Table 2

Pre- and Postlicensure Comparison Table

Domain	Prelicensure (2004–2005)	Postlicensure (2009–2012)
HPV counseling in the clinical encounter	High clinician receptivity Low patient/parent HPV knowledge Complexity of topic challenging HPV infection counseling typically not part of guidance about STI prevention	High clinician receptivity High patient/parent receptivity Low patient/parent HPV knowledge Topic ever more complex with 2 competing vaccines and approval for boys Framing of HPV vaccine as cancer prevention rather than STI prevention
Recommended age	Preference for vaccinating older adolescents Topics discussed with younger girls different from older girls Parents accompany younger adolescents to most primary care visits (though clinicians prefer them not to be present)	Mixed results about age range that clinicians are comfortable vaccinating Framing of HPV vaccine as cancer prevention rather than STI prevention (to get around discomfort of discussing sex with younger girls) Challenges in talking about sex (avoidance of discussion), including parents being present
System and compliance issues	Challenges speculated: Wide range of topics to cover Time constraints Getting adolescents to return for 2 subsequent doses within 6 month	Challenges borne out: Adolescents less likely to return for well-person visit Wide range of topics to cover Time constraints Getting adolescents in for second and third shots difficult Inadequate tracking systems and lack of a reminder system Lack of knowledge about 6-month time frame
External factors	Anticipated impact of mass media advertising campaigns Concern that diverse social or religious beliefs about sexual activity would influence acceptability; fear that adolescents would feel overprotected	Media campaign influential, but brought awareness, not necessarily knowledge Mandatory vaccination proposals generated controversy Less concern about adolescent overprotection; responses to mandatory vaccination proposals negative Bundling of HPV vaccine into adolescent platform

HPV=human papillomavirus; STI=sexually transmitted infection.