A new study was published in JAMA Network. HPV, the human papilloma virus, causes cancer—as many as 44,000 cancers in the United States each year. An HPV vaccine is available and protects against nine virus types:

Types 6 and 11 cause 90% of all anogenital warts;

High-risk types 16 and 18 cause 64% of HPV-related cancers;

High-risk types 31, 33, 45, 52, and 58 cause another 10% of HPV-related cancers.

The HPV vaccine is a prophylactic vaccine. It works best when given before exposure to the virus. The HPV vaccination series is recommended for all boys and girls at age 11-12. It can be given as early as age 9. The number of doses needed depends on the age when starting the series:

First dose < age 15: two doses (0 and 6-12 months)

First dose ≥ age 15: three doses (0, 1-2, and 6 months)

Three doses are also needed for those with HIV or other immunocompromising conditions. Catch-up vaccination is recommended for all patients through age 26.

In October 2018, the US Food and Drug Administration extended the upper age indication for HPV vaccine from 26 up to 45. But not everyone in this older age group needs it. Who does? Those at risk for new HPV infection. ACIP’s new buzzword for this decision process is “shared clinical decision-making,” which is coded blue on the new adult schedule, meaning that you and your patient have to decide.

Here’s what to consider. The HPV vaccine doesn’t treat HPV-related disease. It doesn’t help clear HPV infection; it prevents it. Unfortunately, there’s no clinical antibody test and no antibody titer that can predict immunity. Many adults aged 27-45 have already been exposed to HPV early in life. Those in a long-term mutually monogamous relationship are not likely to get a new HPV infection. Those with multiple prior sex partners are more likely to have already been exposed to vaccine serotypes. For them, the vaccine will be less effective.

However, those with fewer prior sex partners, who are now at risk for exposure to a new HPV infection from a new sex partner, are most likely to benefit from HPV vaccination. With shared clinical decision-making, your patients need to understand the potential value of the vaccine for their circumstances. Then you and your patient have to decide.

Frequently Asked Questions

If you start the series with the 4-valent HPV vaccine, is it okay to complete the series with the 9-valent HPV vaccine?

Answer: Yes, and that’s your only choice. The 9-valent version is the only one now available in the United States.

If a patient has completed a 4-valent vaccine series, should they now get a booster with the 9-valent vaccine? Will insurance pay for it?

Answer: Here’s what ACIP says: “There is no ACIP recommendation for additional 9v HPV doses for persons who previously completed a series of 4v HPV or 2v HPV. ” That’s the official guidance. But remember, “no recommendation” doesn’t mean “not recommended.” Safety is not an issue. But most of the benefit of including the five extra HPV types is for females in preventing cervical cancer. There’s not much additional cancer protection for males. More details can be found in the guidance section on the ACIP website.

As for insurance coverage for another entire series, don’t count on it. ACIP’s 2020 schedule recommends, at most, three HPV doses, so it might be out of pocket if you decide to give more. I’m Dr Sandra Fryhofer.

Sandra Adamson Fryhofer, MD, MACP, FRCP, is a board-certified doctor of internal medicine in Atlanta and adjunct associate professor of medicine at Emory University School of Medicine. She is a liaison to the Advisory Committee on Immunization Practices (ACIP) and serves on ACIP Working Groups for several vaccines.