Teenage girls most at risk of cervical cancer are least likely to be offered HPV vaccination and, those who are, less likely to complete the course, a cross-sectional study of sexual health service users has found.

A total of 2,861 questionnaires were distributed to young women aged 13 to 19 attending sexual health services.1 The response rate was 79% (n = 2,247). Although the majority of participants were from London, coverage of PCTs in England was 48%. Median age was 17 years. Most were of white ethnicity but London showed greater diversity (35% white UK) compared with other areas (85% white UK).

Nearly half, 45%, of respondents were smokers with a higher prevalence (67%) in those not in education, employment or training (NEETs). For those who were sexually active, 59% reported coitarche under 16 years; median number of partners was 3; 20% reported previous chlamydia infection and higher rates of STIs were noted in those who started having sex under 16. NEETs reported more sexual partners (median 4), were more likely to have coitarche under 16 (66%) and higher prevalence of STIs (39%).

Overall, the respondents had higher rates of known HPV-related risk factors. Compared with national data, survey respondents had higher smoking rates (48% vs 14% of 15 year olds), coitarche under 16 (52% vs 38%), previous STIs (25% vs 4%), and a higher proportion of NEETs (8% vs 2% of 16 year olds).

Only 74% of the respondents were offered HPV vaccination (60% by schools, 24% GPs, 15% colleges and 1% other sites); groups that had significantly lower offer rates included those aged 17-19, living in London, non-white ethnicities, NEETs, smokers and those with previous STIs (all P = 0.05).

Of those who declined the offer of HPV vaccination, 57% stated they might have accepted if their parents or friends had been better informed about it, and 22% said they were not adequately followed up.

Of those who had been offered the vaccine, just 65% completed the course, 13% had one or two doses and 22% did not receive any. Respondents who were: living in London, aged 17-19, non-white, NEETs, smokers, and reported a history of STIs were least likely to complete vaccinations. Three quarters of the respondents who did not complete the course gave reasons such as: no longer in school, missed appointments and not offered further appointments - 81% of NEETs reported not being followed up for subsequent vaccinations.

When participants were asked where they would like to receive their vaccinations, 48% stated their GP practice and 43% a sexual health clinic – but the latter is not part of the national delivery programme.

Modelling studies suggest that an 80% completion rate would prevent significant numbers of cervical cancer deaths but only 66% of eligible women completed all three doses according to data from the first three years of the programme.2-4 The rates in this study are much lower with an overall completion rate of 47%.

This group are at increased risk of HPV and cervical cancer and most likely to benefit from a full course of vaccination.

The authors believe that NEETs and 17-19 year olds should be targeted for the HPV programme as they tend to fall through the net and appear to be most at risk of acquiring HPV and cervical cancer, with low completion rates. They suggest that sexual health services might be a valuable addition to delivery venues to target high-risk women.

Some sexual health services already offer opportunistic cervical cytology to patients; it would make sense to include them in HPV vaccination programmes to improve access. However, I believe their role might be limited to offering opportunistic vaccination and that general practice is better equipped for a systematic call and recall programme to support completion of vaccination.

GPs in some CCG areas are already commissioned to improve uptake of other screening programmes such as bowel cancer and elsewhere GPs have been incentivised to offer HPV vaccination to those who have missed the school-based programme. It might be time to reconsider a directed enhanced service for HPV vaccination and catch up programme.