What are the HPV vaccination recommendations for adults ≥ 18 years, including age groups, dosing schedule, contraindications, and special considerations?

HPV Vaccination for Adults ≥18 Years

All adults through age 26 years who are not adequately vaccinated should receive catch-up HPV vaccination without need for shared decision-making, while adults aged 27-45 years may be considered for vaccination only through individualized shared clinical decision-making due to dramatically reduced effectiveness in this age group. 1, 2

Age-Based Vaccination Recommendations

Ages 18-26 Years (Routine Catch-Up)

• Catch-up vaccination is recommended for all persons through age 26 years who are not adequately vaccinated, regardless of sexual history or prior HPV exposure. 1
• This recommendation applies equally to all genders and sexual orientations. 1
• No shared clinical decision-making is required in this age group—vaccination should be offered routinely. 1, 2

Ages 27-45 Years (Shared Clinical Decision-Making Only)

• Catch-up HPV vaccination is NOT recommended for all adults aged 27-45 years. 1
• Instead, shared clinical decision-making is recommended for select individuals in this age range who are not adequately vaccinated. 1
• The American Cancer Society explicitly does NOT endorse vaccination for ages 27-45 years due to minimal benefit—extending vaccination to age 45 prevents only an additional 0.5% of cancer cases compared to stopping at age 26. 2
• The number needed to vaccinate increases from approximately 202 (routine program) to 6,500 to prevent one cancer case when extending to age 45. 2

Key factors favoring vaccination in the 27-45 age group include: 1, 2

• Having new sexual partners or anticipating new partners in the future
• Being a man who has sex with men (MSM)
• Being immunocompromised (HIV infection, solid organ transplant, immunosuppressive therapy)
• Having had few or no lifetime sexual partners (lower likelihood of prior HPV exposure)

Factors arguing against vaccination: 1, 2

• Being in a long-term, mutually monogamous relationship with no anticipated new partners
• Most sexually active adults have already been exposed to multiple HPV types

Age >45 Years

• HPV vaccines are not licensed for use in adults >45 years. 1

Dosing Schedule

Two-Dose Schedule (Started Before Age 15)

• For individuals who initiated vaccination before their 15th birthday, only 2 doses are required. 1, 3
• Administer the second dose 6-12 months after the first dose. 1, 3
• The critical determining factor is the age when the first dose was given, not when subsequent doses are administered—if vaccination started at age 14, the patient qualifies for the 2-dose schedule even if the second dose is given years later. 3

Three-Dose Schedule (Started at Age ≥15 Years)

• For individuals who initiate vaccination at age 15 years or older, 3 doses are required. 1, 3
• Administer doses at month 0, month 1-2, and month 6. 1, 3
• Minimum intervals: 4 weeks between doses 1 and 2; 12 weeks between doses 2 and 3. 3

Immunocompromised Individuals

• All immunocompromised persons require a 3-dose schedule regardless of age at initiation. 3, 2
• This includes individuals with HIV infection, solid organ transplant recipients, and those on immunosuppressive therapy. 3, 2

Interrupted Series

• If the vaccine series is interrupted, do NOT restart—simply continue from where you left off as soon as possible. 3
• There is no maximum time interval between doses; the vaccine does not "expire" or lose effectiveness if doses are delayed. 3

Current Vaccine Product

• Gardasil 9 (9-valent HPV vaccine) is the only HPV vaccine distributed in the United States since 2016. 1, 3, 2
• It protects against HPV types 6,11,16,18,31,33,45,52, and 58. 3, 2

Contraindications and Precautions

Absolute Contraindications

• History of immediate hypersensitivity to yeast or any vaccine component. 3

Precautions

• Defer vaccination for moderate or severe acute illness. 3
• Pregnancy: Vaccination should be delayed until after pregnancy; however, pregnancy testing is not needed before vaccination. 1
• If pregnancy is discovered during the vaccination series, postpone subsequent doses until after delivery. 3

Safe to Vaccinate

• Breastfeeding or lactating women can safely receive HPV vaccine. 1, 3

Special Considerations and Common Pitfalls

Prior HPV Exposure Is NOT a Contraindication

• History of genital warts, abnormal Pap test results, positive HPV DNA test, or known sexual activity are NOT contraindications to vaccination. 1, 4, 2
• Most sexually active adults have been exposed to some HPV types but not all vaccine types. 1, 2
• The vaccine will still protect against HPV types not yet acquired. 1, 4

No Pre-Vaccination Testing Required

• Do not perform HPV DNA testing, antibody testing, or Pap testing before vaccination. 1, 3, 2
• No clinical antibody test can determine whether a person is immune or susceptible to specific HPV types. 1

Prophylactic Only—Does Not Treat Existing Infections

• HPV vaccines are prophylactic only—they prevent new infections but do not treat existing HPV infections or HPV-related diseases. 1, 4, 2
• The vaccine will not clear existing genital warts or accelerate their resolution. 4

Cervical Cancer Screening Continues Unchanged

• Vaccination does not change cervical cancer screening recommendations—all women should continue screening according to existing guidelines regardless of vaccination status. 1, 3, 2
• The vaccine does not protect against all oncogenic HPV types. 3, 2

Co-Administration with Other Vaccines

• HPV vaccine can be administered at the same visit as other age-appropriate vaccines using separate syringes at different anatomic sites. 3

Post-Vaccination Observation

• Patients should sit or lie down for 15 minutes after vaccination due to risk of syncope, particularly in adolescents and young adults. 3

Why Effectiveness Declines with Age

• HPV acquisition typically occurs soon after sexual debut, with the highest infection rates in adolescents and young adults. 1, 2
• Approximately 24% of adolescents report sexual intercourse by 9th grade, and 58.1% by 12th grade. 3
• By the late teens and early 20s, most sexually active individuals have already been exposed to one or more vaccine-type HPV strains, reducing vaccine effectiveness. 1, 2
• The vaccine remains highly effective against HPV types not yet encountered, but the proportion of unexposed types decreases with age and number of sexual partners. 1, 2

Cancer Prevention Impact

• HPV vaccination prevents approximately 28,500-32,100 cancers annually in the United States, including virtually all cervical cancers, ~90% of anal cancers, ~70% of oropharyngeal cancers, and 60-70% of vaginal, vulvar, and penile cancers. 1, 3
• The vaccine also prevents ~90% of genital warts caused by HPV types 6 and 11. 3