Human papillomavirus (HPV) vaccination protects against six types of cancer—cervical, anal, oropharyngeal, penile, vulvar, and vaginal. In the United States (U.S.), HPV vaccination coverage in college students remains low, especially in the Mid-South region, despite the highest risk of HPV infections and disease burden. However, few studies have assessed HPV vaccination among college students here. This study examined factors associated with HPV vaccination among college students in the Mid-South and explored preferred strategies for promoting vaccination. A mixed-methods design comprising a cross-sectional, self-report online survey and dyadic virtual interviews was conducted. Simple random sampling was performed to recruit a total of 417 undergraduate students aged 18–26 from March to May 2021; convenience sampling was performed to recruit three sex-matched dyads of a total of six  undergraduates from survey respondents who had not completed the HPV vaccine series in May 2021. Binary logistic regression analyses showed HPV vaccine knowledge and perceived barriers to vaccination were factors contributing to coverage for both female and male students, while perceived risks of HPV and vaccine hesitancy were factors only among female students. Findings from the qualitative content analysis identified college students’ perceived barriers to the vaccination at multiple levels and preferred strategies for vaccination promotion, corroborating the findings from the survey study. The findings provide implications that benefit the development of tailored interventions aimed at facilitating catch-up vaccination among college students in the Mid-South region. There is an urgent need for further research and the implementation of effective strategies that address the identified barriers and improve HPV vaccine uptake in this population. Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States (U.S.), which occurs through intimate skin-to-skin contact . HPV infThe HPV-attributable cancers are mostly preventable with available vaccines . Since 2Despite the availability of a safe, effective vaccine ,21,22,23The existing literature has indicated that the low rates of HPV vaccination among college students were associated with several multilevel barriers to the vaccination. At the individual level, the barriers included a lack of awareness and knowledge of HPV vaccination , HPV-vacResearch has also shown that several factors could facilitate HPV vaccination among college students. Firstly, education about HPV and the vaccine was positively connected to increasing HPV vaccine intent and uptake among college students . SeveralTo reach the national goal of HPV vaccination and reduce the burden of HPV-attributable cancers, it is imperative to advance catch-up HPV vaccination in the college-aged population through addressing factors influencing the vaccination. However, public health efforts have shifted primarily to adolescent HPV vaccination, and considerable research has investigated factors contributing to parental decision making for adolescent HPV vaccination . By compThis study examined factors associated with HPV vaccination among college students in the Mid-South of the U.S. using a mixed-methods approach. The Mid-South in particular is one of the U.S. regions which has reported high rates of HPV prevalence and cervical cancer mortality and low rates of HPV vaccination ,38, yet Research question 1: What were factors associated with HPV vaccination among college students? If any, how did the factors differ by gender?Research question 2: What were college students’ perceived barriers to HPV vaccination?Research question 3: What were college students’ preferred media and strategies for promoting catch-up HPV vaccination?We employed a mixed-methods, sequential explanatory design to collect quantitative and qualitative data on HPV vaccination among college students at an urban public university in the Mid-South of the U.S. region and then consider these data sources independently, as well as to simultaneously elucidate actionable intervention strategies. This university setting was located in a metropolitan area of the west region of Tennessee, which housed more than 21,000 students, offering baccalaureates through doctoral degrees. According to a recent student enrollment report by the university , about 6For the quantitative data, we used a descriptive and cross-sectional online survey and, subsequently, for the qualitative data, we used virtual, in-depth, dyadic interviews among the survey participants. The university institutional review board approved this study (IRB#: PRO-FY2021-297).We performed simple random sampling to recruit participants through university emails. We obtained a total of 8000 student email addresses (38.1%) which had been randomly selected out of all enrolled students by the university office of institutional research. The inclusion criteria for the survey were students who were aged 18 to 26 years and registered for an undergraduate program at the university at the time of the survey. Students below 18 years old, above 26 years old, or at a postbaccalaureate program were excluded because undergraduates were the target population of the HPV vaccination in this study and the ACIP recommended catch-up vaccination through the age of 26 .Data collection occurred via an online survey tool  between March and May 2021 . We chosHPV vaccination status. We measured participants’ HPV vaccination status as an outcome variable. We assigned vaccinated status when a participant reported having received at least one shot; otherwise, we assigned unvaccinated status.HPV vaccination knowledge. To measure knowledge of HPV vaccination, we employed Karki and colleagues’ adapted HPV knowledge scale and HPV vaccine knowledge scale both with options of “true” (=1), “false” (=0), and “do not know” (=0) . The HPVHPV vaccination beliefs. We assessed beliefs about HPV vaccination among participants with the 12-item HPV belief scale guided by four constructs of the health belief model (HBM) . The HPVPerceived risks of HPV. We measured participants’ perceptions of HPV-related risks using Klasko-Foster and colleagues’ HPV perceived risk scale . ParticiHPV vaccination hesitancy. To assess participants’ hesitancy for HPV vaccination, we adapted Szilagyi and colleagues’ vaccine hesitancy scale . The hesInfluences on HPV vaccination. We employed a single item to ask participants to report the most important influence on receiving the HPV vaccine by selecting one out of a possible six influences. These influences included: personal views and beliefs; healthcare provider’s recommendation; parent/partner/significant other or mass media  recommendation; social media  recommendation; and accessibility .Preferred cancer-related information sources. To assess participants’ recent cancer-related information source during the COVID-19 pandemic, we asked participants to respond to a question of “The most recent time you looked for cancer information during the COVID-19 pandemic, where did you go first?” The options of this question included: books; brochures, pamphlets, etc.; cancer organization; family; friend/co-worker; doctor or health care provider; internet; social media ; library; newspapers; telephone information number; and complementary, alternative, or unconventional practitioner. Additionally, we assessed preferred cancer-related information sources when needed in future using a single question with the same option as the above, “Imagine that you had a strong need to get information about cancer during the COVID-19 pandemic. Where would you go first?”Sociodemographic information. We measured sociodemographic characteristics, including age, gender , race/ethnicity, school year, annual household income, religious importance, health insurance, having a primary care provider, and self-report health status.We performed descriptive statistics and univariate analyses to examine all variables and HPV vaccination status among participants. We ran bivariate analyses to assess the characteristics of the variables by gender. Additionally, we performed ANOVA with Scheffé test for continuous variables, while we performed a chi-squared test for categorical variables. Finally, we ran binary logistic regression analyses to examine the associations between the independent variables and the HPV vaccination status  among female and male participants, separately. We employed listwise deletion to handle missing data. We used Stata 14.2  for data analysis.For better understandings of HPV vaccination among college students, we performed purposive sampling to recruit interview participants among those who had completed the survey. Those eligible for the interviews were the participants who had completed the survey and were not up to date with the vaccination series. We chose the qualitative approach of a dyadic interview over a focus group or an individual interview as the dyadic interview allowed the researchers to quickly recruit participants and two participants to interact with each other and provide in-depth and detailed information . We alsoFor data collection, we developed a semi-structured interview guide of open-ended questions using the existing literature and informed by the quantitative survey domains. We sent a recruitment email through the university email to potential participants between the last week of April and the first week of May in 2021, but prior to the end of the semester. A total of 18 students  who were interested responded to the email. We contacted the respondents via email to screen the eligibility and obtain their permission to schedule interviews. Among the 18 respondents, a total of 6 respondents  agreed to participate in an interview, resulting in two female dyads and one male dyad. The first author conducted a total of three dyadic interviews between the second and the third week of May in 2021. At the beginning of each interview, all participants provided verbal consent. During the interview, the interviewer used a funnel approach to ask a broad question followed by more specific questions to probe respondents’ answers. Each interview took about 60 min to complete. We digitally recorded all interviews via Zoom with participants’ permission. The respondents received a USD 20 e-gift card as an honorarium.We analyzed the interview data transcribed verbatim in a three-stage process, using inductive coding and qualitative content analysis applying the socioecological model (SEM) as a conceptual framework ,46. The In the first stage, the first (S.W.J.), third (S.L.), and fourth authors (H.J.), respectively, read and reviewed all transcripts multiple times to fully understand the responses before coding. As a coder, each author conducted first- and second-level coding independently to generate a joint codebook which included all interview concepts along with corresponding direct quotes. Then, all coders reviewed the codes together as a group and resolved any discrepancies through discussion and consensus. In the second stage, the coders revisited the codebook and transcripts to conduct third-level coding to finalize the codes and categorize the finalized codes into either barriers or facilitators. In the final and third stage, the coders repeated the first-stage process again, categorizing all codes by the barriers and facilitators at the three SEM-based levels, respectively, and identified emerging themes by building relationships among the codes and categories through iteratively comparing the results.Consistent with the mixed-methods sequential explanatory study design, we considered the quantitative data and qualitative data in combination to better understand and identify emergent action steps to improve HPV vaccination coverage. The survey data revealed characteristics or attributes associated with vaccination status (yes/no), which offered us an opportunity to explore how unvaccinated participants may explain their status to inform barriers and facilitators in a more detailed manner. This process included a review of the data and discussion of the implications overall, but specifically among the unvaccinated participants.t-test of the variables of interest for female and male participants. Female students had significantly greater knowledge of HPV  and receipt of the HPV vaccine  compared to male students. With regard to the HBM-based beliefs of HPV vaccination, male students had significantly higher levels of perceived severity , perceived barriers , and perceived susceptibility  compared to female students. No significant difference was found in the perceived benefits. Moreover, female students had a significantly greater perceived risk for HPV  compared to male students. Lastly, there was no significant difference in HPV vaccination hesitancy between the two groups.2χ test showed a significant sex difference in the vaccination status .Approximately 53% (n = 163) of female students reported having received at least one shot of the HPV vaccine compared to 36% (n = 36) of male students. A Participants were also asked to report their preferred sources of cancer-related information during the COVID-19 pandemic. For the sources that female students had recently sought, the Internet  was a primary source, followed by other , a doctor or healthcare provider , social media , and family . Similarly, for the sources that male students had recently sought during the COVID-19 pandemic, the Internet  was a primary source, followed by other , a doctor or healthcare provider , social media , and family . Additionally, participants were asked to report their preferred sources of cancer-related information when needed in future. For the sources that female students preferred to seek in future, the Internet  was their most preferred source, followed by a doctor or healthcare provider , cancer organization , and other . Likewise, for the sources that male students preferred to seek in future, the Internet  was their most preferred source, followed by a doctor or healthcare provider , cancer organization , and libraries .There were a total of six respondents with four females and two males. Out of the six respondents, one was sophomore, two were junior, and three were seniors across different majors at the university. The analysis and interpretation of the interview data revealed several themes aligning under the following two major topic areas: (a) multilevel barriers to HPV vaccination and (b) preferred strategies for catch-up HPV vaccination promotion.At the individual level, a lack of knowledge of HPV and HPV vaccination emerged as the most common barrier to HPV vaccination among college students. Additionally, the analyses revealed that misperceptions of HPV and the vaccination and concerns and worries about HPV vaccination prevented college students from receiving HPV vaccination at the individual level. Other individual-level barriers included college students’ perceived ignorance of HPV-related information, no priority of the vaccination, and lack of time. At the interpersonal level, a lack of recommendations by healthcare providers, parents, or peers was a barrier to HPV vaccination among college students. The analyses also revealed that parent’s decision was an interpersonal-level barrier to the uptake among college students. Finally, at the community level, social and religious norms were a primary barrier to HPV vaccination for college students. The social and religious norms included stigma of HPV and taboo about discussing the HPV-related topics. These norms generated an atmosphere in which college students were reluctant to openly discuss HPV due to embarrassment and the link to encouragement for sexual activities. Additionally, the structural barriers included difficulties in accessing an HPV vaccine, costs, lack of appropriate information, and absence of education on HPV and the vaccination.All students mentioned the need for reliable information on HPV vaccination to facilitate college students to receive the vaccines. Students also suggested that the vaccination-related information should include the following content: the benefits and potential risks  of getting HPV vaccination, the places  available for receiving a vaccination, the vaccination guidelines presented by national health institutes , and evidence  from peer review academic sources. Students also recommended that the information should be designed to target freshmen ; be simple, short, concise, and attractive with visuals  for college students to easily and quickly read and understand; and be interpreted into different languages for those who use English as their second language.Moreover, students suggested several media channels that could effectively deliver information on HPV and the vaccination to college students. These media included university email, printed flyers/brochures, mobile applications, and social media, while students preferred email and social media  over others. Particularly, all students highlighted that social media were the most popular platform to effectively reach college students, deliver the information, and communicate on the vaccination among college students. However, students also pointed out some difficulties in using email and mobile applications. When any information in the university email was long and text-condensed, college students tended to skip or ignore the information. Additionally, one student stated that college students might be reluctant to use a mobile application because downloading an application which would rarely be used into their own mobile phone limited the internal storage space of the phone. Another student suggested that one of the university social media platforms , which was widely used to post interesting stories among college students at the university, could be an effective way to reach students at the university and deliver the vaccination-related information to them.Furthermore, students stated that the provision of appropriate information on HPV and the vaccination via commercials, healthcare providers, parents, or peers could promote college students’ HPV vaccination. Additionally, students mentioned that the recommendations by healthcare providers were the most trusted source of information on HPV and HPV vaccination and a primary facilitator to receiving HPV vaccination for college students. Students also suggested campus-wide initiatives to encourage HPV vaccination, such as a tabling event with giveaways  and e-gift cards. Multiple students pointed out that the student health center could be an accessible place to obtain information and free vaccination for college students.Lastly, for the feasibility of virtual reality (VR) in HPV vaccination education for college students, students were asked to describe their thoughts on using VR for educating college students on HPV vaccination. Most students stated that they were familiar with VR because of their past experiences of using it to play games, indicating that these experiences were interesting and fun. Students also revealed positive attitudes toward VR as an unexplored-yet-promising tool to educating college students on HPV vaccination, while the male dyad showed more experiences and stronger interests in using VR for vaccination education. In particular, both male students indicated that VR could attract college students’ attention to vaccination-related information, expressing their willingness to watch the information through VR. Additionally, a female student stated that using VR might be a better approach to promoting HPV vaccination among college students, compared to other ones such as social media and on-campus tabling events, because VR might enable the information to reach college students whom other approaches might miss. However, while most students stated that using VR would be a breakthrough approach for HPV vaccination education for college students, some students also addressed their concerns about possible difficulties in purchasing or accessing a VR device among college students.Few studies have assessed vaccination hesitancy among college students . One of Female survey respondents had higher levels of HPV knowledge, higher perceptions of risk of HPV, and were more likely to be vaccinated compared to males. This is consistent with current estimates of HPV vaccination among college students with females about 20 percentage points higher than males overall for HPV vaccination series completion in 2021 . The detIn terms of factors influencing HPV vaccination, minimal differences were noted between males and females. Both males and females cited healthcare provider recommendation as the most important, followed by personal views and beliefs. Preferred information sources about HPV vaccination were the internet for males and females, then healthcare providers, followed by social media. There were minimal differences in preferred primary information sources between during the COVID-19 pandemic and expected information-seeking behavior in the future.When considering the results of the survey and interviews, several potential areas for intervention were identified. Prior to the interviews, the survey results were reviewed to inform the in-depth interviews. When evaluating and interpreting the results of both forms of data collection in this mixed-methods study, there were several commonalities identified. Respondents and participants noted barriers and facilitators that were highly actionable for this population. Three primary recommendations for interventions emerged.Results regarding preferred information sources and messaging channels were prescriptive and directive for intervention development and testing. Participants wanted information that was reliable and capitalized on their usual ways of gathering and considering information. In this study, consistent with previous studies, college students indicated support for digital health interventions , specifiOne specific type of intervention that was explored in the qualitative interviews was VR, which was a familiar concept to participants because of their positive experiences with playing games. A small sample of students responded favorably to this potential approach. Students should carry out this type of intervention on their own to allow them time to revisit the key educational messages shared. The primary limitation was being able to access technology to support participation in a VR-based intervention. VR interventions for college students date back more than 10 years to explorations with influences on alcohol behavior ,58, physRegardless of intervention type, the importance of linking increased knowledge and confidence with opportunities for action are critical. This college campus has an on-campus health center, but the health center does not offer the HPV vaccine. As noted in the results, college students’ recommended information about HPV vaccination included how to access the HPV vaccine. Among this highly insured population, converting willingness to opportunities for behavioral performance becomes the primary objective of intervention approaches. Fostering linkages between campuses and vaccination administration is an important implementation strategy for future interventions to promote HPV vaccination with college students.The study has several strengths, including its relatively large quantitative survey sample size for a single college institution, and also the sample’s racial diversity. However, the survey sample was predominantly female, which may limit interpretations related to sex differences between male and females. The survey sample also had a high proportion (85%) of insured respondents with a high level of usual medical care, with almost three-fourths reporting having a health care provider (73%). While the Patient Protection and Affordable Care Act extended benefits of health insurance coverage to dependents up to age 26, we did not assess the nature of coverage, such as parent/caregiver policy or own policy. The college is located in a non-Medicaid expansion state with several noted gaps to preventive health care. However, the sample reported high levels of coverage and access to care. Additionally, although the study employed probability sampling, the sample offered no specific information on the in-state status of the participants. The findings should be carefully interpreted in terms of the characteristics of “Mid-South” college students. The qualitative interview sample was very small in comparison, and the qualitative results should be considered with this in mind. Lastly, the research was conducted during the COVID-19 pandemic. The vaccination attitudes and beliefs reflected in this study may or may not be relevant in the post-pandemic period.The results of this study support previously published assertions about the importance of targeting the catch-up population of college students for HPV vaccination. College students are an ideal population with which to intervene to increase coverage and reduce disease burden. Several opportunities for interventions emerged, including addressing multilevel barriers and aligning intervention approaches with preferences and usual ways in which college students access information. Access to HPV vaccination was noted as an important factor when introducing educational interventions. While the sample size was small, college students in this study were favorable towards VR-based interventions to promote HPV vaccination. Future research should test various implementation strategies to address the multilevel barriers identified in this study and related research to understand the impact on HPV vaccination. In addition, innovative intervention approaches, such as those delivered using VR, should be further explored and developed. College students want to learn more about HPV vaccination and how it may help protect them from HPV diseases. It is critical that we act now to provide them with meaningful information.


The burden of cervical cancer is disproportionately distributed globally, with the vast majority of cases occurring in low- and middle-income countries. Women with human immunodeficiency virus (HIV) (WWH) are at increased risk of human papillomavirus (HPV) infection and cervical cancer as compared to HIV-negative individuals. HPV vaccination remains a priority in regions with a high burden of cervical cancer and high HIV prevalence. With HPV vaccines becoming more accessible, optimal use beyond the initial World Health Organization-recommended target population of 9 to 14-year-old girls is an important question. In March 2022, a group of experts in epidemiology, immunology, and vaccinology convened to discuss the state-of-the-science of HPV vaccination in WWH. This report summarizes the proceedings: review of HIV epidemiology and its intersection with cervical cancer burden, immunology, HPV vaccination including reduced-dose schedules and experience with other vaccines in people with HIV (PWH), HPV vaccination strategies and knowledge gaps, and outstanding research questions. Studies of HPV vaccine effectiveness among WWH, including duration of protection, are limited. Until data from ongoing research is available, the current recommendation for WWH remains for a multi-dose HPV vaccination regimen. A focus of the discussion included the potential impact of HIV acquisition following HPV vaccination. With no data currently existing for HPV vaccines and limited information from non-HPV vaccines, this question requires further research. Implementation research on optimal HPV vaccine delivery approaches for WWH and other priority populations is also urgently needed. Cervical cancer is the fourth most common cancer among women globally, with 604,127 new cases and 341,831 deaths in 2020 . CervicaHPV infections are very common and in particular among people with compromised immune systems  (PWH), organ transplants, or autoimmune diseases). Sub-Saharan Africa (SSA) carries the highest burden of HIV and cervical cancer as compared to the rest of the world . CurrentDespite HPV vaccines having been available for > 15 years, less than a third of the global population of girls live in countries with HPV vaccination programs, leading to a global coverage of 13% in girls below 15 years being fully vaccinated . In AuguIn March 2022, a scientific workshop convened experts in epidemiology, immunology, and vaccinology to discuss the state-of-the-science of HPV vaccination in women with HIV (WWH). Two questions were posed to the experts: what is the performance of HPV vaccination among people who have HIV infection at the time of vaccination, and does HIV acquisition after HPV vaccination of young girls negatively impact vaccine-mediated protection? The experts also discussed the number of HPV vaccine doses required in these two scenarios.This manuscript summarizes the meeting proceedings, including the intersection between HIV and HPV epidemiology, the potential impact of HIV infection on vaccine immunology, experience with HPV vaccines and other vaccines in PWH, and HPV vaccination strategies in the context of high HIV prevalence. The panel also discussed key knowledge gaps and outstanding research questions.2WWH have six times the risk of developing cervical cancer compared to women without HIV infection . In SSA,HIV incidence increases between ages 15 and 19 in most SSA populations, reflecting mean ages of sexual debut . HPV inc+ cell counts and can be partly reduced by timely access to ART  was low (1.2/100 person-years) and appeared higher than published data for an HIV-negative vaccinated cohort (0.1/100 person-years). However, the rate of persistent infections in WWH was lower in vaccinated than unvaccinated historical controls . EvidencThese data highlight the importance of vaccinating PWH as early as possible to minimize the likelihood of prior HPV exposure, ideally before initiation of sexual activity. Appendix A presents a summary of results of completed trials of HPV vaccination among PWH.3.3+, current CD4+ counts, and possibly HIV viral load. Further, rapid control of HIV infection by early and consistent ART improved preservation of immune function  or hepatitis A (HAV) vaccination programs, in place for decades in high-income settings, could be useful models to investigate how vaccine-induced immunity during childhood or adolescence is affected by HIV infection later in life. However, few data are available on this matter in comparison to what has been generated among those vaccinated after HIV infection. Investigating new clinical hepatitis cases in PWH vaccinated against HBV or HAV during childhood or adolescence compared to a healthy control group is hampered by many confounders, such as shared modes of transmission and increased severity of liver disease in case of HIV co-infection . One stu3.4.2+ T cell nadir < 200/μL that improved to > 350/μL after ART (+ T cell memory was identified among WWH (p = 0.04), whereas antiviral CD8+ T cell memory remained intact (p > 0.99).To understand the impact on protection induced by childhood vaccination by subsequent HIV acquisition, a study was performed among 50 pairs of WWH and HIV-negative women who received smallpox vaccine during childhood. All were born prior to 1971 and were vaccinia virus-seropositive at baseline. Memory T cells and antibody responses were evaluated after subsequent HIV infection, with CD4fter ART . To dete+ nadir < 200/μL that reconstitute to > 350/μL by ART will lose antigen-specific CD4+ T cell memory from prior childhood vaccination, and one-fifth will develop an uncharacteristically rapid loss of vaccine-induced antibodies.Longitudinal analyses of vaccinia virus-specific antibody responses were used to measure serological memory over the course of 10 to 21 years. Similar to prior longitudinal studies , vacciniIn summary, lessons from vaccination with non-HPV vaccines prior to HIV infection provide limited information for HPV vaccination. Some PWH might lose detectable antibodies over time in the absence of boosting, suggesting that HIV infection could impact long-lived plasma cells. Caution is warranted when extrapolating immunogenicity data to specific risk groups. Although immunological markers are useful as surrogates or correlates of protection against disease, they are not absolute, since those could be proxy for other unestablished vaccine-induced immune responses that may be mediators or contribute to protection. This is illustrated by two randomized trials assessing an inactivated influenza vaccine in PWH with demonstration of high vaccine efficacy despite attenuated vaccine-induced immune responses . Thus, i4HPV vaccination is a priority in regions with high prevalence of HIV and cervical cancer, with approximately 6% of all new cervical cancer cases diagnosed globally in 2018  in WWH . Yet the4.1To inform programmatic decisions, modeling studies can be used to estimate the impact of vaccination strategies. Using Kenya, a setting of moderate HIV prevalence, as a case study , a modelEven though vaccinating a population likely to have been exposed to HPV might decrease the impact of vaccination, the number of HPV-dysplastic lesions prevented in countries with catch-up vaccination and high coverage, are doubled compared to countries without catch-up vaccination. This is attributed to both direct and indirect herd effects of vaccination . Formal 4.2HPV vaccination programs targeting adolescent girls in high HIV prevalence settings will include, by default, those who will go on to acquire HIV infection as well as those already infected perinatally but undiagnosed. In high HIV prevalence populations, HIV incidence increases rapidly between 15 and 20 years of age ; thus, vThose at risk for HIV and HPV can be reached through school-based vaccination programs, campaign-based vaccination and integration with other routine services like family planning, maternal child health clinics, and vaccination clinics. These service delivery points provide an avenue where there is a ready audience of adolescent girls and young women at risk for HIV and/or HPV infection.As per WHO recommendations, PWH 9 years of age and older should ideally receive three HPV vaccine doses until further evidence is available for reduced schedules in that population. Considering a 20% HPV vaccination coverage in SSA for a full vaccine schedule , HIV inf5Outstanding research questions exist in the fields of epidemiology, immunology, and vaccinology in PWH, as well as the intersection of HPV vaccination implementation and HIV infection. Notably, the key question posed to the experts—will immunocompetent girls at time of HPV vaccination who acquire HIV thereafter have similar HPV vaccine protection as those who are HIV-negative—remains unanswered. Although a direct clinical investigation of this question would be large and challenging to conduct, several ongoing field studies may have the framework to monitor cohorts of immunocompetent girls at high risk for HIV acquisition. Examples of such studies include a study of unvaccinated girls with and without HIV in Botswana  who willBeyond studying individual-level protection, vaccine impact studies that nest cross-sectional HPV prevalence surveys in PWH and immunocompetent individuals may address relevant questions. Notably, the HOPE trial in South Africa  has the Although we are ultimately interested in protection against HPV infection, immunologic studies could be instructive to understand if the HPV-vaccine-induced antibodies produced prior to HIV acquisition are quantitatively and qualitatively similar after HIV infection. For this work, laboratory studies should investigate antibody binding, neutralization, and other functionalities. Inferences can be made based on HPV vaccination among WWH by comparing antibody profiles to an appropriately matched cohort of immunocompetent women. If minimal differences are observed, this strengthens the hypothesis that HPV-vaccine-induced antibodies will remain sufficiently robust even after HIV acquisition. Confirming that circulating antibodies reflect antibodies at local and mucosal anatomic sites in WWH, assessing the role of the vaginal microbiome, and addressing how disruption of the epithelium by HIV impacts susceptibility to infection and the antibody-mediated protection of HPV vaccines, are important questions largely unexplored.Among WWH, there is a robust pipeline of studies initiated in recent years that attempts to address open questions on dosing as well as vaccine effectiveness in different settings. Although the recently updated WHO guidance for HPV dosing among WWH is to receive at least 2 doses, with 3 doses being preferred, several ongoing and new HPV vaccine trials using immunologic and virologic endpoints will generate evidence in WWH on reduced-dose HPV schedules within the next 5 years. Studies in WWH comparing antibody responses of 2 versus 3 doses are ongoing in Africa , Latin America , and Europe (Belgium). There is also an HPV vaccine effectiveness study among WWH comparing 1 to 3 doses of the bivalent, quadrivalent, or nonavalent HPV vaccines in SAA .Anne E. Schuind: Conceptualization, Writing – original draft, Writing – review & editing. Helen Rees: Writing – review & editing. John Schiller: Writing – review & editing. Nelly Mugo: Writing – original draft, Writing – review & editing. Peter Dull: Conceptualization, Writing – review & editing. Ruanne Barnabas: Writing – review & editing. Gary M. Clifford: Writing – original draft, Writing – review & editing. Gui Liu: Writing – original draft, Writing – review & editing. Shabir A. Madhi: Writing – original draft, Writing – review & editing. Rebecca B. Morse: Writing – original draft, Writing – review & editing. Anna-Barbara Moscicki: Writing – review & editing. Joel M. Palefsky: Writing – original draft, Writing – review & editing. Stanley Plotkin: Writing – review & editing. Mónica S. Sierra: Writing – original draft, Writing – review & editing. Mark K. Slifka: Writing – original draft, Writing – review & editing. Alex Vorsters: Writing – original draft, Writing – review & editing. Aimée R. Kreimer: Conceptualization, Writing – original draft, Writing – review & editing. Arnaud M. Didierlaurent: Writing – original draft, Writing – review & editing.The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: AMD reports participation in advisory boards for Sanofi, Bioaster, Speranza and ACM Biolabs, and research grants from GlaxoSmithKline, Moderna, and Roche, outside the submitted work. ABM reports personal fees from Merck & Co. global advisory board honorarium, outside the submitted work. GL is an employee of Merck & Co. NM is a recipient of an Investigator Initiated Grant evaluating ‘Immunogenicity of HPV vaccine among HIV infected adolescents’, outside the submitted work. JMP reports grants and personal fees from Merck & Co., from Vir Biotechnologies, from Antiva Biosciences, from Roche Diagnostics, and other from Virion Therapeutics, outside the submitted work. JS reports participation to DSMB for NCT04508309 and the India/IARC Gardasil trial. SAM reports grants from Bill & Melinda Gates Foundation, Pfizer, GlaxoSmithKline, Minervax and Sanofi, outside the submitted work. SP reports personal fees from Merck & Co. global advisory board honorarium, and personal fees from Sanofi, Inovio, Merck & Co., Janssen, Moderna, Valneva, Codagenix, Pfizer, VaxArt, Meissa, Vaxinnity, Rational, and AstraZeneca, outside the submitted work. RB reports grants from National Institutes of Health and Bill & Melinda Gates Foundation and non-financial support from Regeneron Pharmaceutical, outside the submitted work. All other authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Human papillomavirus (HPV) infects nearly 85% of sexually active Americans during their lifetime, causing most cervical and five other cancers. Routine HPV vaccination is recommended for adolescents to prevent HPV-attributable cancers, but HPV vaccination coverage remains low, especially in Tennessee. In 2021, 54.6% of the population in Shelby County, Tennessee was Black or African American, reporting higher rates of new cervical cancer cases than other counties in Tennessee. While medical and public health professionals (HPs) play a critical role in promoting vaccination coverage, little is known about the factors HPs perceive to influence HPV vaccination for this population. This study sought to explore HPs’ perceived facilitators and barriers of HPV vaccination among African American adolescents. Qualitative individual interviews with 26 HPs in Shelby County were conducted between October 2019 and February 2020. Interpretive content analysis of the interview data guided by the socio-ecological model revealed several important themes regarding the facilitators and barriers across the individual, interpersonal, and community levels. At the individual level, parental vaccine hesitancy emerged as a leading barrier to HPV vaccination, while appropriate education facilitated the vaccination. At the interpersonal level, a lack of strong provider recommendations impeded HPV vaccination, whereas improved communication skills with patients facilitated the vaccination. Finally, the community-level barriers included a lack of education and social/religious norms; the community-level facilitators included community outreach efforts. HPs should consider development of comprehensive community-based approaches that leverage the facilitators and barriers at multiple levels to increase HPV vaccination among African American adolescents in this region.The online version contains supplementary material available at 10.1186/s12913-023-09415-6. Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States (U.S.) . HPV infTo prevent HPV-attributable cancers, the Advisory Committee on Immunization Practices (ACIP) recommends routine HPV vaccination on the following schedule: two doses (6–12 months apart) for adolescents aged 11–12 years, starting at age 9, and three doses (given over 6 months) for individuals who receive their first dose at age 15 through 26 years  a bus an hour across city to see the doctor.” Another respondent recommended making HPV vaccines accessible at community pharmacy stores. One respondent noted that providing free HPV vaccines could help increase vaccine coverage, saying, “Because they receive these vaccines free from the federal government for children who would otherwise not receive vaccines because their parents can’t afford the vaccines. Or they’re uninsured.”Community outreach efforts. Several respondents stated that community-wide outreach efforts could increase HPV vaccination among African American adolescents. For example, a respondent commented that various community-based approaches to educating residents on HPV vaccination could facilitate the vaccination in the African American community. The respondent said, “Take a section of the city and go out and hand out. Door to door or maybe have a community event and have a table set up just where you would have somebody knowledgeable. And develop some kind of a flyer or something.” Additionally, multiple respondents indicated a need for targeted social marketing and campaigns for HPV vaccination. For example, one respondent said, “I guess the main strategy is, you know, these kind of big community-wide efforts, whether that’s through, you know, mass media, social media, community-based interventions, and then also healthcare-based intervention, right.” Also, respondents commented that a mobile immunization clinic or commercial-based community program could improve HPV vaccination rates in the community.Introduction of a vaccine requirement policy. Multiple respondents mentioned that HPV vaccination for African American adolescents could improve with the implementation of policy to require HPV vaccination for school attendance. A respondent said, “Schools have to have buy-ins. Governments have to have buy-ins and local governments have to have buy-ins because some parents aren’t going to like that.” Another respondent said, “Some states have gone to requiring it for school entry. I don’t think … that’s likely to happen anytime soon in Tennessee, but that is a nationwide that’s an avenue that some states have taken.”As shown in Table Respondents reported individual-level barriers including vaccine hesitancy, medical mistrust, vaccine safety concerns, misinformation, no perceived need, and a lack of awareness. In sub-analyses, vaccine hesitancy emerged as a leading barrier at the individual level, while medical mistrust was connected to vaccine safety concerns, and misinformation was connected to no perceived need and a lack of awareness, respectively.Vaccine hesitancy. Respondents indicated that some African American parents’ hesitancy for HPV vaccines was a primary barrier to adolescent HPV vaccination. One respondent stated that when HPV vaccines were recommended for children, African American parents often expressed a need for time, saying, “I need to talk to my husband/wife” or “I need to do some research.” The respondent also added that these requests usually led to “just a delay” of vaccination for their children. Another respondent expressed feeling frustrated, stating, “Sometimes, I just feel like I failed because it’s just so hard to get across to that population.”Medical mistrust. Several respondents stated that medical mistrust prevented African American parents from vaccinating their children against HPV. Specifically, the analysis showed that medical mistrust interrupted the influence of provider recommendations on vaccine-related decision-making among African American parents. One respondent said, “Some patients feel that … whatever we recommend is going to hurt them.” Also, the analysis revealed that this medical mistrust stemmed from a belief that African Americans could be used as test subjects in unknown medical experiments without their consent and/or without being fully informed. An African American respondent said, “A lot of Blacks feel that … you’re their guinea pig, you’re that white mouse, that white rat being tested. So, they’re shooting something in you, being a black person to see the reaction.”Concerns about safety. Multiple respondents noted that African American parents were concerned about the safety of HPV vaccines which was linked to parents’ anxiety and/or fear pertaining to the administration of the vaccine to their children. For example, one respondent said, “I know … concerns that it’s [the vaccine’s] not safe.” An African American respondent also said, “To be honest, we as Black people … we are afraid of shots.” The respondent indicated parent’s concerns, saying “So I can say again, ‘fear of the unknown.’ … [Parents think] they [doctors]’re putting this infection, these viruses into our children. That’s how they’re so sick.”Misinformation. Respondents viewed misinformation about HPV vaccines as a potential barrier to HPV vaccination for African American adolescents. This misinformation included vaccine-related side effects among adolescents, including autism and cancer. One respondent said, “… over the years of interacting with our patient population, we’ve seen increasingly more individuals who have sort of being indoctrinated with misinformation about safety issues associated with HPV.” Some respondents reported, “Children became autistic after they got the vaccine and I’ve seen a lot of Facebook post about that,” “We’ll have folks who come and say, well, this [HPV vaccine] caused …this cancer in them or other things,” and “Patients that have looked up information online for themselves, and then for that reason they did not get the HPV vaccination.” Also, respondents indicated that misinformation spreads quickly from person-to-person through social media platforms, including Facebook. One respondent said, “People just pass it on and negativity travels really fast.” Another respondent added, “They may have misinformation they might have got from the Internet or talking to neighbors.” Multiple respondents commented that many of their patients, including African Americans had obtained misinformation about the HPV vaccine from online sources which had a greater influence on their vaccine-related decision-making than did the information provided by their healthcare providers. For example, one respondent said, “The Internet has played a role in hesitancy with the HPV [vaccine].” Another respondent added, “So they are kind of believing more of what’s online than what they’re being taught from their physicians.”No perceived need. Several respondents noted that many African American parents perceived no need for HPV vaccination for their children because they believed that their child was not sexually active yet. A respondent stated that African American parents often linked HPV to sexual activity, saying “They had the impression that it really was not applicable to their child because their child was not sexually active.” Another respondent said, “My child has not, [is] not going to have sex until marriage and they’re not going to marry anyone who’s ever had sex before. So, we don’t have to worry about that.”A lack of awareness. Respondents indicated that a lack of awareness of HPV vaccination among African American parents was a barrier to the vaccination for their children. For example, a respondent said, “I mean, because a lot of people at first had not even heard of HPV. They were like, is that HIV? … What is that?” Another respondent said, “Immunizations [are] just not really on their radar.”The interpersonal-level barriers respondents reported included a lack of provider recommendations and a lack of recommendation strength.A lack of provider recommendations. A lack of provider recommendations emerged as one of the interpersonal-level barriers. For example, a respondent said, “We noted that parents were not being prompted by their local providers to get HPV immunization.” Another respondent captured their experience with patients, saying, “Did your pediatrician mention it to you? No. Has your OBGYN [Obstetrics and Gynecology] from somewhere else mentioned it to you? No. Your family practitioner? No. That’s most of the patients’ answers.” A respondent attributed the lack of recommendations to providers’ perceptions toward HPV vaccination, saying “I think it [HPV vaccination] at times isn’t a priority for providers.”A lack of recommendation strength. Respondents commented that provider recommendations lacked appropriate strength, which might hinder HPV vaccination among African American adolescents. For example, a respondent said, “When we offer the [HPV] vaccine, it’s offered as a choice.” Another respondent said, “It [HPV vaccine] is not really being promoted by their primary care providers as something that’s necessary.” Additionally, a respondent said, “They [Healthcare providers] don’t routinely promote HPV vaccines. And even when they come in for that 11-to-12-year visit, when they’re getting meningococcal and TDaP, it’s like, ‘OK, you have to have these.’ And they either say, ‘You don’t have to have the HPV [vaccine],’ or they say, ‘Do you want the HPV [vaccine]?’”.Respondents reported community-level barriers including a lack of vaccine-related public education, social and religious norms, no policy requirement in schools, and issues in the healthcare system.A lack of public education. Respondents identified a lack of education about HPV and the vaccine in the African American community as a barrier to adolescent HPV vaccination for African American parents. One respondent said, “The public didn’t really know a lot about it [HPV].” Another respondent said, “Well, the number one thing for me is education.”Social and religious norms. Respondents stated that social and religious norms interfered with receiving HPV vaccination in the African American community. A respondent stated that African American parents were worried about the possible stigmatization associated with HPV and believed that giving their child the HPV vaccine was akin to giving them permission to have sex. Furthermore, multiple respondents indicated HPV was a taboo topic in their religious communities. For example, a respondent said, “I think a big barrier is that we don’t want to [talk about HPV] because for religious reasons.” Another respondent said, “People don’t talk about that stuff [HPV] because it’s a place that claims to be religious, so they don’t talk about it. So, their religious affiliation can put them at risk, for things like this, HPV.”No policy requirement in schools. Respondents identified the absence of policies requiring the HPV vaccination in schools as a barrier. Multiple respondents noted that many African American parents did not want to vaccinate their children against HPV if doing so was not compulsory. For example, a respondent said, “They’ll come with their school forms showing what’s required as far as the immunizations to get into their colleges and universities and they’ll say, ‘Oh, this one isn’t required. So, we don’t want that one.’ And that’s 9 times out of 10. That’s the HPV.” Additionally, a respondent stated that no requirement of HPV vaccination in schools might imply to parents that the HPV vaccination was not important because they believed that schools prioritize and/or mandate public health.Issues in the healthcare system. Respondents expressed several issues in the current healthcare system regarding HPV vaccination. A respondent reflected on the limitations healthcare providers faced when trying to track the vaccination history of children, mainly because the HPV vaccine was inaccurately included in the electronic medical record (EMR). The respondent stated, “There is a Tennessee registry where we—for at least the last five years, maybe three years—have been dumping all our information when we give vaccines. It doesn’t communicate yet with our EMR.” Furthermore, multiple respondents pointed to another barrier: insufficient time for communication with patients. For example, a respondent said, “The pediatricians, they’re so busy with the things that they gotta get done.” Another respondent stated, “And part of that, too, is time because of the way the schedules are set up in the offices. Your schedule is stacked and all you are allotted is fifteen minutes per patient.” Moreover, a respondent identified the cost of the HPV vaccination as a barrier. Finally, several respondents noted that a lack of transportation hindered many African American adolescents from accessing HPV vaccinations in the community. For example, a respondent said, “Some of the barriers, there are people can’t just they can’t get to the doctor’s office. They don’t have transportation.” Another respondent said, “Sometimes the parents are just, ‘I have seven kids, I don’t have time for that. I’m the only one provider providing I don’t have anyone take care of my little ones. I don’t have any transportation.’”.This research team explored medical and public health professionals’ perceptions toward HPV vaccination among African American adolescents in Shelby County, TN by applying the SEM as a conceptual framework. Several themes emerged regarding facilitators and barriers pertaining to HPV vaccination across the individual, interpersonal, and community levels. The findings were consistent with the existing literature. The findings also contribute to the addition of important knowledge in the current body of research on HPV vaccine practices in the African American community, especially in the Shelby County, TN, which has reported high rates of new cervical cancer cases and suboptimal rates of HPV vaccination. Additionally, the findings provide implications for comprehensive community-based practices and future research to increase HPV vaccination coverage in this region.At the individual level, the research team found that parental vaccine hesitancy was a leading barrier to HPV vaccination among African American adolescents. Prior studies also identify vaccine hesitancy as a top barrier to initiation and completion of the HPV vaccination series –31. AlsoAt the interpersonal level, the research team found that the lack of provider recommendations and strength of the recommendation prevented African American adolescents from receiving HPV vaccination, whereas both provision of the provider recommendations and improved communication skills with patients facilitated their HPV vaccination. Substantial research demonstrates that provider recommendations are one of the strongest predictors of the vaccination for adolescents –44. MultAt the community level, the research team found that the barriers to HPV vaccination included a lack of education in the community, social and religious norms, no requirement for school enrollment, and issues in the healthcare system, while the facilitators included enhanced accessibility in communities, community outreach programs, and introduction of a vaccine requirement policy. These findings illuminate several implications for community-based approaches to increase HPV vaccination in African American adolescents. First, HPV vaccination education should address social and religious norms including stigma toward HPV infection and relevant cancers and the taboo of discussing HPV-related topics as a way to normalize HPV vaccination for cancer prevention –53. CollMost of the findings in this study are supported by prior studies among African Americans. A qualitative study by Fields et al. demonstrated that an explicit vaccine recommendation from a healthcare provider functioned as a moderator of HPV vaccination among African American women . In addiThis study included some limitations that might influence the interpretations of the findings. Given the nature of qualitative research focused on a small number (26) of respondents from the target population , these findings cannot be generalized to all African American adolescents in the U.S., and instead, should be carefully interpreted within the context of the study participants and location. Comparison studies with a detailed description may enhance the transferability of the findings . Also, tThis study captured the perceptions of medical and public health professionals regarding HPV vaccination among African American adolescents in Shelby County, TN. Respondents provided insight into the facilitators and barriers to the vaccination of this population against HPV. The findings of this study offer a better understanding of what is needed to develop comprehensive, community-based approaches that leverage the facilitators and barriers at multiple levels to increase HPV vaccination among African American adolescents in this region.Below is the link to the electronic supplementary material.Supplementary Material 1


In addition to participating in the focus group, CHWs and HCPs completed a brief questionnaire. Focus groups were voice recorded and transcribed for qualitative analysis. Independent coders conducted content analysis to identify the salient themes of the focus groups. Several important findings emerged from this study highlighting the barriers to HPV knowledge, gaps in the self-perceived role of HPV cancer prevention, and opportunities to action. Financial, knowledge, patriarchy, behaviors, attitudes, and fears were identified as the perceived patient-related barriers to promoting HPV cancer prevention. Both CHWs and HCPs explained that their female patients are often discouraged by their husbands from seeking out sexual health-related healthcare. Finding suggest the need for community tailored education on HPV and “best practice” trainings for HPV prevention that is applicable to both CHWs and HCPs.The Human Papillomavirus (HPV) is the most common sexually transmitted infection and nearly every person who is sexually active will get HPV at some point in their lifetime without having the HPV vaccine. Healthcare Providers (HCPs) and Community Health Workers (CHWs) play an essential role in promoting the HPV vaccine and providing education about HPV in communities. Three focus groups with CHWs ( The Human Papillomavirus (HPV) is the most common sexually transmitted infection with as many as 43 million infections in 2018 . ScreeniThe U.S.-Mexico border region, where HPV prevalence for any subtype has been found to be 53.2%, is reported to have the highest cervical cancer rates in the United States, with 8.4 cases of cervical cancer for 100,000 females . El Pas. AdolescTo further understand the barriers to HPV education delivery and HPV vaccine uptake in , it is important to understand that sexual health education plays a key role in both. Sexual health education in Texas is focused on abstinence-only education. Health literacy is essential in lowering STI rates, including HPV . The El. The curCHWs, also known as promotors/as de salud, play an essential role in educating the community, promoting healthy behaviors, and providing resources. These individuals have been referenced as paraprofessionals who have a deep understanding of the community they are serving and whose primary goal is to provide healthcare resources and education to said community . CHWs arCHWs act as vital links to the health care system by providing referrals, transportation, food assistance, social support, and removing situational barriers, among other services. Texas is one of 16 states in the U.S. where CHWs are required to follow a state-wide training requirement through state government programs, colleges, or training centers that emphasize health education and community outreach . ProgramOther barriers traditionally overcomed by CHWs are language differences between providers of services and clients. The U.S. Census has a poverty threshold of $31,661, and , has a poverty rate of 18.8%, with a per capita income average of $21,683 . Texas aHealthcare providers (HCPs)  are other key figures in health care education who receive a different education and training than CHWs. Curricula vary as they are based on the degree being obtained. HPV education and training is inconsistent with knowledge gaps across the various healthcare professions as it is not often a focus in the various curricula . Both CHHPV vaccinations have been received with low enthusiasm and acceptance by different communities. The latest vaccination rates from 2020 report that only 54% of adolescents have received two or three doses at the recommended time  . HispaniThe , a border town with an 80% Hispanic population, is a prime location for exploring the barriers to HPV vaccination uptake. HPV-data and research are prominent in the health care field yet the frequency with which they reach the community may not be sufficiently efficient to improve knowledge gaps or change attitudes and perceptions . Gaps inThe current study is part of a 5-year behavioral research project that will assess HPV-related knowledge, attitudes, and practices in a Hispanic community, identify barriers and facilitators of vaccine uptake, and develop and utilize interventions to improve vaccination, screening, and health literacy. The project follows three aims: (1) Identify predictors of HPV vaccine acceptability, knowledge, and screenings (VAKs) among Hispanic adults, (2) assess the practices and behaviors of emerging and current healthcare providers, followed by an intervention to improve provider recommendation and patient communication strategies, and (3) develop, implement, and deploy a culturally-tailored, bilingual, intervention to increase HPV vaccine uptake, screenings, and critical health literacy across a broad age range (26–45).This focus group falls under aim 3 and is one of three focus groups  that will be used to inform the intervention . These tThe study was cross-sectional and qualitative in nature. Data was collected through three online focus groups of CHWs and HCPs. Focus groups are considered effective research methods, and, in their online modality, online focus groups remain effective and provide a convenient flexibility . During CHWs and HCPs were recruited to participate by local partner agencies in , the project manager, and CHWs working with the research team through flyers and word of mouth. These local agencies included federally qualified health center, community-based organizations, local department of public health, the Mexican consulate, local cancer care centers, and the primary institution. These agencies are committed to understanding the health needs of the community and to increasing health access, and they supported the aims of the research project. Willing participants were invited to take part in a brief survey followed by a focus group through the online service Zoom (2020). The initial survey asked participants to answer demographic questions and questions about their HPV knowledge, attitudes, and practices. Upon completion, participants were given the focus group information and invited to participate. During these Zoom sessions, participants were first introduced to the research team and to the navigation tools that would be used for the group discussions; ground agreements for the discussion were established; and a detailed explanation of the informed consent was given, after which participants submitted them electronically. Once consent forms were submitted, the recording of the session began with the participant’s permission, and facilitator began asking the focus group questions to facilitate discussion. Participants were asked about their knowledge about HPV, their knowledge about the HPV vaccine, their HPV health messaging, and recommendations to improve HPV vaccination uptake. Their participation was voluntary and anonymous and had an average duration of 1.5 h. Two researchers trained in Public Health and Social Work facilitated the groups using a structured open-ended question guide. Data were gathered between April and June 2020.n = 17). Both groups were combined in data analysis due to similarity in scope and group characteristics. The third focus group was with HCPs and was conducted in English. The third focus group occurred over the span of two different dates. On the first date, seven HCPs  (n = 7) were part of the focus group with the same online modality. Due to time constraint and interest for the participants to finish the entirety of the questions, a second date was added for the focus group. On the second date, only four (n = 4) of the original participants were able to come back and finish the study. After the focus groups the recordings were transcribed by trained transcribers from the research team, who protected the anonymity of the participants. Upon completion of the focus groups, participants were given $30 gift cards to compensate for their time and participation.The first two focus groups were conducted in Spanish and in total included 17 CHWs ,n = 17) and HCPs (n = 7) stated that they would recommend that patients receive it. Two HCPs reported:The roles CHWs and HCPs saw for themselves in HPV cancer prevention shared similarities, however, were distinct in some of their approaches see . Additio“If we make strong recommendations on the provider side, if the provider and the staff is knowledgeable, it’s up to date with the most current information, then we are making those really strong recommendations and not be so lackadaisical: ‘well there is a vaccine if you want it, if not…’ you know… because… they come to us, they come to us because we are the professionals. We were supposed to know this stuff.”“Having advanced practitioners or nurse practitioners go out to the community and educate patients and geared towards schools, maybe some sort of school age children, High Schools, elderly, adults, parents, let’s have something for the parents, education for the parents, go into the community.”CHWs displayed a range of awareness and knowledge about HPV, some evidencing strong knowledge of HPV-associated risks, such as cervical, uterine, and oral cancers, and others having only basic or very little knowledge of HPV stating “It is one of the most common STI’s. I do not really know too much about it besides that.”CHWs gained their knowledge of HPV in different ways, the majority learning of it through HPV-affected family, friends, or clients; some gaining awareness through school or work-related trainings or courses; and one learning about HPV through a gynecologist. During the initial pre-focus groups survey, when asked “Do you believe you are properly informed about HPV?” one CHW strongly agreed, five agreed, nine were not certain, and two did not agree.HCPs displayed clinical knowledge of HPV, stressing its association with cancer and genital warts. They reported a variety of ways of having learned about HPV, including experience in school and clients with HPV infections, pediatricians or pharmaceutical representatives, or self-education. “I first learned of HPV when the pharmaceutical company started coming around and talking about it, but further than that, I went ahead, and I educated myself with the content.” When asked, “Do you feel adequately informed about HPV?” during the initial pre-focus group survey, one HCP strongly agreed, three agreed, three were undecided.CHWs and the HCPs identified many similar perceived obstacles in their efforts to prevent HPV cancer in the Hispanic community of . These obstacles related to the community members’/patients’ financial situations, knowledge of HPV, influence of patriarchy, and attitudes. Additional patient-related barriers mentioned by HCPs were behavior and fear see .Non-patient-related obstacles mentioned by HCPs were high cost of HPV vaccines, vaccine accessibility, and inconsistency in practices and information provided by HCPs, which causes distrust in patients and results in patients not seeking out medical care, including HPV-related care. One HCP mentioned Providers giving unnecessary pap smears as an example of this last obstacle.“Primary care providers do not carry the vaccine, so now they have to out to either a pharmacy or try to seek it somewhere else which to me, if you don’t have it there, you don’t capture them when they are at the visit. How likely are they to follow up, or how soon are they likely to seek out this vaccine and get it done?”The current study provides unique insight into the barriers that CHWs and HCPs perceive are faced by Hispanic communities they serve. These include financial challenges, knowledge about HPV, and socio-cultural factors such as patriarchy . Several important findings emerged from this study which highlight the need for community-tailored interventions. For example, CHWs and HCPs both expressed financial concerns related to patients lacking health insurance and other resources to obtain services. These findings were expected given that , has a poverty rate of 18.8% , and recAnother important finding that emerged was that both CHWs and HCPs discussed knowledge barriers related to countering misinformation and misperceptions about HPV and the HPV vaccine. These findings are congruent with a review by Zimmet et al.  reportinCulture emerged as an important fact that contributes to sexual health-related healthcare. The cultural barriers of women’s sexual health not being openly discussed within Hispanic communities fosters feelings of shame and embarrassment. Furthermore, there is a notion of strong adherence to gender roles in the Hispanic community. Hispanic males are often associated with the term “machismo” which can be defined as an over masculine character that is often reported as “possessive of women” and women playing a submissive role in their relationship. Notably, our findings revealed that both CHWs and HCPs explained that their female patients are often discouraged by their husbands from seeking out sexual health-related healthcare, “The wives that could not go get the Pap smears because they were afraid of their spouse finding out.” This left women needing to keep Pap smear appointments in secret to avoid conflict with their partner.Similarly, Guerra-Rodríguez et al.  investigThis study explored small sample sizes, thus findings are not generalizable. Bias may have been introduced due to the use of self-selection of focus group members. Responses may have been impacted by the historical underpinnings of the study—it was being done during COVID-19 and via technology due to COVID-19—in that the pandemic milieu may have prevented respondents from being able to focus on the intent of certain questions, and the technology-mediated nature of the groups may have been distracting and intimidating for some. Although current literature supports the use of Zoom based focus groups. In addition, one focus group was not able to finish in one session, necessitating the reconvening of the group to finish, which resulted in the loss of three members of the group due to scheduling conflicts.The themes of this study highlight the barriers that CHWs and HCPs perceive are experienced by the community members they serve when these people are trying to access health and social services. The overarching finding points to a lack of knowledge and education surrounding HPV and preventative measures among Hispanic communities. This lack of knowledge is many times replaced by erroneous information and myths about HPV, both of which are exacerbated by stigma and cultural factors that further prevent individuals from adopting preventive practices. Another important barrier is the lack of access to health care. There is limited knowledge about the community resources available due to a lack of health insurance and finances. A high rate of uninsurance is another important obstacle that was identified. Lower rates of insurance come with medical outcomes such as being more likely to die from health-related problems, unwillingness to seek treatment regardless of the severity of symptoms, and increased emergency room services as an only option.Identifying missed opportunities can make the difference on quality of health care services. Utilizing routine health care visits to educate about HPV, sexual health, and the vaccine to parents, youth, and children can further close the gaps of HPV vaccine uptake. However, these opportunities are being missed due to self-reported lack of knowledge from CHWs and HCPs, as well as not being fully comfortable initiating these conversations. Education is important both for the health professionals and the community, and it must be culturally tailored to meet the needs of the communities.The perceived barriers show a need for tailored messaging and interventions for different populations. This study evidenced the need for both CHWs and HCPs to be more literate in HPV health. Although all CHWs and HCPs stated they would recommend HPV vaccination for increasing vaccine uptake, they will need to be thoroughly versed in HPV health, including an effective, community-tailored method for responding to misconceptions and myths about HPV and the vaccine. Without an increase in knowledge and available resources, CHWs and HCPs will miss opportunities to make strong recommendations for the HPV vaccine and narrow the gaps in vaccine uptake.Additionally, HCPs everywhere need to maintain up-to-date practices and messaging regarding sexual healthcare--including preventive care and treatment--to give the best care and to engender trust in their patients, who have experienced distrust and lack of confidence in HCPs due to inconsistent messaging and practices. The Health Care System needs to address the need to develop a complimentary approach to educating for CHWs and HCPs to strengthen their ability to challenge barriers like gender roles and improves their capacity to improve community HPV health literacy that respects and draws from strengths in their community and challenges misinformation that impedes health literacy.The health messaging and recommendations given By CHWs and HCPs Are important To consider while developing educational programs and interventions. These educational programs and interventions should Use different methods To target different Age groups, including But Not limited To social media, media outlets, and health fairs. Talking about HPV and sexual health In a Hispanic community needs To Be normalized To invite members of The community To take preventive practices and remove The myths that surround The virus. CHWs and HCPs need To continue To spread information and resources As well As encourage individuals To seek health care despite these interruptions. Closing The HPV vaccine uptake gaps will require The health care system To work together with The community.As part of the 5-year behavioral research project, this focus group will inform the intervention of a RCT that will be launched during Fall 2023 to attempt to vaccinate 400 Hispanic adults. Participants will go from being unvaccinated or having an incomplete vaccination series, to be fully vaccinated during a 9-month time period where they will be followed-up by the researchers to understand how their knowledge, attitudes, and practices change over the time of the study.With Hispanic adults being the audience, the RCT intervention will be culturally tailored. The perspectives of CHWs and HCPs will be essential in the development of these interventions, particularly as they are familiar with this population’s strengths and weaknesses.Research should continue to be done beyond this study and continue to enrich the knowledge we have on diverse communities and their specific needs. In order to create change in health prevention and services, the different barriers that are preventing access need to be understood from a close or direct perspective. CHWs and HCPs are at the forefront of advocating and educating the community about preventive health measures and consequences associated with HPV-related illnesses. To do a better job at closing gaps and creating positive change, health care provider education needs to become a priority across settings and disciplines.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving humans were approved by the University of Texas at El Paso Institutional Review Board. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.EM designed the study and obtained IRB approval, was instrumental in the development and revision of the manuscript. AJ analyzed the qualitative data and reported on the findings. AG helped with the qualitative data analysis and drafted the introduction and methods of the study. GF drafted the discussion and revised the manuscript. All authors read and approved the final manuscript.This work was supported by the National Institutes on Minority Health and Health Disparities (NIMHD) (grant no. U54MD007592), a component of the National Institutes of Health (NIH).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The 2021 Chinese Expert Consensus on the Clinical Application of the Human Papillomavirus (HPV) Vaccine recommended vaccination for women who previously received ablative or excisional treatment for high-grade squamous intraepithelial lesion (HSIL). This study evaluates the cost-effectiveness of HPV vaccination in women previously treated for cervical precancerous lesions.We used a Markov model to simulate the disease progression of both low- and high-risk HPV subtypes. We followed a cohort of 100,000 women aged 18-45 years who received treatment for cervical precancerous lesions for a lifetime (80 years). We used the Incremental Cost-Effectiveness Ratios (ICER) with a 5% discount rate to measure the cost-effectiveness of nine vaccination strategies, including a combination of HPV bivalent (HPV-2), quadrivalent (HPV-4) and nonavalent vaccine (HPV-9), each with three vaccination doses . We conducted one-way sensitivity analysis and probabilistic sensitivity analysis. We followed the CHEERS 2022 guidelines.Compared to the status quo, the nine vaccination strategies would result in $3.057-33.124 million incremental cost and 94-1,211 incremental quality-adjusted life-years (QALYs) in 100,000 women previously treated for cervical precancerous lesions. Three vaccination strategies were identified on the cost-effectiveness frontier. In particular, ICER for one-dose HPV-4 vaccination was US$10,025/QALY compared to the status quo (no vaccination); ICER for two-dose HPV-4 vaccination was US$17,641//QALY gained compared to one-dose HPV-4 vaccination; ICER for three-dose HPV-4 vaccination was US$27,785/QALY gained compared with two-dose HPV-4 vaccination. With a willingness-to-pay of three times gross domestic product per capita (US$37655), three-dose HPV-4 vaccination was the most cost-effective vaccination strategy compared with the lower-cost non-dominated strategy on the cost-effectiveness frontier. A probabilistic sensitivity analysis confirmed a 99.1% probability of being cost-effective. If the cost of the HPV-9 is reduced to 50% of the current price, three-dose HPV-9 vaccination would become the most cost-effective strategy.Three-dose HPV-4 vaccination is the most cost-effective vaccination strategy for women treated for precancerous cervical lesions in the Chinese setting. AccordiVaccination is the primary strategy to prevent HPV infection and hence consequent cervical cancer in women. Available HPV vaccines in China include bivalent (HPV-2), quadrivalent HPV-4), and nonavalent vaccines HPV-9). HPV-2 includes the domestically-produced products Cecolin and Vozevir and the imported product Cervarix. Previous studies have shown that there is little difference in safety and efficacy between domestic and imported HPV-2  and reflect the potential severity of cervical carcinogenesis . TreatmeStudies have been conducted to evaluate the cost-effectiveness of HPV vaccination in the Chinese population , 29–33, 22.1We constructed a Markov model using TreeAge Pro 2021 to simulate the transition from low-risk type HPV infection to genital warts and from high-risk type HPV infection to cervical cancer in 100,000 women aged 18-45 years after treatment for cervical precancerous lesions for a lifetime (life expectancy 80 years) Figure 1The model contained a total of 21 health states, including HPV negative, low-risk HPV positive, genital warts, high-risk HPV positive, CIN2, CIN3, hysterectomy, local cancer, regional cancer, distant cancer, death from cervical cancer, etc. HPV-positive individuals may clear the infection or progress to HPV-related lesions , genital warts may regress to HPV negative or low-risk HPV positive, CIN2 and CIN3 may regress to HPV negative, high-risk HPV positive or progress to local cervical cancer, A proportion of CIN3 patients who undergo hysterectomy will no longer be at risk of developing cervical cancer. We set an age-specific natural mortality rate for all health states and an additional rate of death from cervical cancer at each stage for patients with cervical cancer. A proportion of patients diagnosed with cervical cancer were treated and we considered survivors of cervical cancer treated for more than 20 years to be cured. The length of each cycle of the model was 1 year, and we made a half-cycle correction.2.2The WHO Strategic Advisory Group of Experts on Immunization (SAGE) concluded that single-dose schedules provide comparable efficacy to the two or three-dose regimens. We set up nine different vaccination strategies in the model, including one, two, and three doses of HPV-2, HPV-4, and HPV-9 vaccination. The status quo is no vaccination. In consideration of price and protection, the HPV-2 we have chosen is a domestic vaccine named Cecolin. A study of women aged 27-45 years in China showed that nearly 60% of this age group were willing to receive the HPV vaccine , so we a2.3We obtained the probability of annual transition from the published literature . We cond2.4We assumed a discount rate of 5% for the cost and quality-adjusted life-years (QALYs). We analyzed the results by comparing the incremental cost-effectiveness ratios (ICER). As China does not currently have a specific willingness-to-pay (WTP), we compared the ICER to 1 and 3 times GDP per capita to determine the cost-effectiveness of the program   in the participating women , and HPVIn conclusion, our study demonstrated that the three-dose HPV-4 vaccination was the most cost-effective vaccination strategy. However, a substantial reduction in the price of three-dose HPV-9 vaccination may enable it to become the most cost-effective vaccination strategy. Our study provides important evidence for the development of HPV vaccination guidelines and health policies in China.The original contributions presented in the study are included in the article/MZ designed the project, designed and constructed the model, ran the modeled analyses, interpreted, graphed, and tabulated the results, and was responsible for the write-up of the document. HanL, HuaL and MW contributed to technical and modeling advice throughout the project and critically revised the manuscript. ZZ and LZ supervised all aspects of the study, contributed to the design of the project, the design of the model, and the interpretation of the results, and critically revised the manuscript. All authors contributed to the article and approved the submitted version.


Human papillomavirus (HPV)-related diseases are highly prevalent in men worldwide, comprising external anogenital condyloma, anal intraepithelial neoplasia (AIN), penile intraepithelial neoplasia (PIN), and anogenital and oropharyngeal cancers. There is exceptionally low vaccine coverage in the male population. Only 4% of men were fully vaccinated, worldwide, as of 2019. The aim of this review is to assess the impact of HPV vaccination on male disease. Three databases  and Clinical Trials.gov were searched. We included thirteen studies, eight randomized controlled trials (RCTs), and five cohorts, comprising a total of 14,239 participants. Regarding anal disease, seven studies reported HPV vaccine efficacy ranging from 91.1% to 93.1% against AIN1, and ranging from 89.6% to 91.7% against AIN2|3 and anal cancer. Five studies showed an efficacy against genital condyloma of 89.9% in HPV-naïve males, varying between 66.7% and 67.2% in intention-to-treat populations. Studies reporting no efficacy have included older participants. These results support vaccination of young men previously infected, beyond HPV-naïve males. The evidence quality was moderate to low for most outcomes, namely genital diseases. RCTs are needed to assess the efficacy of HPV vaccination on male oropharyngeal cancer. Human papillomavirus (HPV) is the most common agent of sexually transmitted diseases . HPV-relAnogenital warts account for a high burden of HPV-related diseases, with an incidence rate among males of 103 to 168 per 100,000 per year , being mWe have been witnessing an alarming increase in the number of anal cancer cases, with an estimated rise of 2% per year . Anal caMen who have sex with men (MSM) are at high risk of HPV-related anal disease. People living with human immunodeficiency virus (HIV) infection (PLWH) have an estimated incidence rate of 35 per 100,000 person-years for anal cancer, and a recurrence rate of 50% for high-grade anal intraepithelial neoplasia (HGAIN) within a year . PLWH arPenile cancer is a rare entity. Globally, it has been estimated that there are 22,000 cases per year ; around At present, there are two HPV vaccines licensed in males. They are composed of virus-like particles and induce immunity against certain HPV types present in the vaccine. The quadrivalent HPV vaccine (4vHPV), first licensed in the EU in 2006, covers HPV-6,11,16,18 and the nine-valent HPV vaccine (9vHPV), licensed in the EU in 2015, which additionally protects against HPV-31,33,45,52,58 . In 2014versus placebo, in preventing HPV-related disease? This systematic review aimed to assess the available evidence on the impact of male HPV vaccination in preventing HPV-related diseases, which include anogenital warts, recurrent respiratory papillomatosis, anal intraepithelial neoplasia, penile intraepithelial neoplasia, anal and penile cancers, and HNC.The authors sought to answer the following research question: how effective is the male HPV vaccine, This systematic review followed the 2009 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) checklist . As eligThe control group had to be males who received placebo or were unvaccinated. For a representative sample of the male population worldwide, we did not exclude men based on sexual orientation and on health status such as HIV status, HPV infection status, or history of HPV-related disease. We excluded (1) studies that evaluated immunogenicity focused on clinical manifestations of disease; (2) studies about infection incidence rates and prevalence, considering that we would not be able to analyze the presence or absence of a relationship between HPV vaccines and HPV-related diseases; (3) studies reporting administration of the vaccine combined with biologically active adjuvants; (4) the use of intralesional HPV vaccine; (5) studies portraying the efficacy of the vaccine by herd protection given by female HPV vaccination; and (6) estimates using statistical models to avoid the influence of confounders on the measurement of the direct efficacy of the vaccination; (7) reviews; (8) systematic reviews; (9) non-randomized controlled trials; (10) cross-sectional studies; (11) case series and (12) case reports; and (13) animal studies .Our search was focused on high-level scientific evidence of the efficacy of HPV vaccination on clinical manifestations of male disease. We considered studies published from January 2010 to October 2022. No study was excluded based on language.ClinicalTrials.gov was searched systematically (last update 22 December 2022) for unpublished or ongoing trials. The queries used are presented in The searched electronic databases were MEDLINE (PubMed), Web of Science, and Scopus, and were last accessed on 29 October 2022, for all studies. Additionally, Screening and a full-text review of the searched studies were performed by two independent investigators (C.R. and C.L.) using the COVIDence platform , and conflicts were solved by reaching a consensus. Two independent reviewers (C.R. and Â.R.F.) used standardized Excel tables to allow the extraction of relevant study data. Conflicts that emerged during the extraction were solved by a third reviewer (C.L.). The variables considered important to data extraction included first author and publication year, study design, base study, study site, study period, duration of follow-up, characteristics at enrollment, intervention and comparator, number of participants, inclusion criteria, exclusion criteria, outcomes, results, limitations, sponsorships, and conflicts of interest.consensus. The RoB2 tool assesses five domains of bias in randomized controlled trials: (1) bias arising from the randomization process, (2) bias due to deviations from intended interventions, (3) bias due to missing outcome data, (4) bias in measurement of the outcome, and (5) bias in selection of the reported results. The overall risk-of-bias judgement was categorized either as low, some concerns, or high. The risk-of-bias assessment was carried out using the following recommended tools: Cochrane risk-of-bias tool for randomized trials (RoB2) , and theThe ROBINS-I tool comprises seven domains of bias in non-randomized controlled studies: confounding factors, selection of participants for the study, classification of interventions, deviations from intended intervention, missing data, measurement of outcomes, and selection of the reported results. The overall ROBINS-I judgement was categorized as low, moderate, serious, or critical. For both tools, the categorization of a domain in a level of risk-of-bias will classify the study at this severity score. To homogenize the nomenclatures of the diseases and simplify the reading, we will refer to high-grade anal intraepithelial neoplasia (HGAIN) and high squamous intraepithelial lesion (HSIL) as anal intraepithelial neoplasia (AIN) grade 2/3, and low squamous intraepithelial lesion (LSIL) as AIN grade 1. Similarly, we will refer to high-grade penile intraepithelial neoplasia (HGPIN) and high squamous intraepithelial lesion (HSIL) as penile intraepithelial neoplasia (PIN) grade 2/3, and low squamous intraepithelial lesion (LSIL) as PIN grade 1  Supplem. ClinicalTrials.gov, resulting in a total of 633 studies. After duplicates (n = 182) were eliminated, screening of the title and abstract (n = 451) was carried out to select the studies that answered the investigation question. After this screening, 57 studies were eligible for full-text review. From those, 43 studies were excluded according to the following exclusion criteria: assessment of immunogenicity and herd immunity (n = 24), wrong study design (n = 14), unsuitable interventions (n = 3), and finally, evaluation of efficacy only in girls and women (n = 2). Consequently, we finally included 13 studies in the study analysis  Ferris et al.  and GoldRegarding vaccine efficacy in the prevention of HPV-related anogenital diseases, the included studies found that the highest vaccine efficacy was observed for AIN 1|2|3 ,40,41,42PLWH and MSM have a greater risk of developing disease associated with HPV. HIV infection can reduce vaccine immunogenicity and effectiveness due to low immune response in these patients . MSM mayVaccinating women can protect heterosexual men, but this herd protection does not extend to MSM and bisexual men . Not conOur systematic review included studies that enrolled PLWH, although none of them reported on the difference in HPV vaccine efficacy between PLWH and HIV-negative people. The study by Bergman et al. and two systematic reviews by Zhan et al. found that HPV vaccination is effective and safe in PLWH ,55. HoweOur review supports previous findings, namely regarding higher HPV vaccine efficacy in boys before sexual debut . MoreoveOne of the strengths of this systematic review results from the number of participants analyzed, which reached 14,239 boys and men. Another strength is the fact that we were able to include a diverse study population  from several countries worldwide, meaning we could observe real-life scenarios and allowing the generalization of the findings. Our review was conducted based on internationally accepted methods, and the tools used for evaluation of the studies’ risk-of-bias are part of the recommended ones. Concerning the quality assessment using RoB2 and ROBINS-I tools, the two independent reviewers reached a substantial agreement ,60During the selection process, we came across to some publications assessing the impact of the vaccine on RRP and HNC, but they failed to meet the defined inclusion criteria. The limitations of our review mainly arise from the limitations of the included studies. Overall, the studies included males of a narrow range of age, mostly young males with somewhat limited sexual activity, thereby challenging the generalization of the results to other populations ,32,37,42HPV-related diseases in the male population represent an emerging problem, resulting in morbidity and mortality and associated with huge health costs due to recurrence and cancer risk. Finding a way to prevent them is a crucial public health strategy. Increasing vaccination coverage, regardless of sexual orientation or gender identity, and monitoring the impact of vaccination should become public health priorities.This systematic review supports the recommendation of early vaccination of boys before the onset of sexual activity. There is clear evidence of the HPV vaccine’s efficacy in men up to the age of 26 years old, with or without history of HPV-related disease. HPV vaccination protects against anal and genital warts and AIN1|2|3.It is worth considering the impact of the HPV vaccine on HPV-related penile cancer and PIN in future studies. Moreover, in the future, it will be important to carry out RCTs that include more MSM and PLWH, and to evaluate the efficacy of vaccination on genital disease. An unanswered question in this systematic review involves the vaccine’s efficacy against RRP and HNC; this is due to the lack of RCT studies addressing this topic.