Mixed-methods study in England and Northern Ireland to understand young men who have sex with men’s knowledge and attitudes towards human papillomavirus vaccination

Objectives Men who have sex with men (MSM) are at greater risk for human papillomavirus (HPV)-associated cancers. Since 2016, MSM have been offered the HPV vaccination, which is most effective when received prior to sexual debut, at genitourinary medicine clinics in the UK. In September 2019, the national HPV vaccination programme will be extended to boys. This study aimed to understand young MSM’s (YMSM) knowledge and attitudes towards HPV vaccination. Design Questionnaires assessed YMSM demographics, sexual behaviour, culture, knowledge and attitudes towards HPV vaccination and stage of vaccine decision-making using the precaution adoption process model. Focus groups explored sexual health information sources, attitudes, barriers and facilitators to vaccination and strategies to support vaccination uptake. Questionnaire data were analysed using descriptive statistics and focus group data were analysed thematically. Setting Questionnaires were completed online or on paper. Focus groups were conducted within Lesbian Gay Bisexual Transgender Queer organisational settings and a university student’s union in England and Northern Ireland. Participants Seventeen YMSM (M=20.5 years) participated in four focus groups and 51 (M=21.1 years) completed questionnaires. Results Over half of YMSM were aware of HPV (54.9%), yet few (21.6%) had previously discussed vaccination with a healthcare professional (HCP). Thematic analyses found YMSM were willing to receive the HPV vaccine. Vaccination programmes requiring YMSM to request the vaccine, particularly prior to sexual orientation disclosure to family and friends, were viewed as unfeasible. Educational campaigns explaining vaccine benefits were indicated as a way to encourage uptake. Conclusions This study suggests that to effectively implement HPV vaccination for YMSM, this population requires clearer information and greater discussion with their HCP. In support of the decision made by the Joint Committee on Vaccination and Immunisation, universal vaccination is the most feasible and equitable option. However, the absence of a catch-up programme will leave a significant number of YMSM at risk of HPV infection.


Strengths and limitations of this study
• This is the first study in the UK to explore YMSM's knowledge and attitudes toward HPV vaccination.
• Use of a theoretical model of behaviour change, facilitates clear conceptualisation of health behaviour change and YMSM's stage of HPV vaccine decision making.
• The qualitative component obtained a diverse range of views of YMSM in England and Northern Ireland.
• Survey findings should be interpreted with caution due to the sample size.

Introduction
Human papillomavirus (HPV), the most common sexually transmitted infection (STI) worldwide 1 , has serious health consequences for men and women. HPV is recognised as a causative agent in cervical cancer, and is associated with anogenital tumours, oropharyngeal cancers, and genital warts 2 .
While boys and girls aged 12-13 years are vaccinated in school in Australia 3 4 , the current United Kingdom (UK) strategy of vaccinating all girls aged 12-13 years does not protect young men-whohave-sex-with-men (YMSM) against HPV infection and related diseases 5 as they will not benefit from herd immunity 6 .
The UK Joint Committee on Vaccination and Immunisation's (JCVI) statement on MSM HPV vaccination 7 recommended that vaccination programmes be extended to MSM aged up to 45 years via Genitourinary Medicine (GUM) clinics. Mathematical modelling suggests that for MSM aged 40 or over, HPV vaccination in GUM clinics is likely to be an effective and cost-effective method of reducing HPV-related disease burden in MSM in England 8 and elsewhere. Northern Ireland, Scotland and Wales are offering the HPV vaccine to MSM attending GUM clinics. Following a pilot programme in England which found moderate uptake and did not report completion rates, vaccination is now offered in GUM clinics. The JCVI are also considering whether to extend the adolescent female vaccination programme to all males. An interim statement (July 2017) suggested that given the current high uptake in females, extending immunisation to all adolescent males is "highly unlikely to be cost effective in the UK" (p13) 9 , although in November 2017, the final decision was delayed, and it is understood that further modelling is underway 10 .
The absence of a vaccination programme for all adolescent boys leaves UK YMSM without funded access to the HPV vaccine at the recommended age (12-13 years) -before exposure to HPV 11 . There is often a delay between the age of first sexual contact with another man and disclosure of sexual orientation to a healthcare professional (HCP) 12 , and it is likely that MSM will have multiple sexual partners, resulting in increased risk of HPV acquisition before attending a GUM clinic 13 . The benefit of a targeted programme may be limited due to the likelihood that many MSM acquire HPV in their teenage years 13 . As not all MSM access GUM clinics, this setting may lead to insufficient vaccination coverage. Modelling work in Australia indicated that a HPV vaccination programme targeting boys only with at least 84% coverage would reduce HPV infection in MSM by 90% 14 .
A systematic review found that MSM HPV vaccine knowledge was low and MSM did not consider themselves at risk of infection, although over half would accept the vaccine if offered 11 . Most of these studies were conducted in North America (and none in the UK), with MSM over 26 years.
Minimal attention has been given to the knowledge and attitudes toward HPV vaccination among adolescent and YMSM (aged 16-24 years). This is an important area for research because MSM may acquire HPV at a young age, close to their sexual debut (the age of which is decreasing) 13 . This study aimed to examine the knowledge and attitudes of UK YMSM towards HPV vaccination to inform policy and practice recommendations for accessing this hard to reach group, supporting vaccination uptake and the optimisation of protection from HPV.

Study design
We conducted questionnaires and focus groups with YMSM aged 16-24 years.

Participant eligibility and recruitment
The survey was administered online and advertised via various LGBTQ organisations. In addition, prior to the focus groups, participants were asked to complete the questionnaire. We have combined both the online and pen and paper completions for this paper. We aimed to achieve data saturation 22 by recruiting 8-10 YMSM per focus group with a mix of social background, age, ethnicity, and religion. YMSM was defined through self-identification as male (including transgender male), at or over the age of sexual consent, sexually attracted to men, or had sex with a man 13 . Age inclusion criteria were based on the World Health Organisation's definition of "young": 15 -24 years. A minimum of 16 years was specified as it is the age of sexual consent in the UK.
For the focus groups, potential participants were provided with written study information, and asked to register their interest at local Lesbian Gay Bisexual Transgender Queer (LGBTQ) advocacy groups, university information days, university student union clubs and societies, and secondary school LGBTQ groups. Advocacy groups advertised the study through social media and snowball sampling was employed.
Data collection CF conducted the focus groups within LGBTQ organisational settings and a university student's union building.
The questionnaires (Supplementary Material A) assessed demographics (adapted from Hickson et al.) 15 ; sexual behaviour (adapted from Sadlier et al.) 16 ; culture (adapted from Zou et al.) 17 ; and HPV vaccine stage of decision making using the Precaution Adoption Process Model (PAPM) 18 . The PAPM has six stages of behaviour change decision-making and has been used to examine knowledge and attitudes to HPV vaccination 19 . Those who indicated awareness of the HPV vaccine, were asked to complete validated HPV knowledge/attitudes scales 20 21 .
The focus group topic guide (Supplementary Material B) was applied flexibly to allow for emergent issues and began by exploring sources of sexual health information and advice before engaging in sexual activity (not presented here). Perceptions of HPV risk in relation to six other STI's were then discussed using a sorting task in which a list of STIs were ordered by what is least to most concerning (findings not reported here). Attitudes towards HPV vaccine, barriers and facilitators to vaccination and possible intervention strategies to support vaccination uptake were explored. Experiences of disclosing sexual orientation to HCP were also discussed. All participants were informed that the HPV vaccine was most protective if received prior to first sexual encounter. Participants were asked to reflect as to how they would have viewed taking the vaccine when they were 12-13 years.

Patient and Public Involvement
The HPV knowledge/attitude questionnaire scales were adapted for use with MSM through consultation with an Expert Panel including a key stakeholder group (The Rainbow Project [TRP]) and MSM focus groups.
YMSM were not involved in the development of the qualitative component of this study, however staff from the TRP helped develop the study design and documentation.

Analysis
Participants' PAPM vaccine decision-making stage was classified into six stages: unaware, unengaged, undecided, decided not to vaccinate, decided to vaccinate and those who had already been vaccinated 19 . Knowledge and attitudes held by participants about HPV and HPV vaccination were analysed using descriptive statistics.
Focus groups were audio recorded, transcribed verbatim, anonymised and analysed thematically 23 using QSR NVivo (version 10.0). This approach was chosen because it offers a clear analysis process while remaining flexible 23 . JK and CF independently coded the first transcript systematically, lineby-line, compared their coding and reached consensus. These initial codes were then applied to the remaining transcripts. The content of all the codes was read and compared to each other to iteratively

Participant characteristics
Between September 2016 and March 2018, questionnaires were completed by 51 YMSM. Four focus groups in Northern Ireland (n=3) and England (n=1) were conducted between September and December 2016 with 17 YMSM (Table 1). Focus group size ranged from 2-6 participants and lasted a mean of 44.34 minutes (range=40.4-50.4). The majority (n=49) were sexually active and reported both oral and anal intercourse in the past 12 months (n=35), a wide range of partner numbers (M= 5 partners, range 0-25), and 'sometimes ' (n=17) or 'never' (n=16) used condoms. 29 participants had accessed sexual health services ( Table 2). Nineteen participants (37%) had never heard of HPV. Of those who had heard of HPV in accordance with the PAPM, 18% were in the 'decided to act' stage of vaccine decision-making (stage 5), none had decided that they did not want the vaccine (stage 4), and 22% had already been vaccinated (stage 6) ( Table 3).
Participants were aware that HPV affected men, the method of HPV transmission and that vaccination was most effective if given prior to sexual debut; however, awareness of the link between HPV and genital warts and the severity of an HPV infection was lower as the majority of YMSM thought HPV infection always required treatment and that infection with HPV would always lead to health problems (Table 3).
Thirty-three participants reported that HPV vaccination had never been discussed with or recommended by a HCP (Table 3). The mean age participants were willing to disclose their sexuality to a HCP was 18.3 years (range=11-23, SD=2.40) ( Table 3). The most comfortable setting cited to receive the HPV vaccine was primary care or LGBTQ-specific services, rather than GUM clinics (Table 3).  Anonymous quotes illustrating two key themes are presented below.

Willingness to be vaccinated
Despite a perceived lack of knowledge about HPV and the vaccine and the threat posed to men, most participants were willing to receive the vaccine and wanted more information.

P1: I only knew about it because of the cervical cancer (…)
P2: I didn't even know that was what it was for.

P1: I didn't know even if like that would apply to us, so I don't even know what the dangers
are.

Focus group 2
Participants were motivated to receive the vaccine to protect their health and a small number of participants suggested that the cost and number of doses of the vaccine were not barriers to

Implementation recommendations
Promoting and raising awareness of the vaccine Better understanding of the benefits and side-effects of the vaccine were expected to encourage uptake. To promote the vaccine and inform YMSM, awareness campaigns and advertisements on the internet, radio, TV, social media, in University society's, LGBTQ youth groups and dating apps were suggested.
For this generation particularly, social media and TV ads and newspapers -well, probably not newspapers, but radio ads as well. You know, a campaign around getting people vaccinated, I think that would be very beneficial for young people these days.

Focus group 3, unidentifiable speaker
Participants suggested including information about the vaccine for YMSM in primary care and the sexual health education curriculum in schools. Indeed, it was noted that there is a lack of MSMspecific sexual health and relationship information provided in the latter.

Identifying and offering YMSM the HPV vaccination
The ideal pre-exposure timing for vaccination and the fluid, undefined nature of sexual preferences at a young age were perceived as barriers to identifying eligible recipients. There were mixed feelings about whether it would be acceptable for HCPs to ask boys (<16 years) to disclose their sexuality for this purpose due to concern about parents being informed and a lack of a trusting relationship. It was, however, also noted that questions about sexuality need to be normalised, particularly in primary care. The focus group participants wanted the benefits of vaccination to be explained and for the vaccine to be offered in a natural, relaxed manner, opportunistically, rather than having to request it. Participants felt they would be unlikely to request the vaccine because they would need more knowledge and they felt too uncomfortable. Written invitations from GPs offering the vaccine to eligible patients were also suggested. However, this would require boys to identify as MSM when registering or being asked about their sexuality by a HCP. A small number of accounts suggested it would be acceptable to refer patients to receive the HPV vaccine in sexual health clinics if it was not available in a GP setting. Offering the vaccine in schools when YMSM are beginning to have their first sexual encounters was suggested. Similarly, the school nurse was a trusted individual for some and therefore may be an acceptable person to provide the vaccine.

Discussion
This is the first study to examine the views of YMSM towards the HPV vaccine in the UK. Despite being sexually active and willing to disclose sexual orientation to receive the vaccine, most participants had never been recommended the HPV vaccine, suggesting that MSM are not being offered the vaccine at the most opportune time. The data also suggested that HPV knowledge in YMSM is low, with almost half of participants being unaware of HPV or the vaccine. YMSM were willing to receive the vaccine but wanted additional information about HPV and the vaccine. Given the reluctance to disclose information about sexuality to HCP (prior to disclosure to significant others), the wide range of sexual partner numbers, and lack of consistent contraceptive use, combined with the importance of supporting vaccination prior to potential exposure, the findings highlight significant barriers to MSM accessing the vaccine. Early provision of information was recommended through awareness campaigns, advertisements and the school health education curriculum. However, even with enhanced awareness, programmes that rely on YMSM to present for vaccination (particularly prior to sexual orientation disclosure) were not viewed as feasible. Furthermore, preferences for GPs or specialist HCPs offering the vaccine were dependent on the relationship with the HCP. Offering the vaccine to MSM in schools was thought to be acceptable.

Strengths and Limitations
This is the first study in the UK exploring this topic with YMSM. By conducting this research in more than one setting we can comment on the transferability of our findings; we found minimal differences in attitudes towards HPV between settings. The use of a theoretical model of behaviour change, the PAPM, also facilitates clear conceptualisation of health behaviour change and YMSM's stage of HPV vaccine decision making.
We aimed to continue data collection until saturation, however recruitment difficulties and the study timeframe meant that the decision to cease recruitment was pragmatic. The sensitivity of the topic, the hard to reach population and the lack of monetary compensation for the participant's time are possible explanations for this. The sample size is however, considered appropriate as it has obtained a diverse range of views of YMSM. Those who self-selected to participate may be more comfortable with their sexuality than those who did not agree. Indeed, recruiting through LGBTQ organisations narrowed our participant pool to those engaged with these services who had disclosed their sexual orientation.
The small sample size for the quantitative data resulted in a lack of statistical power and should be interpreted with caution. The interview sample age range of 16-24 years is older than the target population for the vaccine -12-13 years. Although the participants were asked to consider how they would view the vaccine and strategies to implement it among YMSM, it is unclear whether current YMSM share similar attitudes.

Implications for research and practice
The reluctance of YMSM to discuss their sexuality with HCPs before they have disclosed to significant others has important implications for the success of an HPV vaccination programme.
Other qualitative work with MSM has shown support for vaccinating all adolescent boys in school in part to protect against stigma arising from vaccination policies targeting MSM 28 . This would also remove the barrier of MSM having to request the vaccination, especially prior to sexual debut 26 .
Our finding that MSM are unlikely to disclose sexual orientation to a HCP prior to sexual debut, has been reported elsewhere 12 , suggesting that HPV vaccine programmes delivered by HCPs would be of "limited benefit" 12 . Participants in our study recommended the vaccine be offered by HCPs rather than expecting them to request it, however it is unclear whether initial reluctance to disclose sexuality would prevent vaccination uptake. The absence of a HCP's recommendation has previously been identified as a barrier to vaccination 29 . A new NHS England standard recommending "sexual orientation monitoring" whereby patients aged 16 and over are asked to disclose their sexual orientation at every face-to-face appointment may help to identify those eligible for vaccination 30 . Although this standard would not help identify those younger than 16 years who may benefit from the vaccine.
Previous research has found that most MSM have positive attitudes towards vaccinations against STIs and would be willing to receive the HPV vaccine 28 . However, individual and systemic barriers, such as access to sexual health clinics, disclosure of sexual orientation, concern about confidentiality or belief that HPV vaccine is not effective after sexual debut, may compromise the effectiveness of vaccination strategies 28 . Additionally, perceptions that HPV is relatively uncommon and harmless may lead to low desirability of the vaccine resulting in suboptimal coverage and therefore reduced cost-effectiveness 28 .
In line with our findings, awareness raising strategies are vital to HPV vaccination programme success 31 32 . To raise awareness and motivate vaccine uptake, a public health campaign may be necessary 27 . When developing strategies for HPV vaccination programmes, stakeholders can learn from the introduction of vaccinations such as hepatitis B and should engage with the target population and co-ordinate between stakeholders to ensure consistent messages 31 .

Conclusions
This study suggests that UK YMSM's are willing to receive the HPV vaccine. However, the UK's current HPV vaccine programme that relies on MSM to present for vaccination (particularly prior to sexual orientation disclosure) was not viewed as feasible. The importance of supporting vaccination prior to potential virus exposure combined with the reluctance to disclose information about sexual orientation means personal knowledge and awareness of the HPV vaccine is important therefore, early provision of information is recommended. Offering the vaccine in healthcare and education settings

IF 'YES' PLEASE READ THE FOLLOWING STATEMENT AND TICK THE APPROPRIATE RESPONSE FOR YOU:
The JCVI has recommended men who have sex with men aged up to 45 years receive the HPV vaccine.
Which of the following best describes your thoughts on the HPV vaccine for men-who-have-sexwith-men?
I have never thought about vaccination against HPV I am undecided about vaccination against HPV I have decided and do not want to vaccinate myself against HPV I have decided to do want to vaccinate myself against HPV I have already been vaccinated against HPV

Can you time how long it takes you to complete this next section of the survey?
Please answer the following questions to the best of your ability:

Introduction (5-10 min) Explain purpose of focus group
Before we begin I'm going to give some background to the study, an overview of the study's aim, the purpose of this focus group and details of who is funding the work.
In this focus group/interview we are going to be discussing Human papillomavirus (HPV) which is a very common infection involved in most cervical cancers. It is transmitted via skin-to-skin contact, most commonly during sexual activity. A vaccine has been developed that protects against this infection There are two purposes of this study. Firstly we want to understand the knowledge and attitudes of young (16-24 years) MSM towards the HPV vaccination. Secondly we are trying to identify ways to support young MSM to have this vaccination. We are particularly interested in how to support young MSM as the HPV vaccination is expected to provide greatest protection if it is given before the first sexual encounter.
The aim of this interview/focus group is to explore your knowledge and attitudes towards this vaccine, to identify things which may encourage or discourage vaccination and possible strategies to support vaccination uptake.
These interviews will contribute towards recommendations for any efforts to support the targeted vaccination of MSM, particularly those younger than 24 years of age.
This study has been funded by Cancer Research UK.

Explain audio recording procedures
Before we get started, I'd like to tell you that I will be recording the conversation to help us remember what we discussed and so that verbatim quotes can be used in future publications. You can ask for the recording to be stopped at any time and you can stop participating at any time without having to give a reason. What you say will be kept confidential and anonymous.

Guidelines for focus groups only
• Honesty -no right or wrong answers. Everyone's experiences and opinions are important. Feel free to agree or disagree with the views of others in the group. • Confidentiality -We want people to feel comfortable about sharing potentially sensitive information so please do not discuss what is said during the group with others outside. • Respect -you may not agree with what is said by others in the group but it is important to show respect to each other and to allow everyone a turn to express their opinions. • Audio recording -Where possible please try to ensure that only one person is speaking at a time to aid the audio recording and transcription.

Sources of information and advice (10 mins)
To begin I'd like us to discuss where you got or would get information / advice about sexual health issues before engaging in any form of sexual activity with another man. This includes kissing, masturbation/hand jobs, oral sex and anal sex.
Where did you / would you receive or look for sexual health information and advice?
What are your reasons for choosing these places to find information or advice?
For which types of sexual activities are you most likely to seek advice?
Did you / would you consider speaking to a healthcare professional, including GPs, university health services or GUM clinics?
What are your reasons for doing / not doing this?
Could the information or advice you received or are currently receiving have been improved at all? Can you talk me through your reasons for ordering the concerns like this? The vaccine is most protective if it is received prior to first sexual encounter as this represents a potential exposure to HPV. Before being offered the vaccination it is likely that you would be asked to reveal your sexual orientation to a healthcare professional.

Attitude towards HPV vaccination (30 mins)
Thinking back to when you first disclosed your sexual orientation to someone, who did you disclose to?
Has any healthcare professional ever asked you about your sexual orientation?
If yes, did this happen before or after you had sex with another man?
If yes, how did the healthcare professional ask you for this information?
What were the circumstances in which the healthcare professional asked you for this information?
Could the way this information was asked have been improved at all? If yes, how?
If no, how happy would you be you to disclose your sexual orientation to a healthcare professional? What are your reasons for this?
Are there any types of healthcare professional that you would feel more comfortable disclosing your sexual orientation to than others (e.g. school nurse, GP, GUM clinic staff)?
What do you think is the best way for healthcare professionals to identify young (16-24 years) MSM who may be eligible for a HPV vaccine?
Prompts to be used if necessary: -Through parents e.g. letters home to parents through school -In private without parents/guardians -Using a written questionnaire given in healthcare setting from 12/13 onwards? -Face-to-face -Via community LGBT organisations?
Who would you prefer to offer the HPV vaccination to you (e.g. GP, GUM clinic, school nurse etc.)?
Has anyone been offered or requested the HPV vaccine? (e.g. privately) For what reason do you think you were offered/did you request the HPV vaccine?
How would you react to being offered the HPV vaccine?
How willing would you be to go and ask to have the HPV vaccine?
What things might prevent you or make you less likely to ask for/ accept the HPV vaccination?
What things might encourage you or make you more likely to ask for/accept the HPV vaccination?

Strategies to support the introduction of HPV vaccination in MSM (30 mins)
In the last set of questions we'd like to discuss your views on the best approach to encouraging the uptake of HPV vaccination in young MSM.
How could we increase young MSM awareness of the need to receive the HPV vaccination?
How could young MSM be encouraged to take up the HPV vaccine?
Prompts -Awareness campaigns through schools, GUM clinics, social media etc.

Close (2-3 mins)
That is the end of my questions. Before we finish is there anything I haven't covered today that you would like to add?
We would like you to read our interpretation of the focus group. This shall be done by us sending you an email summary of the group discussion. We would like you to let us know if you feel it is an accurate interpretation of what was discussed. If you would like to do this, please provide us with an email address. This will not be kept confidential, and only used for this purpose.

End audio recording
Thank participant(s) and answer questions.

Strengths and limitations of this study
 This is the first study in the UK to explore YMSM's knowledge and attitudes toward HPV vaccination.  Survey findings should be interpreted with caution due to the sample size.

Introduction
Human papillomavirus (HPV), the most common sexually transmitted infection (STI) worldwide 1 , has serious health consequences for men and women. HPV is recognised as a causative agent in cervical cancer, and is associated with anogenital tumours, oropharyngeal cancers, and genital warts 2 .
While boys and girls aged 12-13 years are vaccinated in school in Australia 3  and Wales are currently offering the HPV vaccine to MSM attending GUM clinics. Following a pilot programme in England 9 which found suboptimal uptake (45%) and did not report completion rates, vaccination is now offered in GUM clinics. Hence it is important to assess the reasons why MSM might not be willing to accept the vaccine through targeted HPV vaccination. An interim statement in July 2017 suggested that given the current high uptake in females, extending immunisation to all adolescent males is "highly unlikely to be cost effective in the UK" (p13) 10 11 . In July 2018, the JCVI recommended that the national HPV vaccination programme should be extended to include adolescent boys. It is planned that the programme, beginning in September 2019, will include boys aged 12/13 (England, school year 8; Northern Ireland, school year 9). Although some may now query the importance of the MSM programme (particularly for YMSM), this will still be valid for a number of years, particularly as the government have indicated that they will not initiate a catch-up programme for boys so there are still a significant number who will remain unprotected. Indeed, it is worth noting that it took 5 years of deliberation by the JCVI to make this decision and that boys aged 13 plus will not be offered the vaccine in schools.
The absence of a catch-up vaccination programme leaves many UK YMSM without funded access to the HPV vaccine before exposure to HPV 12 . There is often a delay between the age of first sexual contact with another man and disclosure of sexual orientation to a healthcare professional (HCP) 13 , as a result, it is likely that MSM will have multiple sexual partners before attending a GUM clinic resulting in increased risk of HPV acquisition 14 .
A systematic review found that MSM HPV vaccine knowledge was low and MSM did not consider themselves at risk of infection, although over half would accept the vaccine if offered 12 . Most of these studies were conducted in North America (and none in the UK), with MSM over 26 years of age.
Minimal attention has been given to the knowledge and attitudes toward HPV vaccination among adolescent and YMSM (aged 16-24 years). This is an important area for research because MSM may acquire HPV at a young age, close to their sexual debut (the age of which is decreasing) 14 . This study aimed to examine the knowledge and attitudes of UK YMSM towards HPV vaccination to inform policy and practice recommendations for accessing this hard to reach group, supporting vaccination uptake and the optimisation of protection from HPV. Despite the changes to the vaccination programme made since this research, in the absence of a catch-up programme, the newly implemented universal programme will cover not all YMSM. Therefore, understanding YMSM knowledge and attitudes to HPV remains relevant in the UK. Our findings are also relevant for guiding other programmes internationally that do not have a gender neutral programme and are considering implementation of a programme for YMSM.  15 ; sexual behaviour (adapted from Sadlier et al.) 16 ; culture (adapted from Zou et al.) 17 ; and HPV vaccine stage of decision making using the Precaution Adoption Process Model (PAPM) 18 . The PAPM has six stages of behaviour change decision-making and has been used to examine knowledge and attitudes to HPV vaccination 19 . Those who indicated awareness of the HPV vaccine, were asked to complete validated HPV knowledge/attitudes scales 20 21 .

Patient and Public Involvement
The HPV knowledge/attitude questionnaire scales were adapted for use with MSM through consultation with an Expert Panel including a key stakeholder group (The Rainbow Project [TRP]) and MSM focus groups.
YMSM were not involved in the development of the qualitative component of this study, however staff from TRP helped develop the study design and documentation.
The findings will be disseminated to YMSM via social media and TRP. For the focus groups, potential participants were provided with written study information, and asked to register their interest at local LGBTQ organisations, university information days, university student union clubs and societies, and secondary school LGBTQ groups. Organisations advertised the study through social media and snowball sampling was employed.
CF conducted the focus groups within LGBTQ organisational settings and a university student's union building.
Prior to the focus groups, participants were asked to complete the questionnaire (described above).
The focus group topic guide (Supplementary Material B) was applied flexibly to allow for emergent issues and began by exploring sources of sexual health information and advice before engaging in sexual activity (not presented here). Perceptions of HPV risk in relation to six other STI's were then discussed using a sorting task in which a list of STIs were ordered by what is least to most concerning (findings not reported here). Attitudes towards HPV vaccine, barriers and facilitators to vaccination and possible intervention strategies to support vaccination uptake were explored. Experiences of disclosing sexual orientation to HCP were also discussed. All participants were informed that the HPV vaccine was most protective if received prior to first sexual encounter. Participants were asked to reflect as to how they would have viewed taking the vaccine when they were 12-13 years. Questionnaire data was inputted to SPSS v12 and analysed descriptively with frequencies and proportions reported for categorical data and mean and standard deviation for continuous data. Due to lack of statistical power it was not possible to utilise inferential statistics for analysis. Participants' PAPM vaccine decision-making stage was classified into six stages: unaware, unengaged, undecided, decided not to vaccinate, decided to vaccinate and those who had already been vaccinated 19 . If participants indicated they were not sexually active they were asked to skip the sexual contact questions. If they indicated that they had never heard of the HPV vaccine they did not complete the knowledge/attitude scores. Knowledge and attitudes held by participants about HPV and HPV vaccination were analysed using descriptive statistics.  The majority (n=49) were sexually active and reported both oral and anal intercourse in the past 12 months (n=35), a wide range of partner numbers (M= 5 partners, range 0-25), and 'sometimes' (n=17) or 'never' (n=16) used condoms. Twenty-nine (57%) participants had accessed sexual health services (Table 2).
Nineteen participants (37%) had never heard of HPV and did not complete the rest of the questionnaire. Of those who had heard of HPV in accordance with the PAPM, 18% were in the  (Table 3).
Participants were aware that HPV affected men, the method of HPV transmission, and that vaccination was most effective if given prior to sexual debut. However, awareness of the link between HPV and genital warts and the severity of an HPV infection was lower as the majority of YMSM thought HPV infection always required treatment and that infection with HPV would always lead to health problems (Table 3).
Thirty-three participants (65%) reported that HPV vaccination had never been discussed with or recommended by a HCP ( Table 3). The mean age participants were willing to disclose their sexuality to a HCP was 18.3 years (range=11-23, SD=2.40) ( Table 3). The most comfortable setting cited to receive the HPV vaccine was primary care or LGBTQ-specific services, rather than GUM clinics (Table 3).

Identifying and offering YMSM the HPV vaccination
The ideal pre-exposure timing for vaccination and the fluid, undefined nature of sexual preferences at a young age were perceived as barriers to identifying eligible recipients. There were mixed feelings about whether it would be acceptable for HCPs to ask boys (<16 years) to disclose their sexuality for this purpose due to concern about parents being informed and a lack of a trusting relationship. It was, however, also noted that questions about sexuality need to be normalised, particularly in primary care. The focus group participants wanted the benefits of vaccination to be explained and for the vaccine to be offered in a natural, relaxed manner, opportunistically, rather than having to request it. Participants felt they would be unlikely to request the vaccine because they would need more knowledge and they felt too uncomfortable.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59

Discussion
This is the first study to examine the views of YMSM towards the HPV vaccine in the UK. Despite being sexually active and willing to disclose sexual orientation to receive the vaccine, most participants had never been recommended the HPV vaccine, suggesting that MSM are not being offered the vaccine at the most opportune time. The data also suggested that HPV knowledge in YMSM is low, with almost half of participants being unaware of HPV or the vaccine. YMSM were willing to receive the vaccine but wanted additional information about HPV and the vaccine. Given the reluctance to disclose information about sexuality to HCP (prior to disclosure to significant others), the wide range of sexual partner numbers, and lack of consistent contraceptive use, combined with the importance of supporting vaccination prior to potential exposure, the findings highlight significant barriers to MSM accessing the vaccine. Early provision of information was recommended through awareness campaigns, advertisements and the school health education curriculum. However,  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n  l  y even with enhanced awareness, programmes that rely on YMSM to present for vaccination (particularly prior to sexual orientation disclosure) were not viewed as feasible. Furthermore, preferences for GPs or specialist HCPs offering the vaccine were dependent on the relationship with the HCP. Offering the vaccine to MSM in schools was thought to be acceptable. We accept that many of these issues will now hopefully be addressed by the extension of the current female vaccination programme to boys in September 2019, although the lack of catch-up programme for boys would indicate that there is still a need for the vaccine programme to target YMSM for at least the next six years as a significant number of YMSM will be a risk of HPV infection. In addition, these findings offer insights into barriers to vaccination for YMSM which will be useful if the uptake of a universal vaccination programme is low.

Strengths and Limitations
This is the first study in the UK exploring this topic with YMSM. By conducting this research in more than one setting we can comment on the transferability of our findings; we found minimal differences in attitudes towards HPV between settings. The use of a theoretical model of behaviour change, the PAPM, also facilitates clear conceptualisation of health behaviour change and YMSM's stage of HPV vaccine decision making.
We aimed to continue data collection until saturation, however recruitment difficulties and the study timeframe meant that the decision to cease recruitment was pragmatic. The sensitivity of the topic, the hard to reach population and the lack of monetary compensation for the participant's time are possible explanations for this. Therefore, the findings must be read with caution. Those who self-selected to participate may be more comfortable with their sexuality than those who did not agree. Indeed, recruiting through LGBTQ organisations narrowed our participant pool to those engaged with these services who had disclosed their sexual orientation. The small sample size for the quantitative data resulted in a lack of statistical power to analyse data using inferential statistics and should be  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n l y considered in generalising beyond the study sample. Small sample sizes in research with sexual and gender minorities is a recognised limitation 24 . The interview sample age range of 16-24 years is older than the target population for the vaccine -12-13 years. Although the participants were asked to consider how they would view the vaccine and strategies to implement it among YMSM, it is unclear whether current YMSM share similar attitudes.

Implications for research and practice
The reluctance of YMSM to discuss their sexuality with HCPs before they have disclosed to significant others has important implications for the success of an HPV vaccination programme.
Previous research shows that MSM disclosing their sexuality to significant others, visiting HCPs in the past year, and previous STI diagnosis predict disclosure to a HCP 25 . In the absence of a catch-up programme for boys, additional measures to support YMSM to access the vaccine are necessary. For instance, information may need to be provided to young men outside of healthcare settings including educational contexts during sex and relationship education or HCPs may need to take an active role in opportunistically providing information during consultations for non-sexual health related matters. To support the latter, GPs and other HCPs may require additional education and training 26,27 .
Our finding that MSM are unlikely to disclose sexual orientation to a HCP prior to sexual debut, has been reported elsewhere 13 , suggesting that HPV vaccine programmes delivered by HCPs would be of "limited benefit" 13 . Participants in our study recommended the vaccine be offered by HCPs rather than expecting them to request it; however it is unclear whether initial reluctance to disclose sexuality would prevent vaccination uptake. The absence of a HCP's recommendation has previously been identified as a barrier to vaccination 31 . A new NHS England standard recommending "sexual orientation monitoring" whereby patients aged 16 and over are asked to disclose their sexual orientation at every face-to-face appointment may help to identify those eligible for vaccination 32 .
Although this standard would not help identify those younger than 16 years who may benefit from the vaccine.
Previous research has found that most MSM have positive attitudes towards vaccinations against STIs and would be willing to receive the HPV vaccine 29 30 . However, individual and systemic barriers such as access to sexual health clinics, disclosure of sexual orientation, concern about confidentiality or belief that HPV vaccine is not effective after sexual debut, may compromise the effectiveness of vaccination strategies 30 . Additionally, perceptions that HPV is relatively uncommon and harmless may lead to low desirability of the vaccine resulting in suboptimal coverage and therefore reduced cost-effectiveness 30 .

Acknowledgement:
We would like to thank the MSM and TRP stakeholders who informed the development of the HPV knowledge/attitude questionnaire scales.

IF 'YES' PLEASE READ THE FOLLOWING STATEMENT AND TICK THE APPROPRIATE RESPONSE FOR YOU:
The JCVI has recommended men who have sex with men aged up to 45 years receive the HPV vaccine.
The aim of this interview/focus group is to explore your knowledge and attitudes towards this vaccine, to identify things which may encourage or discourage vaccination and possible strategies to support vaccination uptake.
These interviews will contribute towards recommendations for any efforts to support the targeted vaccination of MSM, particularly those younger than 24 years of age.
This study has been funded by Cancer Research UK.

Explain audio recording procedures
Before we get started, I'd like to tell you that I will be recording the conversation to help us remember what we discussed and so that verbatim quotes can be used in future publications. You can ask for the recording to be stopped at any time and you can stop participating at any time without having to give a reason. What you say will be kept confidential and anonymous.

Guidelines for focus groups only
• Honestyno right or wrong answers. Everyone's experiences and opinions are important. Feel free to agree or disagree with the views of others in the group. • Confidentiality -We want people to feel comfortable about sharing potentially sensitive information so please do not discuss what is said during the group with others outside. • Respectyou may not agree with what is said by others in the group but it is important to show respect to each other and to allow everyone a turn to express their opinions. • Audio recording -Where possible please try to ensure that only one person is speaking at a time to aid the audio recording and transcription.  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59

Sources of information and advice (10 mins)
To begin I'd like us to discuss where you got or would get information / advice about sexual health issues before engaging in any form of sexual activity with another man. This includes kissing, masturbation/hand jobs, oral sex and anal sex.
Where did you / would you receive or look for sexual health information and advice?
What are your reasons for choosing these places to find information or advice?
For which types of sexual activities are you most likely to seek advice?
Did you / would you consider speaking to a healthcare professional, including GPs, university health services or GUM clinics?
What are your reasons for doing / not doing this?
Could the information or advice you received or are currently receiving have been improved at all? Can you talk me through your reasons for ordering the concerns like this?  1  2  3  4  5  6  7  8  9  10  11  12  13  14  15  16  17  18  19  20  21  22  23  24  25  26  27  28  29  30  31  32  33  34  35  36  37  38  39  40  41  42  43  44  45  46  47  48  49  50  51  52  53  54  55  56  57  58  59  60   F  o  r  p  e  e  r  r  e  v  i  e  w  o  n l y I'd like us to move on now to discuss your views about being offered the HPV vaccination. The vaccine is most protective if it is received prior to first sexual encounter as this represents a potential exposure to HPV. Before being offered the vaccination it is likely that you would be asked to reveal your sexual orientation to a healthcare professional.

Attitude towards HPV vaccination (30 mins)
Thinking back to when you first disclosed your sexual orientation to someone, who did you disclose to?
Has any healthcare professional ever asked you about your sexual orientation?
If yes, did this happen before or after you had sex with another man?
If yes, how did the healthcare professional ask you for this information?
What were the circumstances in which the healthcare professional asked you for this information?
Could the way this information was asked have been improved at all? If yes, how?
If no, how happy would you be you to disclose your sexual orientation to a healthcare professional? What are your reasons for this?
Are there any types of healthcare professional that you would feel more comfortable disclosing your sexual orientation to than others (e.g. school nurse, GP, GUM clinic staff)?
What do you think is the best way for healthcare professionals to identify young (16-24 years) MSM who may be eligible for a HPV vaccine?
Prompts to be used if necessary: -Through parents e.g. letters home to parents through school -In private without parents/guardians -Using a written questionnaire given in healthcare setting from 12/13 onwards? -Face-to-face -Via community LGBT organisations?
Who would you prefer to offer the HPV vaccination to you (e.g. GP, GUM clinic, school nurse etc.)?
Has anyone been offered or requested the HPV vaccine? (e.g. privately) For what reason do you think you were offered/did you request the HPV vaccine?
How would you react to being offered the HPV vaccine?
How willing would you be to go and ask to have the HPV vaccine?
What things might prevent you or make you less likely to ask for/ accept the HPV vaccination?
What things might encourage you or make you more likely to ask for/accept the HPV vaccination?

Strategies to support the introduction of HPV vaccination in MSM (30 mins)
In the last set of questions we'd like to discuss your views on the best approach to encouraging the uptake of HPV vaccination in young MSM.
How could we increase young MSM awareness of the need to receive the HPV vaccination?
How could young MSM be encouraged to take up the HPV vaccine?
Prompts -Awareness campaigns through schools, GUM clinics, social media etc.

Close (2-3 mins)
That is the end of my questions. Before we finish is there anything I haven't covered today that you would like to add?
We would like you to read our interpretation of the focus group. This shall be done by us sending you an email summary of the group discussion. We would like you to let us know if you feel it is an accurate interpretation of what was discussed. If you would like to do this, please provide us with an email address. This will not be kept confidential, and only used for this purpose.