Comment: Progress on vaccination for HPV too vital to lose

By Lisa Jarvis / Bloomberg Opinion

Vaccinations for human papillomavirus (HPV) among teens in the U.S. dropped precipitously during the early pandemic, a disappointing reversal for shots that can prevent more than 33,000 cases of cancer each year. Worse, efforts to get vaccinations back on track could be stymied by legal challenges.

We can’t let a decade worth of slow and steady progress in HPV vaccinations be lost.

Getting the U.S. public to accept the HPV vaccine as a safe and effective part of routine health care has been a decade-long slog. That effort involved allaying (unfounded) beliefs that these shots, by preventing HPV, could encourage sexual activity among teens. That’s because the virus excels at spreading through skin-to-skin contact; so much so that nearly everyone is exposed, perhaps more than once, during their lifetime. And while the immune system can get rid of the infection most of the time, certain strains can stick around for years, kicking off a process that morphs otherwise healthy cells into cancerous ones.

So there’s no doubt about the benefit of these shots: The HPV vaccine can nearly eliminate cases of cervical cancer, and have a profound impact on many others, including anal, penile, vaginal, vulvar and certain head and neck cancers.

These vaccines also save the health-care system money. A recent study commissioned by St. Jude’s Children’s Research Hospital found that preventing cancers by increasing the rate of completed HPV vaccinations could lower national direct health-care spending by more than $26 million.

Those are among the reasons HPV vaccination is now the norm for adolescents in many parts of the U.S. From 2016 to 2021, the percentage of teens receiving their first shot in the vaccine series leaped from roughly 60 percent to nearly 77 percent. And the gap between vaccination rates among girls, the initial targets of these shots in 2006, and boys, for whom it was recommended by Centers for Disease Control and Prevention in 2011, is finally starting to close.

The pandemic has threatened to upend that progress. Disruptions to routine doctor visits and shifting priorities during appointments meant that about 1 million doses were missed in 2020. Data from CDC’s annual survey of teen vaccinations suggests at least a partial recovery in 2021, but we won’t have complete data until next year.

The missed doses also coincide with an increasingly hostile climate for preventive health-care services that fall under the broad umbrella of reproductive or sexual health. That politicization of routine health care could erode access to — and acceptance of — HPV vaccines.

In the wake of the Supreme Court’s ruling in Dobbs v. Jackson Women’s Health Organization, which resulted in the overturning of the landmark abortion decision Roe v. Wade, access to many other therapies and preventive services, including HPV vaccination, could be at risk. Reproductive health experts worry that states with the most draconian laws around abortion might next try to limit access to FDA-approved medicines or vaccines that have long been viewed by conservative groups as controversial. For example, Texas lawmakers earlier this year tried to ban gender-affirming care for teens, and more states are trying to make it harder to access hormonal therapies.

And even if individual states don’t take up such causes, private insurers might. That risk to the HPV vaccine was made clear earlier this month by a decision in a lawsuit brought against the U.S. government by a Christian employer, Braidwood Management. The company said the Affordable Care Act required it to cover certain kinds of preventive care that violated its religious beliefs, and a Texas judge agreed; in part, at least. The ruling said that Braidwood did not have to offer health insurance that covered PrEP, medicine taken to prevent transmission of HIV.

But the original suit wasn’t only focused on PrEP. It also called out coverage of contraceptives, HPV vaccination, and screening and counseling for sexually transmitted infections. And even though the suit ultimately didn’t impact coverage of the HPV vaccines, the decision doesn’t insulate them from future challenges, says Andrew Twinamatsiko, associate director of the Health Policy and the Law Initiative at the O’Neill Institute at Georgetown University Law Center. The Texas ruling “makes other preventive services vulnerable to religious challenges, however spurious.”

These types of legal challenges to preventive care are occurring in states where HPV vaccination rates are already among the lowest in the country. In Texas, for example, only 51 percent of teens were up to date on their HPV vaccination in 2021.

Mississippi, which brought the Dobbs case to the Supreme Court, ranks last in the country for HPV vaccinations among teens; just 33 percent of teens there have been fully vaccinated against the virus. A recent survey of providers there revealed many reasons for the shortfall, from anti-vaccination views, to the connotation of HPV with sexual activity, to the way providers were talking to parents about the vaccine; offering it as an option rather than recommending it as normal care, for example.

People working in reproductive and sexual health are bracing themselves for more legal challenges, which if upheld could make HPV vaccines less affordable to some families. Just as important, they could upend the notion that these shots are a routine part of health care.

“We should feel positively and optimistically about the progress that’s been made and not allow this reframing of HPV vaccination as this weird fringe thing,” says Melissa Gilkey, a professor at University of North Carolina’s Gillings School of Global Public Health.

Fortunately, there are some states showing how to get it right. Rhode Island stands out as having the highest HPV vaccination rate in the country in 2021. That’s not surprising given the state is among the few to mandate the shots. Starting in 2015, children there have been required to begin the series before entering seventh grade. Mandates probably aren’t going to be the answer for every state, but places where it is politically feasible (and where it won’t draw negative attention to these shots) should be considering them.

And the St. Jude’s report also suggested a side avenue for improving HPV vaccination: improving meningococcal vaccination, which is typically also offered when a child turns 11. That vaccine is mandated in many, but not all states, and the report found that people who get one often get the other. Health-care workers should be trained to strongly recommend both, the researchers said.

But helping the HPV vaccine regain its momentum will be difficult — if not impossible — if the courts don’t continue to recognize these cancer preventions as fundamental health care. It would be simply shameful to go backward with a vaccine that could spare so many people from cancer.

Lisa Jarvis is a Bloomberg Opinion columnist covering biotech, health care and the pharmaceutical industry. Previously, she was executive editor of Chemical & Engineering News.