Genotype-Specific Concordance of Chlamydia trachomatis Genital Infection Within Heterosexual Partnerships.

BACKGROUND: Sexual transmission rates of Chlamydia trachomatis (Ct) cannot be measured directly; however, the study of concordance of Ct infection in sexual partnerships (dyads) can help to illuminate factors influencing Ct transmission. METHODS: Heterosexual men and women with Ct infection and their sex partners were enrolled and partner-specific coital and behavioral data collected for the prior 30 days. Microbiological data included Ct culture, and nucleic acid amplification testing (NAAT), quantitative Ct polymerase chain reaction, and ompA genotyping. We measured Ct concordance in dyads and factors (correlates) associated with concordance. RESULTS: One hundred twenty-one women and 125 men formed 128 dyads. Overall, 72.9% of male partners of NAAT-positive women and 68.6% of female partners of NAAT-positive men were Ct-infected. Concordance was more common in dyads with culture-positive members (78.6% of male partners, 77% of female partners). Partners of women and men who were NAAT-positive only had lower concordance (33.3%, 46.4%, respectively). Women in concordant dyads had significantly higher median endocervical quantitative Ct polymerase chain reaction values (3,032) compared with CT-infected women in discordant dyads (1013 inclusion forming units DNA equivalents per mL; P < 0.01). Among 54 Ct-concordant dyads with ompA genotype data for both members, 96.2% had identical genotypes. CONCLUSIONS: Higher organism load appears associated with concordance among women. Same-genotype chlamydial concordance was high in sexual partnerships. No behavioral factors were sufficiently discriminating to guide partner services activities. Findings may help model coitus-specific transmission probabilities.

Event-level marijuana use, alcohol use, and condom use among adolescent women.

BACKGROUND: It is widely believed that marijuana use and alcohol use directly intercede on successful condom use. However, measurement differences and inconsistent findings in past research remain unclear whether marijuana and alcohol work directly to influence condom behavior, or spuriously function through other factors that actually reflect an increased likelihood of vaginal sex. The current study prospectively disentangles the association of marijuana and alcohol use on condom behavior among adolescent women. METHODS: Young women (N=387; 14-17 years) provided daily sexual diaries as part of a longitudinal cohort study (1999-2009) of sexual behavior and sexual relationships. To separate the effects of marijuana and alcohol use on vaginal sex from condom use (when vaginal sex occurs), we estimated a 3-category outcome variable (no vaginal sex, vaginal sex with a condom, vaginal sex without a condom), alternating no sex (Model 1) and sex without a condom (Model 2) as the referent categories. Generalized estimating equation multinomial logistic regression adjusted odds ratios for multiple sexual events from the same young woman over time. RESULTS: Subjects contributed 14,538 coital events; 30% of these events were condom-protected. Neither marijuana nor alcohol use was directly associated with lower condom use; the strongest effect of condom use (adjusted odds ratio) and nonuse was performance of these behaviors in the past week. CONCLUSIONS: This study finds no evidence of a relationship between marijuana or alcohol use and condom nonuse. Both condom use and nonuse were identified as consistent behavioral patterns, regardless of the effect of marijuana and alcohol use.

The developmental association of sexual self-concept with sexual behavior among adolescent women.

Developing a sexual self-concept is an important developmental task of adolescence; however, little empirical evidence describes this development, nor how these changes are related to development in sexual behavior. Using longitudinal cohort data from adolescent women, we invoked latent growth curve analysis to: (1) examine reciprocal development in sexual self-concept (sexual openness, sexual esteem and sexual anxiety) over a four year time frame; (2) describe the relationship of these trajectories with changes in sexual behavior. We found significant transactional effects between these dimensions and behavior: sexual self-concept evolved during adolescence in a manner consistent with less reserve, less anxiety and greater personal comfort with sexuality and sexual behavior. Moreover, we found that sexual self-concept results from sexual behavior, as well as regulates future behavior.

Variation in sexual behaviors in a cohort of adolescent females: the role of personal, perceived peer, and perceived family attitudes.

PURPOSE: Little is known about how adolescent sexual behaviors develop and the influence of personal or perceived social attitudes. We sought to describe how personal, perceived peer, and perceived family attitudes toward adolescent sexual activity influence sexual behaviors of adolescent females' over time. METHODS: Between the years of 1999 and 2006, 358 English-speaking female adolescents, aged 14-17 years, were recruited from three urban adolescent clinics. Participants completed quarterly and annual questionnaires over a span of 4 years. Primary outcomes included engagement in any of the following eight sexual behaviors: kissing, having breasts touched, having genitals touched, touching partners' genitals, oral giving, oral receiving, anal, or vaginal sex. Three attitudinal scales assessed personal importance of abstinence, perceived peer beliefs about when to have sex, and perceived family beliefs that adolescent sex is negative. We used generalized estimating equations to identify predictors of each sexual behavior and compared whether personal, perceived peer, or perceived family attitudes predicted sexual behaviors over time. RESULTS: The odds of reporting each sexual behavior increased with age but were lower among those whose personal or perceived family attitudes were less positive. Participants' personal attitudes toward adolescent sex were the strongest predictor of engagement in all eight sexual behaviors even after controlling for perceived peer and perceived family attitudes. CONCLUSIONS: Female adolescent's personal attitudes toward abstinence appear to be the strongest predictor of engagement in a variety of sexual behaviors. Efforts to influence adolescent attitudes toward abstinence may be an important approach to reducing sexual behaviors that increase the risk of pregnancy and sexually transmitted infections.

Improving adolescent and young adult health - training the next generation of physician scientists in transdisciplinary research.

To address the critical shortage of physician scientists in the field of adolescent medicine, a conference of academic leaders and representatives from foundations, National Institutes of Health, Maternal and Child Health Bureau, and the American Board of Pediatrics was convened to discuss training in transdisciplinary research, facilitators and barriers of successful career trajectories, models of training, and mentorship. The following eight recommendations were made to improve training and career development: incorporate more teaching and mentoring on adolescent health research in medical schools; explore opportunities and electives to enhance clinical and research training of residents in adolescent health; broaden educational goals for Adolescent Medicine fellowship research training and develop an intensive transdisciplinary research track; redesign the career pathway for the development of faculty physician scientists transitioning from fellowship to faculty positions; expand formal collaborations between Leadership Education in Adolescent Health/other Adolescent Medicine Fellowship Programs and federal, foundation, and institutional programs; develop research forums at national meetings and opportunities for critical feedback and mentoring across programs; educate Institutional Review Boards about special requirements for high quality adolescent health research; and address the trainee and faculty career development issues specific to women and minorities to enhance opportunities for academic success.

Factors associated with event level anal sex and condom use during anal sex among adolescent women.

PURPOSE: To examine the distribution of and factors associated with event-level heterosexual anal sex and of event-level condom use during anal sex among adolescent women. METHODS: Adolescent women (N=387; age 14-17 years at enrollment) were recruited from primary care clinics for a longitudinal cohort study of sexually transmitted infections and sexual behavior. Data were taken from daily sexual diaries; generalized estimating equation logistic regression assessed the likelihood of anal sex or condom use during anal sex on a given day. RESULTS: Heterosexual anal intercourse is a small but nonrandom event-level component in adolescent women's sexual behavior. About 30% of anal sex events were condom protected. Mood, partner, and situational factors predicted anal sex, but not condom use during anal sex; within-day and recent behavior factors were the strongest influences on both outcomes. CONCLUSIONS: Our findings suggest the importance of providers' screening adolescent women patients during office visits about anal sex and about condom use during anal sex, as well as asking questions about the context of these behaviors to appropriately tailor risk reduction counseling.

Repeated Chlamydia trachomatis genital infections in adolescent women.

BACKGROUND: Repeated Chlamydia trachomatis infections are common among young sexually active women. The relative frequency of reinfection and antibiotic treatment failure is undefined. METHODS: Adolescent women enrolled in a longitudinal cohort had behavioral and sexually transmitted infection assessments performed every 3 months, including amplification tests for C. trachomatis, ompA genotyping, and interviews and diary entries to document sex partner-specific coitus and event-specific condom use. Repeated infections were classified as reinfection or treatment failure by use of an algorithm. All infections for which treatment outcomes were known were used to estimate the effectiveness of antibiotic use. RESULTS: We observed 478 episodes of infection among 210 study participants; 176 women remained uninfected. The incidence rate was 34 episodes/100 woman-years. Of the women who were infected, 121 experienced 1 repeated infections, forming 268 episode pairs; 183 pairs had complete data available and were classified using the algorithm. Of the repeated infections, 84.2% were definite, probable, or possible reinfections; 13.7% were probable or possible treatment failures; and 2.2% persisted without documented treatment. For 318 evaluable infections, we estimated 92.2% effectiveness of antibiotic use. CONCLUSIONS: Most repeated chlamydial infections in this high-incidence cohort were reinfections, but repeated infections resulting from treatment failures occurred as well. Our results have implications for male screening and partner notification programs and suggest the need for improved antibiotic therapies.

Time from first intercourse to first sexually transmitted infection diagnosis among adolescent women.

OBJECTIVE: To determine the time between first intercourse and first sexually transmitted infection (STI) with Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis and time between repeated infections. DESIGN: Observational study. SETTING: Three adolescent medicine clinics. PARTICIPANTS: A cohort of 386 urban young women aged 14 to 17 years at enrollment. MAIN OUTCOME MEASURES: Age at first intercourse; organism-specific interval between first intercourse and first STI diagnosis; interval between repeated infections; and age at first STI test prior to study participation. RESULTS: Participants had first intercourse at a young age (first, second, and third quartiles were 13, 14, and 15 years of age, respectively). By age 15 years, 25% of the women acquired their first STI, most often C trachomatis. Median interval between first intercourse and first STI diagnosis was 2 years. Within 1 year of first intercourse, 25% had their first C trachomatis infection. Repeated infections were common; within 3.6, 6, and 4.8 months, 25% of the women with prior C trachomatis, N gonorrhoeae, and T vaginalis infection were reinfected with the respective organisms. Considerable delay in STI testing was found for those who began sex at a younger age. The median interval between first sex and first test were 4.9, 3.5, 2.1, 1.8, and 1.2 years for those who had first sex at ages 10, 11, 12, 13, and 14 years, respectively. CONCLUSIONS: Timely screening and treatment are important for prevention of STI sequelae. For urban adolescent women, STI screening (especially for C trachomatis) should begin within a year after first intercourse and infected individuals should be retested every 3 to 4 months.

Depressive symptoms and sexual risk behavior in young, chlamydia-infected, heterosexual dyads.

PURPOSE: To examine associations between depressive symptoms and dyad-level sexual risk behavior in young heterosexual dyads with sexually transmitted infection (STI). METHODS: Chlamydia-positive 14-24-year-old, heterosexually active outpatients and their opposite-sex partners completed an assessment that included demographics, past and recent STI risk behaviors, and the Beck Depression Inventory (BDI). Participants in the top 25% of BDI scores within gender were categorized as depressed. Variables were created to identify dyads in which the female or male partner was depressed, as well as a measure of concordance of depression between partners. Dyad-level STI risk variables were created from the STI risk characteristics reported by each dyad member, and associations between these and the depression variables were analyzed. RESULTS: The 130 dyads were comprised of young men and women at high STI risk. One-third of dyads had at least one depressed partner. Dyads in which the female partner was depressed had greater partner age difference, greater total number of lifetime partners, and one or more partners reporting substance use within 2 hours before sex, compared with dyads in which the female partner was not depressed. Dyads in which the male partner was depressed were more likely than the nondepressed-male dyads to report substance use before sex. All dyads in which both partners were depressed reported substance use before sex. CONCLUSIONS: In young, chlamydia-infected, heterosexual dyads, depressive symptoms, especially in women, is related to increased dyad-level STI risk, including greater partner age difference, more partners, and substance use before sex.

Reactive arthritis: a review.

This review article summarizes the available literature on adolescent reactive arthritis. A review of the pathophysiology, diagnosis, and treatment guidelines will be helpful to better diagnose and treat reactive arthritis.

Chlamydia trachomatis positivity rates among men tested in selected venues in the United States: a review of the recent literature.

The cost-effectiveness of screening men for Chlamydia trachomatis depends in part on the prevalence of chlamydia in the screened population and the ease with which screening programs can be implemented. Screening in venues with high rates of chlamydia positivity among men may therefore be an important adjunct to chlamydia control. To evaluate the recent US literature on chlamydia positivity in chlamydia screening programs among asymptomatic men in nonsexually transmitted disease clinic settings, we reviewed published articles between 1995 and June 2007, using PubMed as the primary search tool. Articles were abstracted and positivity rates summarized by type of venue, race/ethnicity, age group, and US region. The overall median positivity rate was 5.1%. The highest rates were observed among men tested in juvenile (7.9%) and adult (6.8%) detention facilities, among blacks (6.7%), the 15 to 19 years old (6.1%) and 20 to 24 years old (6.5%) age groups, and among men screened in the southern United States (6.4%). Chlamydia rates among men are high in certain venues, particularly correctional settings, but also depend on the demographic composition of the target population and location. Programs considering male chlamydia screening programs should conduct pilot programs to assess chlamydia positivity as well as feasibility and cost in target venues.

Variations in coital and noncoital sexual repertoire among adolescent women.

PURPOSE: Little is known about factors associated with the day-to-day selection and orchestration of sexual repertoire among adolescent women. Analyzing differences in adolescent women's sexual activity may augment both the clinical and behavioral understanding of sexuality development and sexual decision making, and may yield important points to enhance existing programs for prevention of sexually transmitted infection or pregnancy. METHODS: Adolescent women (N = 387, aged 14-17 years at enrollment) were recruited from primary care adolescent clinics serving primarily lower- and middle-income patients. Data were taken from daily sexual diaries. A four-category outcome variable, using generalized estimating equation multinomial logistic regression assessed the likelihood of specific sexual behaviors on a given day: none (abstinence), non-coital-only, coital-only, and dual noncoital/coitus. Separate models were analyzed for fellatio, cunnilingus, and anal sex. Predictor variables included age, menstrual bleeding, alcohol or marijuana use, positive or negative mood, recent coitus, recent noncoital sexual activity, partner support or negativity, sexual interest, feeling in love, time of the week, and same-day noncoital behaviors. Coital-only sexual behavior was used as the reference category. RESULTS: Among adolescent women, abstinence is prevalent on the majority of days. When sexual activity does occur, coital-only activity is most common; however, noncoital behaviors alone and/or in tandem with coitus are not rare. CONCLUSIONS: Differing associations of intrapersonal, partner and situational variables with specific types of day-to-day sexual activity underscores a complex sexual repertoire which may be insufficiently examined with a simple focus on coital risk.

Situational and relational factors associated with coitus during vaginal bleeding among adolescent women.

Menstruation is a normal, developmental event anchored in contradictory value systems. Although it demarcates a transition to womanhood, it is often associated with negative sentiments such as shame, camouflage and discomfort. Certain behavioral expectations, including avoiding sexual intercourse, also accompany menstruation. Research has generally suggested that sex does decrease during menstruation. However, not all sexual activity is suppressed during menses; both individual and relationship factors provide influence. Accordingly, this study investigated situational and relational factors associated with the day-to-day likelihood of sex and vaginal bleeding among 387 (aged 14-17 at enrollment) adolescent women. Generalized estimating equation logistic regression, in SUDAAN 9.0, was used; predictors of coitus and bleeding included recent sexual activity, past coitus/bleeding, marijuana use before intercourse and higher partner support, higher sexual interest and lower feelings of being in love. The findings highlight appropriate areas of focus for information, education and STI prevention counseling.

Susceptibility of middle adolescent females to sexually transmitted infections: impact of hormone contraception and sexual behaviors on vaginal immunity.

PROBLEM: The resistance and/or susceptibility to infections can be influenced by patterns of immunomodulators. Based on this and the high rate of sexually transmitted infections (STIs) in adolescents, we examined the longitudinal relationship between sexual behaviors, hormonal contraceptive use, and bacterial vaginosis (BV) with vaginal-associated immunomodulators in adolescent females. METHOD OF STUDY: Over 27 months, subjects completed detailed questionnaires, and consented to vaginal swabs for STI testing, and vaginal lavages for identification of immunomodulators including T-helper, proinflammatory, and chemokines. Concentrations of immunomodulators were correlated with each parameter together with prevalence of STIs. RESULTS: Each parameter had a limited influence on vaginal immunomodulators with no evidence of any pattern(s) associated with infection. Conversely, the local presence of proinflammatory cytokines and neutrophils in those with an STI indicated some immune responsiveness. CONCLUSION: Sexual behaviors, contraceptive usage, and BV do not appear as factors in susceptibility of adolescents to STIs through the influence of local immunomodulators.

Mycoplasma genitalium among adolescent women and their partners.

PURPOSE: Mycoplasma genitalium is a possible sexually transmitted pathogen and its study among the adolescent age group has been limited. In this longitudinal study, the epidemiology, natural history, and associated clinical findings of M. genitalium among adolescents in a primary care setting were explored. METHODS: A sample of 383 young women (14-17 years of age) and 117 male partners provided sexual behavior data and urogenital samples for polymerase chain reaction testing to detect M. genitalium, Chlamydia trachomatis, and other sexually transmitted infections. Women were tested quarterly for up to 27 months and, during every other quarter, tested weekly. The presence of any signs or symptoms of infection among the female subjects was also documented. RESULTS: Cumulatively, 13.6% (52/383) of women tested positive for M. genitalium. All women with M. genitalium, except one, were sexually experienced. M. genitalium was associated with number of sexual partners (p < .001) and C. trachomatis infection (p < .03). M. genitalium was more likely among male partners of M. genitalium-positive women (p < .02); 31.3% of untreated M. genitalium cases had infection lasting over 8 weeks. M. genitalium was not associated with the presence of clinical signs or symptoms of infection. CONCLUSIONS: Findings support sexual transmissibility of M. genitalium and add to understanding of M. genitalium natural history and clinical findings.

The developmental association of relationship quality, hormonal contraceptive choice and condom non-use among adolescent women.

PURPOSE: Consistent condom use is critical to efforts to prevent sexually transmitted infections among adolescents, but condom use may decline as relationships and contraceptive needs change. The purpose of this research is to assess changes in condom non-use longitudinally in the context of changes in relationship quality, coital frequency and hormonal contraceptive choice. METHODS: Participants were women (aged 14-17 years at enrollment) recruited from three urban adolescent medicine clinics. Data were collected at three-month intervals using a face-to-face structured interview. Participants were able to contribute up to 10 interviews, but on average contributed 4.2 interviews over the 27-month period. Independent variables assessed partner-specific relationship quality (five items; scale range 5-25; alpha = .92, e.g., this partner is a very important person to me); and, number of coital events with a specific partner. Additional items assessed experience with oral contraceptive pills (OCP) use and injected depo medroxy-progesterone acetate (DMPA). The outcome variable was number of coital events without condom use during the past three months. Analyses were conducted as a three-level hierarchical linear growth curve model using HLM 6. The Level 1 predictor was time, to test the hypothesis that condom non-use increases over time. Level 2 predictors assessed relationship quality and coital frequency across all partners to assess hypotheses that participants' condom non-use increases over time as a function of relationship quality and coital frequency. Level 3 predictors assessed the participant-level influence of OCP or DMPA experience on time-related changes in condom non-use. RESULTS: A total of 176 women reported 279 sex partners and contributed 478 visits. Both average coital frequency and average condom non-use linearly increased during the 27-month follow-up. At any given follow-up, about 35% reported recent OCP use, and 65% reported DMPA use. HLM analyses showed that condom non-use increased as a function of time (beta = .12; p = .03, Level 1 analysis). Increased condom non-use over time was primarily a function of increased coital frequency (beta = .01; p = .00), although higher levels of relationship quality were associated with increased condom non-use at enrollment (beta = .44; p = .00, Level 2 analysis). The temporal rise in condom non-use significantly increased among DMPA users (beta = .06; p = .00) but not OCP users (Level 3 analysis) (beta = -.04; p = .06). CONCLUSIONS: Developmentally, relationship characteristics and coital frequency appear to have increasing weight in decisions about condom use. Hormonal contraceptive methods are not equivalently associated with the overall temporal decline in condom use. Future research associated with dual contraceptive/condom use should address differential factors associated condom use in combination with different hormonal methods.

Incidence and correlates of unwanted sex in relationships of middle and late adolescent women.

OBJECTIVES: To determine the 3-month incidence of unwanted sex and to examine relationship factors and health-risk behaviors associated with incident unwanted sex. DESIGN: Data collected from face-to-face interviews every 3 months in a longitudinal study with a minimum of 2 interviews and maximum of 10 across 27 months. SETTING: Primary health care clinics for teens in an urban setting. PARTICIPANTS: Adolescent women aged 14 through 17 years. MAIN OUTCOME MEASURES: At each 3-month visit, cervical and vaginal specimens were obtained for the evaluation of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis infection; for each partner, relationship characteristics and sexual behaviors were assessed, as well as the occurrence of unwanted sex. A logistic model was used to account for within-subject variability to model the probability of unwanted sex as a function of predictor variables. RESULTS: A total of 279 participants with a mean age of 15.9 years were enrolled, and most were African American (88.5% [247/279]). Unwanted sex was reported by 40.9% (n=114) of participants and in 15.5% (292/1880) of partner-visits. The most prevalent type of unwanted sex was due to fear that the partner would get angry if denied sex (37.6%, or 105 participants). Factors associated with unwanted sex included having a baby with the partner, lower relationship quality, lack of sexual control, less condom use, and partner marijuana use. CONCLUSIONS: Unwanted sex occurs often within the sexual relationships of teens. These unwanted sexual experiences result in risk for sexually transmitted infections and pregnancies. Sexual health counseling to reduce risk should focus on both the patient's and the partner's behaviors.

Incidence and prevalence of herpes simplex virus infections in adolescent women.

OBJECTIVES: We conducted this study to examine the incidence, prevalence, and risk factors for herpes simplex virus (HSV) 1 and HSV 2 infection in a cohort of young women who were closely followed for acquisition of sexually transmitted infections. STUDY DESIGN: Women between the ages of 14 and 18 years had blood and genital specimens obtained quarterly to test for incident sexually transmitted infections. Subjects also had 2 12-week periods each year when they kept a detailed behavioral diary and performed weekly vaginal swabs. Serum specimens were tested for HSV 1 and HSV 2 antibody, and genital specimens were tested for HSV DNA by PCR. RESULTS: A total of 100 subjects enrolled and had at least 2 sera that could be analyzed for seroconversion. The mean age of the subjects was 15.8 years at entry. The HSV 1 and HSV 2 seroprevalence at entry was 59.6% and 13.5%, respectively. During the study, 4 subjects acquired HSV 1 antibody and 7 acquired HSV 2 antibody, but there were no cases of symptomatic HSV infection identified. The annualized incidence among susceptible individuals was 8.9% for HSV 1 and 7.4% for HSV 2. Three of the 7 HSV 2 sero-converters had HSV 2 DNA detected in vaginal swabs. Age, duration of sexual activity, and the presence of other sexually transmitted infections were predictors of HSV 2 antibody positivity. CONCLUSIONS: Acquisition of HSV 1 and HSV 2 is relatively common in adolescent women, although symptomatic infection is uncommon. HSV 2 is shed in the genital tract despite the lack of symptoms.

Family and friend closeness to adolescent sexual partners in relationship to condom use.

PURPOSE: The role of closeness of sexual partners to family and friends (i.e., how well the participant's family and friends knew their primary sexual partner) to a variety of relationship and sexual behavior measures was explored. METHODS: A sample of 151 adolescent females (aged 14-17 years) was assessed. Areas assessed include family and friend closeness, relationship intimacy, length of sexual relationship, and condom use. RESULTS: Bivariate correlations indicated that the integration of the sexual partner into the family and friend networks was related to greater relationship intimacy. Lowered condom use was related to a number of measures, including increased relationship intimacy and increased family closeness. A path analysis was conducted to assess for direct and indirect effects of family closeness, friend closeness, relationship length, and relationship intimacy on condom use. Social network closeness in family and friend networks was implicated in lowered condom use through higher relationship intimacy within adolescent dyads. CONCLUSIONS: Social network theory is useful in understanding adolescent health-related behavior. In particular, the integration of adolescent sexual partners into both family and friend networks is related to the expression of adolescent sexual behavior.