Plans sought to curb teen girls' high STD rate

Adolescent women have a high rate of sexually transmitted infections, and preventing these diseases needs to be an important public health goal, according to a paper presented by Centers for Disease Control and Prevention researchers at the 2008 National STD Prevention Conference in Chicago last month.

"[These] data demonstrate the significant health risk STDs pose to millions of young women in this country," said Kevin Fenton, MD, PhD, director of the CDC's National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention. "Given that the health effects ... are particularly severe, STD screening, vaccination and other prevention strategies for sexually active women are among our highest public health priorities."

The paper, which was an analysis of data on a population-based sample of 14- to 19-year-old girls participating in the 2003-04 National Health and Nutrition Examination Survey, found that 25.7% or approximately 3.2 million of these young women, had at least one sexually transmitted infection. The human papillomavirus was the most common, with 18.3% carrying it. Another 3.9% had Chlamydia trachomatis, and 2.5% had Trichomonas vaginalis. Approximately 1.9% had herpes simplex virus type II. About 15% of those who had an STD had more than one.

"[These data are] a good knock in the head to remind us that we're not really winning the battle as a nation in terms of prevention," said Mitchell B. Miller, MD, a past president of the Medical Society of Virginia, who represents his state at American Medical Association meetings but was speaking personally.

Previous studies regarding individual infections or incidence among certain populations have found similar rates, although this one is the first population-based study to examine the overall combined prevalence of several common STDs.

Experts say they are not surprised by these numbers, and the statistics reflect badly on the effectiveness of current sex education programs, particularly those that focus on abstinence as the only healthy option.

"If anybody had taken the preceding data and done a back-of-the-envelope calculation, they would have come up with something that was not far off from what this data showed," said H. Hunter Handsfield, MD, a board member of the American Social Health Assn. "We cannot take a holier-than-thou approach [to sex education], and 'just say no' never works for anything."

AMA policy recognizes that the primary responsibility for family life education is in the home, but it also supports school-based, developmentally appropriate sex education that is based on science and has been shown to reduce sexual behavior that puts adolescents at risk. The Association opposes education that involves only abstinence and supports inclusion of information about the HPV vaccine in the high-school curriculum.

The concern is not so much for a teen's current health. Physicians and public health officials are worried about how these infections will affect a woman's future. Most HPV infections in this age group will clear on their own. But many won't, leading to cervical cancer. Chlamydia is a leading cause of infertility.

The authors say these data reinforce the need for widespread STD screening in this age group and vaccination against HPV. Current CDC policy calls for all sexually active women younger than 25 to be screened annually for chlamydia. AMA policy also supports state and local medical society efforts to get appropriate legislation to allow minors to consent for the means of STD prevention, diagnosis and treatment.

"Our metrics for judging risk among these young women may not be accurate, and it's reason to take note that the prevalence of these diseases occurs among people we would not ordinarily consider practicing risky sex," said Sara Forhan, MD, MPH, lead author and an officer with the CDC's Epidemic Intelligence Service.

Gaps in prevention

But physicians say there are significant barriers to making an impact on these numbers. The HPV vaccine is expensive and not always covered by insurance. Many adolescent girls never see a physician unless they need a physical for school or sports participation or they're sick. Fitting in a discussion about STDs in these situations can be awkward. Those seeking contraception, which can trigger such conversations, also may have been sexually active for some time.

"Many young people of both genders become engaged in sexual activity before the opportunity to discuss it with their health care professional," said Dr. Miller, a family physician in Virginia Beach, Va.

Other papers presented at this meeting confirmed that many young women are not receiving STD-related health care. CDC researchers analyzed data from the 2002 National Survey of Family Growth finding 79% of sexually active women in this age group received contraceptive services, but 42% received those connected to STD or HIV prevention, screening or treatment. Only 39% received both.

Just more than half, 51%, received these services from a doctor's office. The authors are calling for better integration of contraception and STD services.