1. Chlamydia and Adolescent Patients

2. Objectives
Describe the epidemiology, scope, and risk factors for Chlamydial infection in adolescents
Assess, treat, and prevent Chlamydial infection in adolescent patients utilizing evidence-based guidelines
Discuss ways to improve current clinical practice
Provide referrals for care to adolescent patients

3. Adolescent Sexual Behavior
Knowing which questions to ask

4. YRBS 2013 Condom Use
% of HS Students Who Used a Condom at Last Intercourse
53.1% of HS females used condom at last sex in 2013 from YRBS survey and 65.8% of HS males used condom at last sex in 2013.
(Slightly down from rates in 2011)
Women with first sexual intercourse <age 15 are nearly four times as likely to report a bacterial STI and more than twice as likely to report PID, as women who first had sex after age 18.
Several studies have shown that being in a new sexual partnership is a predictor of an STI due to greater uncertainty about partners’ sexual history and STI status.
More than one sexual partner at a time increases exposure and therefore increases risk of STI.
Use of alcohol and other substances that impair judgment can increase the likelihood of engaging in sexual intercourse without a condom, with multiple partners, or with high risk partners. Approximately 1 in 70 high school students reported having injected an illegal drug and about 18% of 12–19 year olds reported an episode of heavy drinking in the past 30 days.
Sources:
Niccolai LM. New sex partner acquisition and sexually transmitted disease risk among adolescent females. J Adolescent Health 2004; 34(3):216–23.
Gittes EB, Irwin CE. Sexually transmitted diseases in adolescents. Pediatr Rev. 1993;14:180–189.
Source for graph:
YRBS 2013

5. YRBS 2013: U.S. High School Students
YRBS Question
U.S.
% students ever had sex
46.8%
% students who used a condom at last sex
59.1%
% students had sex with 4 or more persons (in lifetime)
15.0%
% students had sex with at least 1 person in last 3 months
34.0%
Source:
The YRBS, or Youth Risk Behavior Survey, is an anonymous survey administered by the CDC every two years in selected high schools throughout the United States. Thus, it is a survey of adolescents in grades 9–12 who are in school. The survey focuses on many different health concerns and behaviors including: mental health, exercise, nutrition, use of seatbelts, substance use behavior, and sexual behavior. We will be briefly review some of the data pertaining to sexual health.
The data is available nationally, by state, and also at local levels. It is helpful to become familiar with the results in your area, especially when trying to sensitize stakeholders about the need to develop services to support adolescents to reduce risk.
CDC YRBS Data 2013

6. ♀ Sexual Behavior with Opposite-Sex Partners
Age (yrs)
Any sex
Vaginal sex
Oral sex
Anal sex
15–19
53%
46%
45%
11%
20–24
88%
85%
81%
30%
These are data from the National Survey of Family Growth, which is a large, household–based survey of US males and females 15–44 years old conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics that obtains information on factors affecting birth and pregnancy rates.
These data illustrate the diversity in sexual behavior with opposite-sex partners among youth aged 15–24 years. You can see that many adolescent and young adults males and females are engaging in vaginal sex, oral sex, and/or anal sex. It is very important to know what type of sex your patients are practicing so you will know which orifices to test for STIs. We have to routinely ask the question, of kids who report sexual activity “are you having vaginal sex, oral sex, or anal sex” to guide our clinical practice.
NSFG

7. ♂ Sexual Behavior with Opposite-Sex Partners
Age (yrs)
Any sex
Vaginal sex
Oral sex
Anal sex
15–19
58%
45%
48%
10%
20–24
86%
82%
80%
32%
These are data from the National Survey of Family Growth, which is a large, household–based survey of US males and females years old conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics that obtains information on factors affecting birth and pregnancy rates.
These data illustrate the diversity in sexual behavior with opposite-sex partners among youth aged 15–24 years. You can see that many adolescent and young adults males and females are engaging in vaginal sex, oral sex, and/or anal sex. It is very important to know what type of sex your patients are practicing so you will know which orifices to test for STIs. We have to routinely ask the question, of kids who report sexual activity “are you having vaginal sex, oral sex, or anal sex” to guide our clinical practice.
NSFG

8. ♂ Sexual Behavior with Same-Sex Partners
Age (yrs)
Any sex with ♂
Anal sex with ♂
Oral sex with ♂
15–19 3% 1% 2%
20–24 6%
These are also data from the NSFG that present the sexual behaviors with same-sex partners among males aged 15–24 years. You can see that the prevalence of same-sex behavior among young men is high enough where you should expect to see male patients in your practice who are engaging in sex with other men. But you are never going to know if you don’t ask. So, it is not only important to ask teens how they are having sex but also with whom they are having sex. STI risk is not just based on what you are doing, but also who you are doing it with.
NSFG

9. Increased Risk for STIs
We are going to briefly describe a few of them:
Biological
Cognitive
Behavioral
Risk for Sexual Abuse
Social/Institutional
Adolescents Face
Increased Risk for STIs

10. Biological Risk Factors: Females
Adolescent cervix
Lack of immunity from prior infections
Smaller introitus
In general, women are at greater risk of acquiring an STI than men. Because female reproductive anatomy is internal, it is more susceptible to infection and infection is more difficult to recognize.
Teenage women may be even more susceptible to a sexually transmitted infection than older women due to increased cervical ectopy (most STIs infect columnar cells in ectopy and not squamous cells covering surrounding cervix and vagina). Adolescent women are also likely to have fewer protective antibodies to STIs, a biologically immature cervix, a smaller introitus, and a higher likelihood of dry sex.
Extent of cervical ectopy was not associated with HPV acquisition in healthy adolescents and young women. Biological vulnerabilities may lie in immune function or other characteristics of the cervical epithelium.
Source:
Obstet Gynecol. 2012 Jun;119(6): doi: /AOG.0b013e f47.Cervical ectopy and the acquisition of human papillomavirus in adolescents and young women. Hwang LY, Lieberman JA, Ma Y, Farhat S, Moscicki AB.
Sources:
Shafer M, Sweet RL. Pelvic Inflammatory Disease in Adolescent Females Adolescent Medicine: State of the Art Reviews 1990;1:545–564.
D.R. Ostergard. The Effect of Age, Gravidity, and Parity on the Location of the Cervical Squamocolumnar Junction as Determined by ColposcopyAmerican Journal of Obstetrics and Gynecology 1977:129:59–60.
Moscicki A. Differences in Biologic Maturation, Sexual Behavior, and Sexually Transmitted Disease Between Adolescents With and Without Cervical Intraepithelial NeoplasiaJournal of Pediatrics 1989;115:487–493.
Lack of lubrication can lead to dry, traumatic sex

11. Cognitive Risk Factors for STIs in Adolescents
Early adolescence: concrete thinking
Often unable to plan ahead for condoms
Serial monogamy in relationships leading to multiple partners
Personal fable
Unable to judge risk for STIs
“Other people get STIs”
There are several cognitive factors that place adolescents at disproportionate risk for STIs. Early adolescence is characterized by concrete thinking. This can inhibit an adolescent’s ability to plan ahead for the need for condoms. Additionally, it may affect an adolescent’s understanding of the future ramifications of an STI.[i]
Having multiple partners is a major risk factors for STIs. In adolescence, most teens are only sexually active with one person at a time which may imply safety from infection. However, adolescent romantic relationships are often very short. Serial monogamy can lead to many lifetime partners and an increase in risk.[ii]
Elkind’s (1967) theory of adolescent egocentrism proposes two distinct but related constructs—the imaginary audience and the personal fable. These two concepts are interrelated. The imaginary audience describes an adolescent’s egocetrism and perception that everything they do is being watched and scrutinized by others. The personal fable is an adolescent’s sense of personal uniqueness which can yield a sense of invulnerability commonly associated with behavioral risk-taking. [ii]
Sources:
Elkind D. Egocentrism in adolescence. Child Development 1967;38: 1025–1034.
Ellen JM. Boyer CB, Tschann JM, Shafer MA. Adolescents' perceived risk for STDs and HIV infection. Journal of Adolescent Health 1996;18:77–181

12. Behavioral Risk Factors
Age at First Intercourse
Sexual Activity with New/Older Partner
Multiple Sexual Partners
Substance Use
Mental Health
Women with first sexual intercourse <age 15 are nearly four times as likely to report a bacterial STI and more than twice as likely to report PID, as women who first had sex after age 18.
Several studies have shown that being in a new sexual partnership is a predictor of an STI due to greater uncertainty about partners’ sexual history and STI status.
More than one sexual partner at a time increases exposure and therefore increases risk of STI.
Use of alcohol and other substances that impair judgment can increase the likelihood of engaging in sexual intercourse without a condom, with multiple partners, or with high risk partners. Approximately 1 in 70 high school students reported having injected an illegal drug and about 18% of 12–19 year olds reported an episode of heavy drinking in the past 30 days.
Older Partners:
Sexual negotiation more difficult
Increased risk of involuntary intercourse, lack of protective behavior, and exposure to STIs
“Persons who initiate sex early in adolescence are at higher risk for STDs, along with persons residing in detention facilities, attending STD clinics, young men having sex with men (YMSM), and youth who use injection drugs. Factors contributing to this increased risk during adolescence include having multiple sexual partners concurrently, having sequential sexual partnerships of limited duration, failing to use barrier protection consistently and correctly, having increased biologic susceptibility to infection, and experiencing multiple obstacles to accessing health care (92).
Source:
Forhan SE, Gottlieb SL, Sternberg MR, et al. Prevalence of sexually transmitted infections among female adolescents aged 14 to 19 in the United States. Pediatrics 2009;124:1505–12.
Sources:
Niccolai LM. New sex partner acquisition and sexually transmitted disease risk among adolescent females. J Adolescent Health 2004; 34(3):216–23.
Gittes EB, Irwin CE. Sexually transmitted diseases in adolescents. Pediatr Rev. 1993;14:180–189.

13. Risk Factor: Intimate Partner Violence
Teen girls who are abused by male partners are 3× more likely to become infected with an STI/HIV than non-abused girls.
Adolescents rarely self-report dating violence and may not recognize their exposure to dating violence as abuse.
Direct questions (with yes or no answers) may not be effective.
Adapted from, “Hanging out or Hooking Up: Clinical Guidelines on responding to Adolescent Relationship Abuse” by Elizabeth Miller, MD, PhD and Rebecca Levenson, MA. (pg.15)
Girls may fear retaliation from partners when notifying them of STI infection
Elizabeth Miller & Rebecca Levenson. Hanging out or Hooking Up:
Clinical Guidelines on responding to Adolescent Relationship Abuse

14. Risk Factor: Social/Institutional
Lack of Transportation
Lack of Insurance/$ to Pay
Concerns About Confidentiality
Adolescents Not Being Screened and Treated
Lack of Sex Ed Regarding Risk and Symptoms
Stigma
There also exist many social and institutional risk factors that contribute to adolescents’ disproportionate risk for STIs, including:
Lack of sex education regarding how to protect oneself from sexually transmitted infections, including condom use;
Lack of insurance or ability to pay for services;
Lack of transportation to clinics or doctors offices;
Concerns about confidentiality which may inhibit young people from seeking care;
Stigma regarding STI testing and diagnosis.

15. STI Protective Factors
Peer support for contraception and condoms
Communication with parents about sex
Connection to family
Connection to school and future success
Connection to community organizations

16. Adolescent STI Burden Why it matters
Now let’s look at the prevalence of outcomes of adolescent sexual behavior related to Chlamydia
Adolescent STI Burden
Why it matters

17. U.S. Preventive Services Task Force: High-Priority Evidence Gaps
Why focus on STI care and treatment for children, adolescents, and young adults?
USPSTF 4th Annual Report identifies:
Long-term harms of HIV antiretroviral therapy
Interventions to prevent STIs in low-risk adolescents and high-risk adolescents
Effectiveness of screening strategies to identify high-risk adolescents
A new report by the U.S. Preventive Services Task Force (USPSTF) identifies three key evidence gaps that relate to sexually transmitted infections. These evidence gaps are: (1) long-term harms of HIV antiretroviral therapy, (2) interventions to prevent STIs in low-risk adolescents and high-risk adolescents, and (3) effectiveness of screening strategies to identify high-risk adolescents. The report, Fourth Annual Report to Congress on High-Priority Evidence Gaps for Clinical Preventive Services, prioritizes evidence gaps related to the care of children and adolescents. The USPSTF also notes that the overall effect of HPV vaccination on cervical cancer is not yet known and is a key evidence gap that should be addressed as well.

18. CDC 2013 Report: STIs and Young People
Incidence
Prevalence
Increased Risk
Cost
~20 million new cases/year:
50% occur in people ages 15–24
Total infections: 110 Million
# of new infections equal among young males (49%) and females (51%)
1 Satterwhite CL, et al. Sexually transmitted infections among U.S. women and men: Prevalence and incidence estimates, Sex Transm Dis 2013; 40(3): pp. 187–193.
2 Owusu-Edusei K, et al. The estimated direct medical cost of selected sexually transmitted infections in the United States, Sex Transm Dis 2013; 40(3): pp. 197–201.
Though young people aged 15–24 make up 25% of sexually active individuals, they comprise half of new STI infections each year.
A CDC study released in March 2008 estimates that one in four young women ages 14 to 19 in the US are infected with at least one of the most common sexually transmitted infections (human papillomavirus, chlamydia, herpes simplex virus, and trichomoniasis). Data were based on an analysis of the 2003–2004 National Health and Nutrition Examination Survey.[ii]
A 2004 study investigating the annual cost of STIs in American young people found that the total estimated burden STIs occurred among 15–24 year olds in 2000 was $6.5 billion (in year 2000 dollars).[iii]
In 2006, the incidence of HIV in young people ages 13–29 was 26.8 per , representing 34% of the total infections. More than half of the infections in this age group were in men who have sex with men (MSM).[iv] However, the 2006 CDC data includes reporting from 33 states and represents 14% of the persons diagnosed that year. Based on back reporting, researchers estimate that the percentage of total infections in young people may be as high as 50%.[v]
Sources:
[ii] CDC Press Release National STD Prevention Conference. Nationally Representative CDC Study Finds 1 in 4 Teenage Girls Has a Sexually Transmitted Disease.
[iii] Hall HI, Song R, Rhodes P, Prejan J, et al. Estimation of HIV Incidence in the United States. JAMA 2008;300:520–529.
[iv] Chesson H, et al. The Estimated Direct Medical Cost of Sexually Transmitted Diseases Among American Youth, Perspect Sex Repro Health 2004;36;1
[v] Morris M, et al. Prevalence of HIV Infection Among Young Adults in the United States: Results From the Add Health Study AJPH 2006; 96(6): 1091–1097
Direct medical costs: ~$16 billion/year

19. Half of New STIs: Ages 15-24
While the consequences of untreated STIs are often worse for young women, the new analysis reveals that the annual
number of new infections is roughly equal among young women and young men (49 percent of incident STIs occurs among
young men, vs. 51 percent among young women).
**HIV incidence not calculated by age in the analysis
CDC estimates that HPV accounts for the majority of newly acquired STIs. While the vast majority (90 percent) of HPV
infections will go away on their own within two years and cause no harm, some of these infections will take hold and
potentially lead to serious disease, including cervical cancer

20. Trends in Chlamydia Infection Among Adolescents
Chlamydia infection increased by an average of 3.3% per year from for females aged 15-19
Rates decreased slightly, , mostly among females and males aged 15-19
First time that overall chlamydia case rates decreased since national reporting began
Rate of chlamydia shows no sign of decline for females aged 20–24
A new report by the Centers for Disease Control and Prevention (CDC) has found that chlamydia infection increased by an average of 3.3% per year from 2005–2012 among females aged 15–19. In women aged 20–24 years, the rate of chlamydia has also demonstrated no sign of decline. The CDC notes that some of this increase reflects improved screening efforts, but also suggests that the actual burden of infection is much greater than indicated in the reported data alone. The report, CDC National Health Report: Leading Causes of Morbidity and Mortality and Associated Behavioral Risk and Protective Factors—United States, 2005–2013, uses data from 19 surveillance sources to determine recent trends in the nation's health.
According to the new CDC 2013 STD Surveillance Report, rates for chlamydia decreased slightly between 2012 and 2103, with that reduction seen mostly among young women and men aged This is the first time that overall chlamydia case rates have decreased since national reporting began and the second year that rates have decreased among adolescent females.
Source:
CDC National Health Report: Leading Causes of Morbidity and Mortality and Associated Behavioral Risk and Protective Factors—United States, 2005–2013
2013 CDC STD Surveillance Report.
2013 CDC STD Surveillance Report
CDC National Health Report –2013.

21. 68% of all Chlamydia Cases Among 15- to 24-Year-Olds
Source:
In 2013, 949,270 cases of chlamydial infection were reported among persons aged 15–24 years of age, representing 68% of all reported chlamydia cases. Among those aged 15–19 years, the rate of reported cases of chlamydia increased 6.4% during 2009–2011, decreased 4.4% during 2011–2012, and decreased 8.7% during 2012– Among those aged 20–24 years, the rate increased 16.1% during 2009–2011 and remained stable during 2011–2013
Among women aged 15–24 years of age, the population targeted for chlamydia screening, the overall rate of reported cases of chlamydia was 3,340.8 per 100,000 females. Rates varied by state, with highest reported case rates in the South.
15- to 19-Year Old Women—In 2013, the chlamydia case rate among women aged 15–19 years was 3,043.3 cases per 100,000 females, a 8.7% decrease from the 2012 rate of 3,331.7 cases per 100,000 females. Decreases in rates of reported cases were largest among 15-, 16-, and 17- year old females.
20- to 24-Year Old Women—In 2013, women aged 20–24 years had the highest rate of chlamydia (3,621.1 cases per 100,000 females) compared with any other age and sex group. The overall chlamydia case rate among women in this age group remained stable during 2012–2013; however, rates of reported chlamydia increased among 23- and 24- year old females
15- to 19-Year Old Men—The chlamydia case rate for men aged 15–19 years decreased 9.0% from cases per 100,000 males in 2011 to cases per 100,000 males in 2013
20- to 24-Year Old Men—In 2013, as in previous years, men aged 20–24 years had the highest rate of chlamydia among men (1,325.6 cases per 100,000 males). The chlamydia rate for men in this age group remained stable during 2012–2013
CDC STD Surveillance Report 2013

22. Chlamydia: Rates by Race/Ethnicity, United States, 2009-2013
Source:
Among the 47 jurisdictions (46 states and the District of Columbia) that submitted data in the race and ethnicity categories in 2013 according to Office of Management and Budget (OMB) standards, rates of reported cases of chlamydia were highest among black men and women. The rate of chlamydia among blacks was 6.4 times the rate among whites (1,147.2 and cases per 100,000 population, respectively). The rate among American Indians/Alaska Natives (697.9 cases per 100,000) was 3.9 times the rate among whites. The rate among Hispanics (377.0 cases per 100,000) was 2.1 times the rate among whites. The rate among Native Hawaiians/Other Pacific Islanders (633.3 cases per 100,000) was 3.5 times the rate among whites. The rate among Asians was lower than the rate among whites (111.5 cases and cases per 100,000, respectively).
During 2009–2013, 40 jurisdictions (39 states and the District of Columbia) submitted chlamydia case report data in the race and ethnicity categories according to the OMB standards. Between 2009–2012, rates increased among all races and ethnicities. During 2012–2013, rates decreased among American Indians/Alaska Natives (5.0%), among blacks (6.8%), and among whites (0.8%), were stable among Hispanics, and increased 10.0% among Native Hawaiians/Other Pacific Islanders.
CDC STD Surveillance Report 2013

23. Significant Racial Disparities
Chlamydia rates in 2013:
The rate for blacks 6.4 times the rate among whites
The rate for American Indians/Alaska Natives 3.9 times the rate among whites
The rate for Hispanics 2.1 times the rate among whites
The rate for Native Hawaiians/Other Pacific Islanders 3.5 times the rate among whites
The rate among Asians was lower than the rate among whites
CDC STD Surveillance Report 2013

24. Chlamydia: Rates by State, United States and Outlying Areas, 2013
Source:
In 2013, rates of reported cases of chlamydia by state ranged from cases per 100,000 population in New Hampshire to cases in Alaska; the rate in the District of Columbia was 1,104.4 cases per 100,000. During 2012–2013, rates of reported chlamydia decreased in 26 states and in the District of Columbia.
CDC STD Surveillance Report 2013

25. Who Is Caring for Adolescents?
Ask the audience: Who is caring for more teens now compared to 5 years ago? RAISE YOUR HANDS!!
I want to ask you to think if you believe that you have been caring for more teen patients now than you did 5 years ago.
Who Is Caring for Adolescents?

26. Clinical Care: Female Adolescents
Source: National Ambulatory Medical Care Survey, 2003–6
Data from National Ambulatory Medical Care Survey of non-federally employed physician offices demonstrates that pediatricians and family medicine docs are really important adolescent health providers.
This slide shows where adolescent females are being seen for health care. Along the x-axis is age and the y-axis corresponds to the percent of females in each age group who are cared for by either pediatricians, family medicine docs or OB/GYNs.
You can see that until the age of 17–18 years, young women see pediatricians and and FP/GPs much more than OB/GYNs. This young age group is when adolescent females are most vulnerable to STIs and pregnancy. So, primary care providers, including pediatricians, are very important health care providers for adolescents. It is IMPORTANT that we provide this essential sexual health care and are able to routinize this care into our practices.
Hoover et al., J Adol Health, 2010

27. Chlamydia: Cases by Reporting Source and Sex, United States, 2004-2013
Most chlamydia cases reported in 2013 were from venues outside of STD clinics. Over time, the proportion of cases reported from non-STD clinic sites has continued to increase. In 2013, among women, only 5.5% of chlamydia cases were reported through an STD clinic. Most cases among women were reported from private physicians/health maintenance organizations (HMOs) (33.2%). Among men, 17.2% of chlamydia cases were reported from an STD clinic in 2013 and 24.3% were reported from private physicians/HMOs.
CDC STD Surveillance Report 2013

28. Chlamydia: Proportion of STD Clinic Patients Testing Positive, 2013
Source:
In 2005, the STD Surveillance Network (SSuN) was established to improve the capacity of national, state, and local STD programs to detect, monitor, and respond to trends in STDs. In 2013, a total of 42 STD clinics at 12 sites collected enhanced behavioral information on patients who presented for care to these clinics.
In 2013, the proportion of STD clinic patients testing positive for chlamydia varied by age, sex, and sexual behavior. Adolescent men who have sex with women (MSW) had the highest prevalence (31.7%), likely reflecting targeted testing of partners of females diagnosed with chlamydia. Among MSW and women, prevalence among those tested decreased with age. The variation in prevalence by age was not as pronounced for gay, bisexual, and other men who have sex with men (MSM)
CDC STD Surveillance Report 2013

29. Case: Erica Erica is a 16-year-old female who presents with dysuria.
What is your initial differential diagnosis?
What additional information do you need?

30. Approach to the Adolescent Key Strategies
Assess developmental level
Discuss confidentiality with adolescent/parent
Appropriately ensure confidentiality, time alone
Brief risk assessment at most visits
STI screening annually if sexually active
Systems for follow-up of confidential results
Ensure all office staff on board with confidential adolescent health care
Systems in place to provide confidential care 30

31. Assessing Sexual Behavior
Include questions that direct testing

32. Sexual History: The Five Ps
Partners
Gender(s), Number (three months, lifetime)
Prevention of pregnancy
Contraception, EC
Protection from STIs
Condom use
Practices
Types of sex: anal, vaginal, oral
Past history of STIs
You may think of adding a 6th “P” to the CDC list for “presentation” or “premier” (referring to when did the adolescent “present” to sexual activity or have their sexual debut). In light of the previous slides which show that young age at sexual debut put adolescents in particular at a higher risk for STIs, the 6th P is suggested.
For a more complete picture of your patient’s health and to determine the cause of Erica’s symptoms, a sexual history is necessary. A sexual history needs to be taken during a patient’s initial visit, during routine preventive exams, and when you see signs of STIs (as in Erica’s case). The dialogue lends itself to the opportunity for risk-reduction counseling and sharing information about behaviors that may place your patient at risk of contracting STIs.
A sexual history allows you to identify those individuals at risk for syphilis and other STIs, including HIV, and to identify appropriate anatomical sites for certain STI tests.
Some patients may not be comfortable talking about their sexual history, sex partners, or sexual practices. Try to put patients at ease and let them know that taking a sexual history is an important part of a regular medical exam or physical history.
The five Ps stand for: Partners, Prevention of pregnancy, Protection from STIs, Practices, and Past history of STIs.
These are the areas that you should openly discuss with your patients. You probably will need to ask additional questions that are appropriate to each patient’s special situation or circumstances.

33. Prevention Counseling
AAP
Patient-centered, age-appropriate anticipatory guidance;
Integrate sex ed into clinical practice; can use educational materials;
Prevention guidance, including abstinence, safer sexual practices, and condoms
ACOG
Counseling for all sexually active individuals
AAFP
High-intensity behavioral counseling (HIBC)
CDC*
HIBC; interactive counseling approaches, i.e., client-centered STD/HIV prevention counseling; motivational interviewing; videos and large group presentations to provide information
USPSTF
Intensive behavioral counseling for all sexually active adolescents and adults at high-STI risk

34. Erica: Sexual History Results
Several episodes of unprotected sex in the last few weeks with one male partner (her only lifetime)
Not on hormonal contraception but uses condoms most of the time
Engages in oral (giving and receiving) and vaginal sex
No known history of STIs

35. Erica: History of Present Illness Results
Erica tells you she has burning with urination and a “yellowish” discharge. She reports itchiness.
She denies abdominal pain and fever and reports no bumps or lesions.
What is the differential diagnosis?

36. Differential Diagnosis
You observe discharge in the vault but not in the os.
You suspect vaginitis.
What are the causes of vaginitis?

37. Differential Diagnosis
Dysuria
Genital Tract Infection
Trichomonas
Vaginitis is infectious or noninfectious inflammation of the vaginal mucosa, sometimes with inflammation of the vulva. Symptoms include vaginal discharge, irritation, pruritus, and erythema.
Vaginitis is one of the most common gynecologic disorders. Some of its causes affect the vulva alone (vulvitis) or in addition (vulvovaginitis).
Three causes of vaginitis include: trichomoniasis, bacterial vaginitis, candidal vaginitis.
Bacterial Vaginitis
Vaginitis
Candida Vaginitis

38. Additional Concerns
Because Erica is a sexually active 16-year-old, she is also at risk for cervicitis.
What are the most common causes of cervicitis?
Chlamydia
Gonorrhea

39. C.T.

40. Most common reportable communicable disease
Chlamydia
Curable bacterial STI
Most common reportable communicable disease
Highest-reported rates among adolescent and young adult females (Aged 15–24)
Usually asymptomatic
Why is this an important topic to discuss?? Our patients, youth aged 15–24, have the highest chlamydia rates!!!!
Chlamydia continues to be the most commonly reported nationally notifiable disease with 1,422,976 cases reported in For the first time since 1995, chlamydia case rates among females did not increase. For the first time since 2000, Chlamydia case rates decreased among both males and females aged 15–19 years. However, both test positivity and the number of reported cases of C. trachomatis infections remain high among most age groups, racial/ethnic groups, geographic areas, and both sexes. Racial differences also persist; reported case rates and prevalence estimates among blacks continue to be substantially higher than among other racial/ethnic groups.
A large number of cases are not reported because most people with chlamydia are asymptomatic and do not seek testing. 
Chlamydia is most common among young people. Chlamydia prevalence among sexually-active young persons aged 14–24 years is nearly three times the prevalence among persons aged 25–39 years.4 It is estimated that 1 in 15 sexually active females aged 14–19 years has chlamydia.5
Source:
Source:

41. Males: Up to 90% asymptomatic
Chlamydia Symptoms
Heavy or prolonged menses
Spotting
Dysmenorrhea
Dyspareunia
Vaginal discharge
Females:
Up to ~80–90% asymptomatic
Males: Up to 90% asymptomatic
Penile discharge
Dysuria
About 80–90% of chlamydia infections10 and up to 80% of gonococcal infections11 in women are asymptomatic.
Source:
Stamm WE. Chlamydia trachomatis infections in the adult. In: Holmes KK, Sparling PF, Stamm WE, Piot P, Wasserheit JN, Corey L, et al, (editors). Sex Transm Dis. 4th ed. New York: McGraw-Hill; 2008:575–93.
Estimates of the proportion of chlamydia-infected people who develop symptoms vary by setting and study methodology; two published studies that incorporated modeling techniques to address limitations of point prevalence surveys estimated that only about 10% of men and 5–30% of women with laboratory-confirmed chlamydia infection develop symptoms.21,22
Based on this information, up to 90% of males are asymptomatic and up to 70–95% of females are asymptomatic.

42. Clinical Syndromes Caused by C. trachomatis
Local Infection
Complication
Sequelae
Conjunctivitis
Urethritis
Proctitis
Epididymitis
Reiter’s syndrome (rare)
HIV risk
Chronic arthritis (rare)
Cervicitis
Endometritis
Salpingitis
Perihepatitis
Infertility
Ectopic pregnancy
Chronic pelvic pain
Pneumonitis
Pharyngitis
Rhinitis
Eye and lung infections
Rare, if any
Males
Females
Source:
Women infected with C. trachomatis or N. gonorrhoeae can develop PID, which, in turn, can lead to reproductive system morbidity such as ectopic pregnancy and tubal factor infertility.
Symptomatic PID occurs in 10%–15% of females with untreated chlamydia.
Among women with PID, tubal scarring can cause infertility in 20% of women, ectopic pregnancy in 9%, and chronic pelvic pain in 18%.9
Source:
In women, untreated chlamydia can spread into the uterus or fallopian tubes and cause pelvic inflammatory disease (PID). Symptomatic PID occurs in about 10 to 15 percent of women with untreated chlamydia.30,31 However, chlamydia can also cause subclinical inflammation of the upper genital tract (“subclinical PID”). Both acute and subclinical PID can cause permanent damage to the fallopian tubes, uterus, and surrounding tissues. 
30. Haggerty CL, Gottlieb SL, Taylor BD, Low N, Xu F, Ness RB. Risk of sequelae after Chlamydia trachomatis genital infection in women. The Journal of infectious diseases 2010;201 Suppl 2:S134–55.
31. Oakeshott P, Kerry S, Aghaizu A, et al. Randomised controlled trial of screening for Chlamydia trachomatis to prevent pelvic inflammatory disease: the POPI (prevention of pelvic infection) trial. BMJ (Clinical research ed) 2010;340:c1642.
The vague symptoms associated with chlamydial and gonococcal PID cause 85% of women to delay seeking medical care, thereby increasing the risk of infertility and ectopic pregnancy. [i] [ii]
Untreated chlamydia may increase a person’s chances of acquiring or transmitting HIV—the virus that causes AIDS.36
36. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sexually transmitted infections 1999;75:3-17.
Westrom L, Joesoef R, Reynolds G, Hagdu A, Thompson SE. Pelvic inflammatory disease and fertility: a cohort study of 1,844 women with laparoscopically verified disease and 657 control women with normal laparoscopy. Sex Transm Dis. 1992;9:185–92.
About 80%–90% of chlamydial infections10 and up to 80% of gonococcal infections11 in women are asymptomatic. These infections are detected primarily through screening. The symptoms associated with PID are vague so 85% of women with PID delay seeking medical care, thereby increasing the risk for infertility and ectopic pregnancy.12 Data from a randomized controlled trial of chlamydia screening in a managed care setting suggest that such screening programs can reduce the incidence of PID by as much as 60%.13
Hillis SD, Joesoef R, Marchbanks PA, Wasserheit JN, Cates W Jr, Westrom L. Delayed care of pelvic inflammatory disease as a risk factor for impaired fertility. Am J Obstet Gynecol. 1993;168:1503–9.
[i] Source: Center for Disease Control and Prevention. STD Surveillance, 2011: Women and Infants.
[ii] Hills SD Wasserheit JN. Screening for Chlamydia—A Key to The Prevention of Pelvic Inflammatory Disease. New England Journal of Medicine. 1996;334(21):1399–1401.
[iii] Fleming DT, Wasserheit IN. From Epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex TransmInf 1999;75:3–17
Infants

43. Non-Gonococcal Urethritis: Mucoid Discharge
Source: Seattle STD/HIV Prevention Training Center at the University of Washington/UW HSCER Slide Bank

44. Swollen or Tender Testicles (epididymitis)
Source: Seattle STD/HIV Prevention Training Center at the University of Washington

45. Normal Cervix
Source: STD/HIV Prevention Training Center at the University of Washington/Claire E. Stevens

46. Chlamydial Cervicitis
Source: STD/HIV Prevention Training Center at the University of Washington/Connie Celum and Walter Stamm

47. Normal Human Fallopian Tube Tissue
Source: Patton, D.L. University of Washington, Seattle, Washington

48. C. trachomatis Infection (PID)
Source: Patton, D.L. University of Washington, Seattle, Washington

49. Chlamydia Screening

50. ♀ Routine Annual Chlamydia Screening
AAP
all sexually active ≤25 yrs
ACOG
all sexually active adolescents
AAFP
all sexually active <24 yrs
CDC*
all sexually active <25 yrs
USPSTF
Final Recommendation Statements Published by the USPSTF, October 2013 to September 2014
If positive test: Repeat testing 3–4 months after treatment; high rate of re-infection among adolescents.
*Draft

51. Chlamydia Screening: Males
Routine Screening NOT recommended for men
Correctional facilities
STI clinics
Selective screening in high-prevalence populations should be considered
Adolescent-serving clinics
AAP: Consider screening in ↑ prevalence clinic settings, e.g., jails or juvenile corrections, Job Corps, STI clinics, SBHCs, and adolescent clinics for patients w/ h/o multiple partners;
MSM for rectal and urethral CT annually if receptive anal or insertive intercourse. Screen Q3–6 months if high risk with multiple or anonymous partners, sex with illicit drug use, or risky sex partners; CT-exposed
AAFP: Insufficient evidence to recommend routine screening
CDC (draft): Consider screening in ↑ prevalence clinical settings (e.g., adolescent clinics, correctional facilities, STI clinics); MSM for rectal and urethral CT annually if receptive anal or insertive intercourse. Screen Q3–6 months if high risk with multiple or partners or HIV+; CT-exposed;
Insufficient evidence to recommend routine screening
USPSTF: Insufficient evidence to recommend routine screening
Routinely screening adolescents who are asymptomatic for certain STIs (e.g., syphilis, trichomoniasis, BV, HSV, HPV, HAV, and HBV) is not recommended. However, young men who have sex with men and pregnant adolescent females might require more thorough evaluation.
With the advent of highly sensitive nucleic acid amplification tests (NAATs) that can be performed on urine, chlamydial infection is increasingly being diagnosed in symptomatic and asymptomatic men. During 2008–2012, the reported chlamydial infection rate among men increased 25.5% (from to cases per 100,000 males) compared with a 11.0% increase among women during the same period (from to cases per 100,000 females)
Source:
Routine screening is not recommended for men. However, the screening of sexually active young men should be considered in clinical settings with a high prevalence of chlamydia (e.g., adolescent clinics, correctional facilities, and STI clinics) when resources permit and do not hinder screening efforts in women.40
40. Workowski KA, Berman S, Centers for Disease C, Prevention. Sexually transmitted diseases treatment guidelines, MMWR Recommendations and reports : Morbidity and mortality weekly report Recommendations and reports / Centers for Disease Control 2010;59:1–110.
Source:
MSM
Multiple partners
AAFP, CDC, USPSTF, AAP Recommendations

52. USPSTF CT Risk Factors Age
♀ ages years,
♂ ages years
New sex partner, >1 sex partner, sex partner w/ STI infection
Inconsistent condom use
H/O or coexisting STIs
Exchanging sex for money or drugs.
Incarcerated populations, military recruits, and patients receiving care at public STI clinics.
Racial Disparities:
Blacks and Hispanics higher CT rates vs. whites
Clinicians should consider the communities they serve and may wish to consult local public health authorities for guidance on identifying groups at increased risk.
Source:

53. USPSTF Justification for ♂ CT
♂ CT may cause nongonoccal urethritis, epididymitis, and rarely urethral structures and reactive arthritis
asymptomatic urethritis uncommon

54. MSM Screening: Chlamydia and Gonorrhea
CDC recommends at least yearly urethral and rectal screening for MSMs who, in the last year, have participated in:
Insertive anal intercourse
Receptive anal intercourse
Receptive oral intercourse (GC only)
Screening is recommended regardless of condom use
For high risk sex behavior, should screen every 3-6 months
The 2010 STD Treatment Guidelines for men who have sex with men (MSM) suggest:
Routine laboratory screening for common STDs is indicated for all sexually active MSM. The following screening tests should be performed at least annually for sexually active MSM:
a test for urethral infection with N. gonorrhoeae and C. trachomatis in men who have had insertive intercourse† during the preceding year; testing of the urine using nucleic acid amplification testing (NAAT) is the preferred approach;
a test for rectal infection§ with N. gonorrhoeae and C. trachomatis in men who have had receptive anal intercourse* during the preceding year (NAAT of a rectal swab is the preferred approach); and
a test for pharyngeal infection§ with N. gonorrhoeae in men who have had receptive oral intercourse† during the preceding year (NAAT is the preferred approach). Testing for C. trachomatis pharyngeal infection is not recommended.
As a side note, for women, the preferred specimen for GC or CT in the reproductive tract is vaginal swab. Cervical swabs can be used but are not necessary, and therefore a full pelvic exam is not required for these screenings.
Source:
Centers for Disease Control and Prevention. STD Treatment Guidelines Special Populations: Men Who Have Sex with men. Available at

55. Women Who Have Sex with Women
Regardless of reported same-sex behavior, providers should consider:
Screening all females for chlamydia and gonorrhea as per recommendations
Offering routine cervical cancer screening and HPV vaccine in accordance with current guidelines.
Source: Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, MMWR 2010;59(12):1–116.

56. Confidentiality and Billing

57. Confidentiality and Billing
Cannot guarantee confidentiality in many cases
Explanation of benefits (EOB) may be sent by insurance company
Teen patient may request for EOB to be sent to alternative address by health plan
Need to know the “paper trail issues” in your health system
Need to have Plan B for confidential services

58. Explanation of Benefits (EOBs) Medicaid vs. Commercial Insurance
EOBs sent to policyholder or insured in most commercial plans
Some health plans NOT sending EOBs if only copayment due
Medicaid does not routinely send EOBs
EOBs do not disclose service/diagnosis
Parent can obtain that info from health plan
No control over lab bills/statements

59. Chlamydia Tests and Treatment

60. Case: Evaluating Cervicitis
How do you evaluate Erica for cervicitis?

61. Chlamydia Diagnosis Culture NAAT EIA DFA DNA Probe Sensitivity: 70%
Specificity: 85%–95%
Sensitivity: 85%–90%
Specificity: >98%
Sensitivity: 50%–65%
Specificity: >95%
Sensitivity: 65%–70%
Specificity: 95%
Sensitivity: 65%–70%
Specificity: 95%
Nucleic acid amplification technology first became available in Commercially available test kits include the Roche© AMPLICOR, which is based on polymerase chain reaction technology; the Gen-Probe APTIMA based on transcription mediated amplification; and the BD ProbeTec™ based on strand displacement amplification. Sensitivities of all these tests are approximately 85–95% and specificities are greater than 98%. Sensitivity for female urine specimens is slightly lower compared to endocervical swab specimens. NAAT assays may suffer from some problems with inhibitors of amplification found in clinical specimens, which slightly reduce test sensitivity. Most NAATs can be performed on male and female urine specimens in addition to urethral and endocervical specimens and, for some, offer the advantage of simultaneous detection of Neisseria gonorrhoeae from one specimen. In addition, specimen adequacy is less of an issue, so costly quality assurance programs needed to evaluate the adequacy of specimens collected for non-amplified methods are not necessary for NAATs.
Culture of urethral or endocervical specimens has long been the gold standard for diagnosis and is used for medico-legal purposes because of its high, near perfect specificity; however, compared to NAAT its sensitivity is approximately 60–80% depending on the laboratory expertise, adequacy of specimen collection and transport conditions. For screening purposes it is impractical for reasons of cost, low sensitivity, complexity, limited availability and long turnaround time.
Gram stain of cervical discharge in females and in asymptomatic males is not recommended because of very low sensitivity of this method.
Sources:
California Chlamydia Action Coalition: Screening Test Information for Medical Directors.
Centers for Disease Control and Prevention. Screening Tests To Detect Chlamydia trachomatis and Neisseria gonorrhoeae Infections—2002. MMWR 2002; 51 (No. RR-15):1–38.
Crotchfelt KA, Pare B, Gaydos C, Quinn TC. Detection of Chlamydia trachomatis by the Gen-Probe AMPLIFIED Chlamydia trachomatis assay (AMP-CT) in urine specimens from men and women and endocervical specimens from women. J Clin Microbiol 1998; 36:391–94.
Preferred

62. Schachter J,et al. Sex Transm Dis. 2008;35:637–42.
NAAT vs. Culture
This slide shows how much more sensitive the NAATs are compared to culture for rectal and oral gonorrhea and chlamydia testing. In this study, all men seen at a SF men’s clinic were tested with both culture in dark blue and NAAT in gray on rectal and oral specimens. You can see that there was much more disease identified with the NAAT tests compared to culture.
Schachter J,et al. Sex Transm Dis. 2008;35:637–42.

63. Chlamydia NAAT Screening: Preferred Noninvasive Genitourinary Specimens
♀: Vaginal swab
Vaginal swab samples are as sensitive as endocervical swab specimens
Urine samples acceptable
♀urine may have ↓ performance compared to cervical swab samples
♂: Urine
Urethral swab samples may be ↓ sensitive than urine
While there is a great deal of choice in terms of sample type, the preferred specimens for chlamydia screening for females and males, and why they are preferred, are listed on this slide. These preferred sample types were delineated in a CT GC Lab Guidelines document developed by the American Public Health Laboratories in conjunction with the CDC, and will form the basis of an MMWR update that will be published on this subject.

64. FDA Clearance All NAATs Certain NAATs Non-FDA cleared for:
Urethral swabs from males
Cervical swabs
Urine from males and females
Certain NAATs
Vaginal swabs
Non-FDA cleared for:
Rectal
Pharyngeal
(Many laboratories have met regulatory CLIA requirements)
Most FDA, not all, tests are cleared for every specimen site
However, labs can run their own standards and use the tests at those sites—e.g., Quest.

65. How to Order Screen
Non-genital GC/CT NAATs can be done by clinical laboratory with CLIA approval
Gen-Probe APTIMA testing
QUEST diagnostics test codes
LabCorp diagnostics test codes
Pharyngeal
70051X
188698
Rectal
16506X
188672
Urine/Urethral
13363X
183194
Relevant CPT Billing Codes:
CT detection by NAAT:
GC detection by NAAT:

66. Chlamydia Treatment Recommended Regimens
Azithromycin 1 g PO single dose
Doxycycline 100 mg PO BID x 7 days
Source:
Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines, MMWR 2010;59(12):1–116
Alternative Regimens:
Erythromycin base 500 mg PO QID x 7 days
Erythromycin ethylsuccinate 800 mg PO QID x 7 days
Levofloxacin 500 mg PO OD x 7 days
Ofloxacin 300 mg PO BID x 7days
CDC STD Treatment Guidelines

67. Hey! There’s an App for That!

68. STI Partner Management Strategies
Provider Referral
Partners contacted by index patient’s provider or by a disease intervention specialist
Patient Referral
Index patient assumes primary responsibility to notify and refer his/her partners at risk
Partners collect medication at public health center or other venue.
Public health workers deliver medications to partners in non-clinical settings.
Providers (1) give patient medication intended for the partners (2) write partners’ prescriptions for medication
Expedited Partner Therapy (EPT)

69. CDC Recommends EPT
EPT: Delivery of medications or prescriptions by persons infected with an STD to their sex partners without clinical assessment of the partners.
EPT laws vary by state:
Permitted in 35 states and the city of Baltimore, MD
Prohibited in 6 states (FL, KY, MI, OH, OK, WV)
Heterosexual sex partners should be evaluated, tested, and treated if:
Had sexual contact with patient during or >60 days of symptom onset/diagnosis of chlamydia or gonorrhea
Source:
EPT “Dear Colleague” letter available at:
**EPT is potentially allowable in 9 states subject to additional actions or policies (this may include specific interpretations of inconsistent or amorphous provisions, supporting policies consistent with legal authorization, or incorporation by reference into treatment guidelines)
(EPT is permissible in 35 states and Baltimore, MD) but not in DC 
-III. Specific administrative opinions by the Attorney General or medical or pharmacy boards concerning EPT (or like practices) (Explanation) District of Columbia Board of Medicine disciplinary order issued 7/31/2003: fined physician $2,000 for prescribing without seeing the patient.  IV. Laws that incorporate via reference guidelines as acceptable practices (including EPT) (Explanation) Regulations incorporate by reference APHA’s CCD Manual, Ninth Ed., Meeting requirements of the 1960 CCD manual is prima facie evidence of good medical or public health practice.  D.C. Mun. Reg. tit. 22, § V. Prescription requirements (Explanation) Label for prescription drug must bear patient’s name. D.C. Mun. Reg. tit. 22, § Pharmacists must keep record of patient name and address for every prescription filled. D.C. Mun. Reg. tit. 22, §
VI. Assessment of EPT’s legal status with brief comments (Explanation) EPT is potentially allowable Incorporation by reference of APHA CCD Manual may authorize the use of EPT provided the jurisdiction recognizes current edition of the manual and the manual reflects existing CDC STD Treatment Guidelines.
An alternative approach to assuring treatment of partners is expedited partner therapy (EPT). EPT is the delivery of medications or prescriptions by persons infected with an STD to their sex partners without clinical assessment of the partners. Clinicians (e.g., physicians, nurse practitioners, physician assistants, pharmacists, public health workers) provide patients with sufficient medications directly or via prescription for the patients and their partners. After evaluating multiple studies involving EPT, CDC concluded that EPT is a “useful option” to further partner treatment, particularly for male partners of women with chlamydia or gonorrhea. In August 2006, CDC recommended the practice of EPT for certain populations and specific conditions and CDC continues to recommend it in Sexually Transmitted Diseases Treatment Guidelines, 2010.
Patients should be instructed to refer their sex partners for evaluation, testing, and treatment. The following recommendations on exposure intervals are based on limited evaluation. Sex partners should be evaluated, tested, and treated if they had sexual contact with the patient during the 60 days preceding onset of symptoms in the patient or diagnosis of chlamydia. The most recent sex partner should be evaluated and treated, even if the time of the last sexual contact was >60 days before symptom onset or diagnosis.
EPT is not routinely recommended for MSM because of a high risk for coexisting infections, especially undiagnosed HIV infection, in their partners.
If concerns exist that sex partners will not seek evaluation and treatment, or if other management strategies are impractical or unsuccessful, then delivery of antibiotic therapy (either a prescription or medication) by heterosexual male or female patients to their partners might be an option. Limited studies to date have demonstrated a trend toward a decrease in rates of persistent or recurrent chlamydia with this approach compared with standard partner referral. Male patients must inform female partners of their infection and be given accompanying written materials about the importance of seeking evaluation for PID (especially if symptomatic).
Patients should be instructed to abstain from sexual intercourse until they and their sex partners have completed treatment. Abstinence should be continued until seven days after a single-dose regimen or after completion of a seven-day regimen. Timely treatment of sexual partners is essential for decreasing the risk for reinfecting the index patient.
Centers for Disease Control and Prevention. Expedited partner therapy in the management of sexually transmitted diseases. Atlanta, GA: US Department of Health and Human Services, 2006.

70. Behaviors Affecting EPT Effectiveness
Patient-delivered specific
Patient did not give Rx to any/all partners
Partners noncompliant with Rx
Patients did not contact partners
General noncompliance
Patients noncompliant with Rx
Centers for Disease Control and Prevention. Expedited partner therapy in the management of sexually transmitted diseases. Atlanta, GA: US Department of Health and Human Services, 2006.
Resumed sex <7 days after case and partner treatment
Sex with new partner(s)

71. EPT Barriers General theoretical liability issues
Rx without an exam
Medical records for treated partner?
Legal issues with minors
Consent to care
Obligation to report sex in minors with older partners
Financial: who pays for partner Rx?
Adverse drug effects
Partner may not seek complete STI assessment
Potential to miss partners’ other STIs, including HIV
Missed counseling opportunities for partners
For the last two bullets, it should be stressed that EPT should not be provided without the exhortations provided through patient referral. It’s not known (or even especially likely) that EPT results in fewer people getting evaluated than the current standard (i.e., patient referral).
Centers for Disease Control and Prevention. Expedited partner therapy in the management of sexually transmitted diseases. Atlanta, GA: US Department of Health and Human Services, 2006.

72. Repeat Testing After Treatment
Pregnant females
Repeat testing, preferably by NAAT, 3 weeks after completion of recommended therapy
Non-pregnant females
Test of cure not recommended unless:
Compliance is in question, symptoms persist, or reinfection is suspected
Repeat testing recommended 3-4 months after treatment
Especially adolescents; high prevalence of repeat infection

73. Erica: Wrap-Up Administer EC and write advanced prescription HIV test
HPV vaccine
Give appointment to return in 3 months

74. Red Book STI Chapters

75. Provider Resources: Sexually Transmitted Infections
National Chlamydia Coalition: ncc.prevent.org
U.S. Centers for Disease Control and Prevention
Statistics and Surveillance Reports:
Expedited Partner Therapy:
Screening & Treatment Guidelines:
American Social Health Association:
U.S. Department of Health and Human Services womenshealth.gov/faq/stdhpv.htm
USPSTF:
ACOG:

76. Provider Resources and Organizational Partners
for Youth
Academy of Pediatricians
American Civil Liberties Union Reproductive Freedom Project
College of Obstetricians and Gynecologists
of Reproductive Health Professionals
for Adolescent Health and the Law
Gay and Lesbian Medical Association

77. Provider Resources and Organizational Partners
Institute
janefondacenter.emory.edu Jane Fonda Center at Emory University
Morehouse School of Medicine
NARAL Pro-Choice New York Teen Outreach Reproductive Challenge (TORCH)
North American Society of Pediatric and Adolescent Gynecology
Physicians for Reproductive Health

78. Provider Resources and Organizational Partners
Information and Education Council of the United States
for Adolescent Health and Medicine
Planned Parenthood Federation of America
Reproductive Health Access Project
Spence-Chapin Adoption Services

79. Please Complete Your Evaluations Now