What are the current human papillomavirus (HPV) vaccination guidelines, including recommended ages, dosing schedules (2‑dose vs 3‑dose), contraindications, and recommendations for adults aged 27‑45 years?

Current HPV Vaccination Guidelines

Routine Vaccination Ages and Initiation

HPV vaccination should be routinely initiated at age 11–12 years, though it can begin as early as age 9 years, with strong encouragement to start at ages 9–10 to achieve higher on-time vaccination rates and maximize cancer prevention. 1

• The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination at age 11 or 12 years for all individuals regardless of gender. 1
• Vaccination can be started as early as age 9 years. 1
• The American Cancer Society specifically encourages providers to offer the vaccine series at age 9 or 10 years to increase on-time vaccination rates, which leads to greater numbers of cancers prevented. 1

Dosing Schedules: 2-Dose vs 3-Dose

The number of doses required depends on the age at which the series is initiated, not the age when subsequent doses are given.

2-Dose Schedule

• For persons initiating vaccination before their 15th birthday: Only 2 doses are required, administered at 0 and 6–12 months. 1, 2
• The age at the first dose determines eligibility for the 2-dose schedule. 2

3-Dose Schedule

• For persons initiating vaccination on or after their 15th birthday: 3 doses are required at 0,1–2 months, and 6 months. 1, 2
• Minimum intervals: 4 weeks between doses 1 and 2, and 12 weeks between doses 2 and 3. 2
• For immunocompromised individuals (HIV infection, solid-organ transplant recipients, those on immunosuppressive therapy): A 3-dose series is required regardless of age at initiation. 2

Series Interruption

• If the series is interrupted, do not restart; resume with the remaining doses as soon as possible with no maximum allowable interval. 2

Catch-Up Vaccination Through Age 26

Catch-up HPV vaccination is universally recommended for all persons through age 26 years who are not adequately vaccinated, with no need for shared clinical decision-making. 1, 2

• This recommendation applies to all individuals regardless of gender, sexual orientation, behavioral risk factors, or prior HPV exposure. 1
• Providers should inform individuals aged 22–26 years who have not been previously vaccinated that vaccination at older ages is less effective in lowering cancer risk due to likely prior HPV exposure. 1

Adults Aged 27–45 Years: Divergent Guidance

Catch-up HPV vaccination is NOT universally recommended for adults over age 26 years.

ACIP Position (2019)

• Shared clinical decision-making is recommended for some adults aged 27–45 years who are not adequately vaccinated. 1
• HPV vaccines are not licensed for use in adults over age 45 years. 1

Factors Favoring Vaccination in Ages 27–45

• New or anticipated sexual partners (having a new sex partner is a risk factor for acquiring new HPV infection). 1
• Few lifetime sexual partners (less likely to have been exposed to vaccine-type HPV). 2
• Men who have sex with men. 2
• Immunocompromised status (HIV, solid-organ transplant, immunosuppressive therapy). 2

Factors Against Vaccination in Ages 27–45

• Long-term mutually monogamous relationship with no anticipated new partners. 1
• Most sexually active adults have already been exposed to multiple HPV types by this age. 1
• Vaccine effectiveness is substantially lower due to prior infections; some previously exposed adults will have developed natural immunity. 1

American Cancer Society Position (2020)

The American Cancer Society does NOT endorse the ACIP recommendation for shared clinical decision-making in ages 27–45 years. 1

• Extending vaccination to age 45 prevents only an additional 0.5% of cancer cases compared with stopping at age 26. 2
• The number needed to vaccinate increases dramatically from approximately 202 (routine program) to 6,500 to prevent one cancer case when extending to age 45. 1, 2
• The ACS cites low effectiveness, minimal cancer prevention potential, burden of decision-making on patients and clinicians, and lack of sufficient guidance on selecting individuals who might benefit. 1

Current Vaccine Product

Gardasil 9 (9-valent HPV vaccine, 9vHPV) is the only HPV vaccine distributed in the United States since 2016. 1, 2

• It protects against HPV types 6,11,16,18,31,33,45,52, and 58. 2
• These types are responsible for approximately 92% of HPV-attributable cancers in the United States (32,100 of 34,800 annual cases). 1

Contraindications and Precautions

Absolute Contraindication

• Immediate hypersensitivity to yeast or any vaccine component. 2

Precautions

• Defer vaccination in persons with moderate or severe acute illness. 2

Pregnancy

• HPV vaccination should be delayed until after pregnancy is completed. 1
• Routine pregnancy testing before vaccination is not required. 1
• If pregnancy is discovered during the series, postpone subsequent doses until after delivery. 2

Breastfeeding

• Lactating individuals can safely receive HPV vaccine. 1

NOT Contraindications

• History of genital warts, abnormal cytology, positive HPV DNA testing, or prior sexual activity are NOT contraindications to vaccination. 2

Administration and Safety

• Administer intramuscularly in the deltoid or anterolateral thigh. 2
• Recipients should remain seated or supine for 15 minutes post-vaccination due to syncope risk, especially in adolescents and young adults. 2
• HPV vaccine may be co-administered with other age-appropriate vaccines using separate syringes and different anatomic sites. 2
• The most common adverse effects are local injection site reactions. 3

Critical Clinical Considerations

No Pre-Vaccination Testing Required

No pre-vaccination testing (Pap test, HPV DNA test, or antibody testing) is recommended to establish appropriateness of HPV vaccination. 1, 2

• No clinical antibody test can determine whether a person is already immune or still susceptible to any given HPV type. 1

Prophylactic Only

HPV vaccines are prophylactic—they prevent new HPV infections but do not treat existing infections, prevent progression of current infections to disease, or decrease time to clearance of HPV infection. 1, 2

Cervical Cancer Screening Unchanged

All women should continue routine cervical cancer screening per existing guidelines regardless of vaccination status. 1

• The vaccine does not protect against all oncogenic HPV types. 2

Cancer Prevention Impact

• HPV vaccination prevents approximately 28,500–32,100 cancers annually in the United States. 1, 2
• This includes virtually all cervical cancers, ~90% of anal cancers, ~70% of oropharyngeal cancers, and 60–70% of vaginal, vulvar, and penile cancers. 2
• The vaccine also prevents about 90% of genital warts caused by HPV types 6 and 11. 2

Common Pitfalls to Avoid

• Do not delay vaccination waiting for the "ideal" age of 11–12 years—starting at age 9 or 10 improves on-time completion rates. 1
• Do not require pre-vaccination testing—it is not recommended and provides no useful information for decision-making. 1, 2
• Do not withhold vaccination from sexually active individuals—the vaccine remains effective against HPV types not yet encountered. 2
• Do not assume vaccination eliminates the need for cervical cancer screening—screening must continue per guidelines. 1
• For ages 27–45, recognize the substantial decline in effectiveness—most benefit occurs with adolescent vaccination, and extending to this age group prevents minimal additional cancers. 1, 2