More than 40 million adolescents (defined as people age 10–19 years) live in the United States.1 These adolescents will be cared for by pediatricians, family practitioners, and mid-level providers;2 therefore, it is important for primary care practitioners (PCPs) to be able to identify, treat, prevent, and provide anticipatory guidance to adolescents and their parents about sexually transmitted infections (STIs).
Questions that often arise in a primary care setting include:
- Can I treat my adolescent patient without parental consent?
- How do I discuss human papillomavirus (HPV) vaccination with a hesitant parent?
- What STIs should I screen for, and how often should I screen for them?
- What are common STI symptoms to recognize and treat in a primary care clinic?
- Are there newer STIs of concern?
This article focuses on these common questions about STIs and emphasizes the big impact a primary care practitioner can have on their adolescent patients' health.
It can be difficult or uncomfortable to have discussions about STI prevention, diagnosis, and treatment with an adolescent. It can be even more difficult as parents of an adolescent to realize that these topics may be discussed in private between a health care provider and their son or daughter. All 50 states and the District of Columbia permit most minors to consent for STI services, and many explicitly include the testing and treatment of HIV. Eighteen states allow a clinician to notify a parent if he or she feels it is in the best interest of the patient, although no states require notification.3 To best ensure that primary care clinics can provide optimal care for their adolescent patients, it is critical to create an adolescent-friendly, competent, developmentally appropriate, and nonjudgmental environment, to see patients as people, and to communicate effectively with patients and their families about confidential care. The provision of confidential care for issues including reproductive health and STI treatment has been shown to lead to an increased likelihood that adolescent patients will seek out health care, as well as better health outcomes.4,5 An STI that is not discussed is one that cannot be prevented or treated.
Human Papillomavirus Vaccination
Human papillomaviruses (HPV) are DNA viruses that infect various types of squamous epithelium; more than 30 genotypes (types) are known to infect the anogenital region.6 Effective HPV vaccinations have been available since 2006. The Centers for Disease Control and Prevention (CDC) Advisory Panel on Immunization Practices (ACIP),7 American Academy of Pediatrics,8 American Academy of Family Physicians,9 and American College of Obstetricians and Gynecologists10 all recommend routine vaccination of adolescents against HPV beginning at age 11 years. The only currently available formulation for HPV vaccination in the United States is nonavalent (9vHPV), which covers seven oncogenic types (HPV 16, 18, 31, 33, 45, 52, and 58) and two types that cause genital warts (HPV 6 and 11).11 Despite these recommendations, HPV vaccination rates remain low, with coverage 22 to 28 percentage points lower than tetanus-diphtheria-acellular pertussis (Tdap) vaccine and quadrivalent meningococcal (MenACWY vaccine),12 which are recommended at the same age.
Barriers to HPV vaccination include health care professionals' concern about parental attitudes toward HPV vaccination, parents' concerns about safety, the age of vaccination (ie, being too early), and not having enough information about HPV vaccination. Many parents have not received a professional's recommendation for HPV vaccination.13 This offers PCPs an important opportunity to improve adolescent patient care coverage by working to allay concerns about HPV vaccination by engaging parents and discussing science and data while avoiding common misconceptions.
My Child Is So Young—Why Do We Need to Vaccinate Her/Him Right Now?
The 9vHPV vaccine is more immunogenic when it is given in early adolescence, leading to a change in ACIP vaccination recommendations. If the 9vHPV series is started prior to age 15 years, two doses spaced at least 6 months apart are required; otherwise, patients should receive the customary three-dose series.14,15 Immunity to the bivalent and quadrivalent HPV vaccines does not wane over the course of 8 to 10 years.15 Additionally, there is a clear association between HPV infection with high-risk types and the development of invasive cervical cancer,6 as well as mounting evidence of an association with other anogenital and oropharyngeal cancers.16 Peak prevalence for genital HPV infection occurs between the ages of 18 and 30 years, due to both behavioral and anatomic risk factors, which include the number of sexual partners (something many parents do not want to hear or consider) and the more anatomically exposed transformation zone of the adolescent cervix. This developmentally normal metaplastic transformation zone is thought to play a role in HPV acquisition and persistence.6,17 Given these age-associated risk factors for HPV exposure, infection, and persistence, and because the HPV vaccine is ineffective against any HPV type to which there has already been natural exposure, it is essential to vaccinate before HPV exposure.14
The HPV Vaccine Is So New—How Do We Really Know That It Works?
It is important to understand that the final efficacy data on HPV vaccination, vis-à-vis cervical cancer and other HPV-related cancers, will not be known for years, given the natural history of HPV-related cancer. However, it has been clearly established that HPV vaccination decreases rates of high-risk HPV infections and cervical dysplasia.14 A meta-analysis that included 20 studies in high-income countries and 140 million person-years of follow up after bivalent or quadrivalent HPV vaccination documented a 68% decrease in HPV types 16 and 18, with possible cross-protection for types 31, 33, and 45 when female vaccination rates were higher than 50%. These higher vaccination rates for female patients also led to a reduction in anogenital warts in unvaccinated male patients, which strongly suggests herd immunity. Countries with lower female vaccination rates still showed protection against HPV 16 and 18 but without cross-protection or herd effect.18 These findings, along with expanded genotype coverage with 9vHPV, leave most experts confident of the vaccination's coming impact on cervical cancer rates and other HPV-associated cancer reduction.
I Have Heard That There Are Serious Side Effects from the HPV Vaccine—I am Uncomfortable Giving It to My Child
Pre- and post-licensure safety data collected in multiple high-income countries have clearly documented the safety of HPV vaccination.19 Multiple post-licensure studies have shown no correlation between HPV vaccination and autoimmune disease, including diabetes mellitus, autoimmune thyroiditis, systemic lupus erythematosus, and arthritis; neurologic conditions including stroke, seizures, central demyelination, Guillain-Barré syndrome, and multiple sclerosis; venous thromboembolic disease; or allergic reaction.20 There may be a slight increase in same-day syncope, which has led most clinics to administer HPV (and other) vaccinations while the patient is seated and to have patients wait for 15 minutes post-vaccination before departing.
I Am Worried That My Child Will See This as Permission to Become Sexually Active
There is no evidence that adolescents change their sexual behaviors after HPV vaccination. Two recent systematic reviews of HPV vaccination and sexual risk-taking showed no evidence of increased risky behaviors, increased STI diagnoses, or younger sexual debut. In fact, there may be enhanced protective behaviors in patients who are vaccinated, including condom and contraception use.21,22 At the population level, no changes were noted in adolescent sexual behavior with the passage of HPV vaccination and education legislation at the state level.23
Questions and concerns that parents bring up should be embraced, rather than dismissed. Nursing and ancillary clinical staff should be well-versed on the science behind HPV vaccination, as they may be the trusted “face of the clinic” in parents' and patients' minds. Every opportunity to vaccinate, at any visit, should be integrated into clinic policy to help improve HPV vaccination update.
Urethritis and Cervicitis
Urethritis and cervicitis are common diagnoses in adolescent patients. In a busy pediatric clinic, it may seem daunting to assess and treat such patients, yet understanding the symptoms, tailoring an evaluation toward individual patients, and knowing when and what to treat empirically are effective and attainable clinical skills for a primary care practitioner.
Male patients with urethritis typically complain of dysuria and mucoid orpurulent urethral discharge, although discharge is not always a prominent finding on physical examination. A presumptive diagnosis of urethritis can be made with a finding of urethral discharge, a Gram stain showing ≥2 leukocytes per oil immersion field, or first-void urinalysis with leukocyte esterase or ≥10 leukocytes per high power field.16 Although many busy pediatric clinics do not have access to rapid Gram stain results, point-of-care urinalysis is generally available and effective.
Cervicitis can be asymptomatic or can be accompanied by vaginal discharge, intermenstrual bleeding, spotting, or postcoital bleeding. For patients with suspected cervicitis, a vaginal speculum examination should be considered. If a clinic is not equipped for a gynecologic examination, a provider- or self-collected vaginal swab and evaluation with light microscopy can be a useful alternative. Cervicitis will almost always present with ≥10 leukocytes per high power field.16 Vaginal secretions can also be quickly evaluated for yeast, clue cells (bacterial vaginosis), and trichomonads.
A number of organisms can cause urethritis and cervicitis, including chlamydia, trichomonas, Mycoplasma genitalium, and gonorrhea. Nucleic acid amplification testing (NAAT) for gonorrhea and chlamydia is available at most clinics, although results are generally not available at the time of the appointment. NAAT for both gonorrhea and chlamydia should be sent even if a patient is empirically treated, as the results will influence follow up and partner notification. Rapid antigen tests and NAAT for trichomonas are not as readily available, and not all are approved by the US Food and Drug Administration for use with urine from male patients, although their use may lead to an increase in diagnosis and treatment of trichomonas in emergency room settings.24,25 It is important to speak with the laboratory to see what trichomonas testing is locally available for both male and female patients, and to check local trichomonas prevalence rates. Light microscopy is specific in the diagnosis of trichomonas, but the sensitivity is low for even experienced clinicians.
Patients with urethritis or cervicitis do not always have chlamydia or gonorrhea. These patients may present with persistent symptoms despite treatment; sometimes they will also present for follow up when negative NAAT tests for chlamydia and gonorrhea from the prior visit are available. In addition to considering trichomonas, attention to M. genitalium, a recently discovered cause of nongonococcal urethritis and cervicitis, is required. Most evidence places M. genitalium second to chlamydia for bacterial etiology of urethritis and cervicitis.16,26,27 Laboratory assays to detect M. genitalium are on the horizon, but they are not currently available to most clinicians; therefore, a high index of suspicion is crucial.
Treatment considerations for cervicitis and urethritis are influenced by practice (ie, primary care with assured follow up, or urgent care with no continuity), by local prevalence rates, and by physical examination and laboratory data. For patients with clear evidence of disease, the current CDC recommendation for empirical treatment is 250 mg/day of ceftriaxone intramuscularly plus 1 g/day of azithromycin orally. Dual therapy for suspected gonorrhea is important and is thought to minimize the emergence of further antimicrobial resistance.16 When there are persistent symptoms and findings, with or without a positive gonorrhea or chlamydia assay, laboratory assay for trichomonas (particularly if local prevalence rates are high) and empirical treatment for both trichomonas and M. genitalium should be considered.26,27 Recommended treatment for trichomonas is a one-time dose of either metronidazole or tinidazole, 2 g orally.16
Treatment of M. genitalium infection can be difficult. The majority of M. genitalium infections are doxycycline-resistant, and azithromycin resistance is now approaching 50% in many studies. There are clear geographic resistance patterns; however, both doxycycline and azithromycin are poor treatment options regardless of location.27 Moxifloxacin is a widely available and reasonable alternative (400 mg orally for 7–14 days), although there are now concerns that resistant strains are becoming more common.27,28 Should there be a concern for multidrug resistant M. genitalium, consultation with an infectious disease or adolescent medicine specialist is warranted.
It is important to understand the clinical differences between pelvic inflammatory disease and cervicitis. Cervicitis does not cause pelvic or abdominal pain, dyspareunia, or systemic symptoms. If any of these symptoms are present, a broader evaluation and longer treatment course is indicated. For those clinicians not equipped or comfortable performing gynecologic examinations, they should refer their patients to an adolescent medicine specialist or gynecologist.
Screening for Sexually Transmitted Infections
Primary care clinicians who see adolescents should be familiar with STI screening recommendations. Recommendations from the United States Preventive Services Task Force (USPSTF) and the CDC are available for reference and updated on the CDC website ( https://www.cdc.gov/std/prevention/screeningreccs.htm).29 Although many of the recommendations are straightforward, others require clinical decision-making. Clinicians are often asked by patients to “test for everything,” at which times a history, risk assessment, and sometimes an examination are important to select the clinically and scientifically relevant tests. The next section discusses pragmatic ways to follow the screening recommendations while caring for the individual patient and the clinic's overall patient population.
All sexually active female patients younger than age 25 years should be tested annually for chlamydia. Pregnant adolescents, adults younger than age 25 years, and those older patients at increased risk for infection should be tested at the time of pregnancy diagnosis and again in the third trimester. All patients should be observed clinically in the few weeks following treatment of chlamydia (sooner and more frequently depending on clinical severity) and retested 3 months after treatment. This is a test for reinfection, and not a test of cure. Pregnant adolescents with chlamydia should be tested for cure 3 to 4 weeks after treatment.16
There is no scheduled screening recommendation for heterosexual adolescent males. Men who have sex with men (MSM) should be screened annually, at minimum, at sites of sexual contact, including the urethra and rectum.16
Screening recommendations are essentially the same as for chlamydia. The only difference is that screening MSM should also include the oropharynx. The commonly used NAATs check for both chlamydia and gonorrhea simultaneously.16
Current recommendations for syphilis screening include all pregnant adolescents at pregnancy diagnosis, with a retest in the third trimester (and again at delivery if substantial risk exists). MSM should be screened at least annually, with consideration given to testing every 3 to 6 months in patients who are at higher risk. Both male and female sexually active adolescents with HIV should be screened for syphilis annually.16
Many laboratories will screen for syphilis with a treponemal test, which, if positive, is followed by a nontreponemal test (eg, rapid plasma regain [RPR], or venereal disease research laboratory [VDRL]). This reverse algorithm is the opposite of that with which many older clinicians are familiar. The treponemal test is more rapid, can be automated, and cost is decreasing, making this an increasingly attractive option for laboratories. Positive treponemal tests are followed by a nontreponemal test, which may be qualitative or quantitative. A positive treponemal test with a negative RPR or VDRL typically indicates past, treated syphilis; however, if there is no documented history of treatment, treatment should be considered while a second treponemal test is run. A positive treponemal test with a positive RPR or VDRL indicates current infection. Familiarity with the clinic's laboratory services and screening algorithm is important when interpreting results.30,31
Herpes Simplex Virus
The USPSTF and CDC recommend against herpes simplex virus (HSV) screening;16 however, this is often one of the screening tests that adolescents request. It is important to discuss with adolescent patients the epidemiology of HSV infection and the pitfalls in population screening. HSV-1 and HSV-2 both cause genital HSV infections. HSV-1 remains a very common cause of gingivostomatitis in children, with some patients having recurrences in the form of cold sores. The presence of HSV-1 immunogloblulin G does not give information on when or where the infection was, and a history of a common childhood infection can lead to unnecessary distress. Currently available HSV-2 serologic assays have low specificity and positive predictive values of 50% to 75% for the general population, making them poor screening tools in most settings.32
Routine screening for trichomonas is not recommended, although it can be considered in female adolescents who are at high risk.12 This recommendation may change as combined trichomonas–chlamydia–gonorrhea assays become more widely available, and if trichomonas remains a common STI.33
Although broad and clearly soliciting clinical decision-making, the CDC recommends that all patients from age 13 to 64 years be tested for HIV (USPSTF suggests age 15–65 years) at least once. In high-risk populations (eg, MSM and injection drug users), HIV testing should be done annually.16 It is important to note that “opt out” protocols are the most successful. Pragmatically, HIV testing may be added at a time when blood is drawn for lipid screening in late adolescence, unless the patient declines.
Most adolescents were vaccinated against hepatitis B virus as infants. It is important to check vaccination records at all visits; if there is concern about hepatitis B virus immunization status, the vaccination series should be initiated or completed, or HBV surface antibody testing sent.
Primary care clinics provide care to most adolescents in the United States, and practitioners have a fundamental opportunity to prevent, diagnose, and treat many common STIs. Understanding the importance of and rationale for confidential adolescent care, of communication with patients and parents on important issues such as HPV vaccination, of pragmatic and evidence-guided STI screening, and an ability to identify and treat common presenting symptoms of STIs is central to quality adolescent health care.
- United States Census Bureau. America's age profile told through population pyramids. https://www.census.gov/newsroom/blogs/random-samplings/2016/06/americas-age-profile-told-through-population-pyramids.html. Accessed August 15, 2019.
- Rand CM, Goldstein NPN. Patterns of primary care physician visits for US adolescents in 2014: implications for vaccination. Acad Pediatr. 2018;18(suppl):S72–S78. doi:. doi:10.1016/j.acap.2018.01.002 [CrossRef]29502641
- Guttmacher Institute. Minors' access to STI services. https://www.guttmacher.org/state-policy/explore/minors-access-sti-services. Accessed August 15, 2019.
- Ford C, English A, Sigman G. Confidential health care for adolescents: position paper of the Society for Adolescent Medicine. J Adolesc Health. 2004;35(2):160–167. doi:. doi:10.1016/S1054-139X(04)00086-2 [CrossRef]15298005
- Gilbert AL, Rickert VI, Aalsma MC. Clinical conversations about health: the impact of confidentiality in preventive adolescent care. J Adolesc Health. 2014;55(5):672–677. doi:. doi:10.1016/j.jadohealth.2014.05.016 [CrossRef]25043835
- Stanley M. Pathology and epidemiology of HPV infection in females. Gynecol Oncol. 2010;117(suppl):S5–S10. doi:. doi:10.1016/j.ygyno.2010.01.024 [CrossRef]
- Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human papillomavirus vaccination—updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2016;65. doi:. doi:10.15585/mmwr.mm6549a5 [CrossRef]
- Committee on Infectious Diseases. Recommended childhood and adolescent immunization schedules: United States, 2019. Pediatrics. 2019;143(3):e20190065. doi:10.1542/peds.2019-0065 [CrossRef]30824606
- American Academy of Family Physicians. Birth through age 18 immunization schedule. https://www.aafp.org/patient-care/public-health/immunizations/schedules/child-schedule.html. Accessed August 19, 2019.
- American College of Obstetricians and Gynecologists. Immunization. https://www.acog.org/About-ACOG/ACOG-Departments/Immunization?IsMobileSet=false. Accessed August 19, 2019.
- Centers for Disease Control and Prevention. ACIP HPV vaccine recommendations. https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hpv.html. Accessed August 15, 2019.
- Walker TY. National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 Years — United States, 2016. MMWR Morb Mortal Wkly Rep. 2017;66. doi:. doi:10.15585/mmwr.mm6633a2 [CrossRef]
- Holman DM, Benard V, Roland KB, Watson M, Liddon N, Stokley S. Barriers to human papillomavirus vaccination among US adolescents: a systematic review of the literature. JAMA Pediatr. 2014;168(1):76–82. doi:. doi:10.1001/jamapediatrics.2013.2752 [CrossRef]
- Dilley S, Miller K, Huh W. HPV vaccination. Gynecol Oncol.2018;148(1):3–4. doi:. doi:10.1016/j.ygyno.2017.11.037 [CrossRef]
- Meites E. Use of a 2-dose schedule for human papillomavirus vaccination — updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2016;65. doi:. doi:10.15585/mmwr.mm6549a5 [CrossRef]
- Workowski KA, Bolan GACenters for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64:1–137.26042815
- Doorbar J, Quint W, Banks L, et al. The biology and life-cycle of human papillomaviruses. Vaccine. 2012;30:F55–F70. doi:. doi:10.1016/j.vaccine.2012.06.083 [CrossRef]23199966
- Drolet M, Bénard É, Boily MC, et al. Population-level impact and herd effects following human papillomavirus vaccination programmes: a systematic review and meta-analysis. Lancet Infect Dis. 2015;15(5):565–580. doi:. doi:10.1016/S1473-3099(14)71073-4 [CrossRef]25744474
- Phillips A, Patel C, Pillsbury A, Brotherton A, Macartney K. Safety of human papillomavirus vaccines: an updated review. Drug Saf. 2018;41:329–346. https://doi.org/10.1007/s40264-017-0625-z. doi:10.1007/s40264-017-0625-z [CrossRef]
- Markowitz LE, Dunne EF, Saraiya M, et al. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP). https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6305a1.htm. Accessed August 15, 2019.
- Madhivanan P, Pierre-Victor D, Mukherjee S, et al. Human papillomavirus vaccination and sexual disinhibition in females: a systematic review. Am J Prev Med. 2016;51(3):373–383. doi:. doi:10.1016/j.amepre.2016.03.015 [CrossRef]27130864
- Kasting ML, Shapiro GK, Rosberger Z, Kahn JA, Zimet GD. Tempest in a teapot: a systematic review of HPV vaccination and risk compensation research. Hum Vaccin Immunother. 2016;12(6):1435–1450. doi:. doi:10.1080/21645515.2016.1141158 [CrossRef]26864126
- Cook EE, Venkataramani AS, Kim JJ, Tamimi RM, Holmes MD. Legislation to increase uptake of HPV vaccination and adolescent sexual behaviors. Pediatrics. 2018;142(3):e20180458. doi:. doi:10.1542/peds.2018-0458 [CrossRef]30104422
- Gaydos CA, Klausner JD, Pai NP, Kelly H, Coltart C, Peeling RW. Rapid and point-of-care tests for the diagnosis of Trichomonas vaginalis in women and men. Sex Transm Infect. 2017;93(S4):S31–S35. doi:. doi:10.1136/sextrans-2016-053063 [CrossRef]28684611
- Territo HM, Wrotniak BH, Bouton S, Burstein GR. A new strategy for trichomonas testing female adolescents in the emergency department. J Pediatr Adolesc Gynecol. 2016;29(4):378–381. doi:. doi:10.1016/j.jpag.2016.01.120 [CrossRef]26820440
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- Soreng K, Levy R, Fakile Y. Serologic testing for syphilis: benefits and challenges of a reverse algorithm. Clin Microbiol Newsl. 2014;36(24):195–202. doi:. doi:10.1016/j.clinmicnews.2014.12.001 [CrossRef]28845073
- Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Serologic screening for genital herpes infection: US Preventive Services Task Force Recommendation statement. JAMA.2016;316(23):2525–2530. doi:. doi:10.1001/jama.2016.16776 [CrossRef]27997659
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