Shared Clinical Decision-Making in HPV Vaccination for Adults

hpv vaccination for adults

We interviewed Dr. Gregory Zimet, PhD, HSPP of IU School of Medicine, and the Indianapolis Center for HPV Research about HPV vaccine recommendations.

What does the shared clinical decision for adults aged 27 – 45 mean in practice?
In 2019, the Advisory Committee on Immunization Practices (ACIP) issued a “shared clinical decision-making” (SCDM) recommendation for HPV vaccination for adults ages 27-45 years. This is in contrast with the “routine” recommendation for those ages 11-26 years. The term “routine” means that the HPV vaccine should be routinely recommended to all persons ages 11-26 years, but with the primary target being ages 11 and 12.

The SCDM recommendation is distinct in that it means that the HPV vaccine should NOT be routinely recommended for the older age range, as many older adults will not significantly benefit from vaccination, though some will. The challenge is how to implement an SCDM recommendation in clinical practice. The answer is in the term itself, “shared clinical decision-making.” An SCDM recommendation, therefore, should involve a process of discussion and shared information between a clinician and a patient. If no discussion occurs, then SCDM has not occurred.

In essence, the idea is that clinicians provide information and ask questions (and answer patients’ questions) to help patients make the decision about whether HPV vaccination is the right choice for them. Again, if the topic of HPV vaccination is not introduced and discussed by the clinician or patient, then no SCDM has taken place.

What does the recommendation mean for adults 27 – 45 years of age? 
First, the reason that there is no “routine” recommendation for adults ages 27-45 years is that the HPV vaccine is, overall, less effective in older compared to younger persons. Young adolescents have a stronger immune response to the vaccine than older individuals. Also, an older person is more likely to have already been infected with one or more HPV types. The vaccine only works to prevent future infections, not treat previous infections.

However, the HPV vaccine available in the U.S . protects against nine types of HPV, seven of which cause cancer. Only a very, very small percentage of adults have been infected with all nine types, so most adults may get some protection from the vaccine. The SCDM recommendation means that an adult aged 27-45 years should have a conversation with their healthcare provider to help them decide if HPV vaccination is the right choice for them.

Which patients should health care providers discuss the HPV vaccine for adults recommendations with?
All patients who have not previously received the HPV vaccine. As noted above, an SCDM recommendation necessarily involves discussions with all patients ages 27-45 years. Decision-making cannot be shared if it is not discussed.

Also, clinicians are often not in the best position to decide, without patient input, whether a given patient might benefit from, or desire, HPV vaccination. Here is an example of how a clinician could introduce the topic: “Let’s talk a little bit about HPV vaccination, which is now available for someone your age. That way, we can figure out if it’s right for you and whether it’s something you would be interested in.”

Would all adults aged 27 – 45 benefit from the HPV vaccine?
No. An adult who had been infected previously with all 9 HPV types the vaccine protects against would gain no benefit from the vaccine. Also, the benefit would be minimal for an adult who had been infected previously with several of the HPV types.

In general, as people grow older, there is an increased likelihood of infection with more HPV types. However, it is difficult to tell for certain whether someone has been previously infected and it is not recommended that HPV DNA testing be done to determine eligibility for vaccination. We often use sexual behaviors as a way of trying to determine who would most benefit from vaccination, though this is an imperfect measure. Someone who has had many lifetime sexual partners and who has a history of sexually transmitted infections (like chlamydia) is more likely to have been exposed to more HPV types than someone who has had, for example, one or two lifetime sexual partners and no history of a sexually transmitted infection.

Should adults who are in a long-term, mutually monogamous sexual partnership get the HPV vaccine?
Yes, they should consider getting the HPV vaccine. Adults who are truly in a long-term, mutually monogamous partnership may benefit most from HPV vaccination. Since they have had a single partner over a long period of time, it is less likely that they have been infected with multiple HPV types. This means that HPV vaccination is more likely to provide future protection if a person begins a new partnership due to separation or divorce, or a partner’s death.

Is the HPV Vaccine safe?
The HPV vaccine is very safe, including for those ages 27-45 years. It is as safe as or safer than other vaccines. No vaccine is 100% safe, but nothing we do in life is 100% safe. For example, using a lawnmower, riding in a car, playing a sport, or walking up a flight of stairs, are all activities that are less safe than getting the HPV vaccine. It is certainly safer to get vaccinated than to not get vaccinated!

Should adults wait for their healthcare provider to recommend the vaccine?
No. Although healthcare providers should bring up HPV vaccination, in practice, this may or may not happen. If the clinician does not bring it up, adult patients who are interested in HPV vaccination or in discussing the vaccine should initiate the conversation with their healthcare provider. As noted above, if a discussion does not take place, it is not shared clinical decision-making.

What is the cost of the vaccine; does insurance cover it?
The out-of-pocket cost for the HPV vaccine comes to about $200 to $250 per dose (vaccine cost + administration & office visit cost). For adults ages 27-45 years, three doses are recommended. As a result, the 3-dose series can cost over $600 if someone has to pay for it themselves. It is likely that some (perhaps many) insurance companies are covering the cost of vaccination for adults ages 27-45 years. Insurance companies typically decide to cover the cost of vaccines that receive a recommendation from the Advisory Committee on Immunization Practices (ACIP), even an SCDM recommendation. However, persons ages 27-45 years who are interested in HPV vaccination should check with their insurance company to confirm that it is covered.

Dr. Zimet is a Clinical Psychologist and Professor in the Department of Pediatrics at Indiana University School of Medicine. He has guided an extensive and multi-faceted research program focused on attitudes about, and acceptance of, vaccines for the prevention of sexually transmitted infections (STI), including the human papillomavirus (HPV) vaccine.

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