Reasons for incomplete STI vaccination among men who have sex with men in an English sexual health service.

BACKGROUND: In England, vaccination for human papillomavirus, hepatitis A, and hepatitis B is recommended for men who have sex with men (MSM). However, uptake is sub-optimal and some men do not complete all recommended vaccine doses. This service evaluation aimed to explore reasons for lack of uptake for each of these vaccines among MSM in one English sexual health service and to inform improvements in service delivery to increase full dose completion rates. METHODS: MSM, ≥18 years, who had previously attended NHS Solent Sexual Health for at least one vaccination, and who had not completed the full dosing regimen for at least one of these vaccines, were invited to participate in an anonymous, online survey between 14/12/2020-11/04/2021. RESULTS: Among 246 MSM (M = 42.1 years), the most common reason for non-vaccination was that participants thought it was unneeded and had not been recommended by a doctor or healthcare provider. None reported vaccine hesitancy. Likewise, the most common reasons for vaccination were doctor/healthcare provider recommendation (51.7-65.6%) and self-protection (60.9-68.1%). The most common reason for not having completed the full course of vaccination was being unaware that the next dose was due (30.0-37.8%). Many participants who had not completed vaccination indicated that a doctor/healthcare provider recommendation would be a motivating factor and that reminder messages and being able to book subsequent appointments in advance would facilitate vaccination. CONCLUSIONS: Sexual health clinicians should be encouraged to discuss STI vaccination with MSM and services should explore possibilities to improve ease and access to vaccine appointments to increase uptake and completion rates.

Using protection motivation theory to explain the intention to initiate human papillomavirus vaccination among men who have sex with men in China.

BACKGROUND: Human papillomavirus (HPV) infection and related diseases are common among men who have sex with men (MSM). The most effective prevention is HPV vaccination. In China, however, men are not included in the HPV vaccination plan. We investigated the intention to initiate HPV vaccination and associated factors among MSM in China. Methods We surveyed 563 unvaccinated MSM aged 18 or older from six cities in China. Participants completed an electronic questionnaire about demographics, knowledge of and attitude towards HPV and HPV vaccine, intention to initiate HPV vaccination, willingness to recommend HPV vaccine to peers, feeling about government policy about HPV vaccination. We used the structural equation modeling (SEM) to analyze factors associated with HPV vaccine intention. Results The knowledge of HPV and HPV vaccine among participants was low. The mean score of knowledge about HPV and HPV vaccine was only 1.59 (range 0-11). The intention to initiate HPV vaccination within 6 months among participants was moderate (43.3% in total, 18.1% for 'very high' and 25.2% for 'above average').

Vaccine acceptability, uptake and completion amongst men who have sex with men: A systematic review, meta-analysis and theoretical framework.

BACKGROUND: Due to an increased risk of sexually transmitted infections (STIs), gay, bisexual and other men who have sex with men (MSM) have been recommended to receive vaccinations against human papillomavirus, meningitis C and hepatitis A/B. This review aimed to compare the rates of vaccine acceptability, uptake and completion, and to identify determinants of vaccine outcomes specific to MSM to inform a theoretical framework. METHODS: In January 2020 four databases were explored to identify vaccination behaviours and associated factors among MSM. A narrative systematic review and meta-analysis were performed. Data were synthesised for theoretical modelling. RESULTS: Seventy-eight studies, mostly from the USA, were included. The average vaccine acceptability was 63% (median = 72%, range: 30%-97%), vaccine uptake 45% (median = 42%, range: 5%-100%) and vaccine completion 47% (median = 45%, range: 12%-89%). Six categories of factors associated with vaccination acceptability, uptake and completion were conceptualised: Individual (e.g., demographic and psychosocial); Interpersonal (e.g., peer education); Healthcare provider (e.g., vaccine recommendation); Organisational and practice setting (e.g., routine collection of patient sexual orientation information that is integrated into a clinical decision support system); Community environment (e.g., targeted health promotion campaigns); and National, state and local policy environment (e.g., public health guidelines targeting MSM). CONCLUSION: Despite overall high levels of acceptability, uptake and completion rates were below targets predicted by cost-effectiveness modelling across all recommended vaccines. These parameters may need to be adjusted for more precise estimations of cost-effectiveness. Addressing the multiple levels of determinants, as outlined in our theoretical framework, will help guide interventions to increase vaccine completion among MSM.

Mixed-methods study in England and Northern Ireland to understand young men who have sex with men's knowledge and attitudes towards human papillomavirus vaccination.

OBJECTIVES: Men who have sex with men (MSM) are at greater risk for human papillomavirus (HPV)-associated cancers. Since 2016, MSM have been offered the HPV vaccination, which is most effective when received prior to sexual debut, at genitourinary medicine clinics in the UK. In September 2019, the national HPV vaccination programme will be extended to boys. This study aimed to understand young MSM's (YMSM) knowledge and attitudes towards HPV vaccination. DESIGN: Questionnaires assessed YMSM demographics, sexual behaviour, culture, knowledge and attitudes towards HPV vaccination and stage of vaccine decision-making using the precaution adoption process model. Focus groups explored sexual health information sources, attitudes, barriers and facilitators to vaccination and strategies to support vaccination uptake. Questionnaire data were analysed using descriptive statistics and focus group data were analysed thematically. SETTING: Questionnaires were completed online or on paper. Focus groups were conducted within Lesbian Gay Bisexual Transgender Queer organisational settings and a university student's union in England and Northern Ireland. PARTICIPANTS: Seventeen YMSM (M=20.5 years) participated in four focus groups and 51 (M=21.1 years) completed questionnaires. RESULTS: Over half of YMSM were aware of HPV (54.9%), yet few (21.6%) had previously discussed vaccination with a healthcare professional (HCP). Thematic analyses found YMSM were willing to receive the HPV vaccine. Vaccination programmes requiring YMSM to request the vaccine, particularly prior to sexual orientation disclosure to family and friends, were viewed as unfeasible. Educational campaigns explaining vaccine benefits were indicated as a way to encourage uptake. CONCLUSIONS: This study suggests that to effectively implement HPV vaccination for YMSM, this population requires clearer information and greater discussion with their HCP. In support of the decision made by the Joint Committee on Vaccination and Immunisation, universal vaccination is the most feasible and equitable option. However, the absence of a catch-up programme will leave a significant number of YMSM at risk of HPV infection.

Preferences for HIV testing services among men who have sex with men in the UK: A discrete choice experiment.

BACKGROUND: In the UK, approximately 4,200 men who have sex with men (MSM) are living with HIV but remain undiagnosed. Maximising the number of high-risk people testing for HIV is key to ensuring prompt treatment and preventing onward infection. This study assessed how different HIV test characteristics affect the choice of testing option, including remote testing (HIV self-testing or HIV self-sampling), in the UK, a country with universal access to healthcare. METHODS AND FINDINGS: Between 3 April and 11 May 2017, a cross-sectional online-questionnaire-based discrete choice experiment (DCE) was conducted in which respondents who expressed an interest in online material used by MSM were asked to imagine that they were at risk of HIV infection and to choose between different hypothetical HIV testing options, including the option not to test. A variety of different testing options with different defining characteristics were described so that the independent preference for each characteristic could be valued. The characteristics included where each test is taken, the sampling method, how the test is obtained, whether infections other than HIV are tested for, test accuracy, the cost of the test, the infection window period, and how long it takes to receive the test result. Participants were recruited and completed the instrument online, in order to include those not currently engaged with healthcare services. The main analysis was conducted using a latent class model (LCM), with results displayed as odds ratios (ORs) and probabilities. The ORs indicate the strength of preference for one characteristic relative to another (base) characteristic. In total, 620 respondents answered the DCE questions. Most respondents reported that they were white (93%) and were either gay or bisexual (99%). The LCM showed that there were 2 classes within the respondent sample that appeared to have different preferences for the testing options. The first group, which was likely to contain 86% of respondents, had a strong preference for face-to-face tests by healthcare professionals (HCPs) compared to remote testing (OR 6.4; 95% CI 5.6, 7.4) and viewed not testing as less preferable than remote testing (OR 0.10; 95% CI 0.09, 0.11). In the second group, which was likely to include 14% of participants, not testing was viewed as less desirable than remote testing (OR 0.56; 95% CI 0.53, 0.59) as were tests by HCPs compared to remote testing (OR 0.23; 95% CI 0.15, 0.36). In both classes, free remote tests instead of each test costing £30 was the test characteristic with the largest impact on the choice of testing option. Participants in the second group were more likely to have never previously tested and to be non-white than participants in the first group. The main study limitations were that the sample was recruited solely via social media, the study advert was viewed only by people expressing an interest in online material used by MSM, and the choices in the experiment were hypothetical rather than observed in the real world. CONCLUSIONS: Our results suggest that preferences in the context we examined are broadly dichotomous. One group, containing the majority of MSM, appears comfortable testing for HIV but prefers face-to-face testing by HCPs rather than remote testing. The other group is much smaller, but contains MSM who are more likely to be at high infection risk. For these people, the availability of remote testing has the potential to significantly increase net testing rates, particularly if provided for free.

Men who have sex with men who do not access sexual health clinics nor disclose sexual orientation are unlikely to receive the HPV vaccine in the UK.

BACKGROUND: Men who have sex with men (MSM) are recommended the Human Papillomavirus (HPV) vaccination due to their higher risk of genital warts and anal cancer. PURPOSE: To examine HPV vaccine acceptability amongst MSM in the UK. METHODS: Using advertisements via Facebook, MSM were recruited to an online survey measuring motivations for HPV vaccination. Logistic regression was performed to identify predictors of HPV vaccine acceptability. RESULTS: Out of 1508 MSM (median age = 22, range: 14-63 years) only 19% knew about HPV. Overall, 55% of MSM were willing to ask for the HPV vaccine and 89% would accept it if offered by a healthcare professional (HCP). Access to sexual health clinics (SHCs) [OR = 1.82, 95% CI 1.29-2.89], the disclosure of sexual orientation to a HCP [OR = 2.02, CI 1.39-3.14] and HIV-positive status [OR = 1.96, CI 1.09-3.53] positively predicted HPV vaccine acceptability. After receiving information about HPV, perceptions of HPV risk [OR = 1.31, CI 1.05-1.63], HPV infection severity [OR = 1.89, CI 1.16-3.01), HPV vaccination benefits [OR = 1.61, CI 1.14-3.01], HPV vaccine effectiveness [OR = 1.54, CI 1.14-2.08], and the lack of perceived barriers to HPV vaccination [OR = 4.46, CI 2.95-6.73] were also associated with acceptability. CONCLUSIONS: Although nearly half of MSM would not actively pursue HPV vaccination, the vast majority would accept the vaccine if recommended by HCPs. In order to achieve optimal uptake, vaccine promotion campaigns should focus on MSM who do not access SHCs and those unwilling to disclose their sexual orientation.

Preferences for the format of text messages containing results of online screening for sexually transmitted infections: a service evaluation.

We conducted an online survey to examine the preferences for receiving a text message with results of a test for sexually transmitted infections (STIs) as part of online self-sampling service at Solent NHS Trust. Findings showed that if all tests were negative, participants would prefer to receive one text message. However, in the event of a positive result, a large majority (86%) would prefer to receive a separate text with the name of the STI for which the test was positive. Similarly, three-quarters (74%) of participants would prefer to receive multiple texts indicating which test was inconclusive and required an additional sample. The results of this survey support a change of practice to sending multiple text messages with the results of online self-sampling that include the names of STIs.

Knowledge and Attitudes of General Practitioners and Sexual Health Care Professionals Regarding Human Papillomavirus Vaccination for Young Men Who Have Sex with Men.

Men who have sex with men (MSM) may be at higher risk for human papillomavirus (HPV)-associated cancers. Healthcare professionals' recommendations can affect HPV vaccination uptake. Since 2016, MSM up to 45 years have been offered HPV vaccination at genitourinary medicine (GUM) clinics in a pilot programme, and primary care was recommended as a setting for opportunistic vaccination. Vaccination prior to potential exposure to the virus (i.e., sexual debut) is likely to be most efficacious, therefore a focus on young MSM (YMSM) is important. This study aimed to explore and compare the knowledge and attitudes of UK General Practitioners (GPs) and sexual healthcare professionals (SHCPs) regarding HPV vaccination for YMSM (age 16-24). A cross-sectional study using an online questionnaire examined 38 GPs and 49 SHCPs, including 59 (67.82%) females with a mean age of 40.71 years. Twenty-two participants (20 SHCPs, p < 0.001) had vaccinated a YMSM patient against HPV. GPs lack of time (25/38, 65.79%) and SHCP staff availability (27/49, 55.10%) were the main reported factors preventing YMSM HPV vaccination. GPs were less likely than SHCPs to believe there was sufficient evidence for vaccinating YMSM (OR = 0.02, 95% CI = 0.01, 0.47); less likely to have skills to identify YMSM who may benefit from vaccination (OR = 0.03, 95% CI = 0.01, 0.15); and less confident recommending YMSM vaccination (OR = 0.01, 95% CI = 0.00, 0.01). GPs appear to have different knowledge, attitudes, and skills regarding YMSM HPV vaccination when compared to SHCPs.

Attendance of MSM at Genitourinary Medicine services in England: implications for selective HPV vaccination programme (a short communication).

BACKGROUND: Human papillomaviruses (HPV) immunisation programmes for female adolescents in the UK offer relatively little benefit to men who have sex with men (MSM). Targeted HPV vaccination for MSM may reduce the high incidence of HPV-related disease among MSM. We used national data from sexual health clinics to calculate the number of MSM attending these clinics throughout England from 2009 to 2014 and to identify their characteristics, to inform the implementation of a targeted HPV vaccination programme in MSM. METHODS: We used the Genitourinary Medicine Clinic Activity Dataset (GUMCADv2) to obtain data for men aged 15-70 years who had attended a GUM clinic in England from 2009 to 2014. We analysed both numbers of MSM attending and number of GUM attendances, age at first attendance, ethnicity and geographical area of the clinic in England. RESULTS: A total of 374 983 MSM attended sexual health services in England between 2009 and 2014. Median age of presentation was 32 years (IQR 25-41) and showed regional geographical variation. Of all men attending sexual health clinics in England, the highest proportion of those identifying as MSM was in London (21%). Excluding visits within 1 month of an initial attendance, 49% of all MSM re-attended within 12 months and 58% within 24 months. MSM aged ≥36 years reattended more frequently than younger MSM. 51% reattended at least twice within 24 months of initial visit. CONCLUSIONS: The majority of MSM reattend clinic at least once within a 24-month period, potentially facilitating the delivery of a three-dose HPV vaccination programme. This would reduce the burden on sexual health clinics and cost to local authorities due to extra visits if HPV vaccination were to be delivered through these services.

UK healthcare professionals' uncertainties, barriers and facilitators to the introduction of targeted human papillomavirus vaccination for men who have sex with men.

BACKGROUND: Female-only human papillomavirus (HPV) vaccination will fail to protect men who have sex with men (MSM) against HPV and its sequelae (i.e. genital warts and anal cancers). In the absence of gender-neutral HPV vaccination, targeted vaccination at sexual health clinics for MSM offers a valuable preventive opportunity. This study aimed to identify sexual healthcare professionals' (HCPs) perceived barriers and facilitators for MSM-targeted HPV vaccination. METHODS: Nineteen telephone interviews with UK-based self-referred HCPs (13 doctors, three nurses, three health advisers) were conducted in October and November 2014. The interviews were recorded and transcribed verbatim. Data were analysed thematically by two researchers. RESULTS: HCPs were unsure about selection criteria, acceptable healthcare settings and the source of vaccination funding for the introduction of MSM-targeted HPV vaccination. Lack of political and public support, MSMs' limited access to HPV vaccination and disclosure of sexual orientation to HCPs, identification of eligible MSM, patients' poor HPV awareness and motivation to complete HPV vaccination were perceived as significant barriers. HCPs believed that the introduction of official guidelines on HPV vaccination for MSM, awareness campaigns and integrated clinic procedures could improve vaccination coverage. CONCLUSION: HCPs recognised a need to protect MSM against HPV. However, several challenges and obstacles associated with the introduction of MSM-targeted HPV vaccination in the UK were reported. HCPs' perspectives and concerns need to be addressed when developing policies and guidelines for a potential MSM-targeted HPV vaccination. Future research needs to examine whether negative views of HCPs towards MSM-targeted HPV vaccination are associated with lower HPV vaccine uptake and completion rates in MSM.

Perceptions of HPV and attitudes towards HPV vaccination amongst men who have sex with men: A qualitative analysis.

OBJECTIVES: Men who have sex with men (MSM) are at risk of genital warts and anal cancer due to human papillomavirus (HPV) infection. This study explores MSMs' perceptions of HPV and HPV vaccination prior to the introduction of this programme. DESIGN: Focus groups and one-to-one interviews with self-identified MSM were conducted between November 2014 and March 2015 in Brighton, UK. METHODS: Participants were recruited from community-based lesbian-gay-bisexual-transgender (LGBT) venues and organizations. Discussions were recorded, transcribed verbatim, and analysed using framework analysis. RESULTS: Thirty-three men took part (median age 25 years, IQR: 21-27), most of whom (n = 25) did not know about HPV, anal cancer (31), or HPV vaccination (26). While genital warts and anal cancer were perceived as severe, men did not perceive themselves at risk of HPV. All MSM would accept the HPV vaccine if offered by a health care professional. The challenges of accessing sexual health services or openly discussing same-sex experiences with health care professionals were perceived as barriers to accessing HPV vaccination. Two participants were concerned that selective HPV vaccination could increase stigma and prejudice against MSM, comparable to the AIDS epidemic. Ten MSM were unsure about the effectiveness of HPV vaccination for sexually active men and were in favour of vaccinating all adolescent boys at school. CONCLUSIONS: Most MSM have poor knowledge about HPV and associated anal cancer. Despite the lack of concern about HPV, most MSM expressed willingness to receive HPV vaccination. There is a need for health education about the risks of HPV and HPV-related diseases so that MSM can appraise the benefits of being vaccinated. Concerns about HPV vaccine effectiveness in sexually active men and possible stigmatization need to be addressed to optimize HPV vaccine acceptability. Statement of contribution What is already known on this subject? Men who have sex with men (MSM) have poor knowledge about HPV and HPV-related diseases. Perceived risk of HPV and attitudes towards HPV vaccination are associated with HPV vaccine acceptability amongst MSM in the United States. There is a gap between acceptability and uptake of HPV vaccination amongst MSM. What does this study add? Due to concerns about compromised effectiveness of the HPV vaccine in sexually active men, most MSM would recommend vaccination of all adolescent boys. Restricted access to sexual health services and the inability to discuss same-sex experiences were perceived as barriers to HPV vaccination. While the HPV vaccine is acceptable amongst MSM, the motivation to be vaccinated and complete the three-dose series might be low.

Sexual healthcare professionals' views on HPV vaccination for men in the UK.

BACKGROUND: Human Papillomavirus (HPV) vaccination for men could prevent anal cancers amongst men who have sex with men (MSM). METHODS: An e-survey of attitudes towards vaccination for men in the UK was conducted in July-August 2014. RESULTS: Among 325 sexual health professionals, 14% were already vaccinating men against HPV, 83% recommended gender-neutral HPV vaccination and 65% recommended targeting MSM. Over 50% reported having poor knowledge about the use of HPV vaccine for MSM and the skills to identify MSM likely to benefit from HPV vaccination. CONCLUSIONS: Clear advice and guidelines on HPV vaccine use for men at sexual health clinics are required to ensure equitable opportunities for vaccination.

Human papillomavirus and vaccine-related perceptions among men who have sex with men: a systematic review.

BACKGROUND: Targeted human papillomavirus (HPV) vaccine could prevent HPV-related cancers and genital warts among men who have sex with men (MSM). In order to develop effective vaccination programmes for MSM, it is crucial to understand their knowledge, beliefs about HPV and attitudes towards HPV vaccine. METHODS: A systematic search of 10 databases examined articles investigating HPV knowledge and HPV-related perceptions among MSM. Each paper was assessed to identify potential research directions in the context of targeted HPV vaccination for MSM. RESULTS: We identified 16 studies that included 5185 MSM and conducted mainly in North America. Generally, participants were over 26 years old, had poor-to-moderate knowledge about HPV and were not concerned about HPV-related diseases. Over a half of MSM were willing to accept HPV vaccine, if offered. However, there was large variability in HPV vaccine acceptability, partially due to inconsistencies in methods of ascertainment but also different levels of HPV vaccine awareness. CONCLUSIONS: Despite several misconceptions and poor knowledge of HPV infection, MSM might be receptive to HPV vaccination. However, further research is needed to identify which factors contribute to potential vaccine uptake in hypothetical MSM-targeted HPV vaccination. Future studies need to target those MSM with little sexual experience, who would benefit most from HPV vaccination.