Adolescents
In the United States, prevalence rates of certain STIs are highest among adolescents and young adults (141). For example, reported rates of chlamydia and gonorrhea are highest among females during their adolescent and young adult years, and many persons acquire HPV infection during that time.
Persons who initiate sex early in adolescence are at higher risk for STIs, as are adolescents living in detention facilities; those receiving services at STD clinics; those who are involved in commercial sex exploitation or survival sex and are exchanging sex for drugs, money, food, or housing; young males who have sex with males (YMSM); transgender youths; and youths with disabilities, substance misuse, or mental health disorders. Factors contributing to increased vulnerability to STIs during adolescence include having multiple sex partners, having sequential sex partnerships of limited duration or concurrent partnerships, failing to use barrier protection consistently and correctly, having lower socioeconomic status, and facing multiple obstacles to accessing health care (141,165).
All 50 states and the District of Columbia explicitly allow minors to consent for their own STI services. No state requires parental consent for STI care, although the age at which a minor can provide consent for specified health care services (i.e., HPV vaccination and HIV testing and treatment) varies among states. In 2019, a total of 18 states allowed but did not require physicians to notify parents of a minor’s receipt of STI services, including states where minors can legally provide their own consent to the service (https://www.cdc.gov/hiv/policies/law/states/minors.html).
Protecting confidentiality for STI care, particularly for adolescents enrolled in private health insurance plans, presents multiple problems. After a claim has been submitted, many states mandate that health plans provide a written statement to the beneficiary indicating the service performed, the charges covered, what the insurer allows, and the amount for which the patient is responsible (i.e., explanation of benefits [EOB]) (166– 169). In addition, federal laws obligate notices to beneficiaries when claims are denied, including alerting beneficiaries who need to pay for care until the allowable deductible is reached. For STI testing and treatment-related care, an EOB or medical bill that is received by a parent might disclose services provided and list STI laboratory tests performed or treatment administered. Some states have instituted mechanisms for protecting adolescents’ confidentiality and limiting EOBs. Additional risks to confidentiality breaches can inadvertently occur through electronic health records, although technology continues to evolve to assist with ensuring confidential care. AAP and the Society for Adolescent Health and Medicine (SAHM) have published guidance on strategies to address emerging risks for confidentiality breaches associated with health information technology (169).
AAP and the SAHM recommend that providers have time alone with their adolescent patients that includes assessment for sexual behavior. The AAP recommendations are available at https://services.aap.org/en/news-room/ campaigns-and-toolkits/adolescent-health-care and the SAHM recommendations are available at https://www.adolescenthealth.org/My-SAHM/Login-or-Create-an-Account.aspx?returnurl= %2fResources%2fClinical-Care-Resources%2fConfidentiality. aspxexternal icon. Discussions concerning sexual behavior should be tailored for the patient’s developmental level and be aimed at identifying risk behaviors (e.g., multiple partners; oral, anal, or vaginal sex; or drug misuse behaviors). Careful, nonjudgmental, and thorough counseling is particularly vital for adolescents who might not feel comfortable acknowledging their engagement in behaviors that make them more vulnerable to acquiring STIs.
Screening Recommendations
Recommendations for screening adolescents for STIs to detect asymptomatic infections are based on disease severity and sequelae, prevalence among the population, costs, medicolegal considerations (e.g., state laws), and other factors. Routine laboratory screening for common STIs is indicated for all sexually active adolescents. The following screening recommendations summarize published clinical prevention guidelines for sexually active adolescents from federal agencies and medical professional organizations.
Chlamydia
Routine screening for C. trachomatis infection on an annual basis is recommended for all sexually active females aged <25 years (149). Rectal chlamydial testing can be considered for females on the basis of reported sexual behaviors and exposure, through shared clinical decision-making between the patient and the provider (170,171). Evidence is insufficient to recommend routine screening for C. trachomatis among sexually active young males, on the basis of efficacy and cost-effectiveness. However, screening of sexually active young males should be considered in clinical settings serving populations of young men with a high prevalence of chlamydial infections (e.g., adolescent service clinics, correctional facilities, and STD clinics). Chlamydia screening, including pharyngeal or rectal testing, should be offered to all YMSM at least annually on the basis of sexual behavior and anatomic site of exposure (see Men Who Have Sex with Men).
Gonorrhea
Routine screening for N. gonorrhoeae on an annual basis is recommended for all sexually active females aged <25 years (149). Extragenital gonorrhea screening (pharyngeal or rectal) can be considered for females on the basis of reported sexual behaviors and exposure, through shared clinical-decision between the patient and the provider (170,171). Gonococcal infection is more prevalent among certain geographic locations and communities (141). Clinicians should consider the communities they serve and consult local public health authorities for guidance regarding identifying groups that are more vulnerable to gonorrhea acquisition on the basis of local disease prevalence. Evidence is insufficient to recommend routine screening, on the basis of efficacy and cost-effectiveness, for N. gonorrhoeae among asymptomatic sexually active young males who have sex with females only. Screening for gonorrhea, including pharyngeal or rectal testing, should be offered to YMSM at least annually (see Men Who Have Sex with Men).
Providers might consider opt-out chlamydia and gonorrhea screening (i.e., the patient is notified that testing will be performed unless the patient declines, regardless of reported sexual activity) for adolescent and young adult females during clinical encounters. Cost-effectiveness analyses indicate that opt-out chlamydia screening among adolescent and young adult females might substantially increase screening, be cost-saving (172), and identify infections among patients who do not disclose sexual behavior (173).
HIV Infection
HIV screening should be discussed and offered to all adolescents. Frequency of repeat screenings should be based on the patient’s sexual behaviors and the local disease prevelance (138). Persons with HIV infection should receive prevention counseling and linkage to care before leaving the testing site.
Cervical Cancer
Guidelines from USPSTF and ACOG recommend that cervical cancer screening begin at age 21 years (174,175). This recommendation is based on the low incidence of cervical cancer and limited usefulness of screening for cervical cancer among adolescents (176). In contrast, the 2020 ACS guidelines recommend that cervical cancer screening begin at age 25 years with HPV testing. This change is recommended because the incidence of invasive cervical cancer in women aged <25 years is decreasing because of vaccination (177). Adolescents with HIV infection who have initiated sexual intercourse should have cervical screening cytology in accordance with HIV/AIDS guidelines (https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-opportunistic-infection/human-papillomavirus-disease?view=fullexternal icon).
Other Sexually Transmitted Infections
YMSM and pregnant females should be routinely screened for syphilis (see Pregnant Women; Men Who Have Sex with Men). Local disease prevalence can help guide decision-making regarding screening for T. vaginalis, especially among adolescent females in certain areas. Routine screening of adolescents and young adults who are asymptomatic for certain STIs (e.g., syphilis, trichomoniasis, BV, HSV, HAV, and HBV) is not typically recommended.
Primary Prevention Recommendations
Primary prevention and anticipatory guidance for recognizing symptoms and behaviors associated with STIs are strategies that should be incorporated into all types of health care visits for adolescents and young adults. The following recommendations for primary prevention of STIs (i.e., vaccination and counseling) are based on published clinical guidelines for sexually active adolescents and young adults from federal agencies and medical professional organizations.
- HPV vaccination is recommended through age 26 years for those not vaccinated previously at the routine age of 11 or 12 years (https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/hpv.html).
- The HBV vaccination series is recommended for all adolescents and young adults who have not previously received the universal HBV vaccine series during childhood (12).
- The HAV vaccination series should be offered to adolescents and young adults as well as those who have not previously received the universal HAV vaccine series during childhood (https://www.cdc.gov/vaccines/schedules/hcp/imz/child-indications.html#note-hepa).
- Information regarding HIV transmission, prevention, testing, and implications of infection should be regarded as an essential component of the anticipatory guidance provided to all adolescents and young adults as part of routine health care.
- CDC and USPSTF recommend offering HIV PrEP to adolescents weighing ≥35 kg and adults who are HIV negative and at substantial risk for HIV infection (80,178). YMSM should be offered PrEP in youth-friendly settings with tailored adherence support (e.g., text messaging and visits per existing guidelines). Indications for PrEP, initial and follow-up prescribing guidance, and laboratory testing recommendations are the same for adolescents and adults (https://www.cdc.gov/hiv/risk/prep).
- Medical providers who care for adolescents and young adults should integrate sexuality education into clinical practice. Health care providers should counsel adolescents about the sexual behaviors that are associated with risk for acquiring STIs and should educate patients regarding evidence-based prevention strategies, which includes a discussion about abstinence and other risk-reduction behaviors (e.g., consistent and correct condom use and reduction in the number of sex partners including concurrent partners). Interactive counseling approaches (e.g., patient-centered counseling and motivational interviewing) are effective STI and HIV prevention strategies and are recommended by USPSTF. Educational materials (e.g., handouts, pamphlets, and videos) can reinforce office-based educational efforts.