HPV vaccination for adults: who still benefits after 18

HPV vaccination is thought of as a vaccine for children – and for good reason: it works best before a person's first sexual contact. According to the Robert Koch Institute (RKI), Germany's public health agency, human papillomaviruses (HPV) cause around 10,000 cancers in Germany every year, about 3,000 of them in men. Many of today's adults were never vaccinated. Is it still worth it at 25, 35 or 45? The honest answer: clearly for some, only modestly for many. Who belongs to which group, however, can be said fairly precisely.

HPV is not just a women's issue

Cervical cancer accounts for the largest share of HPV-related cancers, at about 4,300 cases a year. According to the RKI, a further roughly 2,550 cancers of the oropharynx (the middle part of the throat, including tonsils and base of tongue), about 2,150 anal cancers and around 400 penile cancers each year are attributable to HPV (2025 data, German Centre for Cancer Registry Data). How strongly a cancer depends on HPV varies considerably: the RKI estimates that 84–88% of anal cancers in men are HPV-related, about half of oropharyngeal cancers, and 32–51% of penile cancers.

More common, though harmless, are genital warts. In Germany they occur at about 170 new cases per 100,000 person-years; in men the peak, 457 per 100,000, is at age 25 to 29. The nine-valent vaccine used today protects against them too.

How well does the vaccine work in adults?

The licensing trials in men enrolled 16- to 26-year-olds. In a randomised trial of 4,065 boys and men, the earlier four-valent vaccine reduced genital lesions caused by the vaccine types by about 90% – but only in those who received all three doses and were not infected at the start. Counting all participants, including those already infected, the reduction was about 60%. A sub-study of 602 men who have sex with men (MSM) showed the same pattern for anal precancers (anal intraepithelial neoplasia, AIN): 77.5% fewer vaccine-type AIN among participants not infected at baseline, 50.3% in the whole group.

For older adults the data are fewer and more indirect. In 3,819 women aged 24 to 45, the four-valent vaccine prevented 88.7% of persistent infections and tissue changes caused by the vaccine types over a median of four years – again in women without infection at baseline. For the nine-valent vaccine, one study compared 642 women aged 27 to 45 with 570 women aged 16 to 26: antibody levels were somewhat lower in the older group but met the pre-specified non-inferiority criterion for every type; over 99% developed antibodies. For men aged 27 to 45 there are only antibody data from a small study of 150 participants, also non-inferior. Efficacy in older men is therefore inferred from the immune response, not measured directly.

Why benefit falls with age – but not to zero

The vaccine prevents new infections; it does not cure an existing one. The German S3 guideline explicitly advises against using vaccination as treatment for existing HPV lesions. With each year of sexual activity, the chance rises that a person has already met one or more vaccine types. But protection is type-specific: someone who has had HPV 16 can still benefit from protection against HPV 18, 31 or 45. In the trial of women up to 45, protection was 66.9% even in women who had antibodies indicating a past infection but were currently virus-free – with a very wide range of uncertainty. For genital warts the picture is more sobering: in a Norwegian registry study of more than two million people, vaccination started from about age 20 no longer showed a relevant difference, as the RKI summarises. For most adults with several previous partners, the added benefit is therefore small.

Where it matters more: risk groups

Men who have sex with men

A meta-analysis led by the International Agency for Research on Cancer found 19 anal cancers per 100,000 person-years in MSM without HIV and 85 per 100,000 in MSM with HIV. The MSM study above is the most direct evidence of efficacy in this group – in men up to 26.

People with HIV

According to a meta-analysis in The Lancet, the risk of anal cancer in people with HIV/AIDS is about 29 times that of the general population. The German S3 guideline recommends a three-dose schedule here. For 18- to 26-year-olds with HIV, vaccination "can" be considered after individual assessment that takes sexual history into account. For people with HIV aged 27 or older with multiple previous partners, it explicitly recommends against vaccination – presumably because prior infection is assumed. Other bodies are more generous (see below).

Transplant recipients and others with immunosuppression

After an organ transplant, the risk of vulvar and vaginal cancer is about 23-fold, of penile cancer about 16-fold and of anal cancer almost 5-fold higher. At the same time, the suppressed immune system responds less well to vaccination: in a study of young adult transplant recipients, only 53–68% mounted an antibody response after three doses, depending on HPV type. The response was particularly weak when vaccination was given soon after transplantation, after lung transplantation and with higher levels of the immunosuppressant tacrolimus. The practical rule follows: vaccinate before transplantation whenever possible. The S3 guideline recommends ("should") vaccination for immunosuppressed people aged 18 and over, "especially up to the age of 26", always with three doses.

Women after conisation

After surgical removal of a cervical precancer (conisation, or a loop excision), precancers return in some women. A 2022 meta-analysis in the BMJ found about 57% fewer recurrences of high-grade precancers (CIN2+) in vaccinated women, but rated the certainty of the evidence very low to moderate, because most studies were observational. A 2025 Cochrane review reached a similar conclusion: vaccination "may" reduce the risk, but there were only two randomised trials with 420 women in total. Another meta-analysis found that in observational studies the effect was no longer statistically significant after adjusting for confounders. A Dutch placebo-controlled trial of the nine-valent vaccine (VACCIN) is still running. The S3 guideline is correspondingly cautious: vaccination "can be considered" before or after treatment.

The rules in Germany

STIKO: Germany's Standing Committee on Vaccination recommends HPV vaccination for girls and boys aged 9 to 14, with two doses at least five months apart. Missed vaccinations should be caught up by the day before the 18th birthday; anyone starting at 15 or older needs three doses. There is no STIKO recommendation for adults aged 18 and over (2026 recommendations). Statutory health insurance (GKV) therefore routinely pays only until the 18th birthday.

S3 guideline: The interdisciplinary German S3 guideline on vaccine prevention of HPV-associated neoplasia (AWMF 082-002) goes further. Its recommendation reads (our translation): "HPV-vaccine-naive adults aged 18 to 26 should be vaccinated against HPV regardless of sex." This is a weak recommendation ("sollten", not the stronger "sollen"), adopted with strong consensus. For unvaccinated people aged 27 and over the guideline advises the opposite: vaccination "should not be recommended". The guideline's validity expired in 2025; no updated version was available at the time of writing.

Cost: From 18, vaccination is usually self-pay. The nine-valent vaccine costs about €200 per dose at the pharmacy, so about €600 for three doses, plus the doctor's fee. Some statutory insurers, however, cover the cost voluntarily as an optional extra benefit ("Satzungsleistung"), often up to a set age limit. It is worth asking your own insurer first. For more on self-pay services, see our article on IGeL.

Other countries

• United Kingdom: MSM can be vaccinated at sexual health and HIV clinics until their 46th birthday. Since September 2023, under-25s receive a single dose; 25- to 45-year-olds receive two, and people with a weakened immune system three.
• France: The health authority HAS extended catch-up vaccination to all women and men up to 26 in April 2025; previously it applied up to 19, and to MSM up to 26. It has been reimbursed up to 26 since December 2025.
• United States: Routine vaccination through age 26; between 27 and 45 based on shared clinical decision-making between clinician and patient. Immunocompromised people, including those with HIV, receive three doses.
• European AIDS Clinical Society (EACS): recommended in 2017 vaccinating people with HIV up to 26, and MSM with HIV up to 40, with three doses.

Anal cancer screening

For people at high risk, screening comes on top of vaccination. The ANCHOR trial randomised 4,459 people with HIV aged 35 and over who had high-grade anal precancers (HSIL) to treatment or monitoring. After a median of 25.8 months there were 9 versus 21 anal cancers – 173 versus 402 per 100,000 person-years, 57% fewer. In absolute terms: about two fewer cancers per 1,000 people treated per year.

Since 2024, the International Anal Neoplasia Society (IANS) has recommended screening for MSM and transgender women with HIV from 35; for other people with HIV and for MSM and transgender women without HIV from 45; for organ transplant recipients from ten years after transplantation; and for women after vulvar cancer or its precursors. The German-Austrian guideline led by the German AIDS Society (S2k, 2025) sets similar age thresholds for people with HIV: MSM and transgender women from 35, everyone else from 45. With high-grade precancers of the cervix, vulva or penis, or a very low CD4 count (nadir below 200/µl), screening applies regardless of age. For transplant recipients it suggests screening from ten years after transplantation. The standard is inspection, a digital examination and an anal swab for cytology; abnormal results lead to magnified examination (high-resolution anoscopy), every 12 to 24 months.

Safety

In the study of women aged 27 to 45, about 85% had injection-site symptoms, mostly pain or swelling, and about 24% had vaccine-related systemic reactions such as headache – similar to younger women. There were no vaccine-related serious events. Vaccination is not given during pregnancy. Importantly, the vaccine does not replace screening: women should continue to attend cervical cancer screening even if vaccinated.

What this means for you

• Under 18 and unvaccinated? Catch up now. Statutory insurance pays until the day before your 18th birthday.
• Age 18 to 26: The S3 guideline gives a weak recommendation in favour. The fewer sexual partners so far, the greater the benefit. Ask your insurer about coverage.
• Age 27 to 45 without particular risk: The benefit is usually small. Vaccination can make sense, for example when starting a new relationship after a long monogamous one. This is an individual decision.
• MSM, people with HIV, immunosuppressed people: Raise vaccination actively – three doses with immunodeficiency or HIV. Ask about anal cancer screening too.
• Before a planned transplant: Complete your vaccinations beforehand, HPV included. See our article on adult vaccinations.
• After conisation: Vaccination is a reasonable option with uncertain benefit. It does not replace follow-up checks.

This article is general information and not individual medical advice. Decisions about tests and treatment belong in a conversation with your own physician.