HPV Vaccination among LGBTQ Populations. HPV & Cancer Conference Ankeny, Iowa May 2017

Transcription

1 HPV Vaccination among LGBTQ Populations HPV & Cancer Conference Ankeny, Iowa May 2017

2 Introductions Annie-Laurie McRee, DrPH Paul A. Gilbert, PhD Assistant Professor Assistant Professor Division of General Pediatrics Department of Community and Adolescent Health and Behavioral Health Deputy Director Healthy Youth Development Prevention Research Center University of Minnesota Director of Training Prevention Research Center University of Iowa

3 Prevention Research Centers Supported by CDC Collaborating with academic & community partners Focusing on applied research and promotion of best practices

4 Roadmap Introduction Background Exemplar: Outsmart HPV Conclusions Questions & Discussion

5 Background

6 Definition: Health Disparities Health disparities are differences in health that are unnecessary, avoidable, unfair and unjust. There are alternatives to group differences We can intervene to prevent these differences We can intervene to prevent these differences Whitehead in Braveman & Gruskin, 2003

7 Definition: Health Equity Health equity is the value under-lying a commitment to reduce and ultimately eliminate health disparities Health equity means striving to equalize opportunities to be healthy. Our values determine the structure of health risks and associated outcomes Braveman, Kumanyika, Fielding et al., 2003

8 HPV Infection Sexual minority men are a disparity population for HPV and related disease. HPV infection prevalence (any) Anal cancer incidence (per 100,000) Sexual minority 57-93% 26-43% History of genital warts 7% 4% Heterosexual Smith et al,. 2011; Joseph et al., 2008; Dingh et al., 2008

9 HPV Vaccine HPV vaccination is primary prevention HPV Type ~60% oropharyng. & 36% penile cancers >90% Genital ~66% of ~15% of cervical warts cervical & 90% of cancers anal cancers*

10 HPV Vaccination Recommendations Routine vaccination at age Females age Males age Special populations Men who have sex with men (MSM) Transgender persons Immunocompromised persons (e.g., HIV+) Meites et al., 2016

11 % Vaccinated Immunization Coverage: Adolescents Ages Healthy People 2020 Goal Year Tdap Meningococcal HPV (3 doses, females) HPV (3 doses, males) Reagan-Steiner, 2015

12 HPV Vaccine Uptake Sexual minority women Equivalent or better initiation and completion as heterosexual peers McRee et al., 2014; Daniel-Ulloa et al., 2016; Agénor et al., 2016 Sexual minority men Low uptake overall with few differences from heterosexual peers Better completion among gay/bi men Cummings et al.,2015; Reiter et al., 2015Daniel-Ulloa et al., 2016; Meites et al., 2014; Agénor et al., 2016

13 Correlates of HPV Vaccination Knowledge (but may be low among MSM) Attitudes (e.g., acceptability, perceived benefit, worry) Framing as cancer prevention Healthcare provider recommendation Perceived barriers (e.g., access, perceived discrimination) Fenkl et al., 2015; Onyeabor et al., 2015; Gilbert PA et al., 2011; Cummings et al., 2015; Reiter et al., 2015; McRee et al., 2010; Gerend at al.,2016; Nadarzynski et al., 2017; Fontenot et al., 2016

14 Outsmart HPV: An Exemplar

15 Preliminary Study (2013) Purpose: To determine HPV vaccine coverage and identify correlates of vaccination National, cross-sectional online survey (N=1005) Eligibility criteria years old U.S. resident English speaking Reiter et al., 2015 Self-identify as lesbian, gay, bisexual,

16 Correlates of HPV Vaccination Worry about HPV-related disease Social/community vaccination norms Perceived vaccination barriers **p<.01 aor 1.5 ( ) * 1.6 ( )* 0.4 ( )** Statistically significant ORs from multivariable models. *p<.05, Model also controlled for: HPV knowledge, insurance status, routine medical care, disclosure of sexual orientation to a provider, lifetime sexual partners, perceived vaccine effectiveness, harms, anticipated regret Reiter et al., 2015

17 Reasons for Getting Vaccinated A doctor recommended it 46% To protect against cancer 18% Parent said to 11% To protect sexual partners 11% 0% 10% 20% 30% 40% 50% Reiter et al., 2015

18 Reasons for not getting vaccinated Unaware males could get HPV vaccine Not sexually active 15% 17% Have only 1 sexual partner (HPV-) Hadn't heard of HPV vaccine Lack of a recent doctor's appointment No doctor recommendation 12% 12% 10% 9% Vaccine safety concerns 3% 0% 10% 20% Reiter et al., 2015

19 Outsmart HPV: Pilot Study Population-targeted, individuallytailored mhealth HPV vaccine intervention for sexual minority men Information specific to sexual minority men Information and resources tailored to individual demographics and attitudes/beliefs Mobile friendly based on YSMM preferences & high technology use in population ( >90%) Funded by NCI: #R21 CA

20 Outsmart HPV: Pilot Study Population-targeted, individuallytailored mhealth HPV vaccine intervention for sexual minority men. Developed based on preliminary study (2013) and input from young gay and bisexual men Eligibility criteria: Age Self-identify as gay or bisexual Live in the U.S. Funded by NCI: #R21 CA Not have received any doses of HPV

21 Recruitment Recruited men (n=150) through Facebook (Fall 2016) Most successful recruitment ads: Showed image of a couple or group Had text that mentioned an STD Reiter & McRee, In press

22 Study Portal Access to eligibility screener for new users Returning user access to all materials, surveys

23 Control group Based on CDC s Vaccine Information Sheets (VIS)

24 Intervention group Homepage Populationtargeted, individuallytailored content in 4 key areas Text, infographics & other visual content Plus monthly

25 Population-targeted info about HPVinfection

26 Population-targeted info about HPV vaccine

27 Tailoring example: Vaccination motivations

28 Q&A highlights concerns identified at baseline

29 Click to expand box and see answers

30 Content addressing barriers

31 such as developing skills for accessing care

32 Intervention plan addressing individual motivations, goals and needed resources

33 Enrolled Participants (n=150) Sexual self-identity Gay 83% 59% years old 57% non-hispanic white 37% college degree Bisexual 17% 72% 20% in a partnership or married 82% had health insurance 47% had a check-up

34 Preliminary Results: Beliefs & Attitudes Worry about HPV-related disease (1-4) Perception MSM risk > hetero. men (1-5) Interv. Mean Contro l Mean P- value * Perceived short-term harms (1-5) * HPV vaccination self-efficacy * (1-5) Regression models and control for the baseline level of the outcome and HPV adjust vaccine for statistically intent significant in next baseline 6 differences in income 0.21 between months groups. (1-5) p<.10; *p<.05

35 Preliminary Results: Acceptability & Satisfaction Information quality Interv, Mean Control Mean Easy to understand Relevant System quality Like how it looked Loads graphics quickly & easily Easy to navigate Usefulness Improves my ability to make healthier choices All items were on a 5-point agree-disagree scale. *p<

36 Summary First study of an HPV vaccine intervention for YGBM Highly acceptable to the target population Few statistically significant effects on attitudes & beliefs but trend toward favoring the tailored intervention Small sample size Short follow-up time frame Need to examine vaccination in longitudinal work

37 Conclusions

38 Conclusions & Next Steps Low HPV uptake among MSM meets definition of health disparity We have identified intervention targets to increase uptake Social norms Provider recommendation Continue developing/disseminating interventions Target populations should also include clinicians

39 Next steps Don t neglect sexual minority women Mixed findings of differential uptake There may be lower perception of risk Bisexual & heteroflexible sub-groups often neglected Tremendous gaps in HPV knowledge about transgender & gender nonconforming persons Scant attention to date Additional complexity (e.g., men with cervix)

40 Questions & Discussion

41 Thank you! Annie-Laurie McRee, DrPH Paul A. Gilbert, PhD

42 References Agénor M, Peitzmeier SM, Gordon AR, et al. (2016). Sexual orientation identity disparities in human papillomavirus vaccination initiation and completion among young adults US women and men. Cancer Causes Control; 27: Braveman P, Gruskin S (2003). Defining equity in health. J Epidemiol Community Health; 57: Braveman P, Kumanyika S, Fielding J et al. (2011). Health disparities and health equity: The issue is justice. Am J Public Health; 101: S149-S155. Cummings T, Kasting ML, Rosenberger JG et al. (2015). Catching up or missing out? Human papillomavirus vaccine acceptability among 18- to 26-year-old men who have sex with men in a US national sample. Sex Transm Dis; 42: Daniel-Ulloa J, Gilbert PA, Parker EA (2016). Human papillomavirus vaccination in the United States: Uneven uptake by gender, race/ ethnicity, and sexual orientation. Am J Public Health; 106: Dinh TH, Sternberg M, Dunne EF, Markowitz LE. Genital warts among 18- to 59- year-olds in the United States, NHANES, Sex Transm Dis. 2008;35(4): Fenkl EA, Jones SG, Schochet E, Johnson P (2015). HPV and anal cancer knowledge among HIV-infected and non-infected men who have sex with men. LGBT Health; DOI: /lgbt Fontenot HB, Fantasia HC, Vetter R, Zimet GD (2016). Increasing HPV vaccination and eliminating barriers: Recommendations from young men who have sex with men. Vaccine; 34: Gerend MA, Madkins K, Phillips G 2 nd, Mustanski B (2016). Predictors of human

43 References (cont.) Joseph DA, Miller JW, Wu X, et al. Understanding the burden of human papillomavirus-associated anal cancers in the US. Cancer. 2008;113(10 Suppl): McRee AL, Reiter PL, Chantala K, Brewer NT (2010). Does framing human papillomavirus vaccine as preventing cancer in men increase vaccine acceptability? CEBP; 19: McRee AL, Katz ML, Paskett ED, Reiter PL. HPV vaccination among lesbian and bisexual women: Findings from a national survey of young adults. Vaccine. 2014;32(37): Meites E, Kempe A, Markowitz LE. Use of a 2-Dose Schedule for Human Papillomavirus Vaccination Updated Recommendations of the Advisory Committee on Immunization Practices MMWR. 2016;65(49); Onyeabor OS, Martin N, Orish VN, Sanyaolu AO, Iriemenam NC (2015). Awareness of human papillomavirus vaccine among adolescent African American males who have sex with males: A pilot study. J Racial Ethn Health Disparities; 2: Petrosky E, Bocchini JA, Hariri S et al. (2015). Use of 9-valent human papillomavirus (HPV) vaccine: Updated HPV vaccination recommendations of the Advisory Committee on Immunization Practices. Morb Mortal Wkly Rep; 64: Reiter PL, McRee AL. Recruiting young gay and bisexual men for an HPV vaccination study via social media. Journal Medical Internet Research. In press. Reiter PL, McRee AL, Katz ML, Paskett ED (2015). Human papillomavirus vaccination among young adult gay and bisexual men in the United States.