Adolescent HPV Vaccination: Empowerment, Equity and Ethics

Challenges affecting the roll-out and uptake of human papillomavirus (HPV) vaccination have been described in numerous countries. They include, among others, insufficient political will, inadequate involvement from healthcare professionals in recommending the vaccine, and resistance from certain groups who express a lack of confidence in or distrust of these vaccines. The present paper examines an ethical challenge that also has communication-related implications: the special attention to the principles and processes of informed consent that the authors argue is required in light of vaccination of adolescents against a disease that may have serious consequences much later in life.

The paper begins with an examination of what constitutes informed consent in the context of adolescent HPV vaccination and the implications for information provision and models of consent. Whether adolescents should have the right to self-consent for HPV vaccination is a subject of debate, despite it being an intervention for sexually transmitted infection (STI) prevention. Notably, "the benefits to individuals in terms of cancer prevention are not apparent until several decades later, once those adolescents have already reached the legal age of consent and when it may be too late to vaccinate. This is in stark contrast to vaccinations delivered in early childhood, which are primarily intended to protect against infections in the first few years of life, when children cannot reasonably be expected to make informed decisions about their healthcare." In light of available evidence, the authors assert that there is "a strong case favoring the active involvement of adolescents and the inclusion of their views in the informed consent process, even in jurisdictions where parental consent is the default requirement for general medical care."

Practical recommendations, as the authors frame them, are as follows:

• In settings where written consent is required and where there is legal basis, adolescents should be allowed to self-consent to HPV vaccination as a right. Alternatively, a dual consent approach with equal weight given to parent and adolescent decisions could be implemented.
• In all settings, adolescents, including those without decision-making capacity, should be adequately informed about the benefits and consequences of HPV vaccination, as well as what they should expect during the vaccination process. Information should be age-appropriate and should include considerations of the benefits and risks of vaccination, the consequences of a decision to vaccinate or not vaccinate, and the implications for cancer screening later in life.
• In the delivery of school-based HPV vaccination, issues of privacy could be an issue, as pregnancy status may need to be determined at the time of vaccination. The unintentional disclosure of this information could result in individuals being stigmatised. Anxiety resulting from the spread of rumours among students has also been reported by some studies. Thus, integrating respect for privacy as a key aspect in the processes of consent and delivery is key, as is better informing adolescents about what to expect during the vaccination process.

The authors subsequently discuss the consequences that these greater demands on the informed consent process have for both vaccine financing and gender-based vaccination policies in adolescents. For example, they point to analyses indicating that publicly funded HPV vaccination is likely to promote greater equity by affording proportionately greater health benefits to lower-income groups. Furthermore, particularly in settings where female HPV vaccination coverage is modest and difficult to increase, there may be a strong scientific case for extending vaccination to boys with the same financing mechanisms as those available for vaccinating girls. Notwithstanding these cost-effectiveness considerations, according to the authors, strong arguments exist for extending universal, publicly-funded HPV vaccination to adolescent boys based on principles of autonomy, social justice, and gender equity. One reason they cite is that "studies have found support for HPV vaccination of boys from community members, parents, and healthcare providers, who consider this an important way to emphasize boys' responsibilities toward sexual health and reduce gender-based stigma surrounding sexual activity....Indirectly, therefore, a gender-neutral approach promotes the moral norm of a shared responsibility in all adolescents regardless of gender, while reducing misconceptions of girls as having principal responsibility for HPV transmission and prevention, potentially increasing consent for vaccination and improving vaccine uptake."

In suggesting directions for future research, the authors observe that adolescents' potential role in promoting positive attitudes to vaccination - for example, through the sharing of positive vaccination experiences with unvaccinated peers - has received little attention and warrants further investigation. "Valuing and empowering adolescents in this way not only affirms their role as engaged and active contributors to decision making, but also fulfills a strategic objective of the Global Vaccine Action Plan that 'individuals and communities understand the value of vaccines and demand immunization as both their right and responsibility'."