HPV Vaccine

Pamela Nash Excerpts

Tuesday 2nd July 2013 Commons Chamber

[Mike Freer]

The hon. Gentleman makes a good point. On a small island such as ours it is important that men who are having sex with women, or men having sex with men, are having sex with partners who are vaccinated, and I believe that is a matter not just for England and Wales, but for the whole of the United Kingdom, and we would also then be setting an example for the rest of the world.

Herd immunity is valuable, but it is not foolproof for heterosexual men. I have mentioned that it is valuable where heterosexual men are having sex with vaccinated women, but men who have sex with men are not subject to herd immunity, and that is another element of inequality. Evidence from other countries suggests herd immunity will eventually prevent most, but not all, cases of HPV-related cancer in heterosexual men. There is still work to be done, therefore, on all men having vaccinations against HPV-related cancers.

Some HPV-related cancers are on the rise in the UK, despite the vaccination programme. Throat cancer has overtaken cervical cancer as the leading HPV-related cancer in the UK. Men who have sex with women who are not vaccinated remain at risk. This is of concern to men who, for example, have sex while on holiday or while living outside the UK, or who have sex with unvaccinated migrants to the UK—but men, straight or gay, remain at risk.

The current programme is inequitable, as those men who “stray from the herd” by having sex with unvaccinated women or men will remain at risk. That is why I am seeking a commitment for the HPV vaccination programme to be widened.

The key issue I wish to press is the health inequality in respect of gay men and anal cancer, an inequality perpetuated by the current vaccination policy. Gay men already experience poorer sexual health as a group; they are at an increasing and far higher risk of HIV and other sexually transmitted infections compared with the wider population. Rates of anal cancer in gay men are now equivalent to those for cervical cancer in women before the cervical cancer screening programme was introduced in 1988. HPV is associated with 80% to 85% of anal cancer in men, yet it is not yet possible to screen for or effectively treat anal pre-cancer, as it is for cervical cancer; HPV vaccination is the only effective form of prevention, and it is being denied to men.

Gay men with HIV are particularly susceptible to HPV-related anal cancer and as the number of gay men with HIV continues to rise year on year, so will cases of anal cancer, other HPV-related cancers and warts. In addition to having a disproportionate effect in HIV-positive men, HPV can increase the risk of HIV transmission. HPV can increase skin fragility and overt anal warts can bleed, which enhances the risks of acquisition or transmission of HIV infection. This health inequality between gay men and the general population will continue to widen as long as gay men remain unprotected against HPV. I stress this point as it relates to gay men, but it also affects heterosexual men who are equally unprotected.

[Pamela Nash (Airdrie and Shotts) (Lab)]

I congratulate the hon. Gentleman on making a powerful argument on a difficult subject. Michael Douglas, the actor, was given much criticism in the press recently for talking about these difficult issues. I know about this, because I had the HPV vaccine as a 17-year-old, so I am glad the hon. Gentleman has brought the matter to the Floor of the House. I just want to highlight the fact that this is an issue not only for homosexual men in terms of the vast health inequalities they have here in the UK, but for heterosexual men. Although we have a successful HPV vaccination programme for young women, we by no means have the whole herd vaccinated just yet.

[Mike Freer]

The hon. Lady makes a good point. Herd immunity is valuable only for those who are sleeping within the herd. Those who have sex outside the herd are at risk, and that inequality needs to be addressed.

The best way to protect all males against HPV-related cancers and warts would be to offer the vaccine to all boys aged 12 to 13, as well as girls, as part of the school-based immunisation programme. The vaccine is most effective when given at this younger age, before people start having sex and before exposure to the strains of HPV. Other countries are starting to do that; the vaccine is available for boys in a number of other countries, including Australia and the United States. I firmly believe that we should follow suit.

If we do not have a widespread vaccination programme for boys, at least, and as a bare minimum, gay men should be offered the vaccine when they first present at a sexual health clinic as men who have sex with men. That would match the current policy on offering hepatitis B vaccinations to gay men. Given the expense of treating HPV-related cancers and warts, there is a strong cost-effectiveness argument for extending the availability of the HPV vaccine. If the inequality is not a powerful argument, the cost savings to the Department of Health must be.

The Joint Committee on Vaccination and Immunisation inquiry that began last year is welcome, although little is known of the progress it is making. If the JCVI looks into the cost-effectiveness of vaccination initiatives, it will find that the case to extend the programme to boys is irrefutable.

Each HPV vaccination for the three-dose programme costs £260. Compare that with the lifetime treatment and care cost of an HIV-positive man or woman at £280,000 a year, the £13,000 cost of treating anal cancer, the £11,500 cost of treating penile cancer, the £15,000 cost of treating for oropharyngeal cancer or the £13,600 cost of treating vulval and vaginal cancer transmitted by an infected male. In 2010, the cost of treating anogenital warts was £52.4 million.

--- Later in debate ---

[Anna Soubry]

I am going to struggle, because that is another good point. I always try to be honest when I come to the Dispatch Box and when hon. Members make good points—points that were made not only by my hon. Friend, but by the hon. Member for Airdrie and Shotts (Pamela Nash).

The point raised by the right hon. Member for Wolverhampton South East (Mr McFadden) is related to the actual vaccine, and I am more than happy to discuss that case, or any other adverse reactions of young women to the vaccine, with him. I am very sorry for his constituent, and I am more than happy to have that discussion with him and help in any way I can. He raises an important point.

As we have heard, in June 2012 the JCVI was presented with data on HPV infections and it noted that there is early evidence to suggest that the HPV immunisation programme in England is lowering the number of HPV 16 and 18 infections—the strains of HPV that are linked to these unpleasant cancers—in females in birth cohorts that have been eligible for vaccination.

I accept that the data are very limited on the prevalence of HPV infections among men who have sex with men, but we hope that research under way at University College London will provide more data and an age profile of HPV prevalence. HPVs, particularly types 16 and 18, are associated with the majority of anal cancers as well as cervical cancers, and to a lesser degree with penile, vaginal, vulval and head and neck cancers, but HPV types 16 and 18 predominate in cancers at those sites that are HPV-related. Data on the impact of HPV vaccination on infection at some of these non-cervical sites are limited.

The JCVI noted that the potential impact of HPV vaccination on non-cervical cancers would make the current HPV immunisation programme even more cost-effective, but it would remain the case that, given the expected effects of immunisation on HPV transmission and the indirect protection of boys that accrues from high coverage of HPV vaccination in girls, vaccination of boys in addition to girls was unlikely to be cost-effective. That argument, which we know is advanced, is combated by all that has been said by my hon. Friends the Members for Sherwood (Mr Spencer) and for Finchley and Golders Green, who urge us to consider the cost of treating someone who has one of these cancers.

Evidence for indirect protection would continue to be evaluated by the ongoing HPV surveillance programme at the former Health Protection Agency, now part of Public Health England, but the JCVI agreed that there may be little indirect protection of men who have sex with men from the current immunisation programme. Therefore, the impact and cost-effectiveness of vaccination strategies for men who have sex with men, with the offer of vaccination through general practice and/or at genito-urinary medicine clinics, needed to be assessed. In addition, data on the prevalence by age of HPV infections in men who have sex with men and in the settings where vaccination could be offered to them were needed to determine the potential effectiveness and cost-effectiveness of HPV vaccination of men who have sex with men. It would also be important to understand better the rates of HPV-related disease in men who have sex with men and the influence of HPV on HIV infection.

As we have heard, in August 2012, the JCVI issued a call for evidence from interested parties, including for information to inform a study on the impact and cost-effectiveness of HPV vaccination of men who have sex with men. Any new proposals for the vaccination of additional groups will require supporting evidence to show that this would be a cost-effective use of resources. The JCVI also asked the HPA, now part of PHE, to undertake that study. The study is under way and, once completed, will be considered by the JCVI, at the earliest in 2014. The Department will consider carefully the advice from JCVI, once the committee has completed its assessment.

[Pamela Nash]

May I reiterate the point the hon. Member for Strangford (Jim Shannon) made about the need to have conversations with ministerial colleagues in Scotland, Wales and Northern Ireland? As the hon. Member for Finchley and Golders Green (Mike Freer) argued powerfully, this is about homosexual men and men who have sex with men, but also about men who have sex with women who have not been vaccinated. It is important to have those conversations with the other nations.

[Anna Soubry]

I am grateful for that intervention. I was about to conclude by saying that it is only fair and right to acknowledge the powerful arguments that have been advanced by a number of hon. Members this evening. They have certainly caused me to take the view that I will not hesitate to contact the JCVI, as a matter of urgency, to raise all these important points with them. The committee is an independent expert body, and when it gives its advice to the Government, the Government are—quite rightly—bound to accept that advice.