Exploring Disparities to HPV Vaccine Uptake in Canada

Despite efforts to increase HPV vaccination coverage in Canada, rates remain below the NACI’s 90% target uptake goal. 6 While a comprehensive exploration of population-specific disparities is beyond the scope of this paper, we will explore HPV vaccine uptake amongst key Canadian sub-populations, including young adults, transgender peoples and MSM.

Catch-Up Vaccination Amongst Young Adults: Expanding the Scope Beyond Adolescents

Initiating vaccination prior to the onset of sexual activity remains a key determinant of HPV vaccine effectiveness. 16 Pre-licensure clinical trials have consistently demonstrated that vaccine uptake preceding HPV exposure provides the greatest level of protection, emphasizing the importance of vaccinating youth. 16 In Canada, school-based vaccination programs have significantly contributed to widespread vaccine uptake, 16 with 76% of 14-year-olds in participating provinces and territories receiving at least one dose of the HPV vaccine in 2023. 6 Similarly, a Canadian systematic review and meta-analysis reported approximately 70% uptake amongst youth in school-based programs, compared to only 19% in community settings (e.g., primary care vaccination). 1 Conversely, vaccine uptake amongst adults (18 years of age and older) lags significantly behind, with only 15% reporting being vaccinated against HPV in 2023. 17 According to the adult National Immunization Coverage Survey conducted in 2023, higher rates of vaccine uptake were observed in adults aged 18–26 years (62.9%), compared to those 27 years and older (12.5%). 17

Despite publicly-funded HPV vaccination in Canada, existing public health strategies (e.g., knowledge campaigns) center predominantly around school-based programs, with little emphasis on catch-up vaccination amongst young adults until the age of 26 years. 18 Although most effective prior to the onset of sexual activity, 16 HPV vaccination remains essential for preventing infections amongst those who were not eligible, or missed school-based programs (e.g., parental hesitancy, delayed implementation), 18 as the vaccine can still protect against HPV genotypes they may have not yet been exposed to. 6 Additionally, due to frequent risky sexual behavior (e.g., multiple partners, unprotected sex) amongst young adults,18,19 increasing catch-up vaccination serves as a critical pathway to improve vaccine uptake, and mitigate the burden of HPV-related infections and associated diseases. According to a recent systematic review exploring catch-up HPV vaccination amongst young adult males- a population who remains disproportionately under-vaccinated compared to females-, health literacy, cost of the vaccine, absence of HCPs recommendation, as well as vaccine safety, efficacy and distrust were identified as barriers to uptake. 19 Young adults are uniquely positioned to make informed health-related decisions, 18 highlighting the importance of optimizing the delivery of inclusive HPV vaccination amongst this age demographic.

Transgender Peoples: Addressing Gaps in HPV Vaccination

Transgender peoples face significant barriers to accessing affirming and competent health services, including preventative care like HPV vaccination.20,21 Despite many Canadian jurisdictions extending publicly-funded HPV vaccination to include transgender peoples, data on vaccine uptake within this population remains scarce.20,21 Transgender men (TM)- individuals assigned female at birth, who identify as male- are particularly vulnerable to HPV, experiencing comparable rates of infection and cervical cancer as cisgender women.20,21 In Canada however, only 56% of TM reported routine cervical cancer screening in 2016, 21 with only 66% receiving at least one dose of the HPV vaccine in an American study in 2019. 22 Furthermore, transgender women (TW)- individuals assigned male at birth, who identify as female- represent another population facing disproportionately lower rates of HPV vaccine uptake, with one American study reporting only 26% uptake amongst a national sample of 18- to 30-year-olds in 2019. 22 Gaps in HPV prevention amongst transgender peoples further highlights the importance of revising existing public health strategies to extend beyond binary, gendered approaches (men and women) to HPV vaccination. 20

Despite limited research efforts and representation in Canadian vaccination databases, transgender peoples face disproportionately higher rates of stigma and discrimination, limited access to health services, and suboptimal gender-affirming care, which can negatively influence vaccine uptake. 22 Similarly, in a systematic review exploring COVID-19 vaccine hesitancy amongst members of the LGBTQ + population, previous negative healthcare experiences resulted in 25% of transgender peoples delaying vaccination, which can significantly increase their susceptibility to morbidity and mortality amidst a global pandemic. 23 In order to mitigate persistent vaccine-related inequities amongst transgender peoples, it is imperative that public health policies, practices and research prioritizes building trusting relationships and safer healthcare environments that take into consideration the unique needs of this underserved population.22,23 If not adequately addressed, we risk exacerbating health inequities and the longstanding systemic injustices experienced by transgender communities. Normalizing inclusive HPV vaccination is a critical step towards increasing vaccine equity, and reducing the burden of HPV-related infections and associated diseases at the public health level.

MSM: A High-Risk Population

While widespread HPV vaccine uptake amongst women can confer herd immunity to heterosexual men, this protection cannot be extended to MSM, who remain disproportionately impacted by adverse HPV-related health outcomes (e.g., anal cancer).11,24 A 2021 systematic review and meta-analysis of 107 studies (n = 36,773 MSM) revealed an overall pooled prevalence of anal HPV at 78%, penile HPV at 36%, oral HPV at 17%, and urethral HPV at 15%, 25 highlighting the significant burden of infection amongst this targeted, high-risk population. To date, most Canadian provinces and territories have extended publicly-funded HPV vaccination programs to include MSM; however, eligibility, access, and uptake vary across jurisdictions.14,15 A cross-sectional study of Canada’s three largest cities (Toronto, Montreal and Vancouver) reported rates of HPV vaccine uptake between 14 to 35% for young MSM (26 years of age and younger) and 2 to 26% for older MSM (27 years of age and older), 26 which remains significantly below national targets. 1 This stark contrast in rates of HPV vaccine uptake amongst MSM highlights the importance of developing inclusive public health interventions aimed at increasing vaccination coverage amongst this demographic.

Despite targeted HPV vaccine recommendations for MSM, multi-level marginalization, stigmatization, homophobia and social influences (e.g., framing HPV as predominantly a women’s health issue) continue to negatively influence vaccine uptake. 27 In a systematic review and meta-analysis exploring vaccine acceptability amongst MSM, several barriers were found to impede vaccination, including socioeconomic disadvantage (e.g., lower levels of education, living in a rural community, less annual income), restricted access and utilization of healthcare services (e.g., sexual health, primary care), suboptimal vaccine-related knowledge and attitudes, and fear of disclosing sexual orientation/practices to HCPs. 27 In order to increase HPV vaccine uptake amongst MSM, it is imperative that public health initiatives (e.g., policies, programs, practices) consider the barriers to vaccine accessibility, the late adoption of males to HPV vaccination programs, as well as the multi-level barriers that reinforce longstanding inequities amongst this underserved population. 27