Invited response

Abstract

Dr. Kapoor expresses concern that human papillomavirus (HPV) vaccination could adversely impact adolescent sexual behaviors and future Papanicolaou (Pap) screening. The same concerns have been articulated previously in professional publications as well as in the popular media [1Zimmerman R.K. Ethical analysis of HPV vaccine policy options.Vaccine. 2006; 24: 4812-4820Crossref PubMed Scopus (62) Google Scholar, 2Colgrove J. The ethics and politics of compulsory HPV vaccination.N Engl J Med. 2006; 355: 2389-2391Crossref PubMed Scopus (135) Google Scholar, 3Specter M. The Bush Administration’s War on the Laboratory.New Yorker. 2006Google Scholar]. Research similarly suggests that some parents and health care providers are concerned about the potential behavioral impact of vaccination [4Davis K. Dickman E.D. Ferris D. et al.Human papillomavirus vaccine acceptability among parents of 10- to 15-year-old adolescents.J Low Genit Tract Dis. 2004; 8: 188-194Crossref PubMed Scopus (289) Google Scholar, 5Chan S.S. Cheung T.H. Lo W.K. et al.Women’s attitudes on human papillomavirus vaccination to their daughters.J Adolesc Health. 2007; 41: 204-207Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar, 6Kahn J.A. Rosenthal S.L. Tissot A.M. et al.Factors influencing pediatricians’ intention to recommend human papillomavirus vaccines.Ambul Pediatr. 2007; 7: 367-373Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar]. These concerns may be driven in part by previous research indicating that highly active antiretroviral treatment, effective postexposure prophylaxis for human immunodeficiency virus (HIV), or investigational HIV vaccines may lead to an increase in risky sexual behaviors or sexually transmitted infections (STIs) [7Wilson T.E. Gore M.E. Greenblatt R. et al.Changes in sexual behavior among HIV-infected women after initiation of HAART.Am J Public Health. 2004; 94: 1141-1146Crossref PubMed Scopus (70) Google Scholar, 8Newman P.A. Duan N. Rudy E.T. et al.HIV risk and prevention in a post-vaccine context.Vaccine. 2004; 22: 1954-1963Crossref PubMed Scopus (27) Google Scholar, 9Stolte G. Dukers N.H. de Wit J.B. et al.A summary report from Amsterdam: Increase in sexually transmitted diseases and risky sexual behaviour among homosexual men in relation to the introduction of new anti-HIV drugs.Eur Surveill. 2002; 7: 19-22PubMed Google Scholar, 10Boily M.C. Bastos F.I. Desai K. et al.Changes in the transmission dynamics of the HIV epidemic after the wide-scale use of antiretroviral therapy could explain increases in sexually transmitted infections: Results from mathematical models.Sex Transm Dis. 2004; 31: 100-113Crossref PubMed Scopus (75) Google Scholar]. Findings have not been consistent, but those studies that do demonstrate an increase in risky behaviors suggest that the most important attitude driving behavioral change may be perceived susceptibility: that is, those who believe they are at less risk for HIV infection are more likely to practice risky behaviors [7Wilson T.E. Gore M.E. Greenblatt R. et al.Changes in sexual behavior among HIV-infected women after initiation of HAART.Am J Public Health. 2004; 94: 1141-1146Crossref PubMed Scopus (70) Google Scholar, 11Ostrow D.E. Fox K.J. Chmiel J.S. et al.Attitudes towards highly active antiretroviral therapy are associated with sexual risk taking among HIV-infected and uninfected homosexual men.AIDS. 2002; 16: 775-780Crossref PubMed Scopus (233) Google Scholar, 12Vanable P.A. Ostrow D.G. McKirnan D.J. Viral load and HIV treatment attitudes as correlates of sexual risk behavior among HIV-positive gay men.J Psychosom Res. 2003; 54: 263-269Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 13Stolte I.G. Dukers N.H. Geskus R.B. et al.Homosexual men change to risky sex when perceiving less threat of HIV/AIDS since availability of highly active antiretroviral therapy: A longitudinal study.AIDS. 2004; 18: 303-309Crossref PubMed Scopus (208) Google Scholar, 14van der Snoek E.M. de Wit J.B. Mulder P.G. et al.Incidence of sexually transmitted diseases and HIV infection related to perceived HIV/AIDS threat since highly active antiretroviral therapy availability in men who have sex with men.Sex Transm Dis. 2005; 32: 170-175Crossref PubMed Scopus (52) Google Scholar, 15Elford J. Changing patterns of sexual behaviour in the era of highly active antiretroviral therapy.Curr Opin Infect Dis. 2006; 19: 26-32Crossref PubMed Scopus (182) Google Scholar]. Thus the term “sexual disinhibition” has been used to explain potential changes in sexual behavior postvaccination. Will sexual disinhibition occur after HPV vaccination? Will vaccinated women choose not to participate in Pap screening? The existing literature concerning factors that influence adolescent sexual and Pap screening behaviors may provide a valuable contextual perspective. This body of work has shown that a diverse set of factors at multiple levels influences adolescent decisions about these behaviors, including sociodemographic characteristics, attachment to school and to faith-based organizations, sexual attitudes, and contextual influences such as community, family, peers, and partners [16Kirby D. Antecedents of adolescent initiation of sex, contraceptive use, and pregnancy.Am J Health Behav. 2002; 26: 473-485Crossref PubMed Scopus (187) Google Scholar, 17Kirby D. Lepore G. Ryan J. Sexual Risk and Protective Factors. Factors Affecting Teen Sexual Behavior, Pregnancy, Childbearing and Sexually Transmitted Disease: Which Are Important? Which Can You Change?.in: The National Campaign to Prevent Teen Pregnancy, Washington, D.C2005: 1-46Google Scholar, 18Marston C. King E. Factors that shape young people’s sexual behaviour: A systematic review.Lancet. 2006; 368: 1581-1586Abstract Full Text Full Text PDF PubMed Scopus (382) Google Scholar, 19Kahn J.A. Goodman E. Huang B. et al.Predictors of Papanicolaou smear return in a hospital-based adolescent and young adult clinic.Obstet Gynecol. 2003; 101: 490-499Crossref PubMed Scopus (38) Google Scholar]. Such factors are likely to play much more significant roles in adolescent decision making about sexual and screening behaviors than is vaccination. Fear of STI—especially HPV, which tends to be poorly understood—is not a critical factor in most adolescents’ decisions about sexual intercourse. Furthermore many clinicians may choose not to discuss the fact that HPV is an STI with 11–12-year-old girls, the target group for vaccination; thus early adolescents may not even be aware that they have been vaccinated against an STI. These realities make it unlikely that HPV vaccination will have a substantial impact on adolescent sexual decision making. Finally, extensive experience with sexuality education and condom distribution programs has confirmed that these programs do not increase risky sexual behaviors [[20]Kirby D. The impact of schools and school programs upon adolescent sexual behavior.J Sex Res. 2002; 39: 27-33Crossref PubMed Scopus (236) Google Scholar]; a preventive measure such as HPV vaccination, especially if accompanied by appropriate counseling, similarly would be unlikely to lead to riskier behaviors. Even if vaccination could lead to an increase in risky sexual behaviors in a small subset of adolescents (perhaps those who hold specific risk perceptions postvaccination), it would be nonsensical for clinicians to withhold a highly effective and potentially lifesaving vaccine for this theoretical reason. Instead clinicians and educators should focus on effective anticipatory guidance and risk reduction counseling to accompany vaccination [[21]Haber G, Malow RM, Zimet GD. The HPV vaccine mandate controversy. J Pediatr Adolesc Gynecol (in press).Google Scholar]. Despite the absence of a compelling rationale underlying concerns about sexual disinhibition after HPV vaccination, the lack of empiric data that can address the issue is a problem. Concerns about adverse behavioral effects of vaccination may impact parental consent for their child to be vaccinated as well as provider willingness to recommend HPV vaccines [4Davis K. Dickman E.D. Ferris D. et al.Human papillomavirus vaccine acceptability among parents of 10- to 15-year-old adolescents.J Low Genit Tract Dis. 2004; 8: 188-194Crossref PubMed Scopus (289) Google Scholar, 6Kahn J.A. Rosenthal S.L. Tissot A.M. et al.Factors influencing pediatricians’ intention to recommend human papillomavirus vaccines.Ambul Pediatr. 2007; 7: 367-373Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar]. Such concerns have also been used to argue against mandated immunization—one of the most effective methods for ensuring universal vaccination [[1]Zimmerman R.K. Ethical analysis of HPV vaccine policy options.Vaccine. 2006; 24: 4812-4820Crossref PubMed Scopus (62) Google Scholar]. If ongoing research demonstrates that vaccination does not lead to a perception of reduced risk or riskier sexual behaviors among adolescents, communicating this information to parents, providers and policymakers may enhance HPV vaccine acceptability, facilitate adolescent vaccination, and inform discussions about mandated HPV immunization. If vaccination does impact attitudes or behaviors among a subset of adolescents, this information can be used to design evidence-based individual educational interventions or public health initiatives to accompany vaccination that will minimize adverse consequences of vaccination. The HPV Vaccine and Behavioral DisinhibitionJournal of Adolescent HealthVol. 42Issue 1PreviewThe article by Chan et al was highly interesting, and highlighted the influence of women’s attitudes on human papillomavirus vaccination to their daughters [1]. However, there is wide concern that HPV vaccination may result in behavioral disinhibition and risky sexual behaviors among vaccine recipients. Vaccination might actually increase the notion among adolescents that condoms are no more necessary, and that it is safe to have multiple sexual partners. For instance, a recent study involving a trial HIV vaccine demonstrated consistent high levels of risky behavior following vaccination [2]. Full-Text PDF