Hepatitis B virus (HBV) infection is of particular concern for gay and bisexual men, as 11% to 20% have serological evidence of past or current infection.1–4 In 1985, HBV vaccine was recommended for groups at high risk for infection, including men who have sex with men.5 The Advisory Committee on Immunization Practices continues to recommend HBV vaccination for high-risk individuals, as well as any other adult who wants the vaccine.6 Despite these recommendations, only 9% to 42% of gay and bisexual men in the United States have received some doses of HBV vaccine.3,7–12 Many of these studies, however, used convenience sampling from only one geographic area, and it has been almost a decade since data for the most recent of these studies were collected. In the interim, new programs integrating HBV vaccination into sexually transmitted disease (STD) clinic services, human immunodeficiency virus (HIV) testing, and syringe exchange programs have been implemented as a way to increase HBV vaccination among gay and bisexual men and other high-risk adults.13–17 In this report, we characterize recent HBV vaccination rates among a national sample of gay and bisexual men.
The University of North Carolina Men's Health Survey interviewed men aged 18 to 59 years who were members of an existing national panel of US households. The survey company identified prospective panel members using list-assisted, random-digit dialing of landline phones. Upon recruitment into the panel, the company collects demographic information, including self-reported sexual orientation, through a background survey. Panel members receive e-mails inviting them to complete multiple internet-based surveys each month, for which they receive free internet access. Panel members with existing computer and internet access accumulate points for completing surveys, which can be redeemed for small cash payments.
In January 2009, we randomly sampled male panel members who had reported their sexual orientation in their background survey, oversampling men who self-identified as either gay or bisexual. Of 874 men invited to participate, 609 (70%) completed our cross-sectional, online survey.18 Response rates were higher among gay and bisexual men compared with heterosexual men (79% vs. 62%). We report data from 306 men who self-identified as either gay or bisexual, excluding all other participants. The institutional review board at our university approved the study.
We assessed HBV vaccination by asking, “The hepatitis B vaccine is a series of 3 shots. How many hepatitis B vaccine shots, if any, have you had?” Response options included “none,” “one,” “two,” “three,” “at least 1 shot, but don't know how many,” and “I don't know if I had any shots.” We classified participants as “vaccinated” (one or more doses received including those who indicated at least 1 shot but unsure of how many) or “not vaccinated” (all other responses). Although primary HBV vaccination for adults consists of 3 doses,6 we defined vaccination as receipt of one of more doses because adequate immunity can develop in some individuals with fewer than 3 doses,6,19,20 and because some younger participants may have received the 2-dose adolescent HBV vaccine regimen.21
Participants provided information on demographic variables and health behaviors (Table 1). We assessed sexual orientation by asking, “Do you think of yourself as…..” with response options of “gay or homosexual (attracted to men),” “bisexual (attracted to men and women),” “heterosexual or straight (attracted to women),” “something else,” and “not sure.” We defined “urban” as living in a metropolitan statistical area and “rural” as living outside of a metropolitan statistical area.22 Participants provided self-reported histories of infection with HIV, HBV, and any other sexually transmitted infections (STIs).
Analyses excluded 14 men with a self-reported history of HBV infection, resulting in an analytic sample size of 292. We used logistic regression to examine bivariate correlates of HBV vaccination. Statistically significant bivariate correlates (P < 0.05) were simultaneously entered into a multivariate logistic regression model. We analyzed unweighted data using SPSS version 17.0 (SPSS Inc, Chicago, IL). All statistical tests were 2-tailed, using a critical α of 0.05.
Most participants were non-Hispanic white (80%), less than 50 years (61%), had a college degree (55%), and reported a household income of at least $60,000 (60%). Most men had not initiated sex before age 16 (64%), indicated 5 or more lifetime sexual partners (88%), and fewer than 5 male sexual partners in the last year (75%). Sixty-one percent had disclosed to their primary healthcare provider that they have had sex with men, 16% reported a history of HIV infection, and 30% reported a history of other STIs.
Overall, 46% (133/292; 95% confidence interval [CI]: 40%–52%) of men indicated they had received one or more doses of HBV vaccine. Most men reporting HBV vaccination indicated they had received 3 doses (71%, 95/133), with fewer reporting 2 doses (5%, 7/133), 1 dose (6%, 8/133), or at least 1 dose but unsure of how many (17%, 23/133). Among men considered to be unvaccinated (n = 159), 114 indicated they had received no doses, 43 did not know if they had received any dose, and 2 had missing data.
In multivariate analyses (Table 1), HBV vaccination was higher among men aged 18 to 29 years compared with men aged 50 to 59 years (odds ratio [OR] = 10.00; 95% CI: 2.36–42.36). HBV vaccination was also higher among men who self-identified as gay (OR = 2.03; 95% CI: 1.03–3.99) or had received flu vaccine within the last year (OR = 1.88; 95% CI: 1.10–3.19). We conducted extensive sensitivity analyses to explore the effect of classifying men who did not know if they had received any dose of HBV vaccine or had missing data as “not vaccinated.” Multivariate correlates did not differ greatly in these analyses, giving us confidence in our findings.
Less than half of gay and bisexual men in this national sample indicated receiving any doses of HBV vaccine, a rate only slightly higher than previous estimates among this population (31%–42%)7–10,12 and males in general in the United States (30%).23 Our results provide an important update and suggest HBV vaccination in this high-risk population remains suboptimal. This may be partly attributable to the lack of a national program for vaccinating uninsured or underinsured adults and low usage of reimbursement programs among insured adults.6 Recent programs have sought to overcome these obstacles and reach high-risk adults. Integration of HBV vaccination into STD clinic services, HIV testing, and syringe exchange programs has been mostly successful in increasing vaccination rates.13–17 One such program achieved 81% coverage (one or more doses) among men who have sex with men who were return clients to an STD clinic.14 Greater availability of these programs and novel approaches for reaching gay and bisexual men who do not attend these venues are needed.
Similar to past studies,8,9 younger men reported HBV vaccination more frequently. This likely reflects US national recommendations to vaccinate children and adolescents against HBV (occurred in 1991 and 1997, respectively24,25) and HBV vaccine school mandates. Currently, 46 states have elementary or middle school mandates for HBV vaccination,26 and 19 states have some type of mandate for college entry.27 These policies would likely not have been in effect for men older than 30 years of age in our study. As more than 80% of people aged 40 and older produce a protective antibody response after 3 doses of HBV vaccine,28 older gay and bisexual men can still benefit from vaccination.
HBV vaccination was higher among gay men compared with bisexual men, as in past research.9 One potential explanation is that more gay men than bisexual men had disclosed to their primary care providers that they have had sex with men (73% vs. 22%; P < 0.001), causing healthcare providers to recognize the need for and recommend HBV vaccination. Healthcare providers should provide environments that facilitate both gay and bisexual men disclosing their sexual behaviors, possibly by posting nondiscrimination statements in their clinics and using gender-neutral language about sexual partners.29 Finally, HBV vaccination was more common among men reporting flu vaccination within the last year, possibly due to their greater use of health services or higher acceptability of vaccines in general.
Our study has several important strengths including the use of a national sample, a high participation rate, and focusing on a high-risk population. Limitations include a cross-sectional study design and self-reported HBV vaccination, although most gay men accurately recall their HBV vaccination status.2 We did not have data on medical conditions that may contraindicate HBV vaccination or on some factors that may indicate vaccination (e.g., history of drug use). Also, 60 men did not have data available on prior HBV infection, although it is likely only a few had been previously infected. Data did not allow for examination of history of individual STIs other than HIV. Although our sample came from a study panel that closely resembles the US population,30,31 most participants were older than 30 years of age, non-Hispanic white, and of high socioeconomic status. At the time of our study, the survey company recruited panel members only using list-assisted, random-digit dialing of landline phones. Despite these limitations, our study provides a needed update on HBV vaccination rates among gay and bisexual men in the United States. Results indicate vaccination rates remain suboptimal and suggest continued efforts to ensure vaccination are needed.
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