• Vaccines
• HIV

In March 2022, we learnt from a senior technical advisor to the Kenyan Ministry of Health that there was an excess in the country’s supply of Gardasil human papillomavirus (HPV) vaccine due to low uptake among their target group of adolescent girls and young women (AGYW),1 with many doses close to their expiry date. We contacted a county health unit to inquire about securing the vaccines for men who have sex with men (MSM), as local private clinics were beginning to advertise and promote HPV immunisation services for boys and young men. Although licensed for use among females and males in the country (see figure 1), the HPV vaccine is freely available in Kenya only to AGYW. The health official’s response was blunt and decisive. ‘They are earmarked for AGYW and we don’t even have enough for them!’ In this commentary, we, care providers at an MSM HIV/STI clinic and allies, call attention to the urgent need to include MSM in Kenya’s HPV immunisation programme—the immediacy of which speaks to other African contexts where anti-gay discrimination hinders availability of and access to health services.2 3

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Figure 1

Billboard sponsored by a private hospital in Nairobi to promote HPV immunisation services for cancer prevention among boys and girls.

Since 2016, our team has been collecting clinical programme data on anal diseases in collaboration with Health Options for Young Men on HIV/AIDS/STIs (HOYMAS), an organisation serving MSM in several Kenyan counties. At the time we approached the county health unit, our clinic had recently assessed and cared for 21 patients with cases of HPV-related anal warts requiring surgical intervention over a 2-month period, while the waitlist of referrals from across the country continued to grow. Between 2016 and 2019, an alarming 7% of the >5000 programmatic cohort participants presented with severe, often recurring, cases of anal warts. These late-stage diseases are likely caused by anal HPV infections coupled with compromised immune systems from HIV coinfections. Although normally caused by HPV 6 and 11 genotypes and classified as low risk for anal cancer, clinicians and outreach workers noted the growing frequency, persistence and late presentation of anal warts that manifest as large, sometimes obstructive, masses requiring medical intervention. These surgeries are accompanied by long recoveries, painful suffering and income losses for those surviving by selling sex. Anal cancers, which we are only beginning to track, were also detected at late stages. Between 2016 and 2019, 239 MSM in Nairobi underwent surgery, 72 of whom had a recurrence requiring additional surgical intervention. In total, this has cost HOYMAS more than $60 000 GBP and the waitlist has overwhelmed the health service delivery system they created for surgeries and for safe, discreet recovery in their former AIDS hospice.

The well-established relationship between HIV and HPV infections sheds light on the prevalence, severity and re-occurrence of anal diseases among Kenyan MSM.4 In 2008, MSM, including male sex workers, living with HIV, began to attend clinics for female sex workers run by our clinical team members in Nairobi. Local activists soon initiated a collaboration with us to assemble a programme to better understand why their community was facing such high rates of HIV. By 2010, these activists established HOYMAS to respond to the sexual health needs of their community and observed 40% HIV prevalence among more than 500 MSM.5 Despite the provision of risk-reduction counselling and the distribution of condoms and lubricant, many HIV negative participants seroconverted in the first 2 years of follow-up—resulting in an alarming annual incidence of 12 per 100 person-years.5 Our team then undertook a community-based study to identify a constellation of factors around the HIV vulnerability of these men: experiences of violence, discrimination, lack of housing, heavy drinking and mental health struggles.6 7 By confronting these risk factors, introducing new prevention technologies such as pre-exposure prophylaxis, and scaling-up efforts to test and treat MSM sooner to foster population-level viral suppression8—we have seen a recession in HIV incidence. However, HIV prevalence remains high with 25% in Nairobi and 18% nationally.9 10 Persistent high HIV prevalence, coupled with the pervasiveness of anal diseases, indeed points to the vulnerability of this group to anal cancer.

MSM have only recently been included in HPV screening and vaccination programmes worldwide, owing to the longstanding linkage between HPV and cervical cancer and its early mischaracterisation as solely a women’s health problem—what Daley et al describe as the ‘feminisation of HPV’.11 It is now well established that MSM are at high risk for HPV-related anal infections and cancers, especially those living with HIV, and they are not likely to benefit from population immunity provided by a female vaccination strategy. Current global immunisation guidelines recommend HPV vaccination for men and women living with HIV up to and including 26 years of age and for MSM living with HIV up to and including 45 years of age. Although high prevalence of HPV, including oncogenic genotypes, has been found among African MSM,12–14 their prevention and treatment needs are largely omitted in HPV programming, including vaccination campaigns. In Kenya, vaccine licensing in males does not necessarily ensure accessibility, without locally informed planning, policy updating and evidence-based implementation.

Aiming to avoid the fallout that occurred in Europe and North America after Gardasil’s early promotion as preventive against a sexually transmitted infection among youth,15 HPV has been framed as a reproductive health issue in Kenya, with a particular emphasis on preventing cervical cancer given the extremely high rates found among females in sub-Saharan Africa. Between 2012 and 2013, scientists rolled out a demonstration programme in Eldoret, Kenya to explore HPV vaccine uptake among AGYW.16 Although providing an important foundation for immunising a group highly vulnerable to cancer, the project offers limited insight into programming for a subpopulation of men who encounter unique health service barriers. Exclusions of MSM are also reflected in Kenya’s 2018 National Cancer Screening Guidelines that narrowly recommends HPV vaccination to AGYW and cervical cancer screening of women aged 25–49.17 No mention is made of the vulnerability of MSM to HPV-related precancerous anal lesions or anal cancers. Such neglect is further evident in the current National HIV Key Populations Guidelines, which do not recommend anal cancer screening programmes. Given the extension of life expectancy through antiretroviral programmes for African MSM living with HIV, such exclusions raise important questions amid rising cancer rates in the shadow of the HIV epidemic.18

Amid dwindling global HIV prevention funding for key populations, which supports programmes like those run by HOYMAS, HPV prevention through vaccination, as well as early detection and treatment, are paramount as a sustainable solution. On the horizon, there are promising developments around anal healthcare proposed by The Global Fund to Fight AIDS, Tuberculosis and Malaria. With respect to Kenya, the most recent Global Fund proposal included the provision of anal healthcare services, with explicit mention of HPV vaccination and anal cancer screening. To ensure that there is movement from policy discussion to decisive action, global health stakeholders must commit to the creation of early detection and treatment programmes and advocate for the expansion of vaccine access to include this highly vulnerable group.