The physicians we interviewed were strongly in favour of prescribing the HPV vaccine and believed it to be an important component of HIV-related care as well as for the health of all GBM regardless of their HIV serostatus. Physicians did not express any concerns regarding the safety of the HPV vaccine; a few indicated that the HPV vaccine had a similar side-effect profile to other vaccines and that they were “pro-vaccine”. As the HPV-9 vaccine was relatively new to the market at the time of the interview (and more expensive), physicians did not articulate any strong preferences for it above the HPV-4 vaccine.
Nonetheless, physicians varied in their opinions as to who should receive a strong or unequivocal recommendation for HPV vaccination. Some physicians were adamant that all their patients should be vaccinated for HPV. For example, one physician believed that HPV vaccination should be done “universally” regardless of a patient’s age so that “we can shut [anal cancer] clinics like this down in a decade” (General Practitioner 5). This participant argued that the slow response to offering HPV vaccine universally is directly responsible for an increase in HPV-associated cancers.
Physicians said that they would clearly recommend the HPV vaccine to GBM who are age 26 and under, or those with health insurance. However, some physicians expressed that they recommended the vaccine to their HIV-positive patients regardless of age or whether or not they had insurance: “I’ve tried to talk about vaccination with everybody who’s [HIV] positive because of the greater rates of anal cancer in MSM who are HIV-positive” (General Practitioner 6). Another physician explained that aside from a select group of older GBM patients—“I mean, there is the 80-year-old guy I might not recommend it [to]”—they recommended HPV vaccination to most GBM patients and to all patients living with HIV (Specialist 8).
Below, we discuss the interrelated factors affecting the strength and frequency of vaccine recommendations for GBM: cost/coverage and the current state of evidence on HPV vaccination. After this review, we illustrate the relative complexity of the recommendation decision-making for physicians.
Factors affecting universal and strong recommendations
Two interrelated factors were described as limiting the strength and/or frequency of the physicians’ recommendations for the HPV vaccine. The first was cost. Some physicians clarified that the only potential negative “side effect” of the vaccine was the financial burden: “But where is the medical harm? There isn’t any. [ …] In my mind, what’s the harm, aside from the $600?” (General Practitioner 4). Another physician declared: “There is not really any danger in getting the vaccine, but the disadvantages are, you know, several hundred dollars, unless you have coverage” (Specialist 8).
The second major factor affecting vaccine recommendation was a lack of clear evidence of the prevention and therapeutic benefits of vaccinating individuals over 26, including for GBM-LHIV, as well as unclear guidelines regarding this population’s vaccine needs. As one physician clarified:
The big unanswered question is the one that we grapple with all the time, is that is there a benefit of giving people who are sexually active, who’ve been sexually active, Gardasil now? Does that really lower their risk of getting an aggressive anal cancer, does it boost their immunity? That’s probably the biggest unanswered question, which is, in my practice, the most important question, because I am giving people Gardasil. But is it doing something? I don’t know. (General Practitioner 4)
Cost and insufficient evidence and national guidelines that are incongruent with publicly funded vaccine programs made it difficult for some physicians to determine
how and
for whom to offer strong and repeated recommendations for vaccination. Physicians described how the confluence of these issues produced an ethical conundrum where it was unclear whether or not the uncertain health benefits of vaccinating at an older age justified the personal expense to patients. For example, one physician explained that they would certainly recommend the HPV vaccine for anyone 9 to 26 years old but added that they did
not systematically recommend it, and even somewhat discouraged it, for people outside of this age range:
And if they were over 26 and asking about it, I would say look, the evidence isn’t as strong because you’ve already been exposed at this point to so many [strains]. And it would be a sort of case-by-case discussion of well, the evidence isn’t as strong and at this point you’d have to pay for it, so this is what this would look like and I’m not routinely recommending it. (Specialist 1)
Thus some physicians’ decisions to recommend the HPV vaccine are based on assumptions of a patient’s presumed contact with HPV, which could range depending on their history of sexual behaviour.
The above physician also went on further to argue that the combination of the cost of the vaccine with the lack of compelling evidence created a challenging ethical dilemma: “It puts me in a – all of us as providers – I think in a bit of an ethical conundrum when we’re saying, I really think you need this thing, please give $300 to somebody else so that you can get it. I think that’s messy, right?” (Specialist 1). Similarly, another physician declared that it was problematic to offer people a medical suggestion that they may not be able to afford: “So that’s where I have problems when, you know, we are saying to people, well you actually will benefit with the vaccine, but you have to go buy it” (Specialist 9).
Conversely, one physician felt more certain about offering a strong recommendation for vaccination despite both the cost and unknown benefits of vaccinating older adults:
I would give it to everybody if we had easy access to it. Anyone who is above [26 years old] I would certainly let them know about it. I would offer it to them and if they were willing to pay for it, absolutely I would give it. I would be like anyone who’s had anal dysplasia or certainly anyone who’s had anal cancer or some kind of HPV related oral or other cancer, I would highly, highly recommend that they spend the money and get it. [ … ] I mean if they’ve got insurance, it’s a no brainer. If they don’t have insurance, I’m going to encourage it for everyone. But I would more strongly encourage it in somebody who has already had evidence of dysplasia or had some complication related to HPV. (General Practitioner 7)
While some physicians described feeling that the evidence on vaccinating older adults was more encouraging, others were less persuaded by the existing data. For example, one general practitioner articulated that there were clear benefits to being vaccinated at any age, but the cost considerations complicated recommendation practices:
A lot of people can’t afford [the vaccine] and it’s not covered and, you know, so we have to decide whether or not it’s really making a difference for them or would it just be completely sufficient for them to continue screening regular follow-up at the anal dysplasia clinic. I mean, then you miss the opportunity for the few patients who will develop an oropharyngeal cancer that there is a benefit there of having Gardasil. (General Practitioner 12)
One physician clarified that while the “HPV vaccine is amazing,” since most of the patients operating in this participant’s practice were HIV-positive they have already been infected with a “bad kind of HPV”, and the benefits of recommending vaccination were unclear. Although this physician argued that the vaccine may have “some benefit” for those with “pre-cancerous changes”, these clinical benefits were also read through a lens of pragmatism and cost considerations, with the physician opining: “Unfortunately, it’s a two-tier system. If they can afford it, or if they have insurance, they get the vaccine. If they can’t afford it and, you know, no insurance, most people don’t get the vaccine” (Specialist 13).
Similarly, a general practitioner argued that vaccinating people with insurance was a “no-brainer”, but that not vaccinating people with the financial resources was “unfortunately the reality of a lot of things in healthcare” (General Practitioner 12). Nonetheless, this participant argued that it was:
[Not] a great injustice that patients who don’t have coverage can’t get the vaccine, because I really am not convinced that it’s a huge difference in terms of prevention when you already have been exposed and you’re let’s say 60 years old and already have established risk factors. How would taking the Gardasil make a huge difference in your life compared to a 10-year-old boy who is, you know, before he starts his sexual life, you know, he is fully covered. (General Practitioner 12)
This participant discussed how his views on HPV vaccination recommendations were often contradicted by other providers who were more “enthusiastic” about recommending vaccination.
Physicians referenced existing guidelines and provincial vaccine insurance program for HPV vaccination. However, these did not always provide sufficient clarity on how to address the issue of vaccination for men older than 26. As one physician averred, “But even in that area, there is no clear guideline on who should be vaccinated and who shouldn’t” (General Practitioner 12). One specialist stated that while they agreed with the NACI guidelines and that HPV vaccination should be considered for all gay men, ultimately this was a decision they leave to their patients: “… I just put that to the patient and they can decide whether they want to spend the money or not” (Specialist 14).
One participant outlined the challenges of relying on existing recommendations, especially among their clientele that was mostly made of men with financial limitations. A host of factors was described as informing their decision to make a recommendation including age, level of HIV viral suppression, private insurance coverage, and a history of abnormal anal Pap results. However, if someone cannot afford the vaccine, the physician described that in such instances:
… it’s a weaker recommendation from me especially because my uninsured patients, many of them are unemployed and on social assistance and may not even have family members that can be a secondary source of funds for health stuff. So it’s a non-starter. If I know that someone does not have the ability to get the vaccine, we’re not going to have a very detailed discussion about it, which I think is different than another clinic. (General Practitioner 15).
Another physician questioned the logic of provincial health insurance program’s focus on men below the age of 26: “The issue is, you know, first of all, there is a cost thing, right? And some provinces have MSM programs, but a lot of them are capped at 26 again. 26 is interesting because it’s – that’s really based on the vaccine indication. So that’s a drug issue, right?” (Specialist 8). For this specialist, vaccine indication was understood to be a key driver of vaccine policy.
Physician-patient discussions about HPV vaccination
A few physicians made it clear that they prioritized discussions on HPV and vaccination with their patients. As one HIV specialist declared: “So, I like, in my [practice] – I go over five things in every visit with every patient: anti-retroviral therapy, vaccines, and then HPV related disease is number three, and then other medical conditions and mental health and addictions” (Specialist 3). Other physicians we interviewed noted that it was often their patients who were initiating a discussion about HPV vaccination, with some commenting that it was about “fifty-fifty” between who raised the issue first (General Practitioner 2). Multiple physicians described that they had some patients who had heard about the vaccine from their friends and/or sexual partners and were bringing it up in clinic.
The cost of the HPV vaccine resulted in several physicians saying that they do not talk about HPV vaccination with certain patients, particularly with those patients they deemed to have financial constraints. One physician explained how economic factors entered into the recommendation decision-making and prevented discussions on vaccination with patients:
Yeah, and remember for a lot of my HIV patients, the majority live on ODSP [i.e. provincial disability insurance]. So, almost $600 is an insurmountable – I mean it’s just, you know, it’s just not feasible at all. So there’s really not a lot of point for me to bring that up to them and mention something I know they can’t afford. And I may be doing them a disservice because maybe they have resources I don’t know about or they have family members, but I think overall if I did that I’d probably cause more anxiety than good. (General Practitioner 2)
This physician went further to discuss how these complex conversations about money and strategies to access the vaccine could take up a lot of time during an already busy appointment, thus producing some hesitancy on their part to bring up the vaccine in the first place:
The problem with HPV is that it’s not good enough just to not see it there [on their medical charts]. Then you’re like, okay, does the person have coverage, do they have money? So then it becomes this, so it’s no longer a routine thing. With HPV, I have to have the discussion first and then they come in and we get talking about something else and the discussion may not happen, whereas if it was covered for everybody, it would just be one of those things that that’s done automatically. (General Practitioner 2)
To mitigate these barriers of cost, some physicians offered different access strategies for their patients, including only taking two doses of the vaccine instead of three,
2 and directing patients to clinics where they know they can get the vaccine more inexpensively. These examples help to illuminate the navigation work some physicians have taken on in order to help get their income vulnerable patients access to the HPV vaccine.