Partner age not associated with recurrent Chlamydia trachomatis infection, condom use, or partner treatment and referral among adolescent women

Addressing Adolescent Relationship Abuse in the Context of Reproductive Health Care

Adolescent relationship abuse (ARA) is a significant public health issue that includes physical, sexual, psychological and cyber abuse, reproductive coercion, and/or sexual exploitation within an intimate relationship in which one or both partners is a minor. ARA is associated with numerous negative outcomes that include all domains of health. Many negative outcomes of ARA are related to reproductive and sexual health (RSH); thus, reproductive health care providers must be equipped to recognize and address ARA. This article will review the epidemiology and outcomes of ARA, followed by a discussion of means to robustly address ARA in health care settings. We recommend a strengths-based approach that promotes healthy adolescent relationships, connects adolescents experiencing ARA to harm reduction resources, and equips adolescents to serve as a resource for their peers.

Sexual risk factors for partner age discordance in adolescent girls and their male partners

AIMS AND OBJECTIVES

To investigate differences in sexual risk factors between adolescent girls reporting similar-aged or older sex partners.

BACKGROUND

Adolescent girls are at significant risk of heterosexual-acquired HIV infection and other long-term reproductive health issues. Sexual partner age discordance in teen girls has been correlated with STIs, lack of protection, multiple partners and earlier age of sexual transition.

DESIGN

A descriptive study comparing girls currently involved with age-discordant partners to those with similar-aged partners. Two-sample t-test for continuous variables and chi-squared test or Fisher's exact test for categorical variables were used to compare groups.

METHODS

Baseline data from 738 sexually active, urban, adolescent girls aged 15-19 were analysed to determine which behaviours were more likely to occur in girls with older partners. Data were collected as part of a gender-specific HIV-prevention intervention in a randomised controlled trial (RCT) tailored to adolescent girls.

RESULTS

Multiple reported sexual risk behaviours were found to significantly differ between the two groups at baseline. Overall, girls with older partners had more episodes of sexual instances (vaginal, anal and oral). Specific sexual risk behaviours were found to be statistically significant between the two groups. Girls with older partners started having sex at earlier ages, had more lifetime sexual partners, higher incidents of STIs and were reluctant to discuss using condoms with their partners. Girls with similar-aged partners were less willing to engage in risky sexual behaviours.

CONCLUSIONS

Findings from this investigation support data from other studies. Relationships with older male partners place adolescent girls at increased risk of HIV/STIs and unintended pregnancy.

RELEVANCE TO CLINICAL PRACTICE

Adolescent girls in age-discordant relationships are at risk of immediate and long-term sexual health morbidities. Identifying girls who are at increased risk by asking tailored questions will enable nurses to recommend appropriate diagnostics for this population and provide age-specific counselling.

The influence of sexual partner on condom use among urban adolescents

PURPOSE

The influence of partner context (e.g., drinking alcohol in the 2 hours prior to sex, ≥3 years age discordant, met in public) on adolescent boys' and girls' condom use is unclear. Among an urban cohort of primarily (86%) minority 17-18-year-olds who reported having sex (n = 1,469), we assessed the association between condom use and partner characteristics for the most recent sexual experience.

METHODS

We used logistic regression to examine the odds of condom use by measured partner familiarity (casual or unexpected) and context characteristics. Analyses were stratified by gender.

RESULTS

Adolescent boys and girls were twice as likely to use condoms with partners they considered casual or unexpected. Adjusting for partner familiarity risk, adolescent boys' tended to decrease condom use with risky context partners. Adjusting for partner familiarity risk, adolescent girls were half as likely to use condoms with partners drinking alcohol 2 hours prior to sex [Odds Ratio (OR) = .6, 95% Confidence Interval (CI) = .4-.9]; ≥3 years age discordant (OR = .5, 95% CI = .3-.8); or met in public places (OR = .6, 95% CI = .4-.8).

CONCLUSIONS

Regardless of partner familiarity risk, adolescent boys and girls faced barriers to condom use with risky context partners. Increased understanding of adolescents' perceptions of and control over partner risk and condom use with risky context partners is needed. Interventions aimed at decreasing adolescent sexually transmitted infections should include strategies for adolescents to choose less risky context partners and negotiate condoms with risky context partners.

It takes 2: partner attributes associated with sexually transmitted infections among adolescents

OBJECTIVES

The aims of this study were to identify partner attributes associated with sexually transmitted infections (STIs) among adolescents and to summarize implications for research and prevention.

DESIGN

The design of this study was systematic review.

METHODS

We identified peer-reviewed studies published in 1990 through 2010 that assessed 1 or more partner attributes in relation to a biologically confirmed STI among adolescents (15-24 years) by searching MEDLINE and included articles. Studies that included adolescents but more than 50% of the sample or with mean or median age of 25 years or greater were excluded.

RESULTS

Sixty-four studies met the eligibility criteria; 61% were conducted in high-income countries; 80% were cross sectional; and 91% enrolled females and 42% enrolled males. There was no standard "partner" definition. Partner attributes assessed most frequently included the following: age, race/ethnicity, multiple sex partners, and STI symptoms. Older partners were associated with prevalent STIs but largely unrelated to incidence. Black race was associated with STIs but not uniformly. Partners with multiple partners and STI symptoms seem to be associated with STIs predominantly among females. Although significant associations were reported, weaker evidence exists for the following: other partner sociodemographics, sexual and other behaviors (sexual concurrency, intimate partner violence, substance use, travel), and STI history. There were no apparent differences by STI.

CONCLUSIONS

Partner attributes are independently associated with STIs among male and female adolescents worldwide. These findings reinforce the importance of assessing partner attributes when determining STI risk. Prevention efforts should continue to promote and address barriers to condom use. Increased efforts are needed to screen and treat STIs and reduce risky behavior among men. A standard partner definition would facilitate the interpretation of findings in future studies.

Strategies for partner notification for sexually transmitted infections, including HIV

BACKGROUND

Partner notification (PN) is the process whereby sexual partners of an index patient are informed of their exposure to a sexually transmitted infection (STI) and the need to obtain treatment. For the person (index patient) with a curable STI, PN aims to eradicate infection and prevent re-infection. For sexual partners, PN aims to identify and treat undiagnosed STIs. At the level of sexual networks and populations, the aim of PN is to interrupt chains of STI transmission. For people with viral STI, PN aims to identify undiagnosed infections, which can facilitate access for their sexual partners to treatment and help prevent transmission.

OBJECTIVES

To assess the effects of different PN strategies in people with STI, including human immunodeficiency virus (HIV) infection.

SEARCH METHODS

We searched electronic databases (the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE) without language restrictions. We scanned reference lists of potential studies and previous reviews and contacted experts in the field. We searched three trial registries. We conducted the most recent search on 31 August 2012.

SELECTION CRITERIA

Published or unpublished randomised controlled trials (RCTs) or quasi-RCTs comparing two or more PN strategies. Four main PN strategies were included: patient referral, expedited partner therapy, provider referral and contract referral. Patient referral means that the patient notifies their sexual partners, either with (enhanced patient referral) or without (simple patient referral) additional verbal or written support. In expedited partner therapy, the patient delivers medication or a prescription for medication to their partner(s) without the need for a medical examination of the partner. In provider referral, health service personnel notify the partners. In contract referral, the index patient is encouraged to notify partner, with the understanding that the partners will be contacted if they do not visit the health service by a certain date.

DATA COLLECTION AND ANALYSIS

We analysed data according to paired partner referral strategies. We organised the comparisons first according to four main PN strategies (1. enhanced patient referral, 2. expedited partner therapy, 3. contract referral, 4. provider referral). We compared each main strategy with simple patient referral and then with each other, if trials were available. For continuous outcome measures, we calculated the mean difference (MD) with 95% confidence intervals (CI). For dichotomous variables, we calculated the risk ratio (RR) with 95% CI. We performed meta-analyses where appropriate. We performed a sensitivity analysis for the primary outcome re-infection rate of the index patient by excluding studies with attrition of greater than 20%. Two review authors independently assessed the risk of bias and extracted data. We contacted study authors for additional information.

MAIN RESULTS

We included 26 trials (17,578 participants, 9015 women and 8563 men). Five trials were conducted in developing countries. Only two trials were conducted among HIV-positive patients. There was potential for selection bias, owing to the methods of allocation used and of performance bias, owing to the lack of blinding in most included studies. Seven trials had attrition of greater than 20%, increasing the risk of bias.The review found moderate-quality evidence that expedited partner therapy is better than simple patient referral for preventing re-infection of index patients when combining trials of STIs that caused urethritis or cervicitis (6 trials; RR 0.71, 95% CI 0.56 to 0.89, I(2) = 39%). When studies with attrition greater than 20% were excluded, the effect of expedited partner therapy was attenuated (2 trials; RR 0.8, 95% CI 0.62 to 1.04, I(2) = 0%). In trials restricted to index patients with chlamydia, the effect was attenuated (2 trials; RR 0.90, 95% CI 0.60 to 1.35, I(2) = 22%). Expedited partner therapy also increased the number of partners treated per index patient (three trials) when compared with simple patient referral in people with chlamydia or gonorrhoea (MD 0.43, 95% CI 0.28 to 0.58) or trichomonas (MD 0.51, 95% CI 0.35 to 0.67), and people with any STI syndrome (MD 0.5, 95% CI 0.34 to 0.67). Expedited partner therapy was not superior to enhanced patient referral in preventing re-infection (3 trials; RR 0.96, 95% CI 0.60 to 1.53, I(2) = 33%, low-quality evidence). Home sampling kits for partners (four trials) did not result in lower rates of re-infection in the index case (measured in one trial), or higher numbers of partners elicited (three trials), notified (two trials) or treated (one trial) when compared with simple patient referral. There was no consistent evidence for the relative effects of provider, contract or other patient referral methods. In one trial among men with non-gonococcal urethritis, more partners were treated with provider referral than with simple patient referral (MD 0.5, 95% CI 0.37 to 0.63). In one study among people with syphilis, contract referral elicited treatment of more partners than provider referral (MD 2.2, 95% CI 1.95 to 2.45), but the number of partners receiving treatment was the same in both groups. Where measured, there was no statistical evidence of differences in the incidence of adverse effects between PN strategies.

AUTHORS' CONCLUSIONS

The evidence assessed in this review does not identify a single optimal strategy for PN for any particular STI. When combining trials of STI causing urethritis or cervicitis, expedited partner therapy was more successful than simple patient referral for preventing re-infection of the index patient but was not superior to enhanced patient referral. Expedited partner therapy interventions should include all components that were part of the trial intervention package. There was insufficient evidence to determine the most effective components of an enhanced patient referral strategy. There are too few trials to allow consistent conclusions about the relative effects of provider, contract or other patient referral methods for different STIs. More high-quality RCTs of PN strategies for HIV and syphilis, using biological outcomes, are needed.

What's age got to do with it? Partner age difference, power, intimate partner violence, and sexual risk in urban adolescents

Adolescent girls with older male main partners are at greater risk for adverse sexual health outcomes than other adolescent girls. One explanation for this finding is that low relationship power occurs with partner age difference. Using a cross-sectional, descriptive design, we investigated the effect of partner age difference between an adolescent girl and her male partner on sexual risk behavior through the mediators of sexual relationship power, and physical intimate partner violence (IPV), and psychological IPV severity. We chose Blanc's framework to guide this study as it depicts the links among demographic, social, economic, relationship, family and community characteristics, and reproductive health outcomes with gender-based relationship power and violence. Urban adolescent girls (N = 155) completed an anonymous computer-assisted self-interview survey to examine partner and relationship factors' effect on consistent condom use. Our sample had an average age of 16.1 years with a mean partner age of 17.8 years. Partners were predominantly African American (75%), non-Hispanic (74%), and low-income (81%); 24% of participants reported consistent condom use in the last 3 months. Descriptive, correlation, and multiple mediation analyses were conducted. Partner age difference was negatively associated with consistent condom use (-.4292, p < .01); however, the indirect effects through three proposed mediators (relationship power, physical IPV, or psychological IPV severity) were not statistically significant. Further studies are needed to explore alternative rationale explaining the relationship between partner age differences and sexual risk factors within adolescent sexual relationships. Nonetheless, for clinicians and researchers, these findings underscore the heightened risk associated with partner age differences and impact of relationship dynamics on sexual risk behavior.

Upsurge of chlamydial reinfection in a large Canadian city: an indication of suboptimal chlamydia screening practices?

OBJECTIVES

Given the limited knowledge on chlamydial reinfection (CR) in Canada, we examined the extent and predictors of CR in Montréal, a large Canadian city.

METHODS

We retrospectively studied all Montréal residents aged > or =10 years for whom > or =1 laboratory-confirmed chlamydial infection was reported to the public health department between 1988 and 2007 (n = 44,580). Each person was passively followed for two years after baseline infection or until reinfection. Socio-demographic factors and histories of other notifiable diseases were examined as potential predictors. Cox multivariate regression was used to model the time to CR. Survival analyses were stratified by age group (<25 vs. > or =25 years).

RESULTS

We estimated an overall two-year CR rate of 6.4%, an incidence density of 3.5 per 100 person-years, and a median time to reinfection of nine months. CR significantly increased over time. Among persons <25 years, reinfection was significantly more likely among females [adjusted hazard ratio (AHR): 1.58] and younger participants (10-14 years: AHR: 2.98; 15-19 years: AHR: 1.81). Residing within the South Central sector was deleterious for six months following initial infection after which it became protective. Among persons > or =25 years, a history of sexually transmitted infections increased the risk of reinfection (AHR: 1.79).

CONCLUSION

CR is a significant and growing problem in Montreal. The current recommendation for a single repeat screening six months posttreatment might be usefully complemented with additional screenings. Our results also underscore the importance of screening high-risk populations, particularly young women.

Repeat infection with Chlamydia and gonorrhea among females: a systematic review of the literature

Determining the magnitude of chlamydia and gonorrhea reinfection is critical to inform evidence-based clinical practice guidelines related to retesting after treatment. PubMed was used to identify peer-reviewed English language studies published in the past 30 years that estimated reinfection rates among females treated for chlamydia or gonorrhea. Included in this analysis were original studies conducted in the United States and other industrialized countries that reported data on chlamydia or gonorrhea reinfection in females. Studies were stratified into 3 tiers based on study design. Reinfection rates were examined in relation to the organism, study design, length of follow-up, and population characteristics. Of the 47 studies included, 16 were active cohort (Tier 1), 15 passive cohort (Tier 2), and 16 disease registry (Tier 3) studies. The overall median proportion of females reinfected with chlamydia was 13.9% (n = 38 studies). Modeled chlamydia reinfection within 12 months demonstrated peak rates of 19% to 20% at 8 to 10 months. The overall median proportion of females reinfected with gonorrhea was 11.7% (n = 17 studies). Younger age was associated with higher rates of both chlamydia and gonorrhea reinfection. High rates of reinfection with chlamydia and gonorrhea among females, along with practical considerations, warrant retesting 3 to 6 months after treatment of the initial infection. Further research should investigate effective interventions to reduce reinfection and to increase retesting.

Comparison of sexual partnership characteristics and associations with inconsistent condom use among a sample of adolescents and adult women diagnosed with Chlamydia trachomatis

BACKGROUND

This analysis compared characteristics of female adolescent and adult sexual partnerships and related these characteristics to inconsistent condom use.

METHODS

Data are from a study of 126 women with prevalent chlamydia infections who reported information about 172 sexual partnerships in the previous 3 months. Characteristics of sexual partnerships included type of partner (main vs. other), duration of sexual relationship (<3 months vs. > or =3 months), partner age difference (<2 years older vs. > or =2 years older), and two scale measures: overlap of social networks (a measure based on how well the participant knew her partner's friends, for example) and intimacy.

RESULTS

Compared with adult partnerships, adolescent partnerships were of shorter duration and had less social overlap but were more likely to be classified by the participants as main partnerships. Among adolescents, longer partnership duration was not associated with higher intimacy, yet higher intimacy was significantly correlated with inconsistent condom use.

CONCLUSIONS

These differences suggest that adolescent females perceive and characterize their sexual relationships differently from adults. This, in turn, may have implications for risk of sexually transmitted infections (STIs). Prevention efforts for adolescents, including interventions and counseling, should consider the nature of their sexual partnerships.

Partner notification of sexually transmitted infections among pregnant women

The object of this study was to determine the factors associated with partner notification (PN) of sexually transmitted infection (STI) exposure among pregnant, low income, Mexican-American (MA) and African-American (AA) women and their male sexual partners. We used a cross-sectional analysis of 166 pregnant women with an STI, enrolled in a randomized controlled trial of behavioural intervention to prevent recurrent STIs. The primary outcome, PN, is notification of, or intent to notify male sexual partner(s) of STI exposure. Pregnant women with one (n = 136) versus multiple (n = 30) partners reported PN for 88.2% and 54.5% of male partners, respectively (P < 0.001). Multivariate logistic regression demonstrated three variables that independently predicted PN: a steady relationship, with one male sexual partner and recent (<30 days) intercourse with the partner. Among the low income, pregnant MA and AA women, the three relationship variables predicted 81.6% of PN and correctly classified 78.5% of males notified and 65.7% of males not notified.

Preventing recurrent sexually transmitted diseases in minority adolescents: a randomized controlled trial

OBJECTIVE

To compare the efficacy of a randomized controlled trial of the Sexual Awareness For Everyone (SAFE) behavioral intervention on teenagers (aged 14 to 18 years) compared with adult rates of reinfection with Neiserria gonorrhea or Chlamydia trachomatis cervicitis, and to identify behaviors associated with recurrent infection.

METHODS

Mexican-American and African-American females with a nonviral sexually transmitted disease (STD) were enrolled in SAFE or assigned to the control group. All participants were interviewed and examined at baseline, 6, and 12 months. The primary outcome variable was reinfection with N. gonorrhea or C. trachomatis. Secondary outcomes were changes in risky sexual behavior.

RESULTS

Teens randomized to participation in SAFE had a statistically lower incidence of recurrent N. gonorrhea and C. trachomatis at 0 to 6 months (52%, P=.04) and cumulatively (39%, P=.04) compared with teens in the control group. Cumulatively, teens as a group had higher rates of reinfection (33.1%) than adults (14.4%) (P<.001). Adolescent reinfection was explained by unprotected sex with untreated partners (adjusted odds ratio [OR] 5.58), nonmonogamy (adjusted OR 5.14), and rapid partner turnover (adjusted OR 2.02). In adults, reinfection was predicted by unprotected sex with untreated partners (adjusted OR 4.90), unsafe sex (adjusted OR 2.18), rapid partner turnover (adjusted OR 3.13), and douching after sex (adjusted OR 2.14).

CONCLUSION

Sexual Awareness for Everyone significantly reduced recurrent STDs in teenagers. Adults and teens randomized to the SAFE intervention had significant decreases in high-risk sexual behaviors as compared with those in the control group. Although not specifically designed for teens, the SAFE intervention worked very well in this high-risk population.

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov, ClinicalTrials.gov, HSC2004415H.

LEVEL OF EVIDENCE

I.

Partner age difference and prevalence of chlamydial infection among young adult women

OBJECTIVES

Sexual partner mixing by age is common among adolescents and adults. Although adolescent girls with older male partners are at increased risk of sexually transmitted infection, the importance of this association in young adults is unclear.

GOAL

To assess the association between partner age difference and prevalence of chlamydial infection among young women.

STUDY DESIGN

Using Wave III of the National Longitudinal Study of Adolescent Health (April 2, 2001-May 9, 2002), the authors examined the relation between the prevalence of chlamydial infection and the partner age among women aged 18 to 26 years.

RESULTS

Among women with most recent partners 2 to 8 years younger, the odds of chlamydial infection were approximately 2 times greater [adjusted odds ratio (OR), 1.8; 95% confidence interval (CI), 0.9, 3.5] than among women with partners within 1-year age difference, adjusting for number of partners in the past year. Prevalence of chlamydial infection was only slightly greater for women with partners 2 to 5 years older (adjusted OR, 1.4; 95% CI, 0.9, 2.3) and partners 6 or more years older (adjusted OR, 1.6; 95% CI, 0.9, 2.8), when compared with women with partners within 1-year age difference. The relation between most discordant partner age difference and chlamydial infection seems to vary by women's race/ethnicity, although these stratified estimates are imprecise.

CONCLUSIONS

These findings suggest that among young adult women, in contrast to adolescents, older male partners are only moderately associated with the prevalence of chlamydial infection. Young adult women have the lowest odds of infection with partners within 1 year of age difference.

Partner Notification of Sexually Transmitted Infections: A Large Cohort of Mexican American and African American Women

OBJECTIVES

To determine factors associated with partner notification (PN) of sexually transmitted infection (STI) exposure among low-income Mexican American and African American women and their male sexual partners.

GOAL

To identify women most likely to notify their partners about an STI exposure.

STUDY DESIGN

Cross-sectional analysis of 775 women with a nonviral STI. The primary outcome, PN, is notification of, or intent to notify male sexual partner(s) of STI exposure. A comprehensive intake interview was used to obtain sociodemographic, psychosocial, communication, and relationship information for the patients and each male sexual partner. Chi square analysis and multivariate logistic regression analysis were used to determine factors independently associated with PN.

RESULTS

The 775 women identified 1122 male sexual partners. Of women with 1, 2, and 3 or more partners, 87.9%, 41.4%, and 25.0% reported PN for all partners respectively. Logistic regression demonstrated that 5 variables independently predicted PN: a "steady" relationship (OR: 5.25; CI: 2.82-4.91), 1 partner (OR: 2.10; CI: 1.71-2.56), recent intercourse (OR: 1.37; CI: 1.21-1.54), anticipated ongoing sexual activity (OR: 1.48; CI: 1.04-2.10), and/or desire for pregnancy with that partner (OR: 1.68; CI: 1.10-2.58). Patient and partner sociodemographic variables were not significantly associated with PN. Responses to specific relationship and communication variables, although significant, did not remain independent in the final logistic regression model.

CONCLUSION

Among low-income Mexican American and African American women, the perception that a relationship with individual partner(s) was committed was predictive of PN.