Pediatric Annals

CME 

Diagnosis and Treatment of Chlamydia, Gonorrhea, and Trichomonas in Adolescents

Meera S. Beharry, MD, FAAP; Taraneh Shafii, MD, MPH; Gale R. Burstein, MD, MPH, FAAP, FSAHM

Abstract

CME Educational Objectives

1. Determine and discuss issues surrounding consent, confidentiality, and billing for sexually transmitted infection (STI) care delivery in the adolescent population.

2. Review currently available testing modalities for STIs and their applicability in the adolescent population.

3. Provide treatment and prevention strategies for the most commonly encountered STIs in the adolescent demographic.

Adolescents and young adults carry the highest rates of infection for the majority of sexually transmitted infections. Primary care providers are an important resource to assist in the diagnosis and treatment of these potentially physically and emotionally damaging infections; the Centers for Disease Control and Prevention (CDC), American Academy of Pediatrics (AAP) and the Society of Adolescent Health and Medicine (SAHM) have developed a variety of tools to assist providers in obtaining an accurate sexual health history in a busy primary care practice.

Chlamydia trachomatis remains the most common reported STI with its highest prevalence among adolescents. It is often asymptomatic, making routine screening an essential component of diagnosis. Many states have adopted laws permitting “expedited partner therapy” to help decrease transmission and increase treatment of sexual contacts. Guidelines for follow-up screening have also been updated to assess for re-infection.

Neisseria gonorrhoeae rates among adolescents are again increasing. Resistance to oral cephalosporins has prompted the CDC to change its treatment recommendations to dual therapy with intramuscular ceftriaxone plus either oral azithromycin or doxycycline the new standard of care. Subpopulations at increased risk for infection include black and Hispanic adolescents and young adults.

Trichomonas vaginalis infections are often asymptomatic but also may present as urethritis or vaginitis. Newer screening methods, such as nucleic acid amplifi cation testing, permit diagnosis of gonorrhea, chlamydia, and trichomonas without the need for a full genital exam and with greater sensitivity and specifi city than earlier screening methods.  

Abstract

CME Educational Objectives

1. Determine and discuss issues surrounding consent, confidentiality, and billing for sexually transmitted infection (STI) care delivery in the adolescent population.

2. Review currently available testing modalities for STIs and their applicability in the adolescent population.

3. Provide treatment and prevention strategies for the most commonly encountered STIs in the adolescent demographic.

Adolescents and young adults carry the highest rates of infection for the majority of sexually transmitted infections. Primary care providers are an important resource to assist in the diagnosis and treatment of these potentially physically and emotionally damaging infections; the Centers for Disease Control and Prevention (CDC), American Academy of Pediatrics (AAP) and the Society of Adolescent Health and Medicine (SAHM) have developed a variety of tools to assist providers in obtaining an accurate sexual health history in a busy primary care practice.

Chlamydia trachomatis remains the most common reported STI with its highest prevalence among adolescents. It is often asymptomatic, making routine screening an essential component of diagnosis. Many states have adopted laws permitting “expedited partner therapy” to help decrease transmission and increase treatment of sexual contacts. Guidelines for follow-up screening have also been updated to assess for re-infection.

Neisseria gonorrhoeae rates among adolescents are again increasing. Resistance to oral cephalosporins has prompted the CDC to change its treatment recommendations to dual therapy with intramuscular ceftriaxone plus either oral azithromycin or doxycycline the new standard of care. Subpopulations at increased risk for infection include black and Hispanic adolescents and young adults.

Trichomonas vaginalis infections are often asymptomatic but also may present as urethritis or vaginitis. Newer screening methods, such as nucleic acid amplifi cation testing, permit diagnosis of gonorrhea, chlamydia, and trichomonas without the need for a full genital exam and with greater sensitivity and specifi city than earlier screening methods.  

Adolescents and young adults, 15 to 24 years of age, carry a disproportionate burden of sexually transmitted infections compared with other age groups in the United States (see Figure 1).1

Figure 1

Figure 1. Most reported gonorrhea and chlamydia infections in the United States in the year 2011 occurred among people aged 15 to 24 years. Image courtesy of Centers for Disease Control and Prevention.21 Reprinted with permission.

Although young people represent only 25% of the sexually active population, they account for more than 50% of the 19 million cases of sexually transmitted infections (STIs) diagnosed annually.1 This increased disease burden is multifactorial and may, in part, be explained by a combination of physiologic susceptibility, stages of psychosocial development, health care underutilization, and confidentiality concerns. Along with age and gender differences, racial disparities exist, with blacks having a higher reported STI burden than Hispanics and whites (see Figure 2).2

Racial and gender disparities for reported cases of gonorrhea, chlamydia, and syphilis in the United States the year 2010. †All rates are for reported cases per 100,000 people.Image courtesy of Centers for Disease Control and Prevention.21 Reprinted with permission.

Figure 2. Racial and gender disparities for reported cases of gonorrhea, chlamydia, and syphilis in the United States the year 2010. All rates are for reported cases per 100,000 people. Image courtesy of Centers for Disease Control and Prevention.21 Reprinted with permission.

Because sexual health is an important component of preventive health care, primary care providers, including those practicing in pediatrics and family practice, have the opportunity to promote healthy sexuality and prevent morbidity associated with risky sexual behaviors, including STI acquisition and transmission and unintended pregnancy occurrence.

Sexual Health History

The most common STIs affecting adolescents are asymptomatic, making adolescent disclosure of sexual behavior a key first step in identifying patients at risk for infection. There are a variety of available tools to assist primary care providers in “routinizing” sexual behavior screening, as well as screening for other behaviors that may affect their adolescent patient’s health.

For example, the clinical care page on the Society for Adolescent Health and Medicine (SAHM) website and the American Academy of Pediatrics’ (AAP) Section on Adolescent Health website, both offer a brief, 16-question health survey that ask about all health-related behaviors, such as sex, drug and alcohol use, depression, violence, nutrition, and exercise.3,4 The survey is easy to read and may be completed confidentially by the adolescent patient in a few minutes when the nurse brings the patient to a triage room for vital sign measurement.

Other validated adolescent health assessment questionnaires, such as AAP Bright Futures and the Rapid Assessment for Adolescent Preventive Services, can also be used for health screening.5,6 Providers can review the patient responses before entering the exam room to determine what follow-up questions need to be asked and which lab tests obtained, such as STI screening, are indicated.

Many adolescents engage in sexual behaviors that can place them at risk for infection. Merely asking an adolescent if he or she is “sexually active” could miss important information that will guide how to evaluate the patient. In order to fully evaluate STI risk, the Centers for Disease Control and Prevention (CDC) recommends asking about “the Five P’s,” (ie, Partners, Pregnancy Prevention, STI Protection, Practices, and Past STI History; see Sidebar 1).7 For example, many adolescents believe that noncoital sex8–10 minimizes their risk for infection and do not consider this behavior as “sex.” In addition, adolescents engaging in same-sex behaviors may feel uncomfortable disclosing this information unless they are asked.

Sidebar 1.

The Five P’s of a Sexual History

  1. Partners

    • “Do you have sex with men, women, or both?”
    • “In the past 2 months, how many partners have you had sex with?”
    • “In the past 12 months, how many partners have you had sex with?”
    • “Is it possible that any of your sex partners in the past 12 months had sex with someone else while they were still in a sexual relationship with you?”
  2. Prevention of Pregnancy

    • “What are you doing to prevent pregnancy?”
  3. Protection from STIs

    • “What do you do to protect yourself from STDs and HIV?”
  4. Practices

    • “To understand your risks for STIs, I need to understand the kind of sex you have had recently.”
    • “Have you had vaginal sex, meaning ‘penis in vagina sex’?” If yes, “Do you use condoms: never, sometimes, or always?”
    • “Have you had anal sex, meaning ‘penis in rectum/anus sex’?” If yes, “Do you use condoms: never, sometimes, or always?”
    • “Have you had oral sex, meaning ‘mouth on penis/vagina’?”

    For condom answers:

    • If “never:” “Why don’t you use condoms?”
    • If “sometimes:” “In what situations (or with whom) do you not use condoms?”
  5. Past history of STIs

    • “Have you ever had an STI?”
    • “Have any of your partners had an STI?”

STI = sexually transmitted infections.

Routinely collecting urine specimens on all adolescents at triage can be helpful in streamlining routine urine STI testing. If the adolescent patient denies sexual practices that may lead to infection, the provider can easily discard the urine specimen. Collecting the urine before the exam facilitates ordering indicated STI screening tests by making the specimen readily available. The National Chlamydia Coalition’s Why Screen? An Implementation Guide for Healthcare Providers, 2nd edition, explains in detail how primary care providers can include adolescent sexual health care and chlamydia screening in the office setting.11

Consent, Confidentiality, and Billing

Minors in all 50 states and the District of Columbia may access STIs services without parental permission.12 If a minor consents to care, the medical information for this care is considered the adolescent’s personal health information and cannot be shared, even with parents, without the adolescent’s consent. Exceptions include that providers are mandated by state law to report suspected cases of physical or sexual abuse, or neglect, and must report certain positive STI test results to the state or local health department.

Confidentiality is critical for many teens. By speaking with adolescents alone, primary care providers can facilitate adolescent disclosure of sexual risk behaviors.13,14 Ideally, all adolescents should be able to view their primary care provider’s office as a safe, nonjudgmental medical home. Recent studies have shown that many adolescents do not get “alone time” with their provider to discuss these sensitive issues.15

In addition to confidentiality breaches by the provider or office, the health insurance claims process can also breach an adolescent patient’s confidentiality. Commercial health plans typically send the policyholder (usually a parent) an Explanation of Benefits (EOB) when the health plan is billed for a health service obtained by one of the covered members. The EOB identifies the patient, the broad category of service received, the date that service was received, and the provider. Although some parents may not inquire about specific details of an adolescent health care visit, those with high deductible health plans may be interested in the specific services to be paid out-of-pocket as part of the deductible. In addition, clinical laboratories may send billing statements to the family regarding STI tests.

On the other hand, Medicaid typically does not generate EOBs. Options to help a commercially insured adolescent patient maintain confidentiality include developing a low-cost visit service or referring the patient to a Title X Family Planning Clinic or local health department STD clinic. Many states provide Medicaid waivers allowing teens to be dually insured by both their parents’ health plan, as well as the Medicaid waiver that pays for confidential sexual health services. In some states teens may request that health plan billing statements regarding their care are sent to an alternative address. Providers should counsel their adolescent patients about the possibility of EOBs sent to the home and their options to avoid disclosure of personal health information through billing.

Routine chlamydia and gonorrhea screening of sexually active adolescent and young adult females are Grade-A/B United States Preventive Services Task Force Services (USPTFS) recommendations.16 Therefore, under the Patient Protection and Affordable Care Act (ACA), females younger than age 25 years can be screened for chlamydia and gonorrhea with no cost-sharing when provided by in-network providers.17 The Current Procedural Terminology (CPT) modifier 33 aids in correctly coding for preventive services that fall under the ACA and have no cost-sharing. Routine male chlamydia and gonorrhea screening are not covered under the ACA .18

Some providers caring for adolescents routinely inform their patients and their families about office policy and practices around adolescent confidentiality and routine STI testing. This can be accomplished by sending families a letter before the preventive care visit or at registration (see Figure 3) and by placing information on the office’s website that outlines services routinely offered, as well as general information from CDC Youth Risk Behavior Surveillance Survey about the prevalence of risky behaviors among youth in the relevant state from CDC Youth Risk Behavior Surveillance Survey Youth Online.19,20 A modifiable template is also available on SAHM and AAP websites.3,4 Proactively informing families of what to expect at the adolescent health care visit, including routine STI screening, decreases the likelihood of patients and parents feeling surprised and dissatisfied with services offered.

A sample letter to parents regarding adolescent health services offered and confidentiality policy.Image courtesy of Society for Adolescent Health and Medicine3. Reprinted with permission.

Figure 3. A sample letter to parents regarding adolescent health services offered and confidentiality policy.Image courtesy of Society for Adolescent Health and Medicine3. Reprinted with permission.

Testing and Management

Because most STIs, such as Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis, are asymptomatic, the CDC, USPSTF, and major medical professional organizations have developed evidenced-based guidelines for routine STI screening of asymptomatic patients at risk of infection.

Chlamydia trachomatis

C. trachomatis (chlamydia) is the most commonly reported bacterial STI. Rates are highest in adolescents and young adults compared with other age groups and have been increasing over the past two decades. From 2011 CDC Surveillance data, females aged 20 to 24 years (3,722 cases per 100,000) and 15 to 19 years (3,416 cases per 100,000) have the highest reported infection rates. In males, those 20 to 24 years (1,343 cases per 100,000) have the highest reported infection rates, followed by those 15 to 19 years (803 per 100,000).21 When assessing for differences in race and ethnicity, black females aged 15 to19 years (7,507 cases per 100,000) have the highest reported chlamydia rates, followed by American Indians/Alaska Natives (3,624 cases per 100,000). Black males aged 15 to19 years also have a significantly higher rate of chlamydia (2,302 cases per 100,000) than their white counterparts (207 cases per 100,000).21

Chlamydia genital infection may cause cervicitis, urethritis, proctitis, and pelvic inflammatory disease (PID) in females. Urethritis, proctitis, and epididymitis are possible manifestations in males. As most chlamydia infections are asymptomatic, including nongenital infections, routine screening of at-risk populations is of utmost importance to prevent transmission to sexual partners and to prevent complications of untreated infection, which includes PID and the potential adverse outcomes of chronic pelvic pain, ectopic pregnancy, and infertility. Chlamydia screening has been found to decrease incidence of PID.22

The CDC recommends annual chlamydia screening for all sexually active females 25 years of age and younger, and to consider screening adolescent and young adult males in higher prevalence populations such as those seen in adolescent clinics, correctional facilities, and STD clinics.7 For males who have sex with males (MSM), the CDC recommends at least annual screening for urethral and rectal infection, based on reported sexual behaviors. MSM with high-risk behaviors, such as multiple or anonymous partners, should be screened every 3 to 6 months.7

Nucleic acid amplification tests (NAATs) are preferred for both chlamydia and N. gonorrhoeae testing because of their superior sensitivity and specificity. Chlamydia and gonorrhea NAATs are licensed for use with urine, urethral, and cervical specimen testing and many are US Food and Drug Administration (FDA)-approved to test vaginal swabs, including patient-collected swabs, and liquid cytology specimens. Patient-collected vaginal swabs are the preferred female genital specimen and are ideal for females who may be reluctant to have a genital exam. Female urine remains acceptable but may have slightly reduced performance when compared to cervical or vaginal swabs.23

Urine is the preferred specimen for male chlamydia testing. Although chlamydia and gonorrhea NAATs are not FDA-approved for oral or rectal specimen testing, laboratories that have met Clinical Laboratory Improvement Amendment (CLIA) requirements and have validated chlamydia and gonorrhea NAAT performance on oral and rectal specimens may offer these tests.23

The preferred chlamydia treatment for adolescents is azithromycin 1 g. Providers are encouraged to administer this treatment in the office, if possible; single-dose therapy decreases issues with compliance. Doxycycline 100 mg twice a day for 7 days is also recommended as first-line chlamydia treatment by the CDC.7

Since most health departments do not have the capacity for chlamydia case investigation and partner notification, many states have adopted expedited partner therapy (EPT) as a possible strategy for partner treatment to break the chain of transmission. EPT is the clinical practice of treating the sex partners of patients diagnosed with chlamydia or gonorrhea by providing prescriptions or medications to the patient to take to his/her partner without the health care provider first examining the partner. Providers can check with the local or state health department to find out if EPT is permissible in their state, or can visit to the CDC’s Legal Status of Expedited Partner Therapy website ( www.cdc.gov/std/ept/legal/default.htm).24

Chlamydia-infected patients should be retested approximately 3 months after treatment or whenever persons next present for medical care in the 12 months following initial treatment, regardless of whether they believe that their sex partners were treated.7

Neisseria gonorrhoeae

Although N. gonorrhoeae rates had been on a downward trend until reaching the lowest rate ever in 2009, they are now increasing again in the adolescent and young adult population. Females aged 15 to19 years (556 cases per 100,000) and 20 to 24 years (584 cases per 100,000) have the highest reported infection rates. In males, those 20 to 24 years have the highest reported infection rates of (451 cases per 100,000), followed by those aged 25 to 29 years (266 cases per 100,000) and 15 to 19 years (248 cases per 100,000). When assessing for differences in race/ethnicity, blacks (427 cases per 100,000) have the highest reported gonorrhea infection rates: about eight times that of Hispanics (54 per 100,000) and 17 times that of whites (25 cases per 100,000).21

In females, gonorrhea infection may cause pharyngitis, cervicitis, urethritis, proctitis, and PID. In males, pharyngitis, urethritis, proctitis, and epididymitis are common with gonorrhea. Although males often experience symptomatic urethritis, infection in females is often asymptomatic. Both gonorrhea pharyngitis and proctitis are often asymptomatic among males and females.

Targeted screening of high-risk populations is of utmost importance to prevent transmission to sexual partners and to prevent complications of untreated infection. Annual gonorrhea screening is recommended for sexually active females younger than 25 years. In males, the CDC recommends at least annual gonorrhea screening for urethral, pharyngeal, and rectal infection for MSM. MSM with high-risk behaviors, such as multiple or anonymous partners, should be screened every 3 to 6 months.7

Due to emerging resistance to second- and third-generation cephalosporins, the CDC now recommends dual therapy to treat uncomplicated gonorrhea infection: ceftriaxone 250 mg as a single intramuscular dose, plus either azithromycin 1 g orally in a single dose, or doxycycline 100 mg orally twice daily for 7 days as first-line gonorrhea treatment.25 For offices that do not provide intramuscular injections, the CDC recommends alternate therapies may be used (see Sidebar 2), but the CDC recommends a test of cure 1 week after treatment if alternate therapies are used. Gonorrhea-infected patients should be retested approximately 3 months after treatment or whenever persons next present for medical care in the 12 months following initial treatment, regardless of whether they believe that their sex partners were treated.

Sidebar 2.

Treatment for Uncomplicated Gonococcal Infections of the Cervix, Urethra, and Rectum

Recommended

Ceftriaxone 250 mg IM once

  PLUS

Azithromycin 1 g orally once

  OR

Doxycycline 100 mg orally twice a day for 7 daysAlternate 1: If Ceftriaxone is not available

Cefixime 400 mg orally once

  PLUS

Azithromycin 1 g orally once

  OR

Doxycycline 100 mg orally twice a day for 7 days

  PLUS

Test of cure in 1 weekAlternate 2 (if patient is allergic to cephalosporin)

Azithromycin 2 g orally once

  PLUS

Test of cure in 1 weekTreatment for uncomplicated gonococcal infections of the pharynx

Ceftriaxone 250 mg IM once

  PLUS

Azithromycin 1 g orally once

  OR

Doxycycline 100 mg orally twice a day for 7 days

IM = intramuscular.

Due to emerging gonorrhea resistance of oral cephalosprins, EPT for gonorrhea has become a controversial practice. Providers should consult with state health departments regarding EPT as an option to treat partners of gonorrhea-infected patients.

Trichomonas vaginalis

The protozoan Trichomonas vaginalis causes T. vaginalis infection. National surveillance data are not available for T. vaginalis because it is not a reportable communicable disease. However, based on population samples, trichomonas prevalence rates have been shown to be high among both adolescents and older females. In large population-based studies, adolescent female trichomonas prevalence rates have ranged from 2% to 14%. Black females have prevalence rates 10 times higher than non-Hispanic whites.26–28 In females, trichomonas infection may be asymptomatic or may cause symptomatic vaginitis. In males, trichomonas infection may also be asymptomatic, but can cause urethritis.

Although T. vaginalis has classically been identified through microscopic examination of vaginal secretions on a slide preparation (ie, “wet mount”), this method has a sensitivity of approximately 60% to 70% and is likely to yield false-negative results.7 A CLIA-waived, antigen-detection, point-of-care test of vaginal swab specimens (OSOM, Sekisui Diagnostics, LLC) is available that can provide test results in 10 minutes. The sensitivity is greater than 83%.7 GenProbe offers a T. vaginalis NAAT (APTIMA; GenProbe) that is very sensitive (95% to 100%) that can be performed on any female specimen tested for a NG/CT NAAT.29

Although not FDA-approved for testing males, providers should check if their clinical laboratory has received CLIA-approval for testing male specimens. Additional clinical laboratory T. vaginalis tests with greater sensitivity compared with wet mount include trichomonas culture in diamond media or other trichomonasis-specific culture systems (eg, InPouch, BioMed Diagnostics, Inc); and a nucleic acid probe test (Affirm VPIII, Becton, Dickinson and Company) for T. vaginalis, Gardnerella vaginalis, and Candida albicans.

Routine T. vaginalis screening of all asymptomatic adolescents is not recommended. However individual and population-based risk factors including new or multiple partners, a history of STIs or HIV, exchanging sex for payment, or injecting drugs may put individuals at higher risk of infection and warrant screening for T. vaginalis.7 The CDC recommended T. vaginalis treatment regimens include metronidazole 2 g orally in a single dose or tinidazole 2 g orally in a single dose.7 Metronidazole is less expensive than tinidazole. For commercially insured patients, tinidazole copayments may be more expensive compared with metronidazole, but Medicaid-based health plans will pay for both. Metronidazole gel is considerably less efficacious for the treatment of trichomoniasis (< 50%) and should not be used. Patients should be advised to avoid consuming alcohol during metronidazole or tinidazole treatment.7

T. vaginalis rescreening at 3 months following treatment can be considered for sexually active females. Sex partners of patients with T. vaginalis should be treated, although EPT efficacy to prevent trichomonas reinfection has not been well studied.7

Counseling and Prevention

The CDC and professional medical organizations recommend that health care providers who care for adolescents should counsel them about sexual behaviors that are associated with risk for acquiring STIs and also should educate them about prevention strategies, including abstinence and other risk-reduction behaviors (eg, consistent and correct condom use). USPSTF recommends high-intensity behavioral counseling (HIBC) to prevent STIs for all sexually active adolescents.30 Although HIBC is a USPSTF Grade-B recommendation and, thus, should be reimbursed under ACA, reimbursement issues remain unclear for this 20 to 30 minute-long, client-centered STI risk reduction counseling strategy, and realistic implementation in primary care offices may be challenging. Other strategies to provide useful sexual health information include offering adolescents and their parents websites with valid adolescent health information that includes sexual health topics. Sidebar 3 lists websites containing valid adolescent health information for adolescents, with most including sites for parents.

Sidebar 3.

Health Information Websites for Adolescent Patients and/or Parents/Guardians

Advocates for Youth:

www.advocatesforyouth.orgThe American Social Health Association adolescent sexual health information:

www.iwannaknow.orgCampaign for Our Children:

www.cfoc.orgThe Center for Young Women’s Health (CYWH):

www.youngwomenshealth.orgChildren Now:

www.talkingwithkids.orgColumbia University’s Health Promotion Program “Go Ask Alice”:

www.goaskalice.columbia.eduMTV collaboration with Kaiser Family Foundation:

www.itsyoursexlife.comPlanned Parenthood Teens:

www.teenwire.comRutgers, the State University of New Jersey, teen sexual health:

www.sexetc.orgSociety of Obstetricians and Gynecologists of Canada:

www.sexualityandu.caNemours Teen Health:

teenshealth.orgWired Kids, Inc.:

www.wiredkids.orgThe American Academy of Pediatrics:

www.healthychildren.org/English/Pages/default.aspx

HIV counseling and testing has been considered an important component of adolescent STI screening and counseling. The CDC recommends routinely offering HIV screening for all patients aged 13 to 64 years.31 At the time this manuscript was written, USPSTF (Grade-A) HIV screening recommendations were being revised to include all adolescents and adults aged 15 to 65 years, as well as younger adolescents and older adults who are at increased risk.32 AAP recommends routinely offering HIV screening to all adolescents at least once by 16 to 18 years of age in health care settings when the HIV prevalence is more than 0.1%.33

Conclusion

Adolescents and young adults carry a disproportionately high burden of STIs. Since most adolescent females most commonly utilize health care services provided by pediatricians and family practitioners, primary care providers have the opportunity to routinely screen the population most at risk for STIs and provide developmentally appropriate education to their patients and their families in the course of a preventive health care visit.

References

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  2. Centers for Disease Control and Prevention. 2011Sexually Transmitted Diseases Surveillance: STD’s in Racial and Ethnic Minorities. Available at: www.cdc.gov/std/stats11/minorities.htm. Accessed Jan. 2, 2013.
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  30. US Preventive Services Task Force. Behavioral Counseling to Prevent Sexually Transmitted Infections: U.S. Preventive Services Task Force Recommendation Statement. AHRQ Publication 08-05123-EF-2, October2008. Available at: www.uspreventiveservicestaskforce.org/uspstf08/sti/stirs.htm. Accessed Jan. 3, 2013.
  31. CDC. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. MMWR. 2006;55(RR14):1–17.
  32. US Preventive Services Task Force. Screening for HIV: Draft Recommendation Statement. AHRQ Publication No. 12-05173-EF-3. Available at: www.uspreventiveservicestaskforce.org/uspstf13/hiv/hivdraftrec.htm. Accessed Jan. 3, 2013.
  33. American Academy of Pediatrics. Adolescents and HIV infection: the pediatrician’s role in promoting routine testing. Pediatrics. 2011;128:1023–1029.
  34. Hoover KW, Tao G, Berman S, Kent CK. Utilization of health services in physician offices and outpatient clinics by adolescents and young women in the United States: implications for improving access to reproductive health services. J Adolesc Health. 2010;46:324–330. doi:10.1016/j.jadohealth.2009.09.002 [CrossRef]

Sidebar 1.

The Five P’s of a Sexual History

  1. Partners

    • “Do you have sex with men, women, or both?”
    • “In the past 2 months, how many partners have you had sex with?”
    • “In the past 12 months, how many partners have you had sex with?”
    • “Is it possible that any of your sex partners in the past 12 months had sex with someone else while they were still in a sexual relationship with you?”
  2. Prevention of Pregnancy

    • “What are you doing to prevent pregnancy?”
  3. Protection from STIs

    • “What do you do to protect yourself from STDs and HIV?”
  4. Practices

    • “To understand your risks for STIs, I need to understand the kind of sex you have had recently.”
    • “Have you had vaginal sex, meaning ‘penis in vagina sex’?” If yes, “Do you use condoms: never, sometimes, or always?”
    • “Have you had anal sex, meaning ‘penis in rectum/anus sex’?” If yes, “Do you use condoms: never, sometimes, or always?”
    • “Have you had oral sex, meaning ‘mouth on penis/vagina’?”

    For condom answers:

    • If “never:” “Why don’t you use condoms?”
    • If “sometimes:” “In what situations (or with whom) do you not use condoms?”
  5. Past history of STIs

    • “Have you ever had an STI?”
    • “Have any of your partners had an STI?”

STI = sexually transmitted infections.

Sidebar 2.

Treatment for Uncomplicated Gonococcal Infections of the Cervix, Urethra, and Rectum

Recommended

Ceftriaxone 250 mg IM once

  PLUS

Azithromycin 1 g orally once

  OR

Doxycycline 100 mg orally twice a day for 7 daysAlternate 1: If Ceftriaxone is not available

Cefixime 400 mg orally once

  PLUS

Azithromycin 1 g orally once

  OR

Doxycycline 100 mg orally twice a day for 7 days

  PLUS

Test of cure in 1 weekAlternate 2 (if patient is allergic to cephalosporin)

Azithromycin 2 g orally once

  PLUS

Test of cure in 1 weekTreatment for uncomplicated gonococcal infections of the pharynx

Ceftriaxone 250 mg IM once

  PLUS

Azithromycin 1 g orally once

  OR

Doxycycline 100 mg orally twice a day for 7 days

IM = intramuscular.

Sidebar 3.

Health Information Websites for Adolescent Patients and/or Parents/Guardians

Advocates for Youth:

www.advocatesforyouth.orgThe American Social Health Association adolescent sexual health information:

www.iwannaknow.orgCampaign for Our Children:

www.cfoc.orgThe Center for Young Women’s Health (CYWH):

www.youngwomenshealth.orgChildren Now:

www.talkingwithkids.orgColumbia University’s Health Promotion Program “Go Ask Alice”:

www.goaskalice.columbia.eduMTV collaboration with Kaiser Family Foundation:

www.itsyoursexlife.comPlanned Parenthood Teens:

www.teenwire.comRutgers, the State University of New Jersey, teen sexual health:

www.sexetc.orgSociety of Obstetricians and Gynecologists of Canada:

www.sexualityandu.caNemours Teen Health:

teenshealth.orgWired Kids, Inc.:

www.wiredkids.orgThe American Academy of Pediatrics:

www.healthychildren.org/English/Pages/default.aspx
Authors

Meera S. Beharry, MD, FAAP, is Adolescent Medicine Section Chief, Department of Pediatrics, McLane Children’s Hospital; and and Assistant Professor, Texas A & M Health Science Center College of Medicine. Taraneh Shafii, MD, MPH, is Assistant Professor of Pediatrics, Division of Adolescent Medicine, University of Washington School of Medicine. Gale R. Burstein, MD, MPH, FAAP, FSAHM, is Clinical Associate Professor of Pediatrics, SUNY at Buffalo School of Medicine and Biomedical Sciences Department of Pediatrics; and Commissioner, Erie County Department of Health, Buffalo, NY.

Address correspondence to: Meera S. Beharry, MD, FAAP, Adolescent Medicine Section Chief, Department of Pediatrics, McLane Children’s Hospital, Scott & White, 2401 S. 31 Street, MS-09-CW403, Temple, TX 76508, USA; email: mbeharry@sw.org.

Disclosure: The authors have no relevant financial relationships to disclose. 

10.3928/00904481-20130128-09

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