Hepatitis A, Hepatitis B and HPV Vaccine Needs and Coverage in MSM Initiating HIV PrEP in a Sexual Health Clinic in Paris

INTRODUCTION Preexposure prophylaxis (PrEP) with tenofovir disoproxil/emtricitabine is a powerful tool to prevent HIV acquisition and provides an opportunity to offer comprehensive prevention services, including assessment for sexually transmitted infections and evaluation of immune status towards vaccinepreventable viral infections such those due hepatitis A virus (HAV), hepatitis B virus (HBV) and human papillomavirus (HPV). In addition to the programme in girls aged 11–19, French guidelines recommended HPV vaccination for men who have sex with men (MSM) ≤26 years old in February 2016 and for all boys aged 11–19 in December 2019. There are no restrictions on HPV vaccine use beyond these age limits, but the cost is not covered by the French Health Service. In reallife settings, suboptimal vaccination coverage against HPV as well as HBV has been reported among European MSM. 4 Our objective was to evaluate HAV, HBV and HPV vaccine needs and coverage in individuals initiating PrEP in a sexual health clinic in Paris. In this observational retrospective singlecentre study, we reviewed all individuals who initiated PrEP between 1 January 2016 and 31 December 2020 with ≥1 year of followup after PrEP initiation. At baseline, we assessed the presence of HAV and HBV antibodies and HPV vaccination status. Immune protection against HAV and HBV was defined as the presence of antiHAV IgG index S/CO >1.00 and antiHBs IgG >10 IU/L, respectively. HPV vaccination status at baseline was assessed through the participants’ recall. Subsequently, we assessed vaccine prescription by physicians for nonimmune and unvaccinated participants, followed by a review of completion of vaccination. Vaccination schedules were considered complete after 2 doses for HAV with a time interval of 0 and 6 months; 3 doses for HBV with an interval of 0, 1 and 6 months; and 3 doses for HPV with an interval of 0, 2 and 6 months. Contrary to HAV and HBV vaccines, HPV vaccine was not accessible in the sexual health centre and had to be purchased from a private pharmacy. Finally, we assessed overall HAV, HBV immune status combining immune protection acquired in the past or by vaccination after PrEP initiation and HPV vaccine coverage. HPV vaccine completion was analysed by age groups ≤26 years old or >26 years old. If any information was missing, individuals were contacted by phone or email to determine whether vaccination had been performed and if not, the reason why. All clinical, biological and prescription data are routinely documented in an electronic health record (NADIS), for which all patients gave consent for the collection and use of their anonymised data after approval by the CNIL (French Data Protection Authority; CNIL authorisation number: 2085881). Statistical data are presented with total numbers and proportions and compared by a χ test. A p value <0.05 was considered statistically significant. A total of 591 PrEP users were analysed. All were MSM with a median age of 33 years (IQR 28–41), including 118 participants (20%) aged ≤26 years. At baseline (table 1), 57.7% (341/591) of PrEP users were immune against HAV and 73.4% (434/591) against HBV. Vaccines were prescribed for 93.2% (233/250) of HAV nonimmune and 87.2% (137/157) of HBV nonimmune participants. Vaccination was completed in 85.8% (200/233) and in 91.2% (125/137) individuals with a HAV and HBV vaccine prescription, respectively. Our results are consistent with other studies where HAV vaccination rates were high, especially among PrEP users. With regards to HPV, only 7 of the 591 (1.2%) individuals had been vaccinated before PrEP initiation, including 4/118 (3.4%) individuals aged ≤26 years. The prescription rate by physicians remained low throughout the study period at 26% (152/584) for all ages and 39.5% (45/114) for those ≤26 years. These results are in agreement with those of other studies which report infrequent HPV vaccination prescription by physicians. 6 Following prescription, the HPV vaccine completion rate was 54.6% (83/152) including 64.4% (29/45) in participants aged ≤26 years. Of 69 individuals who did not complete HPV vaccination despite prescription, 5 (7%) participants did not respond to the questionnaire and 64 (93%) reported the following reasons: forgetting to go to a pharmacy for vaccine delivery (n=29), not feeling at risk (n=20), lost prescription (n=6) and vaccine cost (n=9, all >26 y.o). Several factors may explain our findings: recentness of the French guidelines, vaccine cost and lack of motivation for HPV vaccination, as onethird of the participants described not feeling at risk for this viral oncogenic disease. Finally, combining immunity acquired in the past or by vaccination after PrEP initiation, the overall immune protection rate for these 591 MSM initiating PrEP was 91.5% for HAV, 94.6% for HBV and 15.2% for HPV, including 28% in the ≤26 years age group and 12% in the >26 years age group. Given the high burden of HPVattributable lesions in MSM compared with heterosexual men, a change in Letter