1. Evidence Based STD Screening,
Counseling, and Pregnancy Prevention for
Adolescents
Jeanne E Walker, MSN, CNP
2. STD Prevalence Among Adolescents
• Chlamydia – 6-18% among females
• Gonorrhea – highest incidence among female
adolescents – 610/100,000
• Trichomonas – up to 14% in females; 3-5% of
asymptomatic males
• HSV type I – up to 30% have positive serology
• HPV – 20% of 14-17 year olds and 38% of 18-21
year olds at any given time
Neinstein et al, 2008
3. Risk Factors
• Early coitarche
• Multiple concurrent sex partners
• Sequential sex partners of short term duration
• Inconsistent/incorrect use of barrier methods
• Increased biologic susceptibility to infection
• Obstacles to health care access
• Incarceration
• MSM
• IV drug use
CDC, 2010
4. Consent and Confidentiality
• Minors may consent to their own health services for
STDs in all 50 states and DC. Confidentiality
assured with the exception of limited/unusual
circumstances
• Mandatory reporting/partner notification
• often mandated statements to beneficiaries from 3rd
party payers – breech of confidentiality with regard to
policyholder
5. Screening Recommendations
• Chlamydia – annually for all sexually active females
<25. Evidence insufficient to recommend routine
screening for adolescent males.
• Gonorrhea – annually for all sexually active
adolescent females
• HIV – discussion with all encouraged; recommended
for sexually active and IV drug users
• Routine screening for syphyllis, trich, BV, HSV, HAV,
HBV not recommended if asymptomatic
• HPV/pap – beginning at age 21 (UPSTF, ACOG)
CDC, 2010
6. Primary Prevention Recommendations
• HPV series recommended for 11-12 year old females
(may start as early as 9). Use in females and males
up to age 26.
• HBV vaccine recommended for all adolescents
• HAV vaccine should be offered
• HIV information and testing should be offered to all
adolescents
• Sexuality education should be integrated into clinical
practice by providers caring for adolescents
• CDC, 2010
7. Counseling Guidelines
• Incorporate sexual counseling into routine practice
• Speak to the adolescent at their developmental level
• Ensure confidentiality
• Be non-judgmental
• Prevention – abstaining from all forms of intercourse (vaginal,
anal, oral), or sex only with LTR, monogamous, known to be
uninfected partner. Encourage those who are abstinent to remain
so
• Risk reduction – ideally all partners should be tested first; ask
partner questions; decline sex if obvious STD signs; use a new
condom for each act; get tested regularly; use condoms
consistently
CDC, 2010
8. Barriers - Patient
• Access to care
• Fear/embarrassment
• Wanting to fit in/be accepted by peers
• Not developmentally cognizant of long term
implications
• Immature self-assessment – feelings of infallibility
• Lack of knowledge/misinformation
– One study of rural black adolescents in North Carolina
revealed that although they understood how primary
prevention strategies reduce STD risk, they perceived
abstinence as unlikely, and did not implement strategies that
depended on partner cooperation.
Akers et al, 2012
9. Barriers - Provider
• A periodic AAP survey distributed to pediatricians in
2005
– More than half discussed abstinence, contraception, and
STDs
– 56% offered reproductive health care services, including HIV
testing
– 19% provide condom demonstrations
– 2/3 agree that personalized preventative counseling
decreases high risk behaviors, but 76% say there is a lack of
time
AAP, 2006
10. Barriers - Provider
• 7 out of 10 thought that cultural/language differences,
adolescents’ inaccurate responses to questioning, physician
discomfort are barriers to counseling
• Also cited were the perception of adolescents’ fear of parental
notification of HIV positivity, lack of reimbursement for STD
counseling, lack of interest in adolescent health issues,
insufficient training in discussing STDs, and lack of confidential
reimbursement codes.
AAP, 2006
11. Pregnancy Prevention and Counseling
• 800,000 pregnancies/year in 15-19 year olds, with
51% resulting in live birth (35% abortion, 14% SAB)
• CDC Guidelines
– Have a teen-friendly clinic
– 1st reproductive health visit age 11-15
– Discuss all methods of contraception
– Ask about sexual history
– Counsel regarding dual methods if sexually active/condoms
to prevent STDs
– Take the time to explain how to use the method correctly
CDC, 2012
12. Education and Care Access Strategies
• Sex and family life education in schools – mandated by 19
states and DC. 22 states mandate that abstinence is stressed.
35 states mandate STD/HIV education in schools. Content
typically established by local communities.
• Condom availability programs – instituted by school districts in
NYC and LA in 1991
• School based health centers – nearly 1500 in 1992
ACOG, 2007
• Primary care – individual counseling or group sessions for
teens. Encourage them to have open discussion with their
parents, when possible.
13. Conclusion
• Providers should examine their own biases and
become comfortable discussing sexuality and
attendant issues with adolescents
• Discussion of sexuality, contraception, and STDs
should be incorporated into routine clinical practice
• Follow established screening guidelines
• Care should be individualized, with ongoing
assessment for changing risk factors
• Promote an adolescent-friendly environment
14. References
Akers, A., Gold, M., Coyne-Beasley, T., & Corbie-Smith, G. (2012). A Qualitative Study of Rural
Black Adolescents’ Perspectives on Primary STD Prevention Strategies. Perspectives on Sexual
and Reproductive Health, 44(2), 92-99.
American Academy of Pediatrics (2006). Periodic Survey #63; Issues Surrounding Adolescent
HIV/STD Prevention, Counseling, and Screening. Retrieved from:
http://www.aap.org/en-us/professional-
resources/Research/Pages/PS63_Executive_Summary_IssuesSurroundingAdolescentHIVSTDPr
eventionCounselingandTesting.aspx?
American College of Obstetrics and Gynecology (2007). Strategies for Adolescent Pregnancy
Prevention. Retrieved from: www.acog.org/.../Adolescent%20Health%20Care/.
Centers for Disease Control and Prevention (2010). Sexually Transmitted Diseases. Treatment
Guidelines, Special Populations. Retrieved from:
http://www.cdc.gov/std/treatment/2010/specialpops.htm
Centers for Disease Control and Prevention (2012). Health Care Providers and Teen Pregnancy
Prevention. Retrieved from: http://www.cdc.gov/teenpregnancy/HealthCareProviders.htm
Neinstein, L., Gordon, C., Katzman, D., Rosen, D., & Woods, E. (2008). Adolescent Health Care,
5th ed. Philadelphia: Lippincott, Williams, & Wilkins.
Notas del editor
The annual cost of diagnosing, treating, and managing the long-term sequelae of STDs among adolescents is estimated to be 6.5 billion dollars. This clearly speaks to the need for effective dissemination and implementation of risk reduction strategies. (Akers, et al, 2012)
The first 6 risk factors are most specific to adolescents when considering increased incidence of STDs.Biologic susceptibility secondary to cervical ectopy – when the glandular endocervical cells extend prominently onto the cervix (this regressed with age). These cells are more vulnerable to infections such as chlamydia and gonorrhea. In addition, the risk of acquiring trichomoniasis, chlamydia, herpes and HPV (human papilloma virus) is possibly greatest at first exposure to the STI. Because first exposure often occurs during adolescence, both male and female adolescents are particularly vulnerable. Getting one STI makes it more likely that an adolescent may acquire other STIs.Risk is clearly multifactorial, and includes socioeconomic factors such as high endemic STD rates, sexual and physical abuse, social chaos, poverty, and drug trafficking/use.
Unusual circumstances may include issues such as physical or sexual abuse or other types of imminent dangerMandatory reporting – GC, chlamydia, syphyllis, HIV
Chlamydia screening should be done for at risk adolescent males – sexually active in clinical settings associated with high chlamydia prevalence – adolescent clinics, correctional facilities, STD clinics.WSW (exclusively) should be offered the same screenings. HIV transmission with WSW is much less efficient. WSW are less likely than other adolescents to acquire STDs in general.
Condom use should be discussed and demonstrated as needed.Discussion with adolescents – be attentive, ask good questions, paraphrase to ensure that you understand, be an adult (don’t ‘talk like they do’), help them to feel safe
Access to care – issues include geographic location, PCP/peds vs Planned Parenthood/FP, transportation, lack of finances, Study by Aletha Akers and others – 2006, 37 black adolescents – 20 fe, 17 male. Conclusions were that adolescents try to reduce their STD risk, but do so by ineffective practices. Providers need to not only discuss PP strategies, but help adolescents to identify opportunities to successfully employ them.
Total of 468 appropriate respondents to an 8 page survey mailed to AAP members in 2005
Must discuss emergency contraception, and give rx to have on hand
Access for students in schools may be limited as parents are able to ‘opt out’ – allowed by 35 states. Most of the school programs have been shown to be effective in supporting teens in postponing sex, and in enhancing decision making skills re contraception, abortion, etc.SBHC – pregnancy testing, gyn exams, STD testing and treatment, HIV counseling, but most do not offer contracetption
