STI Quarterly

HPV vaccine update: No association between shot, risky sexual behavior

Continue to counsel: Shot does not protect against other STIs

Good news: Results of a cross-sectional analysis of young women interviewed as part of the National Survey of Family Growth who received recommended vaccinations to prevent human papillomavirus (HPV) infection found no association between HPV vaccination and risky sexual behavior.1

The analysis was designed to examine sexual behavior and demographic correlates of HPV vaccine initiation from the national survey; a total of 1,243 females ages 15-24 responded to questions about receiving the HPV vaccine.

Early in the HPV vaccine delivery process, reports were received that many parents were concerned that receipt of the HPV vaccine would lead to increased sexual risk among vaccinated youth, observes Nicole Liddon, PhD, a health scientist in the Division of Adolescent and School Health at the Centers for Disease Control and Prevention (CDC). Investigators undertook the analysis to determine if such an association exists, explains Liddon, who served as lead author of the study. If the data proved positive, a public health approach would need to be developed to counteract it, she observes.

HPV vaccination was not associated with being sexually active or number of sex partners at either age range (ages 15-19, ages 20-24), researchers note. Another positive note: Among sexually active adolescents ages 15-19, those who received HPV vaccine were more likely to always wear a condom, results indicate.1

"The data that we have is all preliminary in that it is all cross-sectional data," notes Liddon. "We don't know if there is a cause and effect with vaccine and increased sexual risk, but we found no association between the two."

Talk about STI protection

When talking with adolescents about the HPV vaccine, be sure to counsel that the HPV vaccine works by preventing the most common types of HPV that cause cervical cancer and genital warts, but it does not provide protection against other sexually transmitted infections (STIs). (See article below right for information on who should receive the HPV vaccine.)

Researchers enrolled patients ages 13-21 attending a Cincinnati Children's Hospital Medical Center adolescent primary care office to see if adolescent attitudes toward safer sexual behaviors would change after vaccination, says Tanya Kowalczyk Mullins, MD, MS, assistant professor of pediatrics in the Division of Adolescent Medicine at Cincinnati Children's Hospital Medical Center. The primary outcome measures were scales assessing perceived risk of HPV, perceived risk of other STIs, and perceived need for safer sexual behaviors. Each scale had a possible mean scale score of 0-10, with lower numbers indicating lower perceived risk of HPV/STI and less need for safer sexual behaviors.2

Results of the cross-sectional baseline analysis, derived from an ongoing longitudinal cohort study, suggest that most girls understood that the vaccine does not protect them from STIs other than HPV, says Mullins, who served as lead author of the current research. "The vast majority of girls still plan to practice safer sex after getting their first HPV vaccination," reports Mullins. "Our findings are very reassuring. The vast majority of girls understand that safer sex is still important after getting their first HPV vaccination."

Researchers note that while it is appropriate for girls receiving the vaccine to perceive themselves to be at less risk for HPV after vaccination, it is concerning that a small subset of girls also perceived themselves to be at less risk for other STIs; 23.6% of study participants reporting perceived risk of STIs in the lower half of the scale.

Clinicians discussing HPV vaccination with girls and their mothers might need to emphasize the limitations of the vaccine and to specifically address that the vaccine does not prevent other STIs, researchers note. Further studies are needed to examine the association between risk perceptions after HPV vaccination and future sexual behavior.2

Reimbursement a factor

Does reimbursement for the HPV vaccine play a factor in your practice? Findings from a recent survey of Virginia gynecologists and family practitioners indicate reimbursement concerns might have a negative impact on doctors' recommendation of the HPV vaccine.3 The cross-sectional survey questionnaire was mailed to 500 family practitioners and 500 gynecologists. After exclusion of ineligible physicians, 385 of 790 doctors responded.

The cost of the full HPV shot series runs just under $400. While many private insurers cover the immunization series, which is included in the CDC's Advisory Committee for Immunization Practices guidelines, policies vary in the age of the coverage, the reimbursement levels paid by different payers, and the out-of-pocket costs faced by healthcare consumers.4

Statistics show 13% of girls ages 9-18 and 27% of women ages 19-26 years old are uninsured. For those younger than age 19, HPV vaccines are included in the Vaccines for Children (VFC) program. Medicaid also includes the HPV vaccine as part of its early and periodic screening diagnosis and treatment program for women ages 19 and 20. For those age 21 years and older, vaccine coverage is an optional benefit and is decided on a state-by-state basis.4


  1. Liddon NC, Leichliter JS, Markowitz LE. Human papillomavirus vaccine and sexual behavior among adolescent and young women. Am J Prev Med 2012; 42:44-52.
  2. Mullins TL, Zimet GD, Rosenthal SL, et al. Adolescent perceptions of risk and need for safer sexual behaviors after first human papillomavirus vaccination. Arch Pediatr Adolesc Med 2012; 166:82-88.
  3. Young JL, Bernheim RG, Korte JE, et al. Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists. J Pediatri Adolesc Gynecol 2011; 24:380-385.
  4. Henry J. Kaiser Family Foundation. The HPV Vaccine: Access and Use in the U.S. Fact sheet. Accessed at

Who should get the HPV vaccine?

According to the Centers for Disease Control and Prevention (CDC), the human papillomavirus (HPV) vaccines Gardasil (Merck & Co.) and Cervarix (GlaxoSmithKline) are licensed, safe, and effective for females ages 9-26.

The CDC recommends that all 11- or 12-year-old girls receive the three doses of either brand of HPV vaccine to protect against cervical cancer. Gardasil also protects against most genital warts, as well as some cancers of the vulva, vagina, and anus. Girls and young women ages 13-26 should receive the HPV vaccine if they have not received any or all doses when they were younger, advises the CDC.

Gardasil is also licensed, safe, and effective for males ages 9-26. The CDC recommends Gardasil for all boys aged 11 or 12, and for males aged 13-21, who did not get any or all of the three recommended doses when they were younger. All men may receive the vaccine through age 26 and should speak with their provider to find out if getting vaccinated is right for them.

The vaccine is also recommended for gay and bisexual men (or any man who has sex with men) and men with compromised immune systems (including HIV) through age 26, if they did not get fully vaccinated when they were younger, according to the CDC.


Centers for Disease Control and Prevention. HPV Vaccine -- Questions & Answers. Accessed at