Sex and Drugs Adolescent STI s, A Clinical Update

1. Sex and DrugsAdolescent STI�s, A Clinical Update August 31, 2004 Tonya Chaffee, MD,MPH Teen Doc Dept. Peds. SFGH

2. Objectives Through case vignettes: Learn how to approach teens about their sexuality, and assess risks for STI�s Learn the barriers for screening and treatment of STI�s/STD�s in youth, and how you can overcome them. Understand the current trends in adolescent STI�s, and determine what to screen. Learn new methods of screening, diagnosing, and treating/managing STI�s/STD�s in teens.

3. 18 yo female presenting with �vaginal sores�. You ask her if she ever had sex, she says �kind of� What determines if a teen is sexually active? If you are concerned about an STD, how will you determine this, and how might she have acquired an infection?

4. Approaching Adolescent Sexuality What is �sexual activity�? Sexual behavior is a spectrum. Includes coital and non-coital activities: self and partner masturbation, kissing, oral, anal, and vaginal sex. Important to consider this spectrum, as simply asking if a teen is �sexually active�, is not sufficient.

5. Adolescent Sexuality: What are they doing? Self-report of Oral Sex Fellatio by age 16yo: 35% males, 34% females Cunnilingus by age 16: 36% males, 37% females Self-report of Anal Sex: Up to 18 yo 20-25% females Up to 18 yo 23-27% males Oral and anal sex often NOT considered being �sexually active� by teens

6. Adolescent Sexuality: What are they doing? Study of 2066 high school students who described themselves as �virgins� found: 29% had engaged in masturbation of opposite gender partner 31% had been masturbated by opposite gender partner 9% had engaged in heterosexual fellatio w/ ejaculation. 10% had engaged in heterosexual cunnilingus. 1% had engaged in heterosexual anal intercourse

7. Adolescent Sexuality: What are they doing? By age 19 y.o. up to 70-90% of teens report having coital sex (varies by race/sex). Adolescents don�t have sex on a regular basis, tend to have short term relationships, and often have more concurrent partners, (cf unmarried young adults)

8. You are seeing a 16 yo for her 2nd CT infection in 2 months. You ask why her partner isn�t using condoms, and she says �I don�t know� Why do you think her partner is not using condoms? How do you counsel her?

9. Adolescent Sexual Development, Unique Risks for STI�s Why are teens most at risk for STI�s? Biologically more at risk (cervical ectopy and CT in girls) Psychosocial and cognitive changes, placing them at developmental risks (the reason for the more casual relationships) Poor knowledge or misperceptions of STD risk for themselves-->lack of decision making skills. Teen specific barriers in accessing health care. Providers barriers in appropriate assessment for risk, screening, and managing.

10. Adolescent Sexual Development/Psychosocial Cognitive Aspects Adolescents go through a tremendous cognitive and psychosocial transition. They start from a dependent child and transition into a free thinking, and independent, decision making adult. They transition from peer driven influences and norms, to their own individual and autonomous beliefs. Need to consider this when counseling, as some 15 yo are very mature, some 18 yo are not. To ensure communication BE CONCRETE with all.

11. Adolescent Sexual Development: Knowledge, Perception of STI�s Study from a self-report survey of teens knowledge of STI�s showed: 97% had been educated about STI�s. Only 7% knew the most common STI�s, with only 9% knowing the curable STI�s and 3% knowing the incurable STI�s 64% thought HIV was the most common STI. Trichomonas and HPV were the least commonly known STI�s Most sex education stress facts about reproduction, and STD�s, but fail to help teens in decision making skill, address their feelings about sex, and their relationships their forming.

12. What do the teens want? Teens perceive one of the primary roles of physicians is to discuss sensitive topics, including sexuality and STD�s. >70% of teens want to hear about STD�s, condoms, safe sex, and HIV. >50% feel uncomfortable bringing this up w/ providers. Most teens feel uncomfortable talking to their parents about sex, and visa/versa. Most parents want providers to similarly discuss sensitive topics with their teens

13. Teen Barriers to STI Screening and Management Screening important for early detection to reduce reproductive morbidity. However, lack of symptoms prevent teens from seeking timely care to prevent morbidity. Furthermore, teens are often resistant to seeking reproductive health care due to embarrassment, stigma esp. w/ STD�s confidentiality or perceived breech concerns about pelvic exams for young women difficulties navigating health care system (e.g co-pays).

14. Provider Barriers to Screening and Managing for STI�s in Adolescents Physician attitudes and beliefs that teens are not at risk for STI�s one study found only 28% ob gyns would screen adolescents for CT. Why? belief that CT prevalence is low in �their population�. Many providers do not discuss confidentiality with their patients, and are uncomfortable with the �parentectomy� resulting in unknown disclosure of SA. Lack of provider time, comfort, skills in managing STD�s in teens (e.g knowing how to help a teen negotiate a behavior, and engaging a teen in behavior change).

15. So How do we do it?Taking a Sexual History Often not easy for providers-?the more you do it the more you develop your own techniques. Be non-judgmental (this is sometimes not easy e.g patient w/ > 20 sexual partners, and not using condoms). Interview patient alone (including no parents BF/GF�s). Make no assumptions (e.g. sexuality) Start w/ safe questions first (e.g. Are you seeing someone, or in a close relationship�?)

16. Taking a Sexual History, con�t Use gender neutral terms (e.g. �partner�) Ask how often they used condoms, are they sure their partner knows how to store, apply them, and did they use them at last intercourse. (if not why?) Be clear, ask if they understand or quiz them on what you just counseled. Use language they�ll understand or in their own terms. Avoid lecturing. Empower them to make behavioral changes e.g. ask them if they think their behavior is risky, and what they can do to change it? (Motivational Interviewing)

17. What is our Goal? To obtain accurate disclosure of information! To have the young person know more about STI�s, have negotiation skills in preventing STI�s, to be able to make safe decisions about their sexual behaviors, and to develop into a healthy sexually mature adult.

18. You are seeing a sexually active 17 y.o. young woman for her first pap.She is SA for 2 years, with �a lot of partners�, and would like to be �checked for everything� How do you determine what STI�s she is most at risk for? How do you determine what STI�s you will screen her for today?

19. Epidemiology of STI�s in Adolescents: The problem Adolescents carry the highest burden of STI�s of all age populations. Although rates of pregnancy have gone down, rates of STI�s have remained unchanged and even increased in certain populations. U.S. teens still have the highest STD rates of all industrialized nations.

20. Epidemiology: International Rates of Chlamydia

21. Epidemiology: International Rates of GC

22. Epidemiology: International Rates Syphilis

23. Epidemiology: Rates of Sexual Activity

24. Number of Girls 15-19 yoReporting STD�s in SF

25. Adolescent STI�s: Epidemiology CT Chlamydia: Rates highest in teen women: 15-25% in STD clinics, 3-10% in HMO pop�s. (17% + for all labs done at SFGH from July-Sept 2003!) Rates have increased 20% in teen women for ages 15-19yo from 1996-1998. Even though teens have the highest burden of infections, NCQA 2001 reported only 23.5% of young women 15-20 y.o. were screened for CT As a result-->

26. Adolescent STI�s: Epidemiology CT All young sexually active women are considered at risk for CT! CDC recommends annual screening of all sexually active women under 25 y.o. HEDIS is now using CT screening as a measure of quality with health plans (similar to immunization rates) Many health plans are now actively developing means to monitor provider screening.

27. Adolescent STI�s: Epidemiology: GC Gonorrhea: Rates lower than CT, but highest in teens and young women, especially 15-19yo women. Risks: pregnancy, have a h/o STD, and live in urban, low SES areas (esp. African American) Often found as a co-infection w/ CT (30% in some populations) and other STI�s. Rates of floroquinolone resistance increasing in U.S. (esp. Hawaii, California)

28. Adolescent STD�s: Epidemiology: PID PID: With the exception of HIV it is the most costly infection to treat Costs have decreased due to outpt. Tx. regimes Although costs have gone down, the incidence of PID has remained unchanged over the last 10years Risks: h/o prior PID, h/o prior GC/CT, douching, h/o Bacterial Vaginosis.

29. Adolescent STI�s: Epidemiology HSV Genital HSV: Adolescents make up 25% of new diagnoses. Up to 50% can be asymptomatic, when acquired. Most genital HSV are caused by HSV-2, but 30% are caused by HSV-1. (Important to note, when considering how acquired) Condom use not shown to be fully protective in transmission.

30. Adolescent STI�s: Epidemiology HPV HPV: the most common STI Shown to be present in 15-25% of adolescents seeking gyn. care. Risks: early age at first coitus, multiple sex partners (>3 during adolescents), smoking, immunosupression These same risks are shown for cervical dysplasia. Condom use not shown to be fully protective against transmission.

31. Adolescent STI�s: Epidemiology Hepatitis B/C: Hepatitis B: Rates have dropped significantly due to universal immunization, but still see sexual transmission in U.S. Hepatitis C: Considered an STI, but transmission still unclear Now listed in CDC�s STD guidelines. Rates rising dramatically in U.S., including in adolescence. Increased risk if sex w/ know IVDU, Hep C carrier Increased risk if HSV + Increased awareness is increasing detection.

32. Adolescent STI�s Epidemiology: Trichomonas Peak prevalence rates in young women, 16-25yo. (up to 28% in teens in Juvenile Hall) Almost always sexually transmitted. Like GC, often found as a co-infection w/ either GC or CT. Found in women who have sex w/ women. Because its not a reportable STI, rates harder to track.

33. Adolescent STI�s Epidemiology: Syphilis Rates have declined rapidly in the U.S. However, a dramatic increase in some urban areas, primarily with men who have sex with men (MWM). SF now #1 in number of syphilis cases. Syphilis is often a marker for other STI�s including HIV, so its trends often predict other STI trends. Rates are starting to show an increase in other populations, including young women and adolescence.

34. Adolescent STI�s Epidemiology: HIV Rates lowest in adolescents, but�. In adolescence, females rates have increased almost 4 times in last decade. Rates in minority young adult women is one of the fasting rising rates nationwide.

35. Adolescent STI�s Epidemiology: HIV Most new HIV dx�s today are found in later stages of disease. Therefore, this likely reflects acquisition during older adolescence/young adult. An HIV diagnosis in teens often reflects a newly acquired infection. HIV risk in increased 2-5 fold in youth infected w/ other STI�s. Other STI�s have a synergistic effect on HIV rate (due to the inflammation of other STD�s causing easier transmission).

36. Summary for STI Screening in Adolescents All sexually active women (to age 25yo) should be screened annually for CT GC should be screened in high risk populations. If a patient has a h/o STD all other STI�s should be screened including: HIV, Hep C, RPR, Pap, and fully immunized for Hep B, if not already completed series.

37. You were referred a 14 y.o young woman for an �STD evaluation�. She was sexually assaulted 1 month ago, and the police report already made. She reports not having sex prior. How do you evaluate her for STI�s? How do you counsel her about the reliability of her screening tests.

38. Diagnostic Testing GC/CT Culture--by cervical/urethral swab (Gold Standard for sexual abuse reporting) 100 % specific. DNA-probe: method used for cervical specimens. Highly sensitive. Nucleic Acid: method used for urine (FIRST 20-50 mls) Highly sensitive (more than DNA-probe). False Negative: due to inadequate specimen collection or small yield of organism. False Positives: due to recent prior tx�d infection w/ continued excretion of dead organism (up to 1 mo).

39. Diagnostic Testing GC/CT Con�t. Can Gram Stain for GC (GN intracellular diplococci). If GS or culture from non-genital sites, must do a confirmatory test with culture/DFA/DNA probe from genital site to confirm diagnosis (e.g Neisseria in the mouth can give you a false positive) NOTE! For GC DFA/DNA probe, cannot do antibiotic susceptibility testing, only w/ culture method.

40. Diagnosis: PID Diagnosis for empiric treatment (CDC guidelines) is based on a minimum of 3 CLINICAL criteria, in absence of any other explanation. These clinical criteria include: Lower abdominal pain Adenexal tenderness CMT

41. Diagnosis PID con�t. Additive criteria that support but do not rule in PID include: Temp > 38.3 C. Abnormal cervical vaginal D/C. Increase ESR. CT/GC positive. U/S can help determine if TOA or thickened tubes.

42. Diagnostic testing HSV Inspection Culture from base of vesicle (can differentiate between type 1 and 2). DFA can be more sensitive in later stages of disease, but more expensive, and cannot differentiate types. Pap smear--may show intranuclear inclusions and multinucleated cells

43. Diagnosis Syphilis: Dark field microscopy�(call SFGH lab to do) Non-treponemal: RPR/ VDRL Quantitative and needed for f/u to follow titers for treatment, problems w/ FP (insensitive) Treponemal: FTA-ABS Qualitative, and very sensitive. Used to confirm case of syphilis. Remains positive after treatment.

44. Diagnosis Syphilis: Clinical signs Primary: Chancre, painless ulcer Secondary: 1-2 month post infection, rash, (mac/pap) condyloma lata, LAD, fever, splenomegaly, ST, headache, arthralgia. Latent: seropositive w/out symptoms. Early latent (1 year after infection) Late latent (after one year or all others unknown duration) Tertiary: gumma lesions (skin, bones, or internal organs) and CV disease (aortitis)

45. Diagnosis Syphilis: When making dx. must r/o possible neurosyphilis, because: Early invasion can occur in early disease Conventional therapy may not be efficacious if CNS is involved. Indications for CSF examination: Primary/Secondary--if CNS sxs or HIV + Latent--if neurologic or ophthalmic sxs, treatment failure (titers don�t fall) Any tertiary sxs.

46. Diagnosis HIV It is recommened that all individuals seeking STI/STD care be HIV tested. Importance of increased screening is: to quickly diagnose those who are positive provide early treatment prevent further transmission of infection. Informed consent must be obtained, and is recommended through pre/post test counseling. Most screening test use antibody tests w/ 95% positive in first 3 months of infection. The overall window period for antibody tests are 6 months after exposure.

47. Diagnosis: HIV Positive tests must be confirmed with another Ab test (most labs do these days, w/out ordering) Providers should be alert to the possibility of acute retroviral syndrome (fever, malaise, lymphadenopathy, and skin rash)?perform nucleic acid testing for HIV (PCR/Viral load), if indicated. Patients suspected of having recently acquired HIV infection, OR positive test should be referred for immediate consultation with a specialist.

48. Summary of Evaluation and Diagnosis of STD�s In sexual assault, CDC recommends using cultures, otherwise, if non-culture tests are used, they must have a confirmation test (due to poor specificity of non-culture tests) In sexual assault, should screen for all STI�s including: GC/CT/HIV/syphilis/Hep C and B (if not immunized), and Trichomonas/BV. Important to know how reliable a test is based on the risk of your patient, when their exposure was, and how it was collected in determining results and what to do w/ them.

49. You have just been called by the lab on your 16 y.o. sexually active patient who is positive for Chlamydia Trachomatis How would you treat her, her partner? How would do you counsel her regarding her infection? What sort of follow-up should she have?

50. Chlamydia: Treatment Azithromax 1 gm po x 1 Direct-observed-therapy (DOT) preferred for teens due to poor compliance, problems (e.g. accessing prescriptions). Alternative: Doxycyline 100mg po BID x 7 d, Erythromycin Base 500mg po BID x 7 days. Oflaxacin 300mg po bid x 7 d. EES and Oflaxacin not shown to be as efficacious. NO SEX for 7 days after tx after single dose Azithro, or until completed 7 day regimes AND until all partners are tx�d to minimize re-infection.

51. Gonorrhea: Treatment For uncomplicated genital, rectal, and pharyngeal infection: Ceftriaxone: 125mg IM x 1 (cefixime not available as of 12/02) is recommended as first line tx. Azithromycin 2gm (will irradiate both GC/CT, may produce N/V) Alternative: ofloxacin 400mg po x 1, or Ciprofloxacin 500mg po x 1 . If not using ceftriaxone/Azithro, recommend getting GC culture for sensitivity testing, or doing a TOC 4 weeks after tx. Do not need to treat for CT, unless not ruled out. NO SEX until partner treated.

52. PID: Treatment Hospitalize vs outpt. Hospitalize if the following: Cannot r/o other surgical emergency (eg appy.) TOA (abdominal u/s can assess) Pregnancy Inability for ensuring f/u or tolerating outpatient regimes Failure to respond to outpatient regimes Severely ill, n/v/high fever.

53. PID: Treatment Con�t Out patient regimes: Ceftriaxone 250mg IM x 1 plus doxy 100mg po bid for 14 days. Ofloxacin 400mg po bid plus metronidazole 500mg bid both for 14d. (NOTE, consider GC culture if treating w/ floroquinolones). Parental treatments/hospitalized teen Cefotetan or Cefoxitin plus doxy Clindamycin plus Gentamycin Must complete a 14 day course, and can finish w/ oral regimes (I.e doxy) Have partner tested an treated, even if no GC/CT dx�d in patient.

54. HSV: Treatment Primary: Acylovir 200mg 5x/day or 400mg TID for 7-10 days, until complete crusting has occurred. Recurrent: ACV 400mg tid x 5 days. Adjunctive: Sitz baths to help w/ healing, Ibuprofen, topical lidocaine jelly. Avoid oil based tx�s, this may prolong sxs. No intercourse until all lesions healed.

55. Trichomoniasis: Treatment Metronidazole 500mg po bid x 7 days. Or 2gm po x 1. All should be treated whether sxic or not. Treat partner! No sex until both partners treated.

56. You just received a lab notification for and RPR of 1:64, confirmed by FTA-Ab on a patient you just treated for CT. How do you treat her? How would you manage her infection?

57. Syphilis: Treatment Depends on stage: Primary, Secondary, Latent: Benzathine PCN G, 2.4 million units IM x 1. If PCN allergic: TCN 500mg QID x 2 wks, or Doxycyline 100mg BID x 2wks. Late latent, tertiary: Benzathine PCN G, 2.4 mil. Units IM Q wk x 3 wks. If PCN allergic: TCN 500mg QID for 28days, or Doxy 100mg BID for 28 days. Neurosyphilis: Aqueous procaine PCN G 2.4 mil units IM daily + probenicid 500mg QID, both for 10-14 d. See guidelines for PCN allergic.

58. STD Treatment Summary If using alternative treatment from CDC guidelines, it is recommended that you f/u for rescreening to ensure eradication of infection. Treat partner or have them tested and treated California allows for male partner treatment of CT, w/out seeing a provider. Report to public health department (whether treated or not)

59. You are seeing a 15 y.o female who had Chlamydia last week. The log says�Azithromycin was called in�. She is presenting with RUQ tenderness, fever, and vomiting. What STD related infection could she have? Was she treated or what likely happened? How would you counsel her about prevention for re-infection? How would you manage her?

60. Management CT: Patient should refer all sexual partners within 60 days of onset of sxs or diagnosis. Ideally have both partners treated in clinic w/ DOT. TX last sexual partner, regardless of the time interval (e.g.you can give Azithro 2 gm for the patient and partner, best to have them come to clinic w/ patient) If treating for complicated CT infection (e.g PID) treat for 14 days, and f/u clinically in 1-3 days to ensure resolution of sxs.

61. Management: CT Ensure all teens females w/a +CT understand that they are increased risk for infertility/ectopic preg.--> this increases significantly w/ any subsequent STD, especially CT, and PID. If Patient has a history of + CT, it is recommend to CT screen 3- 6 months after infection. This f/u also allows for further behavioral counseling, as well as HIV testing. REPORT TO PUBLIC HEALTH DEPT.

62. Management: Gonorrhea Test and tx all sexual contacts < 60 days from index patient�s sxs/dx. Again, ideally bring patient and partner to clinic to treat. No test-of-cure needed unless sxic. Recommend screening for both CT/GC in 3-6 months due to reinfection for both. REPORT TO PUBLIC HEALTH DEPT.

63. Management: PID If doing outpatient, must follow-up w/in 72 hours to see if clinically improved (I.e. no fever, decreased abd pain) Make sure partner is tested and treated. This is reportable!

64. Management: Syphilis Primary/Secondary: Follow RPR titers 6 and 12 months Latent: Follow titers at 6,12 and 24 mon. Neuro: titers at 6,12, and 24, w/ repeat CSF if CSF pleocytosis initially, and Q 6 months until normal. Retreat and perform CSF if: reoccurring or persistent sxs, a sustained 4-fold increase in titers, or failed 4-fold decrease w/in 6-12 months.

65. Management: HSV Screen for other STI�s. No sex until all lesions are healed, or if prodromal sxs (itching, tingling) w/ a recurrent episode. Should tell all future sexual partners, it can spread when asxic. To prevent re-occurrences: avoid friction (e.g. tight clothing, prolonged intercourse).

66. STD Management Summary Given risk of co-infection with all STI�s, screen other STI�s if not already done (PAP, HIV, RPR, Hep C). Discuss condom use, and other risk behavior reduction. Encourage partner screening and treatment. F/u all STD positives 4-6 months to help reinforce behaviors (abstinence/condom use), and consider re-testing for HIV. For young women�..also counsel about reliable contraception (think of teen pregnancy as a VERY expensive STD!!)

67. STD Prevention Abstinence! Otherwise Condoms!!!!!!!!!