The HPV guide for men

The number of people dying from cancer in the United States fell substantially over the last 30 years. Except when it comes to cancers associated with human papillomavirus (HPV). More people are getting these cancers, and men may be most at-risk. Yet many men don’t realize that HPV can cause them to have cancer in the first place.

“Men just don’t know that HPV is a cancer-causing infection,” Ashish Deshmukh, assistant professor at the University of Texas, Houston, tells Inverse. “What makes that especially striking is that three of the six HPV-associated cancers are common in men, and they are increasing rapidly.”

Men simply don’t know enough about HPV, experts say. But that doesn’t mean they don’t have questions about HPV. Among the most frequently asked: How does HPV affect me? If I am sexually active already, can I still get the vaccine? I thought the vaccine was only for women? How do I know if I have HPV?

The conversation around HPV is changing, albeit slowly. More people know that it’s equally important for young men and young women to be vaccinated. But HPV can affect older men, too — and, all too often, the first time they find out about HPV is when it is too late.

Inverse has the answers. This is your science-backed guide to HPV, for men.

What is HPV and how do you get it?

HPV stands for a group of viruses. There are more than 100 types of HPV, and at least 14 of them cause cancer. Most sexually active people will be infected with one strain or another at some point in their lives. You can get HPV by having vaginal, anal, or oral sex with someone who has the virus — in fact, it is the most-common sexually-transmitted infection as well as the most-common infection of the reproductive tract. About 79 million Americans are currently infected.

Most HPV infections clear up without any intervention a few months after infection. About 90 percent clear up within two years. Some types of HPV have no discernible symptoms, while others can result in genital warts or a disease that causes tumors to grow in the air passages between the nose, mouth, and lungs.

Why does HPV cause cancer?

While HPV itself isn’t a kind of cancer, it can trigger changes in the body that lead to cancer. These cancers are caused by HPV infections that did not go away. Many people already know that HPV can cause cancer — but that knowledge tends to be limited to the fact that HPV causes cervical cancer in women. It can also cause cancer of the vulva, vagina, penis, and anus. It’s also associated with oral and oropharyngeal cancer — that means cancer in the back of the throat, base of the tongue, and tonsils. In the US alone, nearly 35,000 men and women are diagnosed with cancer caused by an HPV infection every year.

In a September 2019 paper co-authored by Deshmukh and published in JAMA Pediatrics, researchers found that, out of a total of 2,562 men and 3,697 women, 80 percent of men and 75 percent of women did not know that HPV can cause oral, anal, and penile cancers. Yet according to the CDC, HPV is responsible for 90 percent of cervical cancers and 60 percent of penile cancers. Seventy percent of oropharyngeal cancers may be linked to HPV, but these are also linked to tobacco and alcohol use, so it is hard to parse exactly how many cases are caused by HPV alone.

Although we know relatively little about HPV-related cancers, the burden of these kinds of cancers appears to be shifting to men, Deshmukh says.

That shift may, in part, be due to the success of public education efforts about HPV and cervical cancer: The HPV vaccine has been recommended for young women and girls since 2006. By 2013, HPV prevalence among female teens had decreased by 56 percent. Between 2008 and 2014, rates of pre-cancer caused by HPV among women who were vaccinated dropped from 55.2 percent to 33.3 percent.

Today, the cancer most-often linked to the virus is oropharyngeal cancer. Between 2008 and 2012, an average of 3,100 women and 12,638 men were diagnosed with oropharyngeal cancer. In a 2017 study, Deshmukh and colleagues noted that incidents of this cancer in men had surpassed the incidence of cervical cancer among women.

Rates of HPV-related anal-cancer diagnoses and deaths also increased dramatically over the last 15 years. It’s a “disconcerting” trend, especially because there’s evidence that vaccinating against HPV can prevent these types of cancers, and because the rise in cancer has happened so recently, Deshmukh says. He suspects that “there might not be knowledge that this cancer is mostly a HPV-associated cancer.”

“By far, the largest misconception around HPV and men is that persistent high-risk HPV causes cancer in women, not men,” Jane Richards Montealegre, assistant professor at Baylor College of Medicine, says. She also co-authored the JAMA Pediatrics study.

The misconception fuels others — notably that the HPV vaccine should be given to girls, not boys, Montealegre says. This has led “to the large gender gap we see in HPV vaccination rates,” she says.

Should men get the HPV vaccine?

When the HPV vaccine came out in 2006, its stated purpose was for the prevention of cervical cancer. Until 2009, it was only approved for use in women.

The phased roll-out was intended to prioritize the vaccine for those at highest risk of cervical cancer, Montealegre says. But “it’s narrow focus on cervical cancer and women really deflected the narrative away from other HPV-associated cancers,” she says.

"Health care professionals need to communicate more often about HPV vaccination and that HPV causes cancer in men."

Today, the CDC recommends two doses of the HPV vaccine for all boys and girls between the ages of 9 and 12. After an adolescent turns 15, they are recommended three shots given over 6 months — that dosage is recommended for everyone through the age of 26.

Things took a turn in October 2018, when the U.S. Food and Drug Administration approved and expanded the use of the vaccine to include men and women aged 27 to 45 years. At the time, Peter Marks, director of the FDA’s Center for Biologics Evaluation and Research, said that the HPV vaccine had the potential to stop 31,200 cases of cancer happening annually.

But the CDC recommends that older, unvaccinated adults should talk to their doctor about “their risk for new HPV infections and the possible benefits of vaccination.”

Since the expansion, the medical community hasn’t seen very much uptick in the older age group, Deshmukh says. It’s true that the vaccine is most beneficial if received at an earlier age — in other words, before the person has had sex. Still, the vaccine “definitely has benefits beyond the age of 27,” he says.

“Officially, if a patient is or has been sexually active with multiple partners, the likelihood they have HPV is reasonably high, thus making the vaccine less helpful,” Nathan Starke, a urologist at Houston Methodist Hospital, tells Inverse. “I think anyone in any age group who does not already have signs or symptoms of warts or genital cancer, should be able to request and receive the vaccine.”

Should older men get the HPV vaccine?

The consensus is that adolescent boys should be vaccinated against HPV. But there's less agreement on whether a man should be vaccinated if they are older than 26.

Alyssa Laserson, a healthcare provider and master’s student at the University of British Columbia, studies HPV among men and boys. Her research indicates that unvaccinated men over the age of 26 should receive the vaccine if:

• They have not been previously diagnosed with a HPV-related disease before.
• They are not in a monogamous relationship, or they engage in sexual activity with multiple partners.
• They are immunocompromised.
• They are men who have sex with men or partners who engage in anal sex.
• They have not had sex before.

“The efficacy of the vaccine goes down substantially as a person ages and engages in sexual activities; that’s why it’s recommended and routinely administered prior to sexual debut,” Laserson tells Inverse.

David Bell, associate professor at Columbia University, tells Inverse that there are at least three reasons why men older than 26 should get vaccinated for HPV:

• They have been referred due to a partner’s positive test.
• Their sexual partners include men.
• They are still interested after having discussions with their doctor about HPV.

Why aren’t more men vaccinated for HPV?

Why more men aren’t vaccinated against HPV is complex and multifaceted. Two barriers are to do with perception and communication: Until recently, the vast majority of media coverage regarding HPV was to do with women, Laserson says. Perhaps inadvertently, this “led to women being lobbied to take responsibility for HPV vaccination — and by extension HPV.” Men, meanwhile, received no such messaging.

The absence of male-focused messaging played to stereotypes that men don’t engage in self-help — as a result, clinicians might not realize they need to promote HPV vaccinations among men.

If parents don’t bring adolescent boys in for vaccination, it is on clinicians to bring up the topic of vaccination to young men. In contrast to women, who have periodic PAP screenings and HPV testing, “there is relatively little practice reason for the realization of HPV causing oral, anal, and penile cancers to be at the forefront of young men’s awareness,” Bell says.

When those cancers do occur, they tend to strike in later life. There is currently no approved test for HPV in men, and no specific treatment for HPV in men. There is no way to know which people who have HPV will develop cancer. The two ways of lowering one’s chance of getting HPV are by using condoms during all types of sex, and by getting vaccinated.

"It's been a nightmare to deal with."

There’s also the issue of paying for the vaccine if you’re older than 26. Sean Purcell, 29, recently received the first of three HPV shots after his doctor recommended it as a way to prevent throat cancer. It was covered by his insurance company, Kaiser, with a $20 copay.

It felt like the obvious choice — his doctor recommended it, the benefits seem straightforward, and he didn’t see any downsides.

“I had heard in the past that there was an age cut-off where they didn’t recommend it after — but they also used to not recommend it for guys, so I figured the guidelines were still in flux,” Purcell tells Inverse.

Brian, 29, wanted the HPV vaccine as “protection for myself and future partners.” He knew, in theory, “we all have it” in some form or another if you’ve had sex, but he wanted to get the vaccine to protect against getting its worst strains. (Brian asked Inverse to use only a pseudonym for privacy reasons.)

He’s received the first two shots — but not the third. He’s not planning on going back for it because of insurance reasons.

“My doctor told me it would be covered by my insurance, and I called Aetna as well to make certain they would be covered and supposedly I would only have to pay my $35 copay,” Brian says. “A month after the first series of shots, I got a bill for around $450 claiming the shot was not covered by my insurance due to my age.”

Both Aetna and his doctor said it was a clerical mistake. So he got the second shot — and another bill. While figuring out what to do, his credit card was automatically charged, and his “case” was closed about six months after the two shots.

“It’s been a nightmare to deal with,” he says. “I’ve called them weekly for about six months. If you’re going to get the vaccine, just make sure your insurance will actually cover it.”

Under the Affordable Care Act, most private and marketplace insurance plans are required to cover (without charging copays or meeting deductibles) all adult vaccines that are recommended by the CDC’s Advisory Committee for Immunization Practices, Montealegre says. This includes HPV, which is named in the recommendations for men and women through age 26.

After 26, insurance coverage gets confusing. There’s no evidence yet pointing to the cost-effectiveness and long-term benefits of vaccinating older men, Deshmukh says. From the population-level standpoint, the data doesn’t indicate that the majority of adults 27 to 45 will benefit from the vaccine.

But “some individuals will — so it’s really on a case by case basis, depending on an individual’s risk behaviors, and should be discussed with a provider,” Montealegre says.

What does the HPV vaccine do?

The HPV vaccine, Gardasil 9, prevents certain cancers and diseases caused by nine types of HPV. It’s estimated that 92 percent of cancers caused by HPV could be prevented by the vaccine.

But a vaccine doesn't just benefit the person that receives it. There is evidence that the HPV vaccine promotes herd immunity to these kinds of HPV across the population. While the data from both men and women is lacking, studies done in women alone indicate that vaccinating young women and girls protects unvaccinated young men from HPV-related cancers, too. A 2019 study published in JAMA found that rates of oral cancer-related HPV strains in unvaccinated men decreased from 2.7 percent in 2009-10 to 1.6 percent in 2015-16. The results suggest some men may be protected by having partners who are vaccinated.

"Less benefits doesn’t mean no benefits."

Vaccinating people with pre-cancer — abnormal cells associated with an increased risk of becoming cancerous — may be effective, too, Deshmukh says. Data suggest HPV vaccinations can cut down the persistence of infection, slowing down the progression to cancer. More clinical trials are needed to establish this benefit of vaccination — but the evidence thus far is promising, he says.

There’s also evidence that family members who are vaccinated are more likely to encourage their children to be vaccinated. Since the HPV vaccination has only been available to males since 2011, it remains to be seen when that first-wave becomes parents whether the number of boys who are vaccinated increases. Currently, only 50 percent of eligible females and 38 percent of eligible males have completed the vaccine series.

“For now, there is nothing we can do about the inability to screen for HPV cancers in men — but we can improve communication about the infection,” Deshmukh says. “Health care professionals need to communicate more often to men about HPV vaccination and that HPV causes cancers in men.”

Because there’s no approved test available to detect the virus in men, “we need a far better understanding of the public’s perception of HPV risk,” Laserson says. Her research backs up Deskmukh and Montealegre’s survey: Most men don’t realize they can have a cancer-causing strain of HPV, and therefore, don’t think they need the vaccine.

“I don’t get very many questions from people about HPV, with the exception of ‘Can you test for it?’” Starke says. When urology patients do bring up HPV, the conversation tends to be about genial warts — not cancer.

When Inverse went to Reddit to ask what men wanted to know about HPV, respondents wanted to know when adult men will have better access to the vaccine. Many said that they want it. But research confirming its long-term benefits needs to catch up to those sentiments before it’s an obvious choice for all insurance providers — and it remains true that one can’t tell if a person is already infected with HPV, and it can take years for cancer to develop.

Still, “less benefits doesn’t mean no benefits,” Deshmukh says. Perhaps it is time for you to ask your provider about the vaccine, too.