Vaccination against Human Papillomavirus (HPV) in Vulnerable Populations – Sexual Minorities

Abstract

The human papillomavirus (HPV) is one of the most frequent sexually transmitted infections worldwide, causing cancers including cervical cancer and diseases such as genital warts and oral papillomatosis, these diseases affect both men and women. HPV vaccination has been one of the main tools to decrease the burden of HPV disease. In many countries, national vaccination programs do not provide for their application to boys, men, as well as adults, although their efficacy and immunogenicity has been demonstrated. There are vulnerable populations such as the LGBTTTIQA population (Lesbian, Gay, Bisexual, Transgender, Transvestite, Intersex, Queer and Asexual) in which HPV immunization should be emphasized since they present greater risks of infection and, they face not only social stigmatization but also often that coming from medical services resulting in cases with more advanced cancers and little primary prevention. When talking about sexual and reproductive health, points of inequity that require their resolution must be analyzed, initiating this, from a bioethical analysis.

1. Introduction

The social content of sexual and reproductive rights is directed more towards the procreation aspect and society frequently ignores the rights towards a sexual, healthy, and pleasant life. Sexuality and reproduction are linked to the dignity of the person, so it is necessary to guarantee in all aspects (social, economic, legal, political strategy and universal health) the physical and mental integrity of the person, of equality gender and universal access to health services, this was raised 20 years ago when the commitment was created at the meeting in Cairo and Beijing [1].

The World Health Organization (WHO) defines the right to sexual health as a: “State of physical, mental, emotional and social well-being in relation to sexuality; it is not just the absence of disease, dysfunction, or weakness. Sexual health requires a respectful and positive approach towards sexuality and sexual relations, as well as towards the possibility of having pleasant and safe sexual relations, free from coercion, discrimination, and violence. Sexual rights must be respected, protected and satisfied in order to achieve and maintain sexual health for all people” [2].

The exercise of sexuality carries risks and one of them is the acquisition of pathogens that are transmitted sexually. There are more than 25 different organisms that can be acquired this way. The consequences of these infections are infertility, ectopic pregnancies, abortions, surgical medical emergencies, such as ruptured pelvic abscesses, cancer and often social discrimination, this aspect is often due to the historical forms in which sexually transmitted infections have been symbolized. In the West, sexually transmitted infections were “feminized” since they considered women as the source of venereal diseases and men as the acquiring, but not infectious, part, in addition, another characteristic was added, the perception that they are not women generally those who transmit them, but only the “promiscuous” and women were penalized for the risk they presented to health, excluding men [3]. At another time, in the 1970s, AIDS (Acquired Immune Deficiency Syndrome) was in the center of the developed world (United States) [3]. In the health measures taken for the prevention of AIDS, genders were underestimated, it was considered a “disease of men … homosexuals”, with results such as the loss of opportunities for protection and prevention of vulnerable populations such as infected women and children with a great impact of public health.

2. Vulnerability

Scientific development has caused several changes and transformations in social relations, giving rise to various ethical dilemmas showing socioeconomic disparities, which leads to a great challenge, the vulnerability of the human being, it is applied to the existential condition of the individual and population groups in certain circumstances of helplessness [4] which forces governments, medical services, and society to protect their individual and social integrity. In the Helsinki declaration, integrity appears as a part of the inviolability of the person [5].

Vulnerability refers to the possibility of being harmed, all human beings are vulnerable, fragile, and not only individually, but there will also be human groups that are more exposed and less capable of defending themselves against abuse and mistreatment such as orphans, women, children, migrants, pregnant women, immunosuppressed patients. Prisoners, disabled, people with gender diversity, LGBTTTIQA (Lesbian, Gay, Bisexual, Transgender, Transgender, Transvestite, Intersex, Queer and Asexual) [6] among the most susceptible to being harmed, therefore, it is necessary to speak of social vulnerability, where we cannot lose the context; cultural, customs, historical situation, social and economic condition, affected gender, ethnic population, where factors such as public policies, availability of services, accessibility of both physical and human resources, existing beliefs and prejudices intervene.

Despite non-discrimination policies and programs, LGBTTTIQA people suffer from discrimination and health disparities as well as lack of communication between patients and health providers with consequences that affect health care with health inequities.

The health risks of lesbian (women who have sex with women, WSW) and bisexual (women who have sex with women and WSWM men) differ from heterosexual women in terms of risks, health behaviors and how they experience health contact [7]. This group frequently faces sexually transmitted infections (STIs), including Human Papillomavirus (HPV) infections. Studies have shown that half of lesbian and bisexual women suffer from a genital HPV infection and one third of them have a high-risk HPV infection [8]. In addition, WSWs face a screening that has not been able to reach optimal levels and where the uptake of patients with genital neoplastic disease often reaches more advanced stages compared to the heterosexual population [9, 10].

Barker [11] mentions some risk factors that can increase the rate of cervical cancer in bisexual women and men such as; increased exposure to smoking, unprotected sex generally during adolescence and inconsistent condom use, and, as previously mentioned, poor attendance at cervical cancer screening and testing for other sexually transmitted infections. Another situation that Baker points out is the low influx of patients with sexual diversity to health services as they perceive discrimination from health personnel coupled with a history of marginalization they have faced due to their sexual preference [11].

When speaking of vulnerability, global bioethics intervenes in the analysis of the circumstances of risk of harm for an individual or population group and the search for new approaches that include different points of solution or avoid current and future bioethical problems, but it will always take care to promote the interests of patients by reinforcing their fundamental rights based on human dignity and human rights.

3. Health services in LGBTTTIQA

All people need medical service, for some groups such as those with sexual diversity, health care can be difficult to access due to inequities in health resources, discrimination, bullying, rejection, violence and stigma, as well as health personnel not trained in the management of people with sexual diversity [12].

One of the studies that show evidence on the perception of health personnel in the health care of lesbian patients in Israel noted; stigmatization is pointed out in the caregivers’ relationships and communication with lesbian women since they consider this group as one with which the nursing personnel do not identify themselves psychologically as members of the same gender. This negative bias has been related to rejection, disrespect, isolation, prejudice, and negatively affected relationships and communication with lesbian, gay, bisexual, and transgender women [13].

LGBTTTIQA people face rejection and stigma from health personnel, which can make it difficult to apply health measures for their comprehensive protection [10]. In this group, high rates of drug, tobacco and alcohol consumption are observed, which favor risky sexual behaviors, on the other hand, there is discrimination in job opportunities with a decrease in the possibility of access to insurance or institutional medical coverage, employment, housing, and economic stability.

4. Human papilloma virus infection

Human papillomavirus (HPV) infection is one of the most common sexually transmitted infections in the world, causing cancers in both men and women [14]. This infection affects at least five areas of the human body; in women; cervix, vulva, vagina, anus and head and neck, while in men anus, penis and head and neck [14, 15] and although genital warts [16] and respiratory papillomatosis are not a malignant pathologies, they are responsible for a great emotional, dysfunctional, sexual and economic impact.

4.1 HPV in lesbian women

In the study of the situational diagnosis of LGBTIQ people in Mexico, they obtained these results; 80% of lesbian women and 81% of bisexual women stated that they had not used any protection during sexual intercourse. 71% of them report having had sexual activity with men [15]. 53% of lesbian women and 35% of bisexual women surveyed in Mexico City reported having children.

In this other study [16] 830 women were identified like gay lesbian sexual activity between 20 and 59 years were analyzed, they found that 53% of women were infected with any type of human papillomavirus, 37% of them with a high-risk human papillomavirus, who by having five or more sexual partners in their lifetime were more likely to become infected with a high-risk type of human papillomavirus. When the group of lesbian women was compared with the heterosexual group, it was observed that in the former there was a lower rate of human papillomavirus infections. HPV infection was more frequent among younger women. The infection remained common among women of all ages.

It is necessary to guarantee sexual minority women, regardless of their age, receive prevention services against HPV and cervical cancer, as well as to inform about the risks of acquisition and pathology associated with HPV in this group. And constantly work with health personnel on the risks present in this group.

4.2 HPV in men

The incidence of anal cancers and others related to the human papilloma virus have increased in the general population, even more in those people who suffer from a human immunodeficiency, such as those affected by HIV.

Anal infection, and anal intraepithelial neoplasia are very common in HIV-negative men who have sex with men (MSM) and to a greater extent are HIV carriers, as well as genital warts.

The disease burden associated with human papillomavirus infection in men is not only the diseases that they can develop; (anal genital, oral cancer, respiratory papillomatosis, and genital warts), another situation is the possibility of infecting women through the sexual route. Lesions of the penis can often be observed in sexual partners of women suffering from cervical epithelial neoplasia. Other aspect that we must not forget is the role of men in cervical cancer, several studies have shown that the husbands of women with cervical cancer do not have a higher prevalence of human papillomavirus than the husbands of control women [17].

There are several studies that demonstrate the impact of the protection and prevention of diseases associated with the human papilloma virus in men with the quadrivalent vaccine [17]. In 86% reduction in persistent infections due to the viral types included in the vaccine in the external genital area has also been observed in boys and heterosexual men and men who have sex with men, in response to this and in response to the Food Drug Administration (FDA) and the Advisory Committee on Immunization Practices (ACIP) approved and recommended routine vaccination of the quadrivalent and nonvalent vaccine in children 9 to 26 years of age for the prevention of human papillomavirus infection [14].

An 86% reduction in persistent infections by the viral types that are included in the vaccine in the external genital area has been observed in boys and heterosexual men as well as those men who have sex with men, in response to the Food Drug Administration (FDA) and the Advisory Committee on Immunization Practices (ACIP) respectively approved and recommended routine vaccination of the quadrivalent and nonvalent vaccine in children 9 to 26 years of age for the prevention of human papillomavirus infection [14].

This scheme shows risk factors that favor the acquisition of HPV in men [13, 18, 19, 20] so it is necessary to reassess the impact on their health, and on those of their partners. (This scheme was carried out by Elsa Díaz MD)

MSM have a high risk of HPV infection. An example is anal cancer, with which an association of 44 times more was found in MSM compared to the general population [21, 22].

4.3 HPV vaccination

Currently there are safe and effective vaccines for the prevention of serious diseases such as cervical cancer, however these have proven their impact in the prevention of other malignant neoplasms such as vaginal, vulvar, anus, penis, head, and neck cancer [20, 21] the quadrivalent and nonvalent vaccines have also proven their effectiveness in preventing benign lesions such as genital warts.

In the multicenter study conducted by Dr. Silvia de San José, which evaluates the potential impact of vaccines against human papillomavirus in reducing diseases associated with the human papillomavirus, an estimate of a reduction of close to 90% in cervical cancer was concluded and a global reduction of 50% of all the cases HPV-related cancer sites [23].

Regarding vaccination in men, studies have been carried out that have proven the safety and efficacy of the quadrivalent vaccine in boys and men, its efficacy has been demonstrated in reducing the 86% in persistent infection in the external genital area in children and straight men and men who have sex with men. Likewise, the 90% efficacy of reducing the incidence of external genital lesions has also been proven [17].

We often have vulnerable patients exposed to HPV infection that can lead to serious complications or fatal outcomes when we have a primary prevention tool such as vaccination.

We have three prophylactic vaccines [19, 20] that prevent human papillomavirus infection; the bivalent vaccine containing virus-like particles of serotypes 16 and 18, quadrivalent; (6, 11, 16, 21) and the nonvalent (16, 18, 31, 33, 45, 52, 58, 6 y 11). Currently, serotypes 16 and 18 are identified as responsible for 70% of cancers attributable to HPV.

Vaccination against HPV has been carried out for 14 years with bivalent and quadrivalent vaccines. In 2009 the FDA approved the quadrivalent vaccine for boys and men ages 9-26 [14]. Later in 2014 the nonavalent vaccine was added, all have proven to be effective in the long term and show persistence of their immunogenicity [24].

The results observed have been short and long term; reduction of the disease burden associated with human papillomavirus, reduction of cervical disease and anogenital dysplasia in different clinical studies and with high effectiveness not only in the population of the initial protocols such as those carried out with the quadrivalent vaccine in the cities of Denmark, Iceland, Norway and Sweden in addition to the open population, where the great impact of the frank decrease in genital warts in addition to dysplasia and cervical cancer has been observed, as has been the case in Australia [25], United States, Canada to mention just a few countries.

One of the objectives in the elimination of cervical cancer proposed by the WHO [26] is to reach 90% of girls vaccinated against HPV, while only 7 countries have included gender-neutral vaccination, on the other hand, in national immunization programs not an age group older than 15 years is considered, which is the age where sexual life generally begins and their behavior is defined.

The efficacy and immunogenicity of HPV vaccination in men during adolescence and even after starting their sexual life has been demonstrated in several studies [21].

One of the fundamental goals of vaccination is to stop the transmission of an infectious agent such as HPV. Maintaining coverage only to women is an insufficient process if you want to eradicate the diseases associated with this virus, especially in those men who have a greater chance of acquiring it and with a greater risk of transforming it into cancer, especially if they have immunosuppression or sexual behavior higher risk such as MSM or bisexual activity [14, 21, 27].

When bioethical analyzes is carried out regarding vaccination and a utilitarian current is applied; the decisions are often made based on the search for the greatest good for the greatest number of people and only the social good is considered. Are individuals being forgotten as people as unique and individual beings? [24].

Vaccination against HPV in men protects them against the pathology associated with the human papillomavirus but at the same time has the potential to protect women through herd or herd immunity for the same reason that female vaccination can protect women. The men [14].

On the other hand, the economic budget that HPV vaccination coverage represents is another important factor in vaccination strategies in a population, especially in those with a low human development index. Let us give an example about vaccination and herd effect, in men who have only sex with men, could they have any immune benefit? if men are not included in vaccination programs. In the study carried out by Hammad Ali et al. In Australia [25], in which they refer to a significant decrease in the proportion of genital warts in young women five years after the application of the vaccine and an impact on the decline of lesions o genital warts in heterosexual men because of herd immunity, but not in bisexual men. Clinical practice is strongly linked to medical ethics, it is required to guide decisions based on principles such as non-maleficence, beneficence, autonomy, and justice. These principles are complementary, not opposed.

Public health starts from a social reality and faces bioethical challenges, which must be analyzed; focus on the problems that society presents and place health at the center of social justice [28], for this, an approach is required that analyzes differences, gender, ethnic and population group, life cycles and social determinants. Bioethics must play a fundamental role in guiding decisions in public health [29] through the articulation of social reality; Identify their needs and those vulnerable groups that may not benefit from making public health policies and stop actions aimed at deepening inequities and the search for social and individual protection.

5. Conclusions

When talking about sexual and reproductive health, it is necessary to point out the existence of inequities, the lack of prevention programs and specific timely detection towards the heterosexual male population and the LGTTTIQA population. There are clinics for patients with sexual diversity, but these are insufficient. The application of vaccination against human papillomavirus should not only be aimed at women, it must be extended to men since they play a fundamental role not only in the transmission of human papillomavirus infection but also in the development of diseases associated with this virus, especially in MSM, this vulnerable and high-risk population group.

Women with gay lesbian activity are a group susceptible to contracting human papillomavirus infection, which requires strategies such as information campaigns on HPV prevention in them and in health professionals, promoting non-stigmatizing communication in health services. Health about sexually transmitted diseases. Improve the screening according to the established guidelines, if these improvements are made, we can prevent them from reaching the heterosexual population with more advanced cervical cancer compared to the heterosexual population.

Bioethics is a field of reflection on ethical problems and dilemmas in medicine and life sciences as well as their relationship with the technologies applied to the human being and what surrounds him; which leads us to rationality, coherence, justice and the recognition of the dignity of each person and therefore to ensure the protection of the most vulnerable such as the poor, the sick, patients with immunosuppression, the disabled, children, women, the elderly, pregnant women and people with sexual diversity who, due to their risks, will require our attention and personalization and individualization in the attention to their sexual and reproductive health.

In the text of Boaventura de Souza [6] “The counter-hegemonic use of law” he mentioned that we are in a historical moment of great technological advances but with societies that show greater inequality and exclusion than ever, which leads to an intense task of reinvention from the scientific, social, politics where values revolve around people and society, and values such as; freedom, equality, autonomy, justice and solidarity do not have a different meaning for each individual.