Disappointing decision on HPV vaccination for boys (UK)

Marge Berer, RHM Editor

The Joint Committee on Vaccination and Immunisation (JCVI) advises the UK Department of Health on its vaccination programme and has been considering the question of whether to vaccinate boys against the Human Papillomavirus (HPV). Today it published its interim recommendations, which do not address a universal programme of vaccination for boys as well as girls.

Background

The UK currently has a programme of HPV vaccination for girls to prevent cervical cancer which is most commonly caused by infection with HPV.  Because it is important to vaccinate before they become sexually active and come into contact with the virus, the vaccination is offered to all girls aged 12-13 years  old.

In addition to cervical cancer, HPV is a factor in many other cancers including anal cancer, penile cancer, mouth cancer and oropharyngeal cancer, all of which affect men as well as women. People living with HIV are at higher risk of all these cancers. Under the current regime, there is no HPV vaccination programme for boys. Assuming men in the UK only have sex with women who have been vaccinated, they should be protected from HPV. However it is safe to assume that men in the UK may also have sex with:

  • women who missed out on vaccination because of their age (vaccination for girls was only introduced in 2008) or parental withdrawal from the scheme,
  • women from countries where there is no vaccination programme,
  • and other men

Recognising the range and seriousness of diseases that can be prevented, the Australian government introduced HPV vaccination for teenage boys in 2013. HPV action, a UK coalition of 35 health-related organisations, has been lobbying for the same ‘gender-neutral’ vaccination in the UK.

The interim decision of the JCVI, published today, is to advise that “a programme for the vaccination of MSM aged 16 to 40 years of age should be implemented in GUM and HIV clinics in the UK using the quadrivalent HPV vaccine, subject to the programme being provided at a cost-effective price”. This suggestion is shortsighted beyond comprehension.

The whole point of talking about the sexual health needs of MSM (men who have sex with men) as opposed to homosexual or gay men in the first place is because men who have sex with men don’t all only ever have sex with other men. As both men and boys, they also sometimes have sex with women. Given that universal vaccination of girls to prevent human papillomavirus (HPV) and genital warts has been accepted as a public health priority globally, surely universal vaccination of boys is equally a priority – since boys and men are at risk of an equally serious range of cancers and other diseases from HPV (especially if they have HIV), and they have genital warts as often as girls and women.

How could anyone have suggested, let alone seriously considered, vaccinating only MSM in the male population in the first place. What did they expect to do as regards adolescent boys – walk into schools and say “Which boys are having sex with other boys here? Raise your hands − and please come to the school clinic now.”??  Or even more absurd, how can they advise waiting until a boy or man attends an STI clinic in order to recognise they are at risk of HPV, and offer them a vaccination after the fact, when it may be too late! It also seems transgender people aren’t on the radar at all, in spite of findings from 15 countries in the Lancet Infectious Diseases in 20131 that 19% of transgender women have HIV(1), and transgender men also have a high HIV prevalence, which puts them at increased risk of HPV infection and HPV-related diseases.

Moreover, studies have shown that a female-specific vaccination approach would be only 60–75% as efficient at reducing HPV prevalence in women as a gender-neutral vaccination(2).

The only sensible policy is universal vaccination, from the same age as girls of 13, and with the same catch-up provisions for those who are older.

References

(1) Baral SD et al. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect Dis, 13: 214-22, 2013.

(2) Kubba T. Human papillomavirus vaccination in the UK: what about boys? RHM 16(32) 97-103

All RHM papers and research round ups on HPV are available to download here

Presentation on UK, Spain and Ireland for September 28th 2014

On September 25th RHM Editor, Marge Berer, participated in an evening meeting held to mark September 28th, International Day of Action for the Decriminalisation of Abortion. Delegates at the meeting held at Amnesty International heard from the Central American Women’s Network (CAWN) and Amnesty about the work both organisations are doing in El Salvador to draw attention to the impact of the total criminalisation of abortion on women’s health and human rights. Amnesty launched this report and CAWN screened Life at Any Price.

Marge Berer then did a presentation capturing latest developments in abortion law and policy in Ireland, Spain and the UK.

UK organisations and others send message of solidarity to Ireland

In the light of the recent case in Ireland (Miss Y) – in which a woman was subjected to multiple violations of her body and rights, amounting to cruel and degrading treatment, including refusal of abortion despite the risk of death, forced hydration, and coerced Caesarean section – we support calls in Ireland for the Government to repeal the 8th Amendment and to replace the Protection of Life in Pregnancy Act with a law that prioritises women’s health and rights. We believe it is not acceptable that an embryo/fetus has equal rights and constitutional protections to a woman; and even less acceptable that when those rights come into conflict the Irish medical and legal system prioritises the rights and life of the embryo/fetus over those of the woman.

We express solidarity with the rallies around Ireland on 20th August, (and the March for Choice, Saturday 27th September) and with:

  • Abortion Rights Campaign
  • Coalition to Repeal the 8th Amendment
  • Doctors for Choice
  • Lawyers for Choice
  • Termination for Medical Reasons (TFMR)                                                                                       and all those organisations and individuals supporting and campaigning for sexual and reproductive rights in Ireland.

Signatories

  • Lisa Hallgarten, Chair, Voice for Choice
  • Abortion Rights
  • Abortion Support Network
  • Dr Donatella Alessandrini, Reader in Law, Kent Law School
  • Alliance for Choice
  • Antenatal Results and Choices
  • APAC-Suisse, Association de professionnels de l’avortement et de la contraception
  • Nicola Barker, Senior Lecturer, Kent Law School
  • bpas
  • Brook, including Book Northern Ireland
  • Dr Ruth Cain, Lecturer in Law, Kent Law School
  • Dr Luis Eslava, Lecturer in Law, Kent Law School
  • FPA
  • John Fitzpatrick, Kent Law Clinic
  • Emily Grabham, Reader in Law, Kent Law School
  • Edward Kirton-Darling, LL.B, LL.M, Solicitor
  • Marie Stopes International
  • My Belly is Mine
  • Connal Parsley, Lecturer in Law, Kent Law School
  • Reproductive Health Matters
  • Sinéad Ring, Senior Lecturer, Kent Law School
  • Professor Sally Sheldon, Kent Law School
  • Hannah Uglow, Solicitor, Kent Law Clinic
  • Toni Williams, Professor of Law

Please get in touch: lhallgarten[at]rhmjournal.org.uk if you or your organisation would like to sign up

#Repealthe8th

#Iamnotavessel

Update: Guidelines on how to implement the ‘Protection of Life in Pregnancy Act’, were published by the Irish Department of Health on 19th September 2014. Paragraph 6.2 of the guidelines say:

“An important consideration in relation to the carrying out of the medical procedure is the issue of the gestational age of the unborn.

There is no time limit imposed by the Act in carrying out the medical procedure. However, the
Act legally requires doctors to preserve unborn human life as far as practicable without
compromising the woman’s right to life. Therefore, there is no specific stage of pregnancy
below which the certifying doctor will not have to consider the possibility of preserving the life
and the dignity of the unborn where practicable without compromising the life of the mother.
Once certification has taken place, a pregnant woman has a right to a termination of
pregnancy as soon as it can be arranged. The clinicians responsible for her care will need to
use their clinical judgment as to the most appropriate procedure to be carried out, in
cognisance of the constitutional protection afforded to the unborn, i.e. a medical or surgical
termination or an early delivery by induction or Caesarean section.
Following certification, if the pregnancy is approaching viability, it is recommended that a multidisciplinary discussion takes place to ascertain the most appropriate clinical management of the case.”

RHM calls for solidarity with groups in Ireland campaigning for reproductive rights

RHM sends message of solidarity to those in Ireland campaigning against the 8th Amendment and for women’s sexual and reproductive health and rights. We support the call for demonstrations across the world − 20 August

Solidarity Statement: 

It took the appalling and easily preventable death of Savita Halappanavar for the Irish government to find the courage to agree to change the Irish abortion law. However, despite the new law making provision for life-saving abortion, it has actually be used against a woman instead, the very first woman to seek an abortion under it − a young woman, 18 years old, an asylum seeker, with an undeniable case. The way she was treated, and the multiple ways in which her rights were violated, is beyond shocking.

Why the Irish Attorney-General failed to intervene on behalf of the young woman needs to be explained. On what legal grounds the Health Service Executive considered it their right to seek a court order to forcibly hydrate the young woman needs to be explained as well. The court judgement giving such permission and also giving permission for a forced caesarean section must be challenged after the fact; it sets an unethical, unconscionable precedent.

The hospital department in question should be shut down for multiple violations of this young woman’s human rights, for refusing to implement the abortion law, and for not referring her on to medical professionals who would have allowed an abortion in line with the new law. The medical professionals who committed these violations should have their right to practise medicine removed.

The new law was never going to help more than a few women every year, but to use it to violate – repeatedly − a young woman’s bodily integrity and autonomy, is akin to judicial and medical rape. It should be treated as a form of torture, and punished.

The government must allow a referendum on the 8th amendment. As with Savita, this case shows it is impossible to address the rights of the woman and the fetus equally. The law’s ambiguity cannot be allowed to stand. Meanwhile, doctors and psychiatrists in Ireland who are committed to women’s health and rights need to make themselves available for women in cases such as this one, who will otherwise have nowhere to turn for help when it is needed.

Support the rallies in:

Dublin - Wednesday 20th August, 18.00, beside The Spire

Galway - We are not vessels! Repeal the 8th Amendment! Wednesday 20th August at 18:00
Eyre Square, Galway City

Cork – Wednesday 18.00, Courthouse

Limerick Pro Choice will be holding an Open Meeting this Wednesday 20th August at 20:00 pm in the Cellar Door.

Belfast – Protest at the treatment of suicidal woman seeking abortion. Wednesday at 18.00
Belfast City Hall

Derry – Guildhall. Wednesday at 18.00

London - Irish Embassy 17 Grosvenor Place, London SW1X 7HR. Wednesday at 18.00

Berlin – Irish Embassy. Wednesday at 18.30

Auckland – Consulate General of Ireland. Wednesday 8.15 a.m.

History: 18 year old asylum seeker in Ireland raped, refused an abortion, threatened suicide, went on hunger and liquid strike, court order obtained by doctors to forcibly hydrate her and do a forced caesarean section at 24-25 weeks of pregnancy. 

This article from the Irish Times includes the woman’s own description of her treatment.

 

 

Are women in the UK clueless about contraception?

Lisa Hallgarten, RHM online editor

Findings from a recent survey of 1,500 women carried out by Bayer (manufacturer of a range of contraceptive products), confirm concerns that women in the UK do not have full access to information about all contraceptive methods and are not receiving a choice of methods from their GP or family planning doctor.

The press release on Bayer’s findings (which are yet to be published in full) announces that ‘Many UK Women Are Not Clued-Up When It Comes To Contraception’.  However, opportunities for women and men to learn more about, let alone access, contraception in the UK have been diminishing in recent years with sex and relationships education de-prioritised in many schools; dedicated family planning services closing; lack of dedicated family planning trained GPs or nurses in many GP surgeries; the premature demise of a government health promotion campaign which included well-received television adverts – encouraging people to talk to each other about less known contraceptive methods; and the closure of both the fpa helpline staffed by experienced family planning trained nurses, and the Brook helpline providing information specifically to young people.

In this context we know that women seeking contraception often ask to talk to their doctor about ‘going on the pill’ as a proxy for discussion of contraception and often doctors take this as a prompt to provide the pill rather than offer the full range of options. Whether this is due to limitations in time, budget constraints, their own preferences, or their own lack of training and knowledge is not captured in this survey.

Good quality contraceptive counselling allows a woman sufficient time and information to consider the right option for herself in the context of: her experience of menstruation and the meanings she attaches to menstruating; her lifestyle; her relationship(s) and frequency of sex; broader health issues; and her intentions regarding pregnancy in the immediate and near future. Not all doctors or family planning providers have the time, knowledge or skill to facilitate this decision-making process. Some doctors do not prescribe more expensive methods such as the patch or contraceptive ring. Meanwhile, there is still widespread ignorance about the potential for IUDs to be fitted up to 5 days after sex as a form of emergency contraception, and some doctors still erroneously believe that the IUD and IUS are not suitable for young or nulliparous women.

The National Institute for Health and Care Excellence (NICE) published guidelines on providing long acting reversible contraceptive methods in 2005, and its recommendations have been widely embraced by policy makers and some health providers. Ongoing research suggests that LARC methods are a good option for those who find user-dependent methods of contraception difficult to use consistently or who find it difficult to negotiate contraceptive use with partners. However, they are not suitable for all women, and promoting long acting methods should not preclude the offer of other methods which are considered less reliable, but may suit some women better. Research published in RHM clearly demonstrates the need to ensure that practitioners do not compromise their commitment to fully informed decision-making or to the rights of women to have methods removed in the event that they are no longer wanted or are causing unmanageable side effects. Practitioners also need to remember the humble condom and meet the ongoing need to promote dual protection, against HIV and STIs as well as pregnancy.

Much has been written about the economic benefits of investment in family planning, but there are no shortcuts. Given the pitfalls we are aware of in a relatively well-resourced health system (UK) where contraception is provided free to women of all ages, there are important lessons to be learned for agencies promoting or participating in the mass roll-out of contraception through initiatives such as FP2020. Health care providers must have the time, training and commitment to provide good quality contraceptive counselling. The full range of methods must be available to reflect the diverse needs of women.  All work must be grounded in a rights-based ethos: prioritising  women – not targets for contraceptive coverage. This is essential to safeguard against coercive practices, and poorly supported decision-making, both of which can lead to early removal or inconsistent use of methods and lack of future trust in, and engagement with, contraceptive and other essential health services.

A note from Marge Berer to potential applicants for the job of RHM Editor

RHM seeks to appoint a new editor in 2015 and the application process is now open. Founding Editor, Marge Berer, has written this note to potential applicants:

Being the editor of Reproductive Health Matters has been an incredible experience. I’ve not only been able to be a full-time editor in this job, but also a lecturer, sharing the knowledge that RHM has published, and a teacher of writing for publication. I’ve also always done this job as an active participant in the field and as an advocate for sexual and reproductive health and rights. In the 22 years since we started the journal, I’ve had the privilege of working with hundreds of the most amazing authors and peer reviewers anyone could hope to meet.

With readers in 186 countries and the support of RHM’s donors, boards and authors, RHM has become a much valued resource in the field for information, knowledge, perspectives, ideas for change on the ground, and recommendations for policy, services, research and action.
The world of journal publishing is increasingly complex and RHM faces a period of transition to online publishing and changes in relation to open access publishing that raise new and different equity-related issues from the past.

Funding will always present a challenge.

However, RHM’s unique perspective, determination to cover controversial, new and neglected issues and challenge orthodoxies is needed now more than ever. I look forward to welcoming someone with the passion and skill to meet these challenges who will take RHM into the future with new ideas and energy.

Details of the job and how apply

The future as envisioned by WHO for the post-2015 agenda: a serious regression from its long-standing commitments on sexual and reproductive health and rights

Marge Berer

Editor, Reproductive Health Matters

What has gone wrong at WHO? The Lancet’s Offline report (31 May)  of what they call “WHO’s definitive statement about the future it envisions for the post-2015 era of sustainable development” signals a serious regression by WHO away from championing its own policies of many years, and makes for a distressing read. Among the policies WHO should be promoting for the post-2015 agenda setting must surely be:

i) the right to the highest attainable standard of health, as one of the fundamental rights of every human being, a goal which has underpinned WHO’s work since it was founded in 1948,

ii) universal access to sexual and reproductive health and rights, and

iii) strengthening of health systems, taking into account the social and economic determinants of health.

“Universal access to sexual and reproductive health and rights” is in line with WHO’s 2004
Reproductive Health Strategy, approved by the 57th World Health Assembly  and reflects more than four decades of work by the Special Programme of Research, Development and Research Training in Human Reproduction (HRP), based at WHO, and most recently a resolution at the 67th World Health Assembly.

The most important international bodies and leaders currently support the inclusion of universal access to sexual and reproductive health as a crucial goal in its own right under the overarching health goal in the post-2015 agenda, and add reproductive rights to this also under gender equality. The Stockholm Statement of Commitment agreed by 260 Parliamentarians from 134 countries at the Sixth IPCI/ICPD Conference in April 2014 states that access to sexual and reproductive health and rights is an ‘indispensable component’ of the post-2015 development framework. On July 4th a letter from Parliamentarians around the world addressed to Dr Margaret Chan, Director General of the WHO, expressed their concern about the omission of reproductive health and ‘strongly’ support for the Stockholm statement.

Moreover, in consultation after consultation, numerous national and international civil society organisations have called for the inclusion of reproductive and sexual health and rights as an integrated whole as well.

It is a serious mistake on WHO’s part to try to bury this issue under Universal Health Coverage, where it will get lost in a sea of competing finance-oriented interests. To do so discounts the consistent support for these goals by the World Health Assembly as well as the work of countless WHO staff and expert advisors.

There are other indications of a systematic pushback and regression away from work on sexual and reproductive health and rights at WHO as well. It is not reflected as a priority in the 12th WHO Global Programme of Work, nor in the just published Health for the World’s Adolescents, an unprecedented omission. This cannot be taken lightly.

Friends of WHO must do everything they can to ensure WHO assumes its leadership role on these issues again and does not fall back on its longstanding commitments.