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Human Papillomavirus Vaccination Among Young Adult Gay and Bisexual Men in the United States Paul L. Reiter, PhD, Annie-Laurie McRee, DrPH, Mira L. Katz, PhD, and Electra D. Paskett, PhD

Oncogenic human papillomavirus (HPV) types (mainly types 16 and 18) cause an estimated 93% of anal cancers, 63% of oropharyngeal cancers, and 36% of penile cancers among men in the United States.1 Nononcogenic HPV types 6 and 11 cause almost all anogenital warts.2 Gay and bisexual men have high rates of HPV infection and HPV-related disease. A recent review suggests that more than 50% of HIV-negative gay and bisexual men have an anogenital HPV infection.3 About 7% of gay and bisexual men report a history of genital warts.4 Anal cancer is also of great concern, with incidence among HIVnegative gay and bisexual men estimated to be 35 cases per 100 000 population.5 The anal cancer incidence rate among all men in the United States is just 1.6 cases per 100 000 population.6 US guidelines began including the quadrivalent HPV vaccine (against HPV types 6, 11, 16, and 18) for males in October 2009.7 The Advisory Committee on Immunization Practices (ACIP) first provided a permissive recommendation that allowed the HPV vaccine to be given to males aged 9 to 26 years but did not include the vaccine in their routine vaccination schedule.7 In October 2011, the ACIP began recommending routine vaccination for boys aged 11 to 12 years with catch-up vaccination for males aged 13 to 21 years.8 Importantly, the ACIP recommends HPV vaccination for men who have sex with men through age 26 years.8 The HPV vaccine series consists of 3 doses, with the second dose administered 1 to 2 months after the first dose, and the third dose is administered 6 months after the first dose.7 The quadrivalent HPV vaccine is currently approved to protect males against genital warts and anal cancer.9 Despite recommendations, recent data suggest that fewer than 21% of males in the United States have received any doses of the HPV vaccine.10---14

Objectives. We examined human papillomavirus (HPV) vaccination among gay and bisexual men, a population with high rates of HPV infection and HPVrelated disease. Methods. A national sample of gay and bisexual men aged 18 to 26 years (n = 428) completed online surveys in fall 2013. We identified correlates of HPV vaccination using multivariate logistic regression. Results. Overall, 13% of participants had received any doses of the HPV vaccine. About 83% who had received a health care provider recommendation for vaccination were vaccinated, compared with only 5% without a recommendation (P < .001). Vaccination was lower among participants who perceived greater barriers to getting vaccinated (odds ratio [OR] = 0.46; 95% confidence interval [CI] = 0.27, 0.78). Vaccination was higher among participants with higher levels of worry about getting HPV-related disease (OR = 1.54; 95% CI = 1.05, 2.27) or perceived positive social norms of HPV vaccination (OR = 1.57; 95% CI = 1.02, 2.43). Conclusions. HPV vaccine coverage is low among gay and bisexual men in the United States. Future efforts should focus on increasing provider recommendation for vaccination and should target other modifiable factors. (Am J Public Health. 2015;105:96–102. doi:10.2105/AJPH.2014.302095)

Although several HPV-related disparities exist among gay and bisexual men, little research has addressed HPV vaccination among this population. Past studies have shown that knowledge about HPV and the HPV vaccine tends to be modest among gay and bisexual men.15---19 Many gay and bisexual men have indicated their willingness to get the HPV vaccine, with estimates ranging from 36% to 86%.16,18---20 Data on actual HPV vaccine coverage are sparse; a past study found only 7% of 68 young adult gay and bisexual men had received any doses of the HPV vaccine.11 This study was, however, conducted before the ACIP recommendation for routine vaccination of males. We built on this past research by examining HPV vaccination among a national sample of young adult gay and bisexual men in the recommended age range for HPV vaccination (18---26 years). We identified correlates of vaccination and why young adult gay and bisexual men are not getting the HPV vaccine. These data will help inform future programs for increasing HPV vaccination among this high-risk population.

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METHODS We surveyed individuals through the Harris Interactive LGBT Panel who were aged 18 to 26 years, lived in the United States, and selfidentified as lesbian, gay, bisexual, or transgender (LGBT).21 This panel is a subset of the multimillion-member Harris Poll Online Panel, a voluntary research panel constructed using online and offline recruitment strategies.22 The Harris Poll Online Panel includes panel members throughout the entire United States and is similar to the US population on several demographic characteristics. Panel members complete multiple online surveys each month in exchange for points that can later be exchanged for rewards. Of 2014 panel members who were confirmed eligible for the study, 1005 (50%) provided consent and completed our crosssectional online survey in October and November 2013. We have included data on 428 young adult men who self-identified as gay or bisexual. These participants were from 47 states and the District of Columbia. We have

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not included data on lesbian and bisexual women (n = 543) or transgender individuals (n = 34) because it is likely that HPV vaccination and factors related to vaccination differ greatly between these groups.

Measures We developed survey items on the basis of our previous HPV vaccine survey research.23---26 Because knowledge about HPV and the HPV vaccine is modest among gay and bisexual men,15---19 we provided participants with informative statements about these topics throughout the survey. Statements described what HPV is and the diseases it can cause, what the HPV vaccine is and who it is available for, the number of doses in the vaccine series, and the potential health benefits of the vaccine. HPV vaccination. HPV vaccine initiation (i.e., receipt of at least 1 dose of the 3-dose series) was the primary outcome for this study. We believe initiation was an appropriate outcome to examine because HPV vaccination for males is still a relatively new health behavior.27 A single survey item asked participants if they had received any doses of the HPV vaccine. For participants who indicated vaccine initiation, subsequent items assessed how many HPV vaccine doses they had received and the main reason they were vaccinated (participants could indicate only 1 reason from a list of potential reasons). For participants who had initiated the vaccine series but not yet received all 3 doses, a survey question asked if they intended to get their remaining doses (yes, no, or don’t know). If participants indicated that they did not intend or did not know if they would receive their remaining doses, an item assessed the main reason they might not receive these doses (participants could indicate only 1 reason from a list of potential reasons). Among unvaccinated participants (i.e., those who had not yet received any doses), we assessed willingness to get the HPV vaccine under 2 conditions: (1) if it were free, and (2) if it cost $400 out of pocket. At the time of the survey, the HPV vaccine cost about $130 per dose (or about $400 for the 3-dose series) for those without health insurance that covered the vaccine.28 We used a 5-point scale for both willingness items, with responses of “definitely not willing,” “probably not willing,” “not sure,”

“probably willing,” and “definitely willing” (possible range = 1---5). We also asked unvaccinated participants the main reason they had not yet received the HPV vaccine (participants could indicate only 1 reason from a list of potential reasons). Correlates. We collected information on various demographic and health-related characteristics (Tables 1 and 2). We focused primarily on constructs associated with HPV vaccination or vaccine acceptability in our past work.23---26 To obtain data regarding sexual identity and determine study eligibility, we asked potential participants, “Of the following, which do you consider yourself to be?” Response options included “heterosexual (straight),” “lesbian,” “gay,” “bisexual,” “transgender,” “other,” “not sure,” and “decline to answer.” We classified participants as having no health insurance, having their own insurance (e.g., through work or school), or having insurance through their parents (which we believe is an important distinction to make for this age group). We asked participants if they had disclosed their sexual orientation to their health care provider and if they thought they had ever been discriminated against by a health care provider because of their sexual orientation.29 We also asked participants if they had ever received a health care provider recommendation to get the HPV vaccine. We assessed participants’ knowledge about HPV with 6 items and classified them as having either high knowledge (answered 4 or more knowledge items correctly) or low knowledge (answered 3 or fewer knowledge items correctly). Examples of the knowledge items included “Do you think you can get HPV from having sex?” and “Do you think HPV can cause anal cancer?” All informative statements about HPV and the HPV vaccine we have described were provided after the knowledge items. We examined participants’ worry about getting HPV-related disease (1 item; possible range = 1---4; response scale ranged from “not at all” to “a lot”), perceived likelihood of getting HPV-related disease (3 items; a = 0.89; possible range = 1---4; response scale ranged from “no chance” to “high chance”), and perceived severity of HPV-related disease (1 item; possible range = 1---4; response scale ranged from “not at all” to “very”). The perceived severity item asked participants how serious they

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thought it would be if they got a disease caused by HPV. Using items on the basis of the Carolina HPV Immunization Attitudes and Beliefs Scale,30,31 we assessed participants’ perceived effectiveness of the HPV vaccine (3 items; a = 0.89, possible range = 1---4; response scale ranged from “not at all” to “a lot”), perceived potential harms of the HPV vaccine (4 items; a = 0.69; possible range = 1---5; response scale ranged from “strongly disagree” to “strongly agree”), and perceived barriers (i.e., vaccine availability and affordability) to getting the HPV vaccine (2 items; a = 0.76; possible range = 1---5; response scale ranged from “strongly disagree” to “strongly agree”). We examined perceived positive social norms by asking participants if they thought other people in the LGBT community are getting the HPV vaccine (1 item; possible range = 1---5; response scale ranged from “strongly disagree” to “strongly agree”). We assessed participants’ anticipated regret if they received the HPV vaccine and fainted (1 item; possible range = 1---4; response scale ranged from “not at all” to “a lot”) and if they did not get vaccinated and later developed an HPV infection that could lead to health problems (1 item; possible range = 1---4; response scale ranged from “not at all” to “a lot”). We coded all continuous variables so that higher values indicated greater levels of that construct.

Data Analysis We used logistic regression models to first identify bivariate correlates of HPV vaccine initiation. We entered variables with P < .1 in bivariate analyses into a multivariate logistic regression model. We constructed 2 multivariate models: (1) 1 that included whether participants had ever received a health care provider recommendation to get the HPV vaccine, and (2) 1 that excluded provider recommendation. We constructed the latter model because HPV vaccination without a provider recommendation is uncommon among males,13,14 and provider recommendation might depend on health care access and use. This approach is consistent with previous HPV vaccination analyses.13,32 Among unvaccinated participants, we used paired t tests to compare willingness to get the HPV vaccine if the vaccine were free and if it

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TABLE 1—Categorical Correlates of HPV Vaccine Initiation Among Young Adult Gay and Bisexual Men (n = 428): United States, 2013 No. Initiated HPV Vaccine / Total No. in Category (%)

Characteristic

cost $400 out of pocket. We analyzed data using SPSS version 19.0 (IBM Corp, Armonk, NY), and all statistical tests were 2-tailed with a critical a of 0.05.

Bivariate OR (95% CI)

RESULTS Demographic characteristics Sexual identity Bisexual Gay

11/119 (9) 45/309 (15)

1.00 (Ref) 1.67 (0.83, 3.36)

18–21

19/126 (15)

1.00 (Ref)

22–26

37/302 (12)

0.79 (0.43, 1.43)

Age, y

Race/ethnicity Non-Hispanic White

33/273 (12)

0.64 (0.32, 1.26)

3/28 (11)

0.56 (0.15, 2.11)

6/48 (13) 14/79 (18)

0.66 (0.24, 1.86) 1.00 (Ref)

Non-Hispanic African American Non-Hispanic other Hispanic Marital status Other

47/357 (13)

Living with partner or married

9/71 (13)

1.00 (Ref) 0.96 (0.45, 2.05)

Education level Some college or less

26/228 (11)

1.00 (Ref)

College degree or more

30/200 (15)

1.37 (0.78, 2.41)

30/231 (13)

1.57 (0.52, 4.68)

Household income, $ < 50 000 ‡ 50 000

22/151 (15)

Not reported

4/46 (9)

1.79 (0.58, 5.49) 1.00 (Ref)

HPV Vaccination

HPV and HPV vaccine Knowledge about HPVa Low knowledge

15/215 (7)

High knowledge

41/213 (19)

1.00 (Ref) 3.18** (1.70, 5.94)

Received health care provider recommendation to get HPV vaccine No

17/381 (5)

Yes

39/47 (83)

1.00 (Ref) 104.38** (42.32, 257.48)

Health and health behaviors Health insurance None On parents’ insurance Insures self Had a routine medical check-up in the last year

3/86 (4)

1.00 (Ref)

28/181 (16)

5.06* (1.49, 17.16)

25/161 (16)

5.09* (1.49, 17.37)

No

21/245 (9)

Yes

35/183 (19)

1.00 (Ref) 2.52* (1.41, 4.50)

Disclosed sexual orientation to health care provider

Overall, 13% (56/428) of participants had initiated the HPV vaccine series. Main reasons for vaccination included because a doctor said to get vaccinated (46%), to protect against cancer (18%), to protect sexual partners (11%), and because a parent said to get vaccinated (11%). Among initiators, 54% (30/56) had received all 3 recommended doses. Only 4 participants who had initiated but not yet completed the series indicated that they might not receive their remaining doses. All 4 of these participants endorsed the response that they had waited too long since their last HPV vaccine dose as the main reason they might not receive their remaining doses.

Correlates of HPV Vaccine Initiation

No

24/265 (9)

Yes

32/163 (20)

2.45* (1.39, 4.34)

1.00 (Ref)

52/396 (13) 4/32 (13)

1.00 (Ref) 0.95 (0.32, 2.80)

Ever discriminated against by health care provider No Yes

Most participants were aged 22 to 26 years (71%), non-Hispanic White (64%), and not married or living with a partner (83%; Tables 1 and 2). About 72% of participants self-identified as gay and 47% had at least a college degree. Half of the participants were classified as having low knowledge about HPV, and only 11% had received a provider recommendation to get the HPV vaccine. Participants generally believed that getting an HPV-related disease would be severe (mean = 3.43; SD = 0.71), although they tended to report low levels of worry (mean = 1.81; SD = 0.87) and perceived likelihood of getting an HPV-related disease (mean = 2.10; SD = 0.64). Participants perceived the HPV vaccine to be moderately effective in protecting against HPV-related disease (mean = 2.81; SD = 0.85).

Continued

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Several variables were correlated with HPV vaccine initiation in bivariate analyses (Tables 1 and 2). The strongest correlate in bivariate analyses was receipt of a health care provider recommendation to get the HPV vaccine. About 83% of participants who had received a provider recommendation had initiated the HPV vaccine series, compared

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appointment (10%), and lack of a doctor’s recommendation to get the HPV vaccine (9%). All other reasons were reported by fewer than 5% of participants. Among these unvaccinated participants, willingness to get the HPV vaccine was high if the vaccine were free (mean = 4.03; SD = 1.09), with 74% definitely or probably willing to get vaccinated (Figure 1). Participants were much less willing to get the HPV vaccine if the vaccine cost $400 (mean = 1.71; SD = 0.94; paired t = 38.34; P < .001). Only 6% of participants were definitely or probably willing to get the vaccine if it cost $400.

TABLE 1—Continued Age at first sexual intercourse, y < 18

28/176 (16)

1.00 (Ref)

‡ 18

28/252 (11)

0.66 (0.38, 1.16)

£4

20/202 (10)

1.00 (Ref)

‡5

36/226 (16)

1.72 (0.96, 3.09)

No. of sexual partners during lifetime

Note. CI = confidence interval; HPV = human papillomavirus; OR = odds ratio. a Low knowledge was defined as £ 3 (of 6) correct knowledge items and high knowledge was defined as ‡ 4 correct knowledge items. *P < .05; **P < .001.

with only 5% of participants who had not (P < .001). In multivariate analyses (Table 3), receipt of a provider recommendation remained the strongest correlate of HPV vaccine initiation (OR = 110.60; 95% CI = 32.67, 374.48). HPV vaccine initiation was lower among participants who perceived greater barriers to getting vaccinated (OR = 0.46; 95% CI = 0.27, 0.78). When we excluded health care provider recommendation from the multivariate model, additional variables were associated with HPV vaccine initiation. Initiation was higher among participants who reported higher levels of worry about getting an HPV-related disease

(OR = 1.54; 95% CI = 1.05, 2.27) or perceived positive social norms of HPV vaccination (OR = 1.57; 95% CI = 1.02, 2.43).

Reasons for Not Getting Vaccinated and Willingness to Get Vaccinated Among unvaccinated participants (n = 372), main reasons for not being vaccinated were not knowing males are allowed to get the HPV vaccine (17%), not being sexually active (15%), not having heard of the HPV vaccine (12%), and having sex with only 1 partner who does not have HPV (12%). Additional reasons included not knowing enough about the HPV vaccine yet (11%), lack of a recent doctor’s

DISCUSSION We are the first, to our knowledge, to describe HPV vaccination among gay and bisexual men using data collected after the ACIP recommendation for routine vaccination of males was released in late 2011.8 Among a national sample of young adult gay and bisexual men, we found that only 13% had initiated the HPV vaccine series. Just more than half of initiators had received all 3 doses, which is comparable to recent estimates among US adolescents.10 Our findings highlight that HPV vaccination is low among young adult gay and bisexual

TABLE 2—Continuous Correlates of HPV Vaccine Initiation Among Young Adult Gay and Bisexual Men (n = 428): United States, 2013 Mean (SD) Correlate

Not Vaccinated (n = 372)

Vaccinated (n = 56)

Bivariate OR (95% CI)

Worry about getting HPV-related diseasea Perceived severity of HPV-related diseaseb

1.73 (0.83) 3.43 (0.70)

2.34 (0.94) 3.48 (0.74)

2.07** (1.53, 2.81) 1.12 (0.74, 1.69)

Perceived likelihood of getting HPV-related diseasec

2.09 (0.66)

2.15 (0.51)

1.17 (0.76, 1.79)

Perceived effectiveness of HPV vaccined

2.76 (0.86)

3.14 (0.74)

1.79* (1.23, 2.60)

Perceived harms of HPV vaccinee

3.02 (0.63)

2.73 (0.85)

0.51* (0.33, 0.79)

Perceived barriers to getting HPV vaccinef

2.82 (0.85)

1.84 (0.92)

0.27** (0.19, 0.40)

Perceived positive social norms of the HPV vaccine in LGBT communityg

3.21 (0.73)

3.54 (0.94)

1.72* (1.20, 2.47)

Anticipated regret if got the HPV vaccine and fainteda

2.15 (0.96)

1.80 (0.82)

0.65* (0.47, 0.91)

Anticipated regret if did not get the HPV vaccine and later got HPV infectiona

3.39 (0.83)

3.75 (0.58)

2.12** (1.29, 3.49)

Note. CI = confidence interval; HPV = human papillomavirus; LGBT = lesbian, gay, bisexual, or transgender; OR = odds ratio. a 4-point response scale ranging from “not at all” to “a lot” (coded 1–4). b 4-point response scale ranging from “not at all” to “very” (coded 1–4). c 3-item scale; each item had a 4-point response scale ranging from “no chance” to “high chance” (coded 1–4). d 3-item scale; each item had a 4-point response scale ranging from “not at all” to “a lot” (coded 1–4). e 4-item scale; each item had a 5-point response scale ranging from “strongly disagree” to “strongly agree” (coded 1–5). f 2-item scale; each item had a 5-point response scale ranging from “strongly disagree” to “strongly agree” (coded 1–5). g 5-point response scale ranging from “strongly disagree” to “strongly agree” (coded 1–5). *P < .05; **P < .001.

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TABLE 3—Multivariate Correlates of HPV Vaccine Initiation Among Young Adult Gay and Bisexual Men (n = 428): United States, 2013 Correlate

Full Model, OR (95% CI)

Excluding Provider Recommendation, OR (95% CI)

Knowledge about HPVa Low knowledge (Ref) High knowledge Received health care provider recommendation

1.00

1.00

1.53 (0.52, 4.44)

1.25 (0.57, 2.73)

to get HPV vaccine No (Ref) Yes

1.00

...

110.60** (32.67, 374.48)

...

Health insurance None (Ref)

1.00

1.00

On parents’ insurance

6.71 (0.91, 59.33)

2.89 (0.75, 11.17)

7.36 (0.82, 54.75)

2.54 (0.63, 10.19)

No (Ref)

1.00

1.00

Yes

0.75 (0.28, 2.03)

1.47 (0.72, 3.02)

No (Ref)

1.00

1.00

Yes

0.61 (0.20, 1.85)

1.80 (0.87, 3.74)

1.00 0.92 (0.35, 2.42)

1.00 1.06 (0.51, 2.20)

Worry about getting HPV-related diseaseb

1.43 (0.84, 2.45)

1.54* (1.05, 2.27)

Perceived effectiveness of HPV vaccinec

1.54 (0.82, 2.90)

1.15 (0.74, 1.78)

Perceived harms of HPV vaccined

0.60 (0.32, 1.16)

0.62 (0.37, 1.05)

0.46* (0.27, 0.78)

0.35** (0.23, 0.53)

1.38 (0.78, 2.46)

1.57* (1.02, 2.43)

0.99 (0.58, 1.69) 1.13 (0.53, 2.37)

0.90 (0.60, 1.33) 1.16 (0.66, 2.03)

Insures self Had a routine medical check-up in the past year

Disclosed sexual orientation to health care provider

No. of sexual partners during lifetime £ 4 (Ref) ‡5

Perceived barriers to getting HPV vaccinee Perceived positive social norms of the HPV vaccine in LGBT communityf Anticipated regret if got the HPV vaccine and faintedb Anticipated regret if did not get the HPV vaccine and later got HPV infectionb

Note. CI = confidence interval; HPV = human papillomavirus; LGBT = lesbian, gay, bisexual, and transgender; OR = odds ratio. The multivariate models included only the variables displayed in the table. a Low knowledge was defined as £ 3 (of 6) correct knowledge items and high knowledge was defined as ‡ 4 correct knowledge items. b 4-point response scale ranging from “not at all” to “a lot” (coded 1–4). c 3-item scale; each item had a 4-point response scale ranging from “not at all” to “a lot” (coded 1–4). d 4-item scale; each item had a 5-point response scale ranging from “strongly disagree” to “strongly agree” (coded 1–5). e 2-item scale; each item had a 5-point response scale ranging from “strongly disagree” to “strongly agree” (coded 1–5). f 5-point response scale ranging from “strongly disagree” to “strongly agree” (coded 1–5). *P < .05; **P < .001.

men in the United States, even 2 years after the updated recommendation was released. The strongest correlate of HPV vaccine initiation among young adult gay and bisexual men was receipt of a health care provider recommendation to get vaccinated. The large effect estimate observed between provider recommendation and HPV vaccine initiation is

likely because of so few males receiving the HPV vaccine without a recommendation, which is consistent with past research.13,14 Interestingly, despite more than 40% of participants having a routine medical check-up in the past year, only 11% had received a provider recommendation. Furthermore, only about 20% of participants who had disclosed their sexual orientation to

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their health care provider had initiated the HPV vaccine series, and disclosure of sexual orientation was not associated with initiation in multivariate analyses. Taken together, these findings suggest that missed opportunities for HPV vaccination continue to occur at medical visits for young adult gay and bisexual men,33 including those who have disclosed their sexual orientation. Health care providers play a central role in HPV vaccination behaviors,32,34 and it is important that they recognize that gay and bisexual men are at high risk for HPVrelated disease and that they minimize missed opportunities for recommending and administering the HPV vaccine to this population. HPV vaccine initiation was lower among participants who perceived greater barriers to getting vaccinated, which supports findings from past studies examining HPV vaccination among females.35 Cost is likely an important barrier to HPV vaccination,36 as the HPV vaccine is among the most expensive vaccines available.28 Indeed, participants in our study were much less willing to get the HPV vaccine if it cost $400 out of pocket than if it were free, similar to what has been shown among parents with adolescent sons.26 It is therefore important that young adult gay and bisexual men be aware of insurance coverage of the HPV vaccine and other potential options available to young adults. The Affordable Care Act requires that many private health insurance plans fully cover the HPV vaccine for young adults,37,38 and Medicaid covers the HPV vaccine for some young adults.39 For young adults without health insurance, there are programs (e.g., the Merck Vaccine Patient Assistance Program40) that may be able to provide the HPV vaccine free of charge if they meet eligibility criteria. We identified additional modifiable factors that may be useful for increasing HPV vaccination among gay and bisexual men. For example, we found that HPV vaccine initiation was higher among participants with higher perceived positive social norms of HPV vaccination in the LGBT community or worry about getting an HPV-related disease. Perceived social norms have previously been correlated with HPV vaccination and vaccine acceptability among female college students and male adolescents.23,41 Thus, future programs that normalize HPV vaccination of males and within the LGBT

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Definitely willing

Probably willing

Not sure

Probably not willing

increase health care provider recommendation for vaccination will be key for increasing vaccination among this population. It will also be important to target other modifiable factors, such as perceived barriers to getting the HPV vaccine, which we found were correlated with HPV vaccination. j

Definitely not willing

If HPV Vaccine Were Free

If HPV Vaccine Cost $400 Out of Pocket

About the Authors 0

20

40

60

80

100

Percentage FIGURE 1—Willingness to get the human papillomavirus vaccine among unvaccinated young adult gay and bisexual men (n = 372): United States, 2013.

community may help increase HPV vaccination among gay and bisexual men. Worry is an emotion that often predicts preventive health behaviors and is related to perceived likelihood and severity.42 Interestingly, participants tended to report low levels of worry about and perceived likelihood of getting HPV-related disease, despite the high rates of HPV infection and anal cancer in this population.3,5 Targeting worry and associated modifiable health beliefs may therefore be another avenue for increasing HPV vaccination among this population. Our findings also suggest that young gay and bisexual men continue to lack knowledge and need basic information about HPV and the HPV vaccine. We found that the most common reasons for not having yet been vaccinated involved a lack of awareness of and knowledge about the HPV vaccine for males. Furthermore, about 50% of participants were classified as having low knowledge about HPV. Although the HPV vaccine has received a great deal of media attention and education programs have been developed, many of these efforts have focused only on the HPV vaccine for females.43---46 Future efforts are needed for males and should include basic information about initiating and completing the HPV vaccine series. Specifically, it should be clear that if the recommended dosing schedule is interrupted, the vaccine series does not need to be restarted and the next dose should be given as soon as possible.7,47 Initiators in this study indicated they might not receive their

remaining HPV vaccine doses only because they had waited too long since their last HPV vaccine dose.

Strengths and Limitations Study strengths include the use of a national sample (study participants were from 47 states and the District of Columbia) and examining a wide range of possible correlates. We focused on gay and bisexual men within the recommended age range for HPV vaccination.8 Limitations of our study include a modest response rate and a lack of data on individuals who did not provide consent for the study. However, the demographic characteristics (e.g., self-identified as bisexual, race/ethnicity, education level) of participants in our study are similar to those from other studies of gay and bisexual men.48---50 Our study was limited to men who selfidentified as gay or bisexual. Some men who have sex with men might not self-identify as gay or bisexual and might still be at high risk for HPV infection and HPV-related disease. Future research is needed to examine HPV vaccination among these men. Lastly, we derived HPV vaccination data from self-report without verification from medical records, although most young adults can accurately recall whether they have received the HPV vaccine.51

Conclusions HPV vaccination is low among gay and bisexual men in the United States. Future efforts to

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Paul L. Reiter and Electra D. Paskett are with the Division of Cancer Prevention and Control, College of Medicine and the Comprehensive Cancer Center, Ohio State University, Columbus. Annie-Laurie McRee and Mira L. Katz are with the Division of Health Behavior and Health Promotion, College of Public Health and the Comprehensive Cancer Center, Ohio State University. Correspondence should be sent to Paul L. Reiter, PhD, Division of Cancer Prevention and Control, The Ohio State University College of Medicine, 1590 North High Street, Suite 525, Columbus, OH 43201 (e-mail: Paul.Reiter@ osumc.edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This article was accepted May 17, 2014.

Contributors P. L. Reiter conceptualized the study, performed data analysis, and wrote the initial article draft. A.-L. McRee helped conceptualize the study and provided direction for data analysis and article writing. M. L. Katz and E. D. Paskett assisted with conceptualizing and writing the article. All authors helped to conceptualize ideas, interpret findings, and review drafts of the article.

Acknowledgments The National Cancer Institute at the National Institutes of Health (grant P30CA016058) provided support for this study.

Human Participant Protection The Ohio State University institutional review board approved the study. Participants provided consent online before the start of surveys.

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American Journal of Public Health | January 2015, Vol 105, No. 1