Fall 1996 Volume 1, Number 3     Annual Hepatitis A   rates   (per 100,000)   San Francisco and U.S.		The challenge of delivering hepatitis vaccines to gay men Men who have sex with men (MHSM) are known to be at increased risk for both hepatitis B and hepatitis A. In 1981, the ACIP recommended that all sexually active gay men receive hepatitis B vaccine. Recently, the Committee also recommended hepatitis A vaccine for MHSM (see HCR, April 1996). But delivering hepatitis vaccines to this group has proved challenging for public health directors across the country. Hepatitis B A 1996 report from CDC (MMWR, March 15, 1996) illustrates the difficulty in delivering hepatitis B vaccine to gay men. Conducted by the San Francisco Department of Public Health, the study analyzed serologic data from gay men aged 17 to 22 in 1992 and 1993. It found that only 3% of subjects showed signs of being vaccinated against HBV (seropositive for anti-HBs without other markers). It also found that 86% of subjects missed opportunities to receive vaccinations during visits to medical providers. The HBV vaccine findings are similar to a 1990 Boston survey that found that only 17 of 150 gay or bisexual clients of a community health center had been vaccinated (McKusker et al., Public Health Reports, 1990: 105:59-64). "We're still not vaccinating this high-risk group," declared Harold S. Margolis, chief of CDC's Hepatitis Branch, at a recent international symposium on viral hepatitis in Rome (see HCR, Summer 1996). "In spite of 15 years of recommendations, very little is happening." Dr. Frances Taylor, director of communicable disease control, City and County of San Francisco, cites four factors that account for the failure of vaccination programs to reach this group. They are: the cost of vaccine, limited health insurance of many young gay men, a mindset of invincibility in which people don't consider themselves to be at risk, and no systematic practice among health care providers to identify MHSM and offer them vaccinations. In the Boston community health center survey, 69% of subjects cited high cost as a deterrent to getting vaccinated, and 31% said they didn't feel that they were at high risk for contracting the disease. Hepatitis A In areas experiencing high rates of hepatitis A among gay men, public health authorities have also experienced difficulties in applying hepatitis A vaccine. Dr. Taylor says that many of the same factors blocking acceptance of hepatitis B vaccine also block acceptance of hepatitis A vaccine. Many young, high-risk gay men in San Francisco do not perceive hepatitis A as a significant health risk. Others, especially younger, less-established gay men, are deterred by the cost of the vaccine. Additionally, some HMO physicians do not push the vaccine because of low reimbursement levels, Dr. Taylor said. The San Francisco health department is using hepatitis A vaccine obtained from the federal Vaccines for Children program in high-risk adolescents under age 19. The vaccine is being administered at three city health clinics. San Francisco is now in the midst of a hepatitis A outbreak that began two years ago. During the first two years, cases in gay men predominated. Although some cases still occur in that group, there has been a drop in the proportion of cases in gay men.