Jump in STIs among teens raises red flags

Diane Straub, MD, MPH, FAAP

Ralph J. DiClemente, PhD

Rates of sexually transmitted infections (STIs) among adolescents and teenagers are continuing to increase. As frontline providers for this population, pediatricians have the opportunity and responsibility for addressing the growing epidemic, said Diane Straub, MD, MPH, FAAP, at the American Academy of Pediatrics (AAP) 2018 National Conference and Exhibition in Orlando, Florida.

In a session titled “Recognizing and managing sexually transmitted diseases in adolescents” on Saturday, November 3, Straub described trends in STI epidemiology and reviewed current guidelines for screening, treatment, and prevention.

“Adolescents and teens with signs and symptoms of STIs are more likely to be seeking care from their pediatricians than at STI or Department of Health clinics,” said Straub, professor of Pediatrics and division chief, College of Medicine Pediatrics, University of South Florida, Tampa, Florida.

“It is important that pediatricians ask patients about sexual activity, provide high-intensity prevention counseling at all clinical visits to sexually active patients, and follow guideline recommendations for screening, testing, and treatment,” she said.

Available data indicate that among adolescents and teenagers, the incidence and prevalence rates are rising for all STIs and particularly for chlamydia, gonorrhea, and syphilis. “Considering Youth Risk Behavior Survey data on sexual activity rates, the trend does not seem to be explained by an increase in sexual activity in this age group. Rather, it may be related to a lack of condom use,” Straub said. “If pediatricians are not following guidelines about high-intensity prevention counseling and do not do appropriate screening and testing for STIs, STI rates will continue to go up.”

According to current screening recommendations, annual screening for chlamydia and gonorrhea is recommended for all sexually active girls and males having sex with males. Screening for heterosexual males should be done based on risk-annual screening is recommended for males seen at adolescent or STI clinics or for those otherwise at increased risk. However, according to Straub, data and common sense suggest that screening and treating asymptomatic males would likely decrease rates in females. For human immunodeficiency virus (HIV), it is recommended that routine screening be performed for all individuals aged 13 to 64 years in all healthcare settings. The frequency of follow-up screening should be determined by risk, she said.

Discussing STI treatment, Straub highlighted the issue of increasing resistance of gonorrhea to standard antibiotics. Consequently, the current recommendation is to use combination therapy including intramuscular ceftriaxone and either oral azithromycin or doxycycline. Straub also emphasized the need for partner treatment. Although this varies by STI, in general all partners in the past 60 days or the most recent partner should be evaluated for STIs and presumptively treated for the specific STI.

Straub also reviewed Expedited Partner Therapy (EPT), a strategy that aims to facilitate treatment for sex partners of a patient diagnosed with chlamydia or gonorrhea. In EPT, the index patient is given prescriptions or medications to give to his or her partner(s).

“Optimally, partners would be evaluated clinically in a healthcare setting, particularly young men who have sex with men, but that is challenging considering partners might not have access to healthcare or at least not in a setting where they would feel comfortable coming to be evaluated for an STI,” Straub said.

“EPT aims to overcome that obstacle, and there is good evidence to support that it should be considered in situations where you think the partner(s) will not be treated. However, pediatricians should know their state laws on this practice because it may not be legal in some states,” Straub cautioned.

Medications should be accompanied by treatment instructions, appropriate warnings (eg, allergy, pregnancy), general health education on STIs, and a recommendation to pursue personal medical evaluation, particularly women with symptoms of pelvic inflammatory disease. Straub also pointed out that the newest recommendation for intramuscular injection for gonorrhea complicates this process, so providers should weigh the likelihood of partners obtaining treatment and consider using alternative oral therapy for treatment, particularly for the heterosexual partner(s) of the index patient.

Commentary

Sexually transmitted infections (STIs) in adolescents continues to be a serious public health problem. As described by Dr. Diane Straub in a session titled “Recognizing and managing sexually transmitted diseases in adolescents” at the AAP 2018 National Conference and Exhibition, there is evidence that the rates of STIs are increasing among adolescents.

During her presentation, Dr. Straub made several salient points. One is that symptomatic adolescents often are not diagnosed and treated at health department STI clinics, but rather by their pediatrician. Thus, pediatricians have an opportunity to identify not only symptomatic infections, but asymptomatic infections as well. This would require intensifying screening of adolescents.

Screening only adolescents who self-report being sexually experienced runs the risk of missing many adolescents who truly are sexually experienced but report otherwise. Adolescents’ self-report of sexual risk behavior is notoriously inaccurate, with a bias to underreport sexual risk-taking behavior (eg, frequency of noncondom sex and number of sex partners).

Conducting an annual biological screen for STIs is one strategy for capturing the great portion of the STI iceberg-the hidden portion that is not likely to be observed on a clinical exam. Including STI biological screening during annual examinations for school would help normalize STI screening by reducing any associated stigma. It can utilize recent advances in noninvasive strategies for the most prevalent STIs and provide an opportunity for pediatricians to engage adolescents in a discussion about healthy sex and STI preventive behaviors.

Although there are guideline recommendations for STI screening, testing, and treatment, it is critical that these guidelines be adopted and utilized. As already noted, asking adolescents whether they are sexually experienced is not likely to lead to an accurate response. Quite to the contrary, it is likely to lead to a self-report bias, severely underestimating the proportion of adolescents who have had sex. Thus, while pediatricians can test for STIs as recommended, a negative test result should not be interpreted to mean that the adolescent is not engaging in sex.

Sexual health counseling needs to start early, before adolescents make the decision to become sexually active. As Dr. Straub points out, lack of condom use may account for increasing STI rates among adolescents. If that is true, then pediatricians are well positioned to provide intensive sexual health promotion counseling. Whether an adolescent is sexually active or purports to not be sexually active, preventive counseling should be implemented early and often as adolescents age. Providing preventive counseling is more likely to be effective when implemented prior to adolescents’ engaging in sexual risk situations.

In an era when an STI or HIV can result in lifelong infection and potentially death, we need a more aggressive strategy-one that is systematic, coordinated, and clearly articulated. Pediatricians are on the front lines in the war on STIs. Although they have the basic tools, pediatricians may benefit from increasing their knowledge about preventive counseling and behavior change strategies for motivating adolescents to adopt and sustain use of condoms during sex, as well as from training to hone their implementation skills. In sum, we need the pediatric equivalent of a full-court press or we run the risk of an expanding STI epidemic among adolescents.

Ralph J. DiClemente, PhD, is professor and chair of the Department of Social and Behavioral Sciences and associate dean of Public Health Innovation at the College of Global Public Health, New York University (NYU), New York, New York. He is also an affiliated scientist at the NYU Center for Drug Use and HIV/HCV Research.