [21,22,31], but when differences were
detected females consistently endorsed vaccination at a higher rate
than males [20,35,36]. Several studies included only male participants
[9,34,37–40]. Of some interest here are two papers from the same US-
based research group: one focusing on a national sample of gay or
bisexual men [38], and the other on a national sample of heterosexual
men [9]. The authors report that 74% of gay/bisexual men expressed
willingness to receive HPV vaccine, but only 37% of heterosexual men
were willing to get vaccinated. It is possible that this marked
difference in acceptability may have been a function of the fact that
a much higher percentage of gay/bisexual respondents knew about
HPV compared to the heterosexual respondents.
It is important to note again that the large majority of these studies
have focused on males over 18 years of age, who therefore would not
qualify for the VFC program in the United States. In addition, it is

Table 1
Parental endorsement of HPV vaccine for sons.

Study Country Participants Sample size Methodology Vaccine focus

Mays et al. [12] United States Parents of 8- to 17-year-olds 34 Individual semistructured interviews with parents attending Genital herpes,
health clinics in Indiana HIV
Zimet et al. [13] United States Parents of 12- to 17-year-olds 278 ACASIs with parents attending health clinics in Indiana STI
Zimet et al. [14] United States Parents of 12- to 17-year-olds 320 ACASIs with parents attending health clinics in Indiana Gonorrhea,
genital herpes,
HIV
Bair et al. [15] United States Parents of 12- to 17-year-olds 119 ACASIs with Latino parents attending health clinics in Indiana STI
Olshen et al. [16] United States Parents 25 Individual and focus group interviews with parents attending HPV
health clinics in Massachusetts
Brabin et al. [17] UK Parents of 11- to 12-year-olds 317 Survey study of parents in Manchester HPV
Noakes et al. [18] UK Parents of 8- to 10-year-olds 26–29 Discussion groups with parents from London, Nottingham, HPV
and Sheffield
Slomovitz et al. [19] United States Mothers of 8- to 14-year-olds 200 Questionnaire study of parents attending health clinics in Texas HPV
Marshall et al. [20] Australia Parents 601 Phone survey of adults in south Australia HPV
Sauvageau et al. [21] Canada Adults 471 Phone survey of adults in Quebec City region HPV
Woodhall et al. [22] Finland Parents of 14- to 15-year-olds 727 Questionnaire study with parents from Tampere HPV
de Visser and UK Parents of school-age children 353 Questionnaire study with parents from Brighton and Hove HPV
McDonnell [23]
Lenehan et al. [24] Canada Adult women 98 Questionnaire study with women attending health clinics in Ontario HPV
Lenselink et al. [25] The Netherlands Parents of 10- to 12-year-olds 356 Phone survey with parents from Nijmegen HPV
Ogilvie et al. [26] Canada Parents of 8- to 18-year-old sons 1381 National phone survey HPV
Dursun et al. [27] Turkey Adult women 1434 Questionnaire study with women attending health clinics HPV
in Ankara, Adana, Alanya, and Konya
Podolsky et al. [28] United States Mothers of 8- to 18-year-olds 308 Questionnaire study with mothers attending health clinics HPV
and El Salvador in New York City and San Vicente
Watts et al. [29] United States Adult women 246 Questionnaire study with women attending health clinics HPV
in Massachusetts

ACASI, audio computer-assisted interview; HIV, human immunodeficiency virus; HPV, human papillomavirus; STI, sexually transmitted infections.
S28 G.D. Zimet, S.L. Rosenthal / Gynecologic Oncology 117 (2010) S26–S31

Table 2
Males: willingness to accept vaccination.

Study Country Participants Sample size Methodology Vaccine focus

Rosenthal et al. [30] United States College students 17–32 years old 518 (48% male)
Questionnaire study in Ohio Genital herpes
Boehner et al. [31] United States College students 18–42 years old 259 (50% male)
Questionnaire study in Ohio Genital herpes
Boehner et al. [31] United States College students 18–54 years old 256 (50% male)
Questionnaire study in Ohio HPV
Auslander et al. [32] United States College students 17–32 years old 518 (48% male)
Questionnaire study in Ohio Genital herpes
Zimet et al. [14] United States Adolescents 12–17 years old 320 (33% male)
ACASIs with adolescents attending health clinics Gonorrhea, genital
in Indiana herpes, HIV
Marshall et al. [20] Australia Adults 18–75 years old 2,002 (49% male) Phone survey of adults in south Australia HPV
Sauvageau et al. [21] Canada Adults 18–69 years old 471 (33% male) Phone survey of adults in Quebec City region HPV
Woodhall et al. [22] Finland Adolescents 14–15 years old 397 (38% male) Questionnaire study with adolescents from HPV
Tampere
Friedman and United States Adults 25–45 years old 314 (48% male) Focus group study with adults throughout the HPV
Shepeard [33] United States
Ferris et al. [34] United States Adults 18–45 years old 571 (100% male) Questionnaire study with men from Augusta, HPV
Georgia
Jones and Cook [35] United States College students 18–32 years old 340 (41% male) Questionnaire study with students at a HPV
northeastern US university
Lenselink et al. [36] The Netherlands College students 18–25 years old 600 (37% male) Questionnaire study with students at colleges HPV
in Nijmegen
Gerend and Barley United States Heterosexual college students 356 (100% male) Questionnaire study with students at Florida State HPV
[37] 18–24 years old University
Reiter et al. [9] United States Heterosexual men 18–59 years 297 (100% male) National web survey HPV
old
Reiter et al. [38] United States Gay and bisexual men 306 (100% male) National web survey
18–59 years old
Simatherai et al. [39] Australia Men who have sex with men 200 (100% male) Survey of sexual health center attendees in Victoria, HPV
19–71 years old Australia
Allen et al. [40] United States College students 18–22 years old 45 (100% male) Focus group study with students at a northeast HPV
US university

ACASI, audio computer-assisted interview; HIV, human immunodeficiency virus; HPV, human papillomavirus.

unclear the extent to which insurance companies will cover male HPV
vaccination and, if they do, what ages will be included in coverage. As
a result, the fairly high out-of-pocket costs of the 3-dose HPV vaccine
may prove to be a significant barrier to vaccine uptake among young
men despite the generally positive attitudes toward vaccination. The
available data on US women 18 years of age and older, a group also not
covered by VFC, indicate very low rates of vaccination compared to
those 13–17 years old [41–43].
Attitudes of HCPs
We identified eight articles that report on attitudes of HCPs toward
HPV/STI vaccination of males (see Table 3). A study of nurse
practitioners indicated relatively high willingness to recommend HIV
or genital herpes vaccination to parents of adolescents [44]. Participants
were more willing to recommend vaccination for older adolescents and
if vaccination was endorsed by the American Academy of Pediatrics. The
gender of the adolescent had almost no effect on willingness to
vaccinate. Two national studies of US pediatricians and family practice
physicians also found greater willingness to vaccinate older versus
younger adolescents [45,46]. However, in contrast to the study of nurse
practitioners, the physicians in both of these studies expressed greater
willingness to vaccinate female compared to male adolescents.
Nonetheless, 80% or more of the respondents indicated that they
would recommend HPV vaccine to male patients 14–17 years of age. A
similar pattern of results was reported in another US study of
pediatricians [47]. A qualitative interview study of pediatricians largely
confirms the findings from the survey research studies [48]. About two-
thirds of the 31 participants indicated that they were equally likely to
vaccinate male and female patients, but the remainder said they were
more likely to recommend HPV vaccination for girls than for boys.
Comparable findings were reported in national studies of Italian
pediatricians [49] and Canadian nurses [50], and in a study of physicians
and nurses in Bangkok, Thailand [51].
Summary of attitude research and recommendations for future directions
Across these studies parents endorsed male vaccination, most men
had moderate to high interest in getting vaccinated, and most HCPs said
that they were willing to recommend HPV vaccination for male patients.
When gender effects occurred, which happened most consistently with
HCPs, the bias was towards vaccinating females more than males. In

Table 3
Health care providers: willingness to recommend HPV vaccine.

Study Country Participants Sample size Methodology Vaccine focus

Mays and Zimet [44] United States Nurse practitioners 224 Survey of nurse practitioners attending professional conference Genital herpes, HIV
Kahn et al. [45] United States Pediatricians 513 National survey of members of the American Academy of Pediatrics HPV
Riedesel et al. [46] United States Family practice physicians 145 National survey of members of the American Academy of Family HPV
Physicians
Daley et al. [47] United States Pediatricians 294 National survey of members of the American Academy of Pediatrics HPV
Kahn et al. [48] United States Pediatricians 31 Individual semistructured interviews with pediatricians from Ohio, HPV
Indiana, and Kentucky
Esposito et al. [49] Italy Pediatricians 311 National survey of attendees at the Annual Congress of the Italian HPV
Society of Pediatrics
Duval et al. [50] Canada Nurses 946 National survey of practicing nurses HPV
Songthap et al. [51] Thailand Nurses and physicians 300 Survey of health care providers in Bangkok HPV

HIV, human immunodeficiency virus; HPV, human papillomavirus.

 G.D. Zimet, S.L. Rosenthal / Gynecologic Oncology 117 (2010) S26–S31
addition, HCPs and parents both expressed greater comfort with
vaccination of older compared to younger adolescents, regardless of
gender. With vaccination of males in the United States now approved by
the FDA, it is even more important to continue to study HPV vaccination
patterns. Despite a universal vaccination recommendation for females
by the ACIP, only about 35% of females 13–17 years of age in the United
States had received one or more doses of vaccine in 2008 [7]. The ACIP's
“permissive” recommendation for males, which is weaker than a
universal recommendation, suggests that even fewer adolescent males
will be vaccinated. The permissive recommendation states that
vaccination of males is at the discretion of the HCP. A recent study of
HPV vaccination among 19- to 26-year-old women found that the
strength of the HCP's recommendation was a very strong predictor of
vaccine uptake [52]. This finding is likely to be true, as well, for
vaccination of males. Understanding how HCPs will make decisions
around male HPV vaccination, therefore, will be an important focus for
future research. A seminal study on hepatitis B virus vaccination of
adolescents found that the most important factor in parents' decisions to
vaccinate was the perception that vaccination was important to the HCP
[53]. This finding suggests that communication about HPV vaccine
between HCPs and parents of adolescent boys will be another valuable
focus of research. Furthermore, few studies have examined adolescent
males' attitudes about receipt of HPV vaccine, perhaps stemming from
the assumption that parents will be the principal decision makers
around male adolescent vaccination. However, research has found that
many parents are in favor of joint parent–adolescent decision making
when it comes to HPV/STI vaccination [17,54]. It may be important,
therefore, to examine how parents and adolescents make decisions
about HPV vaccination, particularly taking into account the adolescent's
age and developmental status. Finally, most of the published research on
attitudes about HPV vaccination, including male vaccination, continues
to come out of industrialized countries. There is an ongoing need for
more research to examine HPV vaccination in general and opinions
about male vaccination in developing nations.
Challenges and controversies in male HPV vaccination
Why vaccinate males?
In many countries HPV vaccine programs have been instituted
with a particular (or sole) focus on girls and young women [55].
However, HPV vaccine has been approved for use with males in
Australia, Mexico, and several other countries, though actually
implementation of male vaccination typically has not been a priority.
As noted above, the FDA just recently licensed the quadrivalent
vaccine for males 9–26 years old in the United States for prevention of
genital warts and the ACIP issued a permissive, rather than universal,
recommendation. Once more conclusive data emerges that HPV
vaccine results in cancer prevention in males and prevents transmis-
sion of the virus, it is possible that the recommendation regarding use
of HPV vaccine in males will be revisited.
Assuming that the vaccine does, in fact, prevent HPV-related
anogenital and head and neck cancers in males and prevents male-to-
female and male-to-male viral transmission, there are compelling
arguments for a gender-neutral approach to vaccination [56–60].
These arguments include the following: (1) female-only vaccination
will not protect men who have sex with men from HPV and HPV-
related diseases; (2) the fastest way to achieve the greatest protection
for females from cervical cancer and its precursors is to vaccinate
males as well as females; (3) vaccinating males is a more equitable
public health policy and recognizes that both genders contribute to
the transmission of HPV; (4) vaccination of males may be more
acceptable to some cultural groups than vaccinating females; (5)
genital warts and HPV-related cancers in males represent costly and
emotionally burdensome conditions that can be prevented more
expediently by vaccinating both males and females; and (6) historically,
S29
implementation of risk-based (or gender-based) vaccination policies
have been less effective and more confusing to the public.
The principal argument against male vaccination is based on the
cost of vaccinating males as determined by cost-effectiveness models.
There are different approaches to development of these models and
different models often use widely varying parameter estimates, which
can result in quite divergent results [61]. However, across models
there is agreement that vaccinating males and females is less cost-
effective than vaccinating females alone [61,62]. There also appears to
be consensus that the value of additionally vaccinating males
increases when lower percentages of females are vaccinated [61]. In
poorer countries, with limited funds available for health care
expenditures, vaccinating males as well as females may be cost-
prohibitive. In the United States, however, cogent arguments can be
made for male vaccination. As noted in the Introduction, US national
surveillance data from 2008 indicate that only about 35% of 13- to 17-
year-old girls have received one or more doses of HPV vaccine [7].
Although this figure may increase somewhat in the coming years, high
levels of vaccination in the United States are not typically achieved
without school-entry requirements. With modest female vaccination
rates, adding male vaccination will have clear health benefits for both
genders. In addition, vaccine policy in the United States is not always
tied directly to cost-effectiveness studies. Conjugate meningococcal
vaccine carries a gender-neutral universal vaccination recommenda-
tion for adolescents despite assessments that suggest it is no more
cost-effective than vaccinating males and females against HPV [63,64].
Finally, health economic analyses frequently use quality-adjusted life-
years (QALYs) as the main determinant of cost-effectiveness. Though
extensively used in these assessments, QALYs are also widely considered to
be imperfect measures of health outcomes and efforts are being made to
improve the QALY or to develop alternative approaches [65,66].
Challenges in vaccine delivery
Unlike the successful school-based approaches to adolescent
vaccination implemented in the UK and Australia, in the United
States vaccines are typically delivered in health care settings. The
advantage of this approach to immunization is that it encourages
regular well-child care visits that are often organized around the
childhood immunization schedule [67]. The disadvantage of the
approach used in the United States is that the main tools used to
achieve high rates of immunization are school-entry requirements
[68,69]. There is no indication, however, that HPV vaccine will be
required for middle-school entry in most states anytime in the near
future [70]. There is evidence that as males progress through their
adolescent years their use of health care diminishes significantly
compared to female adolescents, thus diminishing even more the
opportunities for vaccination [71]. In addition, due to their reproduc-
tive health care needs, adolescent girls overall make greater use of
primary health care services than adolescent boys [72]. Therefore,
with HPV vaccine, which requires two follow-up visits to complete the
three doses, fully vaccinating adolescent males may prove particularly
challenging. Both adolescent males and females in the United States
could benefit from alternative approaches to HPV vaccination,
including the consideration of other venues, such as schools, religious
institutions, and other community settings.
Discussion
HPV vaccination of males has been shown to be safe and efficacious.
Vaccination of males has been approved in the United States and several
other countries, though public health efforts have emphasized female
vaccination. Most likely due to this focus on vaccine for adolescent girls,
there remains limited knowledge among men about the implications
of male HPV infection for men's and women's health. Regardless of
whether a country pursues a female-only or a gender-neutral HPV
S30 G.D. Zimet, S.L. Rosenthal / Gynecologic Oncology 117 (2010) S26–S31
immunization policy, it will be important to do a better job educating
men as well as women about HPV infection, morbidity, mortality,
prevention, and transmission.
Current research suggests that male HPV vaccination is seen as
acceptable to parents, adolescent and young adult males, and HCPs.
However, the lack of knowledge about HPV may, to some extent,
interfere with the real-world implementation of these vaccination
intentions. There are many important research questions that remain
regarding male HPV vaccination, including evaluations of decision
making among parents, sons, and HCPs.
HPV vaccination of males brings with it controversy and
challenges. There has been intensive debate about the value of male
HPV vaccination. Health economics studies have shown that male and
female vaccination is less cost-effective than female-only vaccination.
Particularly for countries with limited financial resources, it may be
important to direct those resources to vaccination of girls rather than
boys. However, a number of cogent arguments have been made for a
gender-neutral approach to HPV immunization. In the United States,
for instance, it is unlikely that rates of female HPV vaccination will
reach high levels. Under these circumstances, vaccinating males may
be an important strategy for achieving the maximum health benefits.
Further, limitations of cost-effectiveness research suggest that these
studies should not be the sole driver of public health policy. Even if
male HPV vaccination is vigorously implemented, there will likely be
some difficult challenges to overcome. In the United States, for
instance, the strategy of providing vaccine in health care settings
makes it difficult to successfully vaccinate large percentages of
patients with a non-mandated vaccine. Given that adolescent males
are less likely to access health care compared to females, it will be a
particular challenge to vaccinate males. HPV vaccination of males,
while a challenge, is also an opportunity for education, research, and
improving public health.
Key points
• Most research shows that parents are interested in vaccinating
their sons against HPV and other sexually transmitted infections
(STI).
• Most research indicates that adolescent and adult males are
interested in receipt of HPV vaccine, as well as other vaccines for
prevention of STI.
• Studies of health care providers indicate a willingness among most
to recommend HPV vaccine for their male patients, though there
was a general preference for vaccinating females.
• In light of the “permissive” recommendation for male HPV
vaccination issued by the US Advisory Committee on Immuniza-
tion Practices (ACIP), health care provider recommendation of
HPV vaccine for males and communication with parents and male
patients will be particularly important.
• More studies about male HPV vaccination need to be carried out in
developing countries.
• Despite the decreased cost-effectiveness of vaccinating both males
and females compared to a female-only strategy, there are
compelling arguments to be made for vaccinating males against
HPV infection in the United States. One of these arguments is that
high rates of HPV vaccination of females in the United States are
likely not achievable without school-entry requirements, thereby
making male vaccination an important public health strategy.
• A major challenge to implementation of adolescent male HPV
vaccination is the traditional US vaccination strategy of immuniz-
ing in health care settings, given that male adolescents make
relatively infrequent use of outpatient health care.
• Males of all ages generally have poor knowledge of HPV infection,
morbidity, transmission, and prevention. Regardless of vaccination
strategies adopted, more efforts should be made to educate males
about HPV and its implications for male and female health.
Conflict of interest statement
Within the past 2 years Dr. Zimet and Dr. Rosenthal have served as paid research
consultants on studies implemented by Merck, Inc. Both Drs. Zimet and Rosenthal are
investigators on investigator-initiated research studies funded by the Merck Investi-
gator-Initiated Studies Program.
References
[1] Block SL, Nolan T, Sattler C, Barr E, Glacoletti KE, Marchant CD, et al. Comparison of
the immunogenicity and reactogenicity of a prophylactic quadrivalent human
papillomavirus (types 6, 11, 16, and 18) L1 virus-like particle vaccine in male and
female adolescents and young adult women. Pediatrics 2006;118:2135–45.
[2] Petäjä T, Keränen H, Karppa T, Kawa A, Lantela S, Siitari-Mattila M, et al.
Immunogenicity and safety of human papillomavirus (HPV)-16/18 AS04-adjuvanted
vaccine in healthy boys aged 10–18 years. J Adolesc Health 2009;44:33–40.
[3] Palefsky J, Giuliano A. Efficacy of the quadrivalent HPV vaccine against HPV
6/11/16/18-related genital infection in young men. Presented at the 2008
Conference of the European Research Organization on Genital Infection and
Neoplasia (EUROGIN); 2008 Nov 12–15; Nice, France. Abstract PS 1-3a.
[4] Giuliano A, Palefsky J. The efficacy of quadrivalent HPV (types 6/11/16/18)
vaccine in reducing the incidence of HPV-related genital disease in young men.
Presented at the 2008 Conference of the European Research Organization on Genital
Infection and Neoplasia (EUROGIN); 2008 Nov 12–15; Nice, France. Abstract SS 19-7a.
[5] US Food and Drug Administration. October 16, 2009 Approval Letter—Gardasil.
Available from: http://www.fda.gov/BiologicsBloodVaccines/Vaccines/
ApprovedProducts/ucm186991.htm [accessed 2009 Nov 10].
[6] Markowitz LE, Dunne EF, Saraiya M, Lawson HW, Chesson H, Unger ER.
Quadrivalent human papillomavirus vaccine: recommendations of the Advisory
Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2007;56(RR-
2):1–24.
[7] Centers for Disease Control and Prevention (CDC). National, state, and local area
vaccination coverage among adolescents aged 13–17 years—United States, 2008.
MMWR Morb Mortal Wkly Rep 2009;58:997–1001.
[8] McPartland TS, Weaver BA, Lee SK, Koutsky LA. Men's perceptions and knowledge
of human papillomavirus (HPV) infection and cervical cancer. J Am College Health
2005;53:225–30.
[9] Reiter PL, Brewer NT, Smith JS. HPV knowledge and HPV vaccine acceptability
among a national sample of heterosexual males. Sex Transm Infect 2009 Nov 30.
[Electronic publication ahead of print].
[10] Pitts MK, Fox C, Willis J, Anderson J. What do gay men know about human
papillomavirus? Australian gay men's knowledge and experience of anal cancer
screening and human papillomavirus. Sex Transm Dis 2007;34:170–3.
[11] Verhoeven V, Baay M, Colliers A, Verster A, Van Royan P, Avonts E, et al. The male
factor in cervical carcinogenesis: a questionnaire study of men's awareness in
primary care. Prev Med 2006;43:389–93.
[12] Mays RM, Sturm LA, Zimet GD. Parental perspectives on vaccinating children
against sexually transmitted infections. Soc Sci Med 2004;58:1405–13.
[13] Zimet GD, Mays RM, Sturm LA, Ravert AA, Perkins SM, Juliar BE. Parental attitudes
about sexually transmitted infection vaccination for their adolescent children.
Arch Pediatr Adolesc Med 2005;159:132–7.
[14] Zimet GD, Perkins SM, Sturm LA, Bair RM, Juliar BE, Mays RM. Predictors of STI
vaccine acceptability among parents and their adolescent children. J Adolesc
Health 2005;37:179–86.
[15] Bair RM, Mays RM, Sturm LA, Perkins SM, Juliar BE, Zimet GD. Acceptability to
Latino parents of sexually transmitted infection vaccination. Ambul Pediatr
2008;8:98–103.
[16] Olshen E, Woods ER, Austin SB, Luskin M, Bauchner H. Parental acceptance of the
human papillomavirus vaccine. J Adolesc Health 2005;37:248–51.
[17] Brabin L, Robert SA, Farzaneh F, Kitchener HC. Future acceptance of adolescent
human papillomavirus vaccination: a survey of parental attitudes. Vaccine
2006;24:3087–94.
[18] Noakes K, Yarwood J, Salisbury D. Parental response to the introduction of a
vaccine against human papilloma virus. Hum Vaccin 2006;2:243–8.
[19] Slomovitz BM, Sun CC, Frumovitz M, Soliman PT, Schmeler KM, Pearson HC, et al.
Are women ready for the HPV vaccine? Gynecol Oncol 2006;103:151–4.
[20] Marshall H, Ryan P, Roberton D, Baghurst P. A cross-sectional survey to assess
community attitudes to introduction of human papillomavirus vaccine. Aust N Z J
Public Health 2007;31:235–42.
[21] Sauvageau C, Duval B, Gilca V, Lavoie F, Ouakki M. Human papilloma virus vaccine
and cervical cancer screening acceptability among adults in Quebec, Canada. BMC
Public Health 2007;7:304.
[22] Woodhall SC, Lehtinen M, Verho T, Huhtala H, Hokkanen M, Kosunen E.
Anticipated acceptance of HPV vaccination at the baseline of implementation: a
survey of parental and adolescent knowledge and attitudes in Finland. J Adolesc
Health 2007;40:466–9.
[23] de Visser R, McDonnell E. Correlates of parents' reports of acceptability of human
papilloma virus vaccination for their school-aged children. Sex Health 2008;5:
331–8.
[24] Lenehan JG, Leonard KC, Nandra S, Isaacs CR, Mathew A, Fisher WA. Women's
knowledge, attitudes, and intentions concerning Human Papillomavirus vaccina-
tion: findings of a waiting room survey of obstetrics-gynaecology outpatients.
J Obstet Gynaecol Can 2008;30:489–99.
[25] Lenselink CH, Gerrits MM, Melchers WJG, Massuger LF, van Hamont D, Bekkers RL.
Parental acceptance of Human Papillomavirus vaccines. Eur J Obstet Gynecol
Reprod Biol 2008;137:103–7.
 G.D. Zimet, S.L. Rosenthal / Gynecologic Oncology 117 (2010) S26–S31
[26] Ogilvie GS, Remple VP, Marra F, McNeil SA, Naus M, Pielak K, et al. Intention of
parents to have male children vaccinated with the human papillomavirus vaccine.
Sex Transm Infect 2008;84:318–23.
[27] Dursun P, Altuntas B, Kuscu E, Ayhan A. Women's knowledge about human
papillomavirus and their acceptance of HPV vaccine. Aust N Z J Obstet Gynaecol
2009;49:202–6.
[28] Podolsky R, Cremer M, Atrio J, Hochman T, Arslan AA. HPV vaccine acceptability by
Latino parents: a comparison of U.S. and Salvadoran populations. J Pediatr Adolesc
Gynecol 2009;22:205–15.
[29] Watts LA, Joseph N, Wallace M, Rauh-Hain JA, Muzikansky A, Growdon WG, et al.
HPV vaccine: a comparison of attitudes and behavioral perspectives between
Latino and non-Latino women. Gynecol Oncol 2009;112:577–82.
[30] Rosenthal SL, Lewis LM, Succop PA, Bernstein DI, Stanberry LR. College students'
attitudes regarding vaccination to prevent genital herpes. Sex Transm Dis
1999;26:438–43.
[31] Boehner CW, Howe SR, Bernstein DI, Rosenthal SL. Viral sexually transmitted
disease vaccine acceptability among college students. Sex Transm Dis 2003;30:
774–8.
[32] Auslander BA, Rosenthal SL, Succop PA, Mills LM, Stanberry LR, Bernstein DI.
Gender-specific predictors of genital herpes vaccine acceptance in a college
population. Int J STD AIDS 2005;16:27–30.
[33] Friedman AL, Shepeard H. Exploring the knowledge, attitudes, beliefs, and
communication preferences of the general public regarding HPV: findings from
CDC focus group research and implications for practice. Health Educ Behav
2007;34:471–85.
[34] Ferris DG, Waller JL, Miller J, Patel P, Jackson L, Price GA, et al. Men's attitudes
toward receiving the human papillomavirus vaccine. J Low Genit Tract Dis 2008;12:
276–81.
[35] Jones M, Cook R. Intent to receive an HPV vaccine among university men and
women and implications for vaccine administration. J Am Coll Health 2008;57:
23–32.
[36] Lenselink CH, Schmeink CE, Melchers WJ, Massuger LF, Hendriks JC, van Hamont
D, et al. Young adults and acceptance of the human papillomavirus vaccine. Public
Health 2008;122:1295–301.
[37] Gerend MA, Barley J. Human papillomavirus vaccine acceptability among young
adult men. Sex Transm Dis 2009;36:58–62.
[38] Reiter PL, Brewer NT, McRee A-L, Gilbert P, Smith JS. Acceptability of HPV vaccine
among a national sample of gay and bisexual men. Sex Transm Dis in press 2009
[39] Simatherai D, Bradshaw CS, Fairley CK, Bush M, Heley S, Chen MY. What men who
have sex with men think about the human papillomavirus vaccine. Sex Transm
Infect 2009;85:148–9.
[40] Allen JD, Fantasia HC, Fontenot H, Flaherty S, Santana J. College men's knowledge,
attitudes, and beliefs about the human papillomavirus infection and vaccine.
J Adolesc Health 2009;45:535–7.
[41] Jain N, Euler GL, Shefer A, Lu P, Yankey D, Markowitz L. Human papillomavirus
(HPV) awareness and vaccination initiation among women in the United States,
National Immunization Survey-Adult 2007. Prev Med 2009;48:426–31.
[42] Conroy K, Rosenthal SL, Zimet GD, Jin Y, Bernstein DI, Glynn S, et al. Human
papillomavirus vaccine uptake, predictors of vaccination, and self-reported
barriers to vaccination. J Womens Health (Larchmt) 2009;18:1679–86.
[43] Allen JD, Mohllajee AP, Shelton RC, Othus MK, Fontenot HB, Hanna R. Stage of
adoption of the human papillomavirus vaccine among college women. Prev Med
2009;48:420–5.
[44] Mays RM, Zimet GD. Recommending STI vaccination to parents of adolescents: the
attitudes of nurse practitioners. Sex Transm Dis 2004;31:428–32.
[45] Kahn JA, Zimet GD, Bernstein DI, Riedesel JM, Lan D, Huang B, et al. Pediatricians'
intention to administer human papillomavirus vaccine: the role of practice
characteristics, knowledge, and attitudes. J Adolesc Health 2005;37:502–10.
[46] Riedesel JM, Rosenthal SL, Zimet GD, Bernstein DI, Huang B, Lan D, et al. Attitudes
about human papillomavirus vaccine among family physicians. J Pediatr Adolesc
Gynecol 2005;18:391–8.
[47] Daley MF, Liddon N, Crane LA, Beaty BL, Barrow J, Babbel C, et al. A national survey
of pediatrician knowledge and attitudes regarding human papillomavirus
vaccination. Pediatrics 2006;118:2280–9.
S31
[48] Kahn JA, Rosenthal SL, Tissot AM, Bernstein DI, Wetzel C, Zimet GD. Factors
influencing pediatricians' intention to recommend human papillomavirus
vaccines. Ambul Pediatr 2007;7:367–73.
[49] Esposito S, Bosis S, Pelucchi C, Begliatti E, Rognoni A, Bellasio M, et al. Pediatrician
knowledge and attitudes regarding human papillomavirus disease and its
prevention. Vaccine 2007;25:6437–46.
[50] Duval B, Gilca V, Boulianne N, Pielak K, Halperin B, Simpson MA, et al. Cervical
cancer prevention by vaccination: nurses' knowledge, attitudes and intentions.
J Adv Nurs 2009;65:499–508.
[51] Songthap A, Pitisuttithum P, Kaewkungwal J, Fungladda W, Bussaratid V,
Koonsaeng S. Knowledge, attitudes, and acceptability of a human papillomavirus
vaccine among healthcare providers. Southeast Asian J Trop Med Public Health
2009;40:1048–56.
[52] Rosenthal SL, Weiss TW, Zimet GD, Ma L, Good MB, Vichnin MD. Predictors of HPV
vaccine uptake among women ages 19–26: importance of a physician's
recommendation. Vaccine in press [Electronic publication ahead of print].
[53] Rosenthal SL, Kottenhahn RK, Biro FM, Succop PA. Hepatitis B vaccine acceptance
among adolescents and their parents. J Adolesc Health 1995;17:248–54.
[54] Juliar BE, Bair RM, Zimet GD, Sturm LA, Mays RM, Perkins SM. Concordance in
decision making for STD vaccination between parents and adolescents. Presented
at the 2006 National STD Prevention Conference; 2006 May 8–11; Jacksonville, FL.
Abstract 230.
[55] WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information
Centre). Human Papillomavirus and Related Cancers in World. Summary Report
2009. Available from: http://www.who.int/hpvcentre [accessed 2009 Nov 10].
[56] Giuliano AR, Salmon D. The case for a gender-neutral (universal) human
papillomavirus vaccination policy in the United States. Point Cancer Epidemiol
Biomarkers Prev 2008;17:805–8.
[57] Michels KB, zur Hausen H. HPV vaccine for all. Lancet 2009;374:268–70.
[58] Szarewski A. HPV vaccines: peering through the fog. J Fam Plann Reprod Health
Care 2008;34:207–9.
[59] Zimet GD. Potential barriers to HPV immunization: from public health to personal
choice. Am J Law Med 2009;35:389–99.
[60] Hull SC, Caplan AL. The case for vaccinating boys against human papillomavirus.
Public Health Genomics 2009;12:362–7.
[61] Kim JJ, Brisson M, Edmunds WJ, Goldie SJ. Modeling cervical cancer prevention in
developed countries. Vaccine 2008;26(Suppl 10):K76–86.
[62] Kim JJ, Goldie SJ. Cost effectiveness analysis of including boys in a human
papillomavirus vaccination programme in the United States. BMJ 2009;b3884:339.
[63] Shepard CW, Orega-Sanchez IR, Scott II RD, Rosenstein NE. ABCs Team. Cost-
effectiveness of conjugate meningococcal vaccination strategies in the United
States. Pediatrics 2005;115:1220–32.
[64] Centers for Disease Control and Prevention (CDC) Advisory Committee on
Immunization Practices. Revised recommendations of the Advisory Committee
on Immunization Practices to vaccinate all persons aged 11–18 years with
meningococcal conjugate vaccine. MMWR Morb Mortal Wkly Rep 2007;56:
794–5.
[65] Smith MD, Drummond M, Brixner D. Moving the QALY forward: rationale for
change. Value Health 2009;12(Suppl 1):S1–4.
[66] Nord E, Daniels N, Kamlet M. QALYs: some challenges. Value Health 2009;12
(Suppl 1):S10–5.
[67] Schor EL. Rethinking well-child care. Pediatrics 2004;114:210–6.
[68] Orenstein WA, Hinman AR. The immunization system in the United States—the
role of school immunization laws. Vaccine 1999;17(Suppl 3):S19–24.
[69] Hinman AR, Orenstein WA, Williamson DE, Darrington D. Childhood immuniza-
tion: laws that work. J Law Med Ethics 2002;30(3 Suppl):122–7.
[70] National Conference of State Legislators. HPV Vaccine: State Legislation
2009–2010. Available from: http://www.ncsl.org/IssuesResearch/Health/
HPVVaccineStateLegislation/tabid/14381/Default.aspx [accessed 2009 Nov 10].
[71] Marcell AV, Klein JD, Fischer I, Allan MJ, Kokotailo PK. Male adolescent use of
health care services: where are the boys? J Adolesc Health 2002;30:35–43.
[72] National Adolescent Health Information Center. A health profile of adolescent
and young adult males. San Francisco, CA: University of California, San Francisco;
2005.