Gender-neutral Human Papillomavirus Vaccination: A Comprehensive Overview

Prevalence and Burden of Cervical Cancer Human papillomavirus (HPV) is one of the most common sexually transmitted infections worldwide. It is estimated that over 80% of sexually active individuals will contract at least one type of HPV at some point in their lives. More than 200 types of HPV have been identified, with around 14 of these being classified as high-risk types due to their strong association with cancer development. Among these, HPV types 16 and 18 are the most oncogenic, contributing to approximately 70% of cervical cancer cases globally. Cervical cancer remains a significant public health burden. According to the World Health Organization (WHO), an estimated 342,000 women died from cervical cancer in 2020, with over 90% of these deaths occurring in low- and middle-income countries. In India alone, cervical cancer is the second most common cancer among women, accounting for over 123,000 new cases and 77,000 deaths each year. Beyond cervical cancer, HPV also contributes to other malignancies including anal, penile, vulvar, vaginal, and oropharyngeal cancers. Notably, in high-income countries, HPV-related oropharyngeal cancers are increasing among men and, in some instances, have surpassed the incidence of cervical cancer. Additionally, nononcogenic HPV types 6 and 11 are responsible for most cases of genital warts, which, while nonfatal, significantly affect quality of life and result in increased healthcare utilization. World Health Organization Strategy and Human Papillomavirus Vaccination Status In 2020, the WHO launched the Global Strategy to Accelerate the Elimination of Cervical Cancer as a public health problem. The strategy sets ambitious “90-70-90” targets to be met by 2030: 90% of girls fully vaccinated with the HPV vaccine by age 15, 70% of women screened using a high-performance test by 35 and again by 45, and 90% of women identified with cervical disease receiving appropriate treatment. Three prophylactic HPV vaccines are currently available: bivalent, quadrivalent, and nonavalent. These vaccines are highly effective in preventing infections from high-risk HPV types and associated precancerous lesions, especially when administered before sexual debut.[1] As of 2023, more than 120 countries have integrated HPV vaccination into their national immunization programs, predominantly targeting adolescent girls. India has recently introduced its first indigenous quadrivalent vaccine, Cervavac, aiming to increase accessibility and affordability. Despite these advances, male vaccination remains limited across most regions, leaving a significant portion of the population susceptible to HPV-related diseases. Gender Neutral Vaccine Strategy: Why There is growing global advocacy for gender-neutral HPV vaccination. The rationale extends beyond reducing cervical cancer incidence to encompassing broader public health, ethical, and economic considerations. First, HPV imposes a substantial burden on male populations. It is responsible for nearly 90% of anal cancers, over 60% of penile cancers, and a significant share of oropharyngeal cancers. Genital warts, which equally affect males and females, are also caused by HPV types 6 and 11 and present a recurrent and distressing condition. Second, relying solely on female vaccination to achieve herd immunity is insufficient. In regions where female vaccine coverage is suboptimal, the population-level impact remains limited. Moreover, men who have sex with men (MSM) do not benefit from herd immunity and remain at high risk for HPV-related conditions unless directly vaccinated. Ethically, selective vaccination strategies reinforce gender disparities and deny boys equal access to preventive healthcare. A gender-neutral strategy promotes fairness, eliminates stigma, and fosters shared responsibility in preventing sexually transmitted infections. From an economic standpoint, while early cost-effectiveness analyses questioned the inclusion of boys, newer models incorporating noncervical cancers and genital warts demonstrate that gender-neutral vaccination is both cost-effective and impactful. The introduction of lower-cost vaccines and single-dose regimens further improves the economic viability of such programs.[2,3] Programmatically, a universal approach simplifies logistics, increases parental acceptance, and supports school-based immunization drives without gender-specific targeting, thus normalizing HPV vaccination as a standard adolescent immunization. Knowledge Gaps Despite the expanding evidence base, significant gaps remain in knowledge, policy, and implementation. Awareness of HPV and its relevance to male health is limited among the general public and even within healthcare communities. Many continue to perceive HPV as a disease primarily affecting women, with little understanding of its role in male cancers. Long-term efficacy and protection duration of HPV vaccines in males – particularly against oropharyngeal cancers – require further research. Most clinical trials have focused on female populations and cervical disease endpoints. Data from low- and middle-income countries regarding HPV prevalence, type distribution, and cancer burden among males remain sparse. This limits the ability to tailor policies and estimate the true cost–benefit ratio of male vaccination in such contexts. Operational barriers such as inadequate infrastructure, vaccine financing, and trained personnel challenge the expansion of gender-neutral programs, especially in resource-limited settings. Cultural stigma around sexually transmitted infections, vaccine hesitancy, and misinformation can also hinder vaccine uptake. Addressing these issues requires multifaceted communication strategies and community engagement. Future Perspective The global health community is increasingly recognizing the importance of inclusive vaccination strategies. As HPV-related cancers among men rise, particularly oropharyngeal cancers, gender-neutral vaccination becomes a critical public health intervention. Countries must consider expanding national policies to include boys in routine HPV immunization schedules. Nations such as Australia, the United Kingdom, and Canada have successfully adopted gender-neutral strategies, demonstrating feasibility and benefits. Surveillance systems must be strengthened to capture sex-disaggregated data on HPV infections and related cancers. Such evidence will inform policy decisions and track progress toward the goal of eliminating HPV-associated malignancies. Widespread education and advocacy campaigns can dispel myths and normalize HPV vaccination for all genders. Schools, primary care settings, and digital platforms can play a pivotal role in awareness building. Improved vaccine access through reduced pricing, integration into universal health coverage schemes, and support from global initiatives like Gavi and the WHO can enhance program scalability. In addition to adolescent vaccination, high-risk groups such as MSM, transgender individuals, and immunocompromised persons should be prioritized for targeted interventions. These populations often face disproportionate HPV-related health burdens and should not be left behind. Ultimately, eliminating HPV-related cancers requires a concerted effort that includes equitable vaccine access, robust screening programs, and continued public health innovation. Gender-neutral vaccination is not just a logical extension of existing strategies – it is an ethical imperative rooted in the principles of justice, equality, and scientific evidence. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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