1Sexually Transmitted Infections prevention, screening, treatment J. Dennis Fortenberry MD MSSection of Adolescent MedicineIndiana University School of MedicineSchool of Medicine.111
2Most people become sexually active during adolescence Sexually Transmitted Infections Why STI are important in health care (especially for adolescents)Most people become sexually active during adolescenceAbout 50% of new STI each year are in 15 – 24 year oldsWith this very superficial look at STD epidemiology, let’s examine the more common syndromes. The most common status for people with STD is to be asymptomatic. But it may be useful to quickly reviewGenital discharge / dysuria syndromesgenital ulcer / lymphadenopathyand dermatologic syndromesSutton’s Law, attributed to the famous bank robber, Willie Sutton:- Why do you rob banks?- Because that’s where the money is.
3Sexually Transmitted Infections U. S Sexually Transmitted Infections U.S. Chlamydia Rates among women and men, by age - per 100,000 Population (2007)Chlamydia rates show much the same thing. These rates translate to a disease prevalence in most areas of 8% to 15% among adolescent women.Among adolescent men randomly selected from the general population, about 6% have chlamydia when screened by nucleic acid amplification tests.1.1 million casesCenters for Disease Control & Prevention, 2009
4Sexually Transmitted Infections Indiana Chlamydia Rates among women and men - per 100,000 Population (2007)Chlamydia rates show much the same thing. These rates translate to a disease prevalence in most areas of 8% to 15% among adolescent women.Among adolescent men randomly selected from the general population, about 6% have chlamydia when screened by nucleic acid amplification tests.Centers for Disease Control & Prevention, 2009
6Skills building and skills practice Empowerment Sexually Transmitted Infections More successful approaches to STI preventionTarget behaviorSexual behaviorPartner communicationCondom useScreening and treatmentEducationSkills building and skills practiceEmpowermentKirby DB et al. Sex and HIV education programs: their impact on sexual behaviors of young people throughout the world. Journal of Adolescent Health. 40(3):206-17, 2007
7Sexually Transmitted Infections Less successful approaches to STI prevention Condyloma acuminata
8Threats and fear Facts and data Silence Stigmatization Abstinence only Sexually Transmitted Infections Less successful approaches to STI preventionThreats and fearFacts and dataSilenceStigmatizationAbstinence onlyFortenberry et al. Relationships of stigma and shame to gonorrhea and human immunodeficiency virus screening. Am J Public Health, 92: , 2002.
9Fails to account for method failure Non-developmental Sexually Transmitted Infections Abstinence-only as an inadequate public health STI prevention strategyFails to account for method failureNon-developmentalWithholding of health informationHeterosexual biasUnderhill K. Sexual abstinence-only programmes to prevent HIV infection in high income countries: Systematic review. Br J Med. 2007; 335:Trenholm C, et al. Impact of 4 Title V Section 510 abstinence education programs-Final report. Mathematica Policy Research Inc. 2007Santelli J, et al. Abstinence-only education policies and programs: a position paper of the Society for Adolescent Medicine. J. Adolesc Health; 38:83-87, 2006
11Failure to recognize risk Stigma Sexually Transmitted Infections Screening as an STI prevention strategyMany STI asymptomaticChlamydiaGonorrheaHIVFailure to recognize riskStigmaCenters for Disease Control & Prevention, 2006
12Older non-pregnant women at increased risk Sexually Transmitted Infections US Preventive Services Task Force Recommendations for Chlamydia screeningOlder non-pregnant women at increased riskAll pregnant women at riskNo recommendations for screening of menAll sexually active women < 25 yearsUS Preventive Services Task Force. Annals of Internal Medicine, 2007; 147:Rietmeijer K, et al. Chlamydia trachomatis positivity rates among men tested in selected venues in the United States: a review of the recent literature.Sex Trans Dis. 35:S8 – S18, 2008
13Older non-pregnant women at increased risk Sexually Transmitted Infections US Preventive Services Task Force Recommendations for Chlamydia screeningOlder non-pregnant women at increased riskAll pregnant women at riskNo recommendations for screening of menAll sexually active women < 25 years
14Sexually Transmitted Infections Age at first coitus – Indianapolis % with nocoital experienceTu et al. unpublished data
15Median age of 1st test = 15 years Sexually Transmitted Infections Time from 1st coitus to 1st STI test by age at 1st coitusMedian age of 1st test = 15 yearsTu et al. Arch Pediatr Adolesc Med (in press)
16Sexually Transmitted Infections Screening for Sexual Activity in Adolescents When, how and who, what Any health maintenance visit age 10 and olderAny “appropriate” sick visitAfter discussion of confidentialityParents etc out of roomHow and who“Do you have a boyfriend or girlfriend right now?” “Have you ever had sex with that person?” “Have you done anything sexual with that person?”YesNoNot reallyWhatPenile/vaginalOral/genitalPenile/analFord CA, et al. Anticipatory guidance regarding sex: views of virginal female adolescents. J Adolesc Health 19: , 1996.Reddy DM, et al. Effect of mandatory parental notification on adolescent girls' use of sexual health care services. JAMA. 288: , 2002.
18High sensitivity and specificity Multiple tests on same sample Sexually Transmitted Diseases Nucleic Acid Amplification Tests AdvantagesHigh sensitivity and specificityMultiple tests on same sampleCan be used in non-traditional venuesVariety of specimen typesCervical/urethralUrineVaginal: consider self-obtainedCook RL, et al. Systematic review: noninvasive testing for Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Int Med. 142(11):914-25, 2005
19Sexually Transmitted Diseases Other screening tests to consider Human immunodeficiency virusHerpes simplex 2SyphilisTrichomonasCenters for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.MMWR 55(RR14):1-17, 2006.
20Sexually Transmitted Diseases Other Prevention Strategies Condom useImmunization
21Sexually Transmitted Infections Condom use for STI prevention Consistent evidence for effectivenessChlamydiaGonorrheaGenital herpesHuman papillomavirusesSyphilisHIVEfficacy for pregnancy preventionDecline in use over time within relationshipsCondom failureBreakageSlippageIncorrect useHolmes KK et al. Effectiveness of condoms in preventing sexually transmitted infections. Bulletin of the World Health Organization 82: , 2004Fortenberry JD et al Condom use as a function of time in new and established adolescent sexual relationships. Am J Public Health 92: , 2002
22Sexually Transmitted Infections Instructions for correct condom use Open package near topCheck orientation but don’t unroll the condomUnroll completely over erect penisCheck the tipLubricantPractice
23Sexually Transmitted Infections Immunization for STI Prevention Hepatitis BHuman papillomavirus preventionQuadrivalent vaccine (types 6, 11, 16, 18)Women ages 9 – 26FDA decision on indication for older women and for adolescent men expected within year
24Sexually Transmitted Infections Diagnosis and Treatment
25Sexually Transmitted Infections STI syndromes common in adolescence Genital Discharge / Dysuria SyndromesGenital Ulcer / LymphadenopathyPelvic pain syndromeDermatologic SyndromesWith this very superficial look at STD epidemiology, let’s examine the more common syndromes. The most common status for people with STD is to be asymptomatic. But it may be useful to quickly reviewGenital discharge / dysuria syndromesgenital ulcer / lymphadenopathyand dermatologic syndromesShew ML, Fortenberry JD. Sexually Transmitted Diseases. in: Finberg L, Kleinman R (eds). Saunder’s Manual of Pediatric Practice. 3rd ed. (2007)
26Sexually Transmitted Infections Diagnosis and Treatment Discharge syndromes
27Sexually Transmitted Infections http://www.cdc.gov/std/default.htm Sexually Transmitted DiseasesTreatment Guidelines – 2006New guidelines will be released in early 2010
35Reduction or absence of Lactobacillis species Gardnerella vaginalis Sexually Transmitted Infections Bacteria associated with Bacterial VaginosisReduction or absence of Lactobacillis speciesGardnerella vaginalisPrevotella spp.Atopobium vaginaeLeptotrichia aminoniiBacterial vaginosis-associated bacterium (BVAB)Fredericks et al. Molecular identification of bacteria associated with bacterial vaginosis. N Engl J Med. 353: , 2005.
36Sexually Transmitted Infections Bacterial Vaginosis Treatment Metronidazole gel, 0.75% 5 gram applicator daily for 5 daysMetronidazole 500 mg BID for 7 daysClindamycin Cream, 2% 5 gram applicator daily for 7 days
37Sexually Transmitted Infections Frothy Discharge Associated with Vaginal Trichomoniasis
47Sexually Transmitted Infections Diagnosis and Treatment Pelvic/Genital Pain
48Sexually Transmitted Infections Diagnosis of Pelvic/Genital Pain Pelvic inflammatory diseaseNot pregnantNo evidence of other causeTenderness of pelvic structuresEpididymitis/orchitisNo evidence of testicular torsion
49Sexually Transmitted Infections Treatment of Pelvic/Genital Pain Pelvic inflammatory disease*Ceftriaxone 250 mg IM plusDoxycycline 100 mg BID for 14 daysMetronidazole 500 mg BID for 14 daysEpididymitis/orchitisDoxycycline 100 mg BID for 10 days* Several regimens are described in CDC treatment guidelines
50Sexually Transmitted Infections Diagnosis and Treatment Dermatologic syndromes
52Identifies most high-risk HPV types Sexually Transmitted Infections Diagnosis of Human Papilloma Virus InfectionsHybrid Capture IIIdentifies most high-risk HPV types16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68Identifies some low-risk HPV types6, 11, 42, 43, 44
53Sexually Transmitted Infections Genital Warts - Treatment Imiquimod 5% Cream, 3 times weekly up to 16 weeksPodofilox 0.5% solution or gel, twice daily for 3 consecutive daysCryotherapyPodophyllin or Trichloracetic acid
54Sexually Transmitted Infections Secondary syphilis - condyloma lata