The pediatrician and the sexually active adolescent. A primer for sexually transmitted diseases

Prevalence and risk factors for Chlamydia trachomatis infection in adolescent females and young women in central Brazil

In order to determine the prevalence and risk factors for Chlamydia trachomatis infection in adolescent females and young women in central Brazil, 296 subjects attending two public health services were evaluated. The overall prevalence of C. trachomatis infection, as determined using polymerase chain reaction, was 19.6% (95% confidence interval [CI], 15.3-24.7). In multivariate analysis, young age (odds ratio [OR]adjusted 2.32, 95%CI 1.1-4.8, p<0.05) and having 2-3 (ORadjusted 3.41, 95%CI 1.6-6.3, p<0.05) or >or=4 sexual partners in life (ORadjusted 3.10, 95%CI 1.1-6.3, p<0.05) were factors significantly associated with chlamydial infection. In conclusion, the prevalence of C. trachomatis infection was high in the studied population and risk factors were related to age and sexual behavior.

Human papillomavirus infection and abnormal cytology of the anus in HIV-infected and uninfected adolescents

OBJECTIVE

To examine the prevalence of and risk for anal human papillomavirus (HPV) infection and abnormal anal cytology in sexually active adolescents.

DESIGN

Prevalence data from adolescents aged 13-18 years with and without HIV infection and with a history of high-risk sexual behavior.

METHODS

HPV DNA was detected using amplification techniques. Abnormal anal cytology was defined as atypical squamous cell of undetermined significance or worse.

RESULTS

Prevalence of anal HPV infection was similar in HIV-infected [28/58 (48%)] and uninfected [9/25 (36%)] boys (P = 0.3). but greater in HIV-infected [59/183 (59%)] than in uninfected [11/82 (13%)] girls (P < 0.001). Perianal warts were a risk for anal HPV in both boys [odds ratio (OR), 15.5; 95% confidence interval (CI), 1.6-149] and girls (OR, 9.9; 95% CI, 1.9-51.3). In subjects without anal warts, HIV infection was significant for girls (OR, 2.3; 95% CI, 1.1-4.9) and homosexual/bisexual orientation was significant for boys (OR, 5.2; 95% CI, 1.3-20.6). Abnormal anal cytology was more common among boys [32/77 (41.6%)] than girls [38/230 (16.5%)] (P < 0.001) and in addition to anal HPV, independent risk factors were positive HIV status in boys (OR, 6.5; 95% CI, 1.5-11.9) and number of partners within the past 3 months in girls (OR, 4.2; 95% CI, 1.5-11.9).

CONCLUSIONS

Strong risk factors for abnormal anal cytology were HIV infection and anal HPV in boys and anal HPV and higher number of sexual partners for girls. The results suggest that anal cytology screening should be considered in HIV infected homosexual/bisexual males.

Child health implications of worldwide urbanization

The upsurge of urbanization, often poorly planned and uncontrolled, has caused major impacts on human societies for at least two centuries. Urban environments and urbanized lifestyles have strong influences on health and well-being, including on infant and childhood populations in developed and underdeveloped countries, as well as among societies in developmental and environmental transition around the world. Urbanization will inevitably have significant impacts on the health of future generations. Notably, the health consequences of urbanized lifestyles are not confined to residents of cities and large towns but rather are becoming manifest in rapidly changing, previously traditional societies in rural and remote areas because globalization is altering infant feeding practices and the dietary habits and lifestyle patterns of their children. In underdeveloped countries, overcrowding and environmental pollution are huge problems that are exacerbated by undernutrition and infection, particularly respiratory and diarrheal diseases. In developed societies, other problems like injuries; poisonings; violence; drug abuse; exposure to chemical, biological, industrial, and atmospheric pollutants, including pesticides; sexually transmissible diseases; and 'lifestyle' diseases, including obesity and cardiovascular disease risk, are of great current and potential importance.

Drug treatment of nonviral sexually transmitted diseases: specific issues in adolescents

Sexually transmitted diseases (STDs) are common and happen more frequently in younger patients. These adolescents have unique risks of acquiring infection because of developing psychosocial skills, biological factors and sociocultural barriers. The clinician must be adept at identifying and modifying these risks through knowledge of the adolescent stages of development and biology, with good history and examination skills that make teens comfortable during their evaluation, and with patient education and treatment. Whereas patient compliance and partner notification can be problematic in any population, teenagers may be more prone not to follow through on these issues. While compliance may notbe as important as previously thought, there is a dearth of studies of patient compliance and STD treatment in adolescents. Guidelines for the treatment of STDs were published by the Centers for Disease Control and Prevention (CDC) in 1998 and the Medical Society for the Study of Venereal Diseases in 1999. Most of the data obtained to formulate these guidelines were not necessarily adolescent specific and few studies, if any, have included adolescent patients since the CDC document was published. In the treatment of chlamydia, it appears that even with relative noncompliance with the 7-day regimen of doxycycline, it is as effective as single dose azithromycin. This has implications in cost control, important for centres with limited funds for treatment. While fluoroquinolone-resistant gonorrhoea has been reported for some time, the number of reports in the US is increasing, with a recent report of decreased susceptibility to azithromycin. As many studies have shown efficacy with single agent therapy with azithromycin in combined gonococcal and chlamydial infection, one must view these new resistance data with concern and give serious consideration to dual agent treatment, especially in the locale of the practitioner. Also, fluoroquinolone use is not advised in patients under the age of 18 years at present because of concerns of adverse effects on cartilage. While not much has changed from the 1998 guidelines for most of the other STDs, there seems to be a general trend in treating pelvic inflammatory disease (PID) on an outpatient basis if good follow-up is assured, even in the adolescent population. There is still debate on whether anaerobe coverage is needed in PID without tubo-ovarian abscess or other complications. One other update includes the use of daily metronidazole gel instead of twice daily usage in the treatment of bacterial vaginosis. With the lack of studies specific to adolescents, it is left up to the clinician to tailor the treatment of adolescents on the basis of current guidelines and patient preferences.

Sexually transmitted infections among HIV infected and HIV uninfected high-risk youth in the REACH study. Reaching for Excellence in Adolescent Care and Health

This review presents the findings of published research in the Reaching for Excellence in Adolescent Care and Health (REACH) Project on sexually transmitted infections (STIs) within the context of the project's scientific agenda. Methods employed in the study for specimen collection, management, and laboratory analysis are presented. This review presents published analyses of cross-sectional data; longitudinal analyses are underway. In addition, baseline prevalence data on selected STIs and sexual risk profiles of the subjects in REACH are presented. High STI rates were evident in both human immunodeficiency virus (HIV) infected and uninfected youth of both genders regardless of sexual orientation. High infection rates at baseline suggest that prevention-oriented programs for risk reduction among adolescents should focus on both HIV infected and at-risk, uninfected youth.

Testing for Chlamydia and sexual history taking in adolescent females: results from a statewide survey of Colorado primary care providers

OBJECTIVES

Little is known about the practice patterns of primary care providers as they relate to assessing risk of and screening for chlamydial infections, an important cause of preventable reproductive morbidity in young women in the United States. The present cross-sectional study was undertaken to assess levels of chlamydia testing, sexual history taking, and prevention practices by Colorado primary care physicians, nurse practitioners, and physician assistants who provide gynecologic care to adolescent females (13-19 years old).

METHODS

Between July 1998 and October 1998, an anonymous, self-administered questionnaire was mailed to a 25% random sample (n = 1265) of Colorado physicians (family practitioners, internal medicine specialists, obstetrician-gynecologists, and pediatricians), nurse practitioners, and physician assistants. Practitioners were identified through professional organization membership, state-licensing bodies, and listings in the yellow pages.

RESULTS

After estimating the eligibility rate among non-respondents, the adjusted response rate was 71.5%. Only 53.8% of providers reported regularly testing sexually active female adolescents for chlamydia; 71.8% of providers regularly took a sexual history. Female providers reported significantly higher levels of regularly taking a sexual history (87. 2% vs 60.6% of males), feeling comfortable discussing sex (94.4% vs 77.8%), discussing sexually transmitted disease (STD) prevention (81. 5% vs 71.3%), and testing for chlamydia (64.4% vs 38.6%). Among provider types, obstetrician-gynecologists, nurse practitioners, and pediatricians were most likely to report regularly taking a sexual history (90.1%, 88.6%, and 76.0%, respectively). Internal medicine specialists were the least likely to report taking a sexual history (43.9%). Pediatricians and nurse practitioners were the most likely to report testing sexually active adolescent females for chlamydia (74.1% and 70.1%, respectively), whereas physician assistants and internal medicine specialists were the least likely (46.0% and 38.5%, respectively). In multivariate analysis, variables independently associated with regularly taking a sexual history included female provider gender (odds ratio [OR]: 5.5; 95% confidence interval [CI]: 2.9-10.9), obstetrics/gynecology specialty (OR: 4.0; 95% CI: 1.7-10. 3; referent group: family practitioners), and provider comfort level in discussing sex (OR: 4.9; 95% CI: 2.3-11.1). Variables independently associated with regularly testing adolescent females for chlamydia included female provider gender (OR: 2.8; 95% CI: 1. 6-4.8), regularly discussing STD prevention (OR: 2.1; 95% CI: 1.1-4. 1), and regularly discussing limiting the number of patients' sex partners (OR: 2.4; 95% CI: 1.4-4.1).

CONCLUSIONS

Only a little over one half of providers (54%) reported regularly performing chlamydia tests on adolescent females who are sexually active by history. Because this falls well short of the recommendations of the Centers for Disease Control and Prevention to test all sexually active female adolescents, efforts are needed to improve STD clinical practices of Colorado physician and nonphysician providers of primary care for adolescent females. Particular efforts are needed to close the provider gender gap.

Adolescents and sexually transmitted diseases

Pediatricians with busy practices have limited time to spend with each patient. But because much of adolescent morbidity and mortality is related to behavioral issues, time and energy are crucial to providing effective counseling and care to adolescents. Many barriers to provision of services to adolescents exist, including time, space, décor, office hours, office fees, and support personnel. Despite these barriers to care of adolescents and, in particular, sexually active adolescents, the need for pediatricians to provide these services is clear. Services include anticipatory guidance and counseling about developing sexuality and sexual behaviors, as well as management of health consequences of sexual behavior. Primary care providers have an opportunity to assist adolescents to develop mature and healthy sexual relationships. This necessitates a full understanding of each patient's unique situation, listening to adolescents' concerns, and honest and straightforward discussion of sensitive information. Beginning the process of discussion of sexuality and relationships early in the pediatric years may help adolescents and their parents to develop healthy sexual attitudes and behaviors.