Universal HPV vaccination and anal cancer screening take centre stage in push to eliminate HPV-associated cancers

Experts convened by the HPV Prevention and Control Board at its 18th technical meeting in Antwerp, Belgium, in June 2025 concluded that eliminating HPV-associated cancers will require extending prevention beyond the traditional focus on cervical cancer in women, combining universal HPV vaccination that includes boys with targeted anal cancer screening for the populations at highest risk. The meeting report, published in BMC Proceedings, synthesises the epidemiology, modelling evidence and country experiences discussed at the meeting.

The case for including men rests on a substantial and growing burden of disease. HPV causes approximately 148,072 cancer cases in men annually worldwide, a figure the meeting’s participants described as likely a substantial undercount, with conservative re-estimates suggesting around 180,000 cases per year. These cancers affect primarily the oropharynx, anus and penis. Oropharyngeal cancer is the most common HPV-associated malignancy in men, and incidence among males in high-income countries has more than doubled over the past 15 years, now exceeding that of cervical cancer in women; men are five times more likely to be diagnosed than women. Age-standardised incidence rates per 100,000 are highest in North America at 6.0, Europe at 5.5 and Oceania at 5.3.

Biological differences between sexes reinforce the argument for vaccinating boys. Men have lower seroconversion rates than women following natural genital HPV infection, suggesting prolonged susceptibility, and unlike in women, in whom HPV prevalence declines with age, oral and genital HPV prevalence in men remains relatively constant across age groups. Data from 64 studies covering approximately 29,900 men show wide variability in anal high-risk HPV prevalence by risk group: 74.3 percent among gay, bisexual and other men who have sex with men living with HIV, 41.2 percent among HIV-negative men who have sex with men, and 6.9 percent in HIV-negative men who have sex with women.

Direct trial evidence supports the superiority of universal over girls-only vaccination. Between 2007 and 2014, a community-randomised trial across 33 Finnish communities enrolled over 80,000 adolescents, randomising them to universal HPV16/18 vaccination, girls-only HPV16/18 vaccination or control hepatitis B vaccination, with overall coverage of 52 percent in girls and 29 percent in boys. In communities where both boys and girls were vaccinated, HPV16/18 prevalence was significantly reduced not only among vaccinated but also among unvaccinated females, and the herd effect was stronger in the universal arms than in girls-only arms. Prevalence of other high-risk types, including HPV18, 31, 33 and 35, was also markedly lower in the universal vaccination group. By contrast, girls-only and lower-coverage arms offered limited herd protection, leaving unvaccinated and marginalised women disproportionately affected. The meeting heard that even moderate-coverage universal vaccination can deliver substantial public health benefits within five years, and that modelling and ecological observations suggest elimination of the most oncogenic types, HPV16 and 18, may be feasible within 15 to 30 years if universal strategies are widely adopted.

Modelling analyses nonetheless identify high coverage in girls as the most efficient strategy for cervical cancer elimination specifically. The HPV-ADVISE transmission-dynamic model, calibrated to six core countries and mapped to 67 low- and middle-income countries and 40 high-income countries, found routine single-dose vaccination of 9-year-old girls to be the most efficient strategy, with adding boys offering limited additional benefit because of herd immunity conferred by high coverage in girls. Increasing coverage in girls from 40 to 80 percent yielded up to three times the reduction in cervical cancer cases compared with initiating vaccination in boys at the same coverage level. However, meeting participants stressed that cost-effectiveness is necessary but not sufficient for policy decisions: when equity, acceptability, programme resilience and the prevention of non-cervical cancers are incorporated, universal vaccination is justified on broader public health grounds, including reducing the projected incidence gap between low- and middle-income and high-income countries.

Global implementation remains uneven. By 2025, 149 of 194 countries had introduced HPV vaccine into national immunisation schedules, but 55 percent of girls worldwide still live in countries without an HPV vaccination programme. Average first-dose coverage rose modestly from 55 percent in 2021 to 62 percent in 2023, and only 16 countries achieved greater than 90 percent first-dose national coverage in 2023. The adoption of the WHO-recommended single-dose schedule has accelerated scale-up, with approximately 28 million girls and 6 million boys aged 9 to 14 receiving a first dose in 2023. Supply dynamics are shifting, with new manufacturers and technology transfers reshaping the market, and supply projected to stabilise at around 100 million doses annually, potentially peaking at 130 million under universal vaccination.

Country experiences presented at the meeting highlighted persistent equity gaps. In Scotland, where the school-based programme was introduced for girls in 2008 and extended to boys in 2019, uptake remains uneven: among pupils in the fourth year of secondary school in 2024/25, coverage was 75 percent in the most deprived areas compared with 91 percent in the least deprived, a gap that has increased substantially since the programme was extended to boys. In Cameroon, early pilot programmes demonstrated strong community engagement, with 74 percent of girls in Foumban and Edéa completing both doses, but the 2020 national rollout faced strong resistance from religious leaders and some healthcare professionals, and two years after launch 84 percent of health facilities were not offering HPV vaccination. A revamped strategy combining a single-dose schedule, extension to boys, periodic intensification of routine immunisation and renewed community partnerships improved coverage across all regions, with four regions reaching over 90 percent coverage in girls and around 40 percent in boys, although the report notes that the concurrent interventions make it difficult to attribute coverage gains to any single measure.

On secondary prevention, the meeting identified anal cancer screening as the most advanced non-cervical strategy warranting immediate attention. The pivotal ANCHOR study, a randomised controlled trial involving more than 10,000 individuals with HIV, demonstrated that treating biopsy-proven anal high-grade squamous intraepithelial lesions through office-based electrocautery reduced progression to anal cancer by 57 percent compared with active monitoring. Notably, 53 percent of men, 47 percent of women and 67 percent of transgender individuals screened were diagnosed with high-grade lesions, highlighting the high prevalence of precancerous lesions in these populations. In the monitoring arm, progression from high-grade lesions to cancer occurred at a rate of 400 per 100,000 person-years, and the risk of progression was 5.26-fold higher for lesions involving more than 50 percent of the anal or perianal canal compared with smaller lesions, providing an early basis for lesion-based risk stratification.

Implementation of anal screening remains constrained despite the publication in 2024 of the first evidence-based guidelines from the U.S. Health and Human Services and the International Anal Neoplasia Society. Barriers include limited high-resolution anoscopy capacity, workforce shortages, stigma, and limited evidence on optimal screening algorithms, with all current screening recommendations based on expert opinion rather than prospective evidence. In the United States, only 22 percent of people in HIV care received care at facilities with on-site high-resolution anoscopy, and one-third attended clinics with no known access to such services. Experiences from Puerto Rico, where over 1,400 patients have been evaluated at the Anal Neoplasia Clinic of the University of Puerto Rico Comprehensive Cancer Centre since 2014, and from Belgium, where an estimated 9,500 people living with HIV aged over 50 and up to 235,000 men who have sex with men and transwomen over 45 may require regular screening, illustrate both the growing demand and the bottlenecks in trained personnel and coordination.

The meeting concluded that integrating universal vaccination with targeted anal cancer screening, supported by equitable access, biomarker development, self-sampling approaches and living guidelines that evolve with emerging evidence, is essential to reducing the HPV-related cancer burden in both women and men. Participants emphasised that vaccinating boys will not protect hard-to-reach girls, since people often partner within their ethnic or social circles where similar barriers to vaccination exist, and that sustained investment in communication, community engagement and workforce training will be required to translate these strategies into population-level impact.

Subject of Research: Universal HPV vaccination and anal cancer screening for the elimination of HPV-associated cancers

Article Title: Elimination of HPV-associated cancers: universal HPV vaccination and the role of anal screening – a meeting report

Article References: Burdier, F. R., Bruni, L., Giuliano, A. R., Mugo, N. R., Roy, K., Palefsky, J. M., Burchell, A. N., Roelandt, P., Baay, M., Man, I., Baussano, I., Waheed, D.-E.-N., & Vorsters, A. (2026). Elimination of HPV-associated cancers: universal HPV vaccination and the role of anal screening – a meeting report. BMC Proceedings, 20(S33), Article 36. https://doi.org/10.1186/s12919-026-00393-1

Image Credits: AI Generated

DOI: 10.1186/s12919-026-00393-1

Keywords: HPV, HPV vaccination, anal cancer screening, cervical cancer elimination, herd protection, ANCHOR trial, high-grade squamous intraepithelial lesions, men who have sex with men, HIV, high-resolution anoscopy, vaccine equity, HPV Prevention and Control Board