ADOLESCENT HEALTH: Screening for STIs

Sexually transmitted infections (STIs) in patients aged 15 to 24 years account for an estimated $6.5 billion of $15.6 billion in direct health expenses spent annually on STIs.¹Chlamydia and gonorrhea strike this age group most frequently (39% and 49% of reported infections, respectively). To prevent such infections, and sequelae that can include impaired fertility and reproductive-tract cancers, Gale R. Burstein, MD, MPH, FAAP, advised making adolescents' sexual health a matter of routine in primary care in her presentation “How Do I improve Screening for Sexually Transmitted Infections in My Practice?”

To that end, it's crucial not only to have systems for confidential care in place, but also to ensure that one's staff is onboard. In the former area, teen-friendly tips from the National Chlamydia Coalition include clearly posting your privacy policy, offering educational materials in private settings, and ensuring that teenagers can discuss their sexual health without parents present. Because the legal ability of minors to consent to interventions such as contraceptive services has grown dramatically, added Burstein, it's also critical to know your state's laws in these areas.

Tools for assessing adolescent risk of STIs should include questions that direct testing, as does the Centers for Disease Control and Prevention (CDC) 5 Ps: partners, sexual practices, past STI history, pregnancy, and STI prevention.

Regarding screening, the American Academy of Pediatrics recommends Chlamydia and gonorrhea screening as follows:

• Sexually active females, aged 25 years or younger: annually.

• Adolescent and young adult (AYA) men who have sex with men, who report high-risk behaviors (such as multiple partners or illicit drug use): as frequently as every 3 months.

• AYAs who have been exposed by an infected partner in the past 60 days: as needed.

Conversely, organizations including the CDC do not recommend routine screening for syphilis in nonpregnant, heterosexual teenagers, or for other STIs including Trichomonas vaginalis, herpes simplex virus, human papillomavirus (HPV), hepatitis A, and hepatitis B, absent individual and population-based risk factors. Generally, annual cervical cancer screening should begin at age 21 years.

Gale R. Burstein, MD, MPH, FAAP, FSAHM, is commissioner, Erie County Department of Health, and clinical professor of pediatrics, State University of New York at Buffalo School of Medicine and Biomedical Sciences, New York.

REFERENCES

1. Centers for Disease Control and Prevention (CDC). 2010 Sexually Transmitted Diseases Surveillance. Available at: http://www.cdc.gov/std/stats10/toc.htm. Last reviewed November 17, 2011. Accessed October 30, 2014.

It's important for pediatricians to discuss STIs with their patients because the majority of teenagers are sexually active, and they should know about the dangers of unsafe sex. If teenagers can't practice abstinence, they need to know their partner well and use protection. In the case of the HPV vaccine, patients should get it before becoming sexually active because it's quite safe and effective.

The vaccine has been approved for children aged as young as 9 years. The original indication for girls was as an anticancer vaccine because genital cancers are far more common in women than in men. Cancer of the penis is rare in the United States, although more common in other countries where men don't commonly get circumcised. However in gay men, anal cancer is occurring in epidemic proportions. That's even more reason for gay men to get the vaccine.

We tell males that the vaccine also protects against genital warts, which are just as common in both genders, and we remind them that the vast majority of girls get those cancer-causing viruses from guys. So we tell the guys that even if they're not worried about themselves, then at least get the vaccine so they don't contract HPV from one girl and give it to another.

Often, parents may not think their teenagers are sexually active, but more often than not, they are. Sometimes teenagers think that if they're having oral sex, they're not having sex. Unfortunately much of the genital herpes we're seeing is type 1, which occurs due to oral-genital contact, so it's very important for pediatricians to discuss these matters with their teenaged patients. For patients aged younger than 18 years, we need to get their parents' permission to talk to them alone. They probably won't talk very freely in front of their parents.

As for STI screening, we encourage female patients to go to their gynecologist and undergo Pap smears as soon as they become sexually active. For the males, if they don't undergo a full examination by their dermatologist, they may not be seeing any other doctors for their sexual health, so there's a little more resistance among teenaged boys to undergo the examination.

Stephen K. Tyring, MD, PhD, MBA, FAAD, is clinical professor of dermatology, microbiology/molecular genetics, and internal medicine at the University of Texas Health Science Center, Houston, and medical director of the Center for Clinical Studies, Houston.

Mr Jesitus is a medical writer based in Colorado. He has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.