Straight talk needed on STI prevention

Despite recommendations to approach sexual issues with patients, many clinicians report barriers to such discussions.

Counseling patients about sexual behaviors, including sexually transmitted infection prevention and screening, remains an ongoing challenge, despite recommendations from major medical organizations, including the CDC, the American Academy of Pediatrics and others.

The recommendations call for health care providers to emphasize the most reliable and realistic ways to reduce STIs, including abstinence from all forms of sex, use of condoms and dams during each sexual encounter, and promoting mutually monogamous relationships with uninfected partners.

However, many clinicians report barriers to STI screening. Time constraints, difficulty in discussing sexual issues with patients because of parental concerns, and low confidence in their STI counseling efforts are some of the most commonly cited barriers.

But these barriers can and should be addressed, according to Charlotte A. Gaydos, DrPH, MPH, MS, who is principal investigator in the Division of Infectious Diseases at Johns Hopkins University School of Medicine, and director of the International Sexually Transmitted Diseases Research Laboratory.

With about 20 million new STIs occurring each year and rising rates of infections, more people are at risk for serious long-term health concerns. HIV, reproductive problems and other long-term health complications associated with STIs equate to high costs for the medical community, totaling around $16.4 billion each year, according to Gaydos.

“There are data showing that certain STDs are going up, but there are other data showing better use of condoms, etc, in the past 10 years, so it is hard to know the real truth about STIs in adolescent populations,” Gaydos told Infectious Diseases in Children. “I suspect, however, the rates are going up in certain populations, depending upon who you are looking at. So it is important to ask about sexual activity in this group of patients.”

Assessing risk

STIs continue to be underdiagnosed nationwide, according to Alison Moriarty Daley, MSN, APRN, PNP-BC, associate professor at Yale University School of Nursing. She said the reason that many STIs are underdiagnosed in youth is because many infections are asymptomatic and teens may be reluctant to discuss sexual issues with their health care provider because of concerns regarding confidentiality.

“Being accepting and available to adolescent patients is most important,” Moriarty Daley told Infectious Diseases in Children. She is a pediatric nurse practitioner at Yale-New Haven Hospital and works in a high school-based health clinic and in an adolescent primary care clinic. She advocates a multitiered step to addressing these issues with adolescent patients, specifically:

• Discussing confidentiality;
• Obtaining detailed health and sexual history to determine risks;
• Asking specific questions regarding type of sexual exposure in “adolescent-friendly” terms;
• Reviewing knowledge about prevention;
• Reviewing history of high-risk behaviors;
• Testing appropriate sites of exposure; and
• Screening all sexually active adolescents.

Asking open-ended questions can help determine risk, even in patients who may be reluctant to share their history, she said.

Screening recommendations

Although screening and reporting recommendations vary by state, most health care organizations recognize HIV, AIDS, chlamydia, chancroid, gonorrhea and syphilis as reportable STIs. Most organizations recommend screening all sexually active adolescents for chlamydia, gonorrhea and others according to risk factors.

Those patients reporting unprotected sexual intercourse, injection drug use, multiple partners, sex with an infected partner, or teens seen in high-risk or high-prevalence settings are considered at higher risk for infection.

“Technology, access to things like webcams, hook-up websites, Internet pornography, etc, are impacting the way that teens are engaging sexually,” Chris Kraft, PhD, a psychologist in the Sexual Behaviors Consultation Unit at Johns Hopkins School of Medicine, told Infectious Diseases in Children. “We need to assess how technology is impacting our patients’ relationships, sexual activities, and how they live.”

Data from the CDC demonstrate that although there are decreases since 1991 in the percentage of high school students who have ever had sexual intercourse and increases in the percentage of sexually active students who used a condom at last sexual intercourse, “the rates for sexual activity are still not as low as we would like and the rates for condom use are still not as high as we’d like. About 61% of sexually active high school students reported condom use in the 2009 National Youth Risk Behavior Survey (YRBS), but that means there are still about 40% that did not,” Laura Kann, PhD, of the CDC’s Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, said during an interview with Infectious Diseases in Children.

Kann and colleagues from the CDC published data in June that looked at YRBS results, collected between January 2001 and June 2009, that examined data on high school students who identified themselves as heterosexual, gay or lesbian, bisexual, or unsure of their sexual identity. The researchers said that across the nine YRBSS study sites that assessed sexual identity, the prevalence among gay or lesbian students of risk behaviors was higher than the prevalence among heterosexual students for a median of 63.8% of all the risk behaviors measured. In addition, the prevalence among gay or lesbian students was more likely to be higher than (rather than equal to or lower than) the prevalence among heterosexual students for behaviors in seven of the 10 risk behavior categories (behaviors that contribute to violence, behaviors related to attempted suicide, tobacco use, alcohol use, other drug use, sexual behaviors and weight manage­ment). Similarly, the prevalence among bisexual students was more likely to be higher than (rather than equal to or lower than) the prevalence among heterosexual students for behaviors in eight of the 10 risk behavior categories (behaviors that contribute to unintentional injuries, behaviors that contribute to violence, behaviors related to attempted suicide, tobacco use, alcohol use, other drug use, sexual behaviors and weight management).

In their conclusions, Kann and colleagues wrote: “Effective state and local public health and school health policies and practices should be developed to help reduce the prevalence of health-risk behaviors and improve health outcomes among sexual minority youths. In addition, more state and local surveys designed to monitor health-risk behaviors and selected health outcomes among population-based samples of students in grades 9-12 should include questions on sexual identity and sex of sexual contacts.”

Robert L. Cook, MD, MPH, who is an associate professor in the Colleges of Medicine and Public Health and Health Professions, department of epidemiology, at the University of Florida, said a questionnaire may be a good place to start for pediatricians who are looking to assess risk behaviors but also may be pressed for time during the office visit.

“Explaining that you would like them to fill in the questionnaire, but that you wouldn’t share it with parents, may help the patients feel more comfortable giving honest answers,” Cook said. “Also, a questionnaire can be done as part of a regular visit, so that it doesn’t seem to them as if you are implying they are sexually active when they may not be. It just becomes something that you do for every patient in the practice.”

Cook said there are data showing that increased screening rates have been associated with decreased long-term consequences. One particular study reported increased screening for chlamydia yielded lower rates of pelvic inflammatory disease.

STI treatment

In most states, minors can consent to their own treatment for sexual issues without the consent of, or notice to, their parents, but the laws vary. In many states, parental notification is needed for abortion, but all states allow minors to receive care related to STIs without parental consent.

The issue becomes more complex if the pediatrician prescribes oral contraceptives, for instance, and the pills show up on a parents’ explanation of benefits.

“There is no easy answer for this,” Cook said, because although the pediatrician may be keeping the patient’s confidentiality, “the parent ends up finding out anyway.” In situations such as these, it is best to assure both the parent and patient that sexuality is one of the top health issues for adolescence, and early STI screening and treatment is key for preventing further long-term complications.

When treating patients for STIs, Moriarty Daley encourages clinicians to “always use the treatment regimen with the fewest doses to enhance compliance.”

Moriarty Daley reviewed several commonly prescribed treatments for differing STIs, and said that the CDC’s 2010 Sexually Transmitted Disease Treatment Guidelines is an invaluable resource for clinicians and provides the most current recommendations for screening and management of STIs.

For chlamydia, azithromycin 1 g as a single dose is best. For gonorrhea, ceftriaxone 250 mg intramuscularly as a single dose is recommended, and cefixime (Suprax, Lupin Pharmaceuticals) 400 mg given orally as a single dose is an acceptable alternative if ceftriaxone is not an option, as per the CDC guidelines. Moriarty Daley said the newest STD treatment guidelines recommend also treating chlamydia for those teens who have gonorrhea because many times both infections occur concurrently.

Regarding human papillomavirus treatment for genital warts, Moriarty Daley said there are many provider- or patient-administered options outlined in the new STD treatment guidelines. Vaccination against HPV is also important, she said, for the prevention of HPV for both male and female adolescents.

Herpes simplex virus treatment varies depending upon whether it is the initial episode or a recurrence. For a first clinical episode, the CDC recommends:

• Oral acyclovir 200 mg five times a day for 7 to 10 days.
• Oral acyclovir 400 mg three times daily for 7 to 10 days.
• Oral famciclovir 250 mg three times daily for 7 to 10 days.
• Oral valacyclovir 1 g twice daily for 7 to 10 days.

For suppressive therapy, there are several options, including:

• Oral acyclovir 400 mg twice daily.
• Oral famciclovir 250 mg twice daily.
• Oral valacyclovir 500 mg every day.
• Oral valacyclovir 1 g every day.

For clinicians, Moriarty Daley said that educating patients about STIs and prevention strategies, including condom negotiation, is as important as diagnosing and providing treatment. She encourages clinicians to provide condoms, make a plan for results/treatment, offer and encourage HIV counseling and testing, and to vaccinate against HPV. Treating partners is also essential in the prevention of reinfection or the infection of future partners, according to Moriarty Daley.

Contraception

Contraceptive counseling provides another opportunity to discuss STIs and offer screening. Moriarty Daley said it is also important to review the benefits and risks of various birth control options to determine what will be the safest and most effective means of pregnancy prevention for each teen. The most common methods used by teens include condoms, oral contraceptive pills, depot medroxyprogesterone acetate and emergency contraception. However, longer-acting methods such as intrauterine contraception and an etonogestrel implant (Implanon, Merck) can be considered.

Consistent and correct condom use should be emphasized as the most effective method, other than abstinence, for prevention of both STIs and pregnancy. Male condoms have a breakage rate of about 2%, which increases with anal sex. Female condoms have an average failure rate of about 21% for typical use and 5% for perfect use for pregnancy prevention.

A limited number of laboratory and clinical studies have shown that female condoms protect against transmission of STIs, but data are much more limited than for male condoms.

In vitro data suggest that the female condom may provide an impermeable barrier to HIV and cytomegalovirus and other STIs, but there are no clinical studies that have specifically evaluated the female condom’s ability to prevent HIV transmission. Two of three randomized trials of behavioral interventions to promote use of the female condom reported that groups assigned to use a female condom had lower STI rates than groups assigned to use male condoms, but the differences were not statistically significant. Results of the third trial indicated that the STI rate in the group that only had access to male condoms was the same as that for the group with access to both male and female condoms.

The advantages of condoms include that they protect against most STIs, with relatively few adverse events, and they are readily available. However, disadvantages of condoms include that they require planning before use, and they must be placed on immediately before sex.

Discussing oral contraception with patients should also include a talk on the pill’s failure rate, which is about 8%. However, that number drops to less than 1% with perfect use, Moriarty Daley said. The advantages of oral contraception include: pregnancy prevention; regulation of menstrual cycles; lighter periods; fewer premenstrual symptoms; and improvement of acne. However, there are some disadvantages that must be taken into account when discussing oral contraceptive use, including the requirement for daily use and side effects such as nausea and spotting, which can result in discontinuation. In addition, they offer no STI protection, and are contraindicated for use for some adolescents.

When discussing oral contraceptive use with patients, Moriarty Daley encouraged clinicians to ask at each visit:

• Did you take the pill each day? When?
• Did you miss any pills?
• How many pills have you missed in a typical week?
• How did you make them up?
• Did you get your period in the inactive row?
• Did you have a normal period?
• Did anything happen that bothered you, such as bleeding? Nausea?
• Did you engage in unprotected sex?

Another contraceptive option that pediatricians could discuss with teenage patients is the depot medroxyprogesterone acetate (DMPA) injection. Perfect use of this vaccine has been associated with about a 0.3% failure rate vs. a typical 3% failure rate. The advantages of DMPA include: pregnancy prevention; fewer compliance problems; and minimal drug interactions. However, disadvantages may include irregular bleeding, weight changes and lack of STI protection.

At follow-up visits, Moriarty Daley encourages clinicians to ask, at every visit:

• Any bleeding?
• If yes, how much? How many days? When? Any other side effects?
• Unprotected sex?
• If weight gain, change in appetite or eating/exercise patterns?
• Any concerns?

Emergency contraception

Regarding emergency contraception, Moriarty Daley said this option should be considered in the case of a condom break, unplanned sexual intercourse, sexual assault or contraceptive failure. Use of emergency contraception with 5 days of unprotected sex has the potential to significantly reduce the risk of pregnancy.

No matter what contraceptive method chosen collaboratively by the adolescent and health care provider, frequent follow-up and the availability of the clinician to answer questions about proper use and side effects enhances effective use. Clinicians should take every opportunity to discuss both STI prevention and contraceptive options with male and female adolescents.

Gaydos said school-based health centers can also play an important role in helping students who may be at risk for STIs, adding that there are at-home testing kits, which can assist with diagnosis.

Gaydos said if the results come back positive, her office works with the patient to get them the help they need, either through their own primary physician or a clinic. – by Colleen Zacharyczuk

For more information:

• CDC. Sexually transmitted diseases treatment guidelines 2010. www.cdc.gov/std/treatment/ 2010. Accessed August 30, 2011.
• Moriarty Daley A. Sex Ed for PNS. Session 221. Presented at: 2011 National Association of Pediatric Nurse Practitioners Annual Conference; March 23-26, 2011; Baltimore.

Disclosures: Moriarty Daley reports having served as a consultant for the Merck Female Population Advisory Board, 2009 and for GlaxoSmithKline, National Cervical Cancer Vaccination Advisory Board, 2009-present. Drs. Cook, Kann and Kraft report no relevant financial disclosures. Dr. Gaydos did not respond to requests for financial disclosures.

Have the updated CDC guidelines on STIs changed how clinicians approach sexuality with their patients?

The guidelines and new adolescent vaccines have changed approach.

There is now a bigger push to make physicians more aware of adolescent sexuality and to talk to adolescents about their sexual practices. High-intensity behavioral counseling is recommended for all sexually active adolescents. Asymptomatic chlamydial infection is common, and annual screening of sexually active women aged younger than 25 years is recommended. The CDC recommendations note that although it may not be cost-effective to screen adolescent males for chlamydia, there is a lot of controversy about that, and it should be considered in clinical settings of high risk, such as among adolescents in juvenile detention centers. Because of the high risk of reinfection among those diagnosed with chlamydia, retesting should be performed 3 months after treatment, or whenever patients next present for care within 12 months.

The meningococcal and HPV vaccines have helped improve health maintenance care of adolescents because these vaccines have created a need for a scheduled adolescent visit to the pediatrician. This presents an excellent time to talk to them about sexuality and related issues.

This adolescent visit gives us a good opportunity to talk about a lot of issues, including ‘what is your sexual partner like?’ The key to this visit and following the guidelines is to remain nonjudgmental, empathetic and ask open-ended questions.

This is also a good time to discuss alcohol and drug use, and other risk behaviors.

Toni Darville, MD, is a member of the Infectious Diseases in Children Editorial Board. Disclosure: Dr. Darville reports no relevant financial disclosures.

My approach has not changed.

In the past 5 years, the availability of female urine screening tests for chlamydia and gonorrhea has revolutionized the way the pediatrician approaches routine gynecological care. Collecting annual routine urine is easy, noninvasive and with relatively fast results for the well adolescent. A routine pelvic examination is no longer needed for everyday contraceptives or for follow-up of sexually active females until age 21 years. Furthermore, the widespread use of HPV vaccines (eg, in our large adolescent practice) has markedly reduced the rates of cervical precancers for all sexually active young females.

Like many non-urban practices, since we have been routinely already screening urines in sexually active females for STIs, coupled with the low rates of chlamydia (< 5% annually) and gonorrhea (< 1% annually) in our rural practice, I do not perceive much of a change is going to happen any time soon. I made about three phone calls to my older adolescents for chlamydia treatment (for patients and partners) in the past 6 months. In addition, we now have rapid inexpensive urine screening tests for BV and trichomonas, which will further reduce our need for pelvic examinations, particularly for the female with UA-negative mild dysuria or non-pruritic vaginitis. Then the only occasional pathogens missing are herpes and venereal warts (mostly seen after age 18 years). So the CDC should encourage the office pediatrician, that all in all, routine young adolescent gynecologist visits have become much quicker and simplified. This may not apply to some more complicated or metropolitan practices.

Yet, as the CDC has implored, we still must be quite familiar with each of the contraceptive methods available, along with STI prevention techniques. Some quick history pearls in helping the practitioner decide which female to screen and educate much more thoroughly, or to just assume as likely sexually active are: boyfriend who is 24 months or more older than the patient; dating steadily for more than 6 months; UTI currently or recently; smoking; school problems; runaway; and single parent household.

Actually, the most difficult part usually is juggling how to handle the parent during the 15-minute visit in private practice. This is where the CDC recommendations falter significantly for the average office pediatrician. More than half of our parents insist on being present during visits for children aged younger than 18 years, and we must try to accommodate them to some degree. I ask for a few minute “wrap-up” discussion with the teen alone. And commonly, the oral contraceptive pill is prescribed as adjunctive therapy for dysmenorrhea or dysfunctional uterine bleeding or acne, etc., to justify the prescription, when it is needed for even more important reasons.

Stan L. Block, MD, is a member of the Infectious Diseases in Children Editorial Board. Disclosure: Dr. Block has received research grants for Merck hpv4 vaccine and GlaxoSmithKline for hpv2 vaccine.

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