Mycoplasma genitalium Infection Is Not Associated With Genital Tract Inflammation Among Adolescent and Young Adult Women in Baltimore, Maryland.

BACKGROUND: Mycoplasma genitalium (MG) is a prevalent sexually transmitted infection, but little is known about the associated inflammatory signatures in the genital tract of adolescents and young adult women. METHODS: Adolescents and young adult women aged 13 to 24 years were recruited. Demographic information, sexual behavior history, and medical history were collected. Vaginal swab samples were tested for MG, Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, bacterial vaginosis, and measurement of 13 cytokines, chemokines, and antimicrobial proteins. Vaginal cytokine concentrations were compared by MG infection status. The strength of associations between multiple factors and MG infection was evaluated. RESULTS: Of 215 participants, 16.7% (95% confidence interval [CI], 12.0%-22.4%) had MG infection. Inflammation was not associated with MG infection (P > 0.05). M. genitalium infection was associated with C. trachomatis infection (adjusted prevalence ratio [aPrR], 3.02; 95% CI, 1.69-5.39), bisexual behavior in the past 3 months (aPrR, 2.07; 95% CI, 1.18-3.64), genitourinary symptoms (aPrR, 2.06; 95% CI, 1.22-3.49), and self-reported Black race (aPrR, 3.53; 95% CI, 1.11-11.18). CONCLUSIONS: Higher levels of genital tract cytokines were not associated with MG infection. C. trachomatis infection, bisexual behavior, self-reported Black race, and genitourinary symptoms were associated with an increased likelihood of MG infection.

Adolescent Sexual Behavior and Emergency Department Use.

OBJECTIVES: The objective of this study was to determine whether adolescents in emergency departments (EDs) who report engaging in high-risk sexual behaviors are less likely to identify a primary care provider (PCP) and more likely to access the ED than their sexually inexperienced peers. METHODS: This was a secondary analysis of adolescents presenting to a pediatric ED with non-sexually transmitted infection (STI)-related complaints who completed surveys to assess sexual behavior risk and health care access. We measured differences in self-reported PCP identification, preferential use of the ED, and number of ED visits over a 12-month period by sexual experience. Secondary outcomes included clinician documented sexual histories and STI testing. RESULTS: Of 758 patients meeting inclusion criteria, 341 (44.9%) were sexually experienced, and of those, 129 (37.8%) reported engaging in high-risk behavior. Participants disclosing high-risk behavior were less likely to identify a PCP (adjusted odds ratio, 0.5; 95% confidence interval [CI], 0.3-0.9), more likely to prefer the ED for acute care issues (adjusted odds ratio, 1.6; 95% CI, 1.0-2.6), and had a higher rate of ED visits (adjusted relative risk, 1.2; 95% CI, 1.0-1.3) compared with sexually inexperienced peers. Among patients disclosing high-risk behavior, 10.9% had clinician-documented sexual histories and 2.6% underwent STI testing. CONCLUSION: Adolescents who reported engaging in high-risk sexual behaviors were less likely to identify a PCP, as well as more likely to prefer ED-based care and make more ED visits. However, ED clinicians infrequently obtained sexual histories and performed STI testing in asymptomatic youth, thereby missing opportunities to screen high-risk adolescents who may lack access to preventive care.

Examining the Role of the Pediatric Emergency Department in Reducing Unintended Adolescent Pregnancy.

OBJECTIVES: To determine pregnancy risk and receptiveness to emergency department (ED)-based pregnancy prevention interventions among adolescents accessing care in the ED. STUDY DESIGN: Cross-sectional electronic survey of adolescent females in a pediatric ED used to calculate the Pregnancy Risk Index, a validated measure estimating the annual risk of becoming pregnant based on recent sexual activity, contraceptive method(s), method-specific contraceptive failure rates, and interest in receipt of ED-based contraceptive services. RESULTS: Of 229 participants, 219 were not pregnant, and 129 reported sexual experience. Overall, 72.4% (n = 166) endorsed negative pregnancy intentions. The overall Pregnancy Risk Index for the 219 nonpregnant participants was 9.6 (95% CI 6.8-12.4), and was 17.5 (95% CI 12.8-22.2) for the 129 sexually experienced participants. A Pregnancy Risk Index greater than the national average of 5 was associated with older age (aOR 3.0; 95% CI 1.5-5.85), nonprivate insurance (aOR 7.1; 95% CI 1.6-32.1), prior pregnancy (aOR 2.7; 95% CI 1.2-6.0), and chief complaint potentially related to a reproductive health concern (aOR 2.6; 95% CI 1.4-5.1). In this cohort, 85.1% (n = 194) believed that the ED should provide information about pregnancy prevention, the majority of whom (64.9%; n = 148) believed that pregnancy prevention services should be offered at all ED visits. CONCLUSION: This study demonstrates a high unintended pregnancy risk among adolescents accessing care in the ED. Adolescents report interest in receiving pregnancy prevention information and services in the ED, regardless of reason for visit. Strategies to incorporate successfully the provision of reproductive health services into ED care should be explored.

A Computerized Sexual Health Survey Improves Testing for Sexually Transmitted Infection in a Pediatric Emergency Department.

OBJECTIVES: To assess whether clinical decision support, using computerized sexually transmitted infection (STI) risk assessments, results in increased STI testing of adolescents at high risk for STI. STUDY DESIGN: In a 2-arm, randomized, controlled trial conducted at a single, urban, pediatric emergency department, adolescents completed a computerized sexual health survey. For patients assigned to the intervention arm, attending physicians received decision support to guide STI testing based on the sexual health survey-derived STI risk; in the usual care arm, decision support was not provided. We compared STI testing rates between the intervention and usual care groups, adjusting for potential confounding using multivariable logistic regression. RESULTS: Of the 728 enrolled patients, 635 (87.2%) had evaluable data (323 intervention arm; 312 usual care arm). STI testing frequency was higher in the intervention group compared with the usual care group (52.3% vs 42%; aOR 2 [95% CI 1.1, 3.8]). This effect was even more pronounced among the patients who presented asymptomatic for STI (28.6 vs 8.2%; aOR 4.7 [95% CI 1.4-15.5]). CONCLUSIONS: Providing sexual health survey-derived decision support to emergency department clinicians led to increased testing rates for STI in adolescents at high risk for infection, particularly in those presenting asymptomatic for infection. Studies to understand potential barriers to decision support adherence should be undertaken to inform larger, multicenter studies that could determine the generalizability of these findings and whether this process leads to increased STI detection. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02509572.

Association of Adolescents' Body Mass Index Classification With Preventive Clinical Care Receipt.

PURPOSE: To examine differences in screening and advising for modifiable risk behaviors during well-visits based on adolescents' body mass index categories. METHODS: Retrospective analyses were conducted with the National Institute of Health's NEXT Generation Health Study data, a nationally representative cohort of 10th graders. In wave 1 (2010), adolescents were classified as being underweight (<4.99th percentile), normal-weight (5-84.99th percentile), overweight (85-94.99th percentile), or with obesity (≥95th percentile) based on the body mass index categories described by the Centers for Disease Control and Prevention. In wave 2 (2011), adolescents were asked by their provider about smoking, alcohol use, use of other drugs, sexual activity, nutrition, and exercise, and whether they were advised about risks associated with these behaviors. RESULTS: The sample consisted of 1,639 eligible participants as follows: 57.8% females, 63.3% 16-year-olds, 47.8% non-Hispanic Whites, 41.5% living in the South, 75.4% with health insurance, and 29.8% with low family affluence. Screening rates for overweight compared to normal-weight males were 51% reduced for smoking, 46% for alcohol use, 47% for other drug use, 57% for nutrition, and 47% for exercise. Screening rates were 40% reduced for other drug use for males with obesity, and 89% reduced for alcohol use for underweight males compared to normal-weight males. Advice receipt for females with obesity compared to normal-weight females was 90% increased for nutrition and 78% increased for exercise. DISCUSSION: Overweight male adolescents reported being less likely to be screened across almost all preventive service topics representing missed opportunities for care delivery.

Childbearing motivations, pregnancy desires, and perceived partner response to a pregnancy among urban female youth: does HIV-infection status make a difference?

Despite a growing literature assessing pregnancy desires among HIV-infected women enrolled in clinical care, little attention has been paid to HIV-infected youth for whom pregnancy is a very relevant issue. In urban areas with high rates of teen pregnancy and HIV infection, further understanding of childbearing motivations and relationship dynamics influencing pregnancy desires among female youth is needed. This study compares the childbearing motivations, pregnancy desires, and perceived partner desire for a pregnancy among predominately African-American HIV-infected (n=46) and HIV-uninfected (n=355) female youth (15-24 years). An HIV-infected status was not significantly associated with childbearing motivations or the desire for a future pregnancy, p>0.10. HIV-infection was, however, associated with an increased likelihood to perceive that one's partner would have a positive response to a pregnancy (adjusted odds ratio [aOR] 3.5, 95% confidence interval [CI] 1.2-10.4, p=0.02) compared to uninfected peers. While race was not associated with participants' own desire for a child, white youth were significantly less likely to perceive a positive partner response to becoming pregnant than their African-American peers (aOR 0.23, 95% CI 0.09-0.56, p=0.001). These data suggest that the desire for childbearing is not diminished by HIV infection among urban female youth, highlighting the need for routine, provider-initiated discussions about childbearing with urban youth to minimized unintended pregnancies and HIV transmission.

Tailoring a sexual health curriculum to the sexual health challenges seen by midwifery, nursing and medical providers and students in Tanzania.

BACKGROUND:  Tanzania is a country experiencing multiple sexual health challenges, but providers receive no formal training in sexual health. AIM:  This study aimed to assess (1) what sexual health challenges are commonly seen in clinics in Tanzania, (2) which are raised by patients, (3) which are not addressed and (4) which topics to prioritise for a sexual health curriculum. SETTING:  Healthcare settings in Tanzania. METHODS:  Participants were 60 experienced and 61 student doctors, nurses and midwives working in Dar es Salaam. The authors conducted 18 focus groups stratified by profession (midwifery, nursing or medicine) and experience (practitioners vs. students). RESULTS:  Providers identified six common sexual health concerns: (1) Human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) and sexually transmissible infection (STI) (especially syphilis and gonorrhoea), (2) sexual violence (including intimate partner violence and female genital mutilation), (3) early and unwanted pregnancy (including early sexual debut and complications from abortion), (4) sexual dysfunctions, (5) key population concerns (e.g. lesbian, gay, bisexual, transgender (LGBT); sex work) and (6) non-procreative sexual behaviour (including pornography and masturbation in males and oral and anal sex practices in heterosexual couples). Across professions, few differences were observed. Homosexuality, sex work, masturbation and pornography were identified as taboo topics rarely discussed. Most participants (81%) wanted one comprehensive sexual health curriculum delivered across disciplines. CONCLUSION:  A sexual health curriculum for health students in Tanzania needs to address the most common sexual health concerns of patients. In addition to teaching sexual science and clinical care, skills training in how to address taboo topics is recommended. Students endorsed almost all sexual health topics, which suggests that a comprehensive curriculum is appropriate.

Understanding high fertility desires and intentions among a sample of urban women living with HIV in the United States.

To assess childbearing motivations, fertility desires and intentions, and their relationship with key factors, we conducted a cross-sectional survey among 181 HIV-infected women of reproductive age (15-44 years) receiving clinical care at two urban health clinics. Fertility desires (59%) and intentions (66% of those who desired a child) were high among this predominately African American sample of women, while the proportion with accurate knowledge of mother-to-child transmission (MTCT) was low (15%). Multivariate regression analyses identified factors significantly associated with the intention to have a child. Notably, age and parity did not remain significant in the adjusted model. The discrepancies between expressed desires and intentions for future childbearing, and the strong role of perceived partner desire for childbearing emphasize the need for universal reproductive counseling to help women living with HIV navigate their reproductive decisions and facilitate safe pregnancies and healthy children.

Knowledge, Beliefs, and Attitudes About Contraception Among Rural Latino Adolescents and Young Adults.

PURPOSE: Latino youth experience significant disparities in rates of teen pregnancy, and reproductive health needs of rural Latino youth are not well understood. The purpose of this study was to describe knowledge, beliefs, and attitudes about contraception among rural Latino adolescents and young adults (Latino youth). METHODS: Eighty-four Latino youth, aged 15-24 years from rural Kansas communities participated in 15 focus groups (FG) and completed an individual survey. The survey assessed demographics and acculturation. FG participants discussed attitudes, subjective norms, and perceived sexual behaviors regarding teen sexuality, pregnancy, and contraception. RESULTS: FGs revealed multiple obstacles to accessing reproductive health services: geographical/rural location, cultural barriers, religious influences, lack of sexual education, and personal attitudes toward pregnancy and contraception use. Participants described close-knit communities with limited access to confidential reproductive health care. They identified cultural and religious factors (sexual taboo, virginity, Familismo, and family dishonor) that influence family planning behaviors among Latino youth and obstruct access to sexual health and contraception knowledge and services. Ambivalence regarding pregnancy intentions was common, along with the belief that contraception equates with abortion. CONCLUSIONS: Latino youth in rural communities face multiple physical and sociocultural obstacles to accessing family planning information and services. Community-based pregnancy prevention interventions must target these obstacles to optimize reproductive health outcomes for Latino youth in rural settings.

Digital technology to address HIV and other sexually transmitted infection disparities: Intentions to disclose online personal health records to sex partners among students at a historically Black college.

Patient portals are creating new opportunities for youth to disclose high-fidelity sexually transmitted infection (STI) laboratory test result histories to sex partners. Among an online survey sample, we describe latent constructs and other variables associated with perceived behavioral intentions to disclose STI test history using patient portals. Participants were co-ed students aged 18 to 25 years (N = 354) attending a southern United States Historically Black College and University in 2015. Three reliable latent constructs were identified by conducting psychometric analyses on 27 survey items. Latent constructs represent, a) STI test disclosure valuation beliefs, b) communication practices, and c) performance expectancy beliefs for disclosing with patient portals. Multivariable logistic regression was used to estimate the relationship of latent constructs to perceived behavioral intentions to disclose STI test history using patient portals. Approximately 14% (48/354) reported patient portal use prior to study and 59% (208/354) endorsed behavioral intentions to use patient portals to disclose STI test history. The latent construct reflecting performance expectancies of patient portals to improve communication and accuracy of disclosed test information was associated with behavioral intentions to disclose STI test histories using patient portals [adjusted odds ratio (AOR) = 1.15; 95% CI = 1.08 to 1.22; p<0.001]. Latent constructs representing communication valuation beliefs and practices were not associated with intentions. Self-reporting prior STI diagnosis was also associated with intentions to disclose using patient portals (AOR = 2.84; 95% CI = 1.15 to 6.96; p = 0.02). Point of care messages focused on improvements to validating test results, communication, and empowerment, may be an effective strategy to support the adoption of patient portals for STI prevention among populations of college-aged Black youth.

Patient Portals as Highly Acceptable Tools to Support HIV Preventative Behaviors Among Adolescent and Young Sexual Minority Men.

PURPOSE: The purpose of this study was to present perceptions about using patient portals to manage HIV and sexually transmitted infection (STI) test results and to communicate with sexual partners among a 2018 nationwide sample of adolescent and young sexual minority men (YSMM) aged 15-25 years. METHODS: Univariate and bivariate analyses were conducted on cross-sectional online survey data. RESULTS: Participants gave high or moderate value to portals that provide tips for sexual health (95.1% [1,168/1,228]), ability to locate HIV/STI testing centers (96.9% [1,190/1,228]), and ability to order home-based HIV/STI testing (96% [1,179/1,228]). Perceived health engagement and dyadic communication benefits of use were sustained at or above 94%. YSMM with a history of HIV/STI diagnosis were less willing to share online results with main (93% vs. 97%; Χ2 = 5.13; p = .02) and nonmain (70% vs. 77%; Χ2 = 5.17; p = .02) sexual partners. CONCLUSIONS: Patient portals represent highly acceptable spaces to deliver comprehensive sexual health services and could support communication on HIV/STI testing with sex partners among YSMM.

Improving LARC Access for Urban Adolescents and Young Adults in the Pediatric Primary Care Setting.

The objective of this quality improvement study was to assess the feasibility, acceptability, and impact of integrating long-acting reversible contraceptive (LARC) delivery services into an academic pediatric primary care practice. Adolescent medicine providers in Baltimore, Maryland, were trained in LARC placement with gynecology providers integrated to offer onsite LARC placement and procedural support. Referrals, appointments, and contraceptive method choice/receipt were tabulated. Of 212 individuals referred for LARC consultations, 104 attended appointments. LARC placement at the initial referral increased from year 1 (N = 1) to year 2 (N = 42; P < .01). Adolescent medicine providers placed more LARCs in year 2 (N = 34) than year 1 (N = 0; P < .01). Patients aged 18 to 24 years were less likely to have a LARC placed than those aged 13 to 17 years (unadjusted odds ratio = 0.47 [0.26-0.86]). In conclusion, provider training and service integration of LARC services within a pediatric practice is feasible, acceptable, and increases LARC access and placement.

Why Didn't You Text Me? Poststudy Trends From the DepoText Trial.

OBJECTIVE: To evaluate the longitudinal impact of a 9-month text message intervention on participant adherence beyond the intervention to highly effective contraceptive methods among urban adolescent and young adult women enrolled in the DepoText randomized control trial (RCT). STUDY DESIGN: Retrospective longitudinal cohort study of long-term follow-up data from the DepoText RCT. Sixty-seven female participants (aged 13-21 years) using depot medroxyprogesterone acetate (DMPA) were recruited from an urban academic adolescent practice in Baltimore, Maryland. The principal outcome measured was a comparison of contraceptive method choice between the control and intervention groups during the 20 months postintervention. RESULTS: Intervention participants were 3.65 times more likely to continue using DMPA or a more efficacious method at the 20-month postintervention evaluation (odds ratio 3.65, 95% CI 1.26-10.08; P = .015). CONCLUSION: Participation in the DepoText trial was associated with continued use of DMPA or a more effective contraceptive method almost 20 months after the intervention exposure ended.

Treatment Considerations for the Cardiometabolic Signs of Polycystic Ovary Syndrome: A Review of the Literature Since the 2013 Endocrine Society Clinical Practice Guidelines.

IMPORTANCE: Polycystic ovary syndrome is characterized by an excess in androgen levels, ovarian dysfunction, and polycystic ovarian morphology but is also associated with metabolic dysfunction and risk factors for cardiovascular disease. To our knowledge, there are few therapeutic recommendations for these cardiometabolic risk factors and little evidence of their long-term clinical relevance to cardiovascular health. OBJECTIVE: To determine metabolic and/or cardiovascular outcomes in polycystic ovary syndrome treatment literature since the publication of the most recent Endocrine Society clinical practice guidelines in 2013. EVIDENCE REVIEW: We searched PubMed using a string of variations of polycystic ovary syndrome, therapy/treatment, and adolescence, and we included English-language original research articles published while the 2013 clinical practice guidelines were disseminated (ie, articles published from January 1, 2011, to June 1, 2015). Articles that appeared relevant based on a review of titles and abstracts were read in full to determine relevancy. References from relevant articles were reviewed for additional studies. FINDINGS: Four topic areas emerged: (1) lifestyle modification, (2) metformin vs placebo or estrogen-progestin oral contraceptives, (3) insulin-sensitizing agents, and (4) estrogen-progestin formulations. Most studies assessed the role of metformin as a monotherapy or dual therapy supplement and found significant benefit when including metformin in polycystic ovary syndrome treatment regimens. Studies showed improvements in cardiometabolic risk factors and, in several, androgen excess and cutaneous and menstrual symptoms. Studies were limited by sample size (range, 22-171), few adolescent participants, and short-term outcomes. CONCLUSIONS AND RELEVANCE: Findings show potential for metformin and estrogen-progestin dual therapy but warrant longitudinal studies examining outcomes from adolescence through middle age to determine the effect on long-term cardiovascular health.

The status of adolescent medicine: building a global adolescent workforce.

Remarkable public health achievements to reduce infant and child mortality as well as improve the health and well-being of children worldwide have successfully resulted in increased survival and a growing population of young people aged 10-24 years. Population trends indicate that the current generation of 1.8 billion young people is the largest in history. However, there is a scarcity of dedicated resources available to effectively meet the health needs of adolescents and young adults worldwide. Growing recognition of the pivotal roles young people play in the cultures, societies, and countries in which they live has spurred an expanding global movement to address the needs of this special population. Building an effective global workforce of highly-skilled adolescent health professionals who understand the unique biological, psychological, behavioral, social, and environmental factors that affect the health of adolescents is a critical step in addressing the health needs of the growing cohort of young people. In this review, we aim to: 1) define a global assessment of the health needs for adolescents around the world; 2) describe examples of current training programs and requirements in adolescent medicine; 3) identify existing gaps and barriers to develop an effective adolescent health workforce; and 4) develop a call for targeted actions to build capacity of the adolescent health workforce, broaden culturally relevant research and evidence-based intervention strategies, and reinforce existing interdisciplinary global networks of youth advocates and adolescent health professionals to maximize the opportunities for training, research, and care delivery.

Quality of life in adolescent girls with polycystic ovary syndrome.

OBJECTIVES: To examine health-related quality of life (HRQL) in adolescents with polycystic ovary syndrome (PCOS), compared with healthy adolescents, and to determine whether clinically observed or self-perceived severity of illness affects their HRQL. DESIGN AND SETTING: Cross-sectional study of female adolescents conducted at an urban, hospital-based adolescent medicine clinical practice. PARTICIPANTS: Ninety-seven adolescent patients with PCOS and 186 healthy patients who were seen for care between October 15, 1999, and March 2, 2001. MAIN OUTCOME MEASURES: Health-related quality-of-life scores as determined by the Child Health Questionnaire-Child Self-Report Form. RESULTS: Adolescents with PCOS scored lower on subscales measuring general health perceptions, physical functioning, general behavior, and limitations in family activities because of illness. Patients scored higher on the change in health in the last year subscale, and most had been diagnosed and initiated treatment for PCOS in the last year. Patients who had higher self-perceived severity of illness also scored lower on the general health perceptions subscale, but clinical severity was not associated with differences in HRQL. CONCLUSIONS: Adolescents with PCOS experience lower HRQL compared with healthy adolescents. Polycystic ovary syndrome and perceived severity of illness negatively affect HRQL in adolescents. This study suggests a need to develop interventions to reduce the distress that patients with PCOS may face as adolescents and young adults.

Fertility concerns and sexual behavior in adolescent girls with polycystic ovary syndrome: implications for quality of life.

OBJECTIVE: To examine the fertility concerns and sexual behavior of adolescent girls with polycystic ovary syndrome (PCOS) as compared to healthy adolescent girls and the effect of these concerns on health-related quality of life. DESIGN AND SETTING: A cross-sectional study of adolescent girls with PCOS (n = 97) and healthy comparisons (n = 186) was conducted at an urban, hospital-based adolescent medicine practice. Participants completed the Child Health Questionnaire Version CF-87 as a measure of health-related quality of life and a general health history questionnaire that included items regarding sexual activity, contraception, fertility concerns, and severity of illness. Findings were evaluated using multivariate logistic and linear regression models. RESULTS: Healthy subjects were 2.8 times more likely to have had sexual intercourse than PCOS participants, though the mean age at initiation of sexual intercourse among sexually active girls was not significantly different between the two groups. Severity of illness and the worry about fertility were not associated with odds of being sexually active. Girls with PCOS were 3.4 times more likely to be worried about their ability to become pregnant than comparisons and concern about future fertility was associated with significant reductions in quality of life. CONCLUSION: Adolescents with PCOS are more concerned about fertility than their healthy peers and this concern may affect their overall quality of life. The finding that more than a third of the adolescents with PCOS in this study were sexually active underscores the importance of providing ongoing counseling on fertility issues, contraception, and STD prevention in the care of adolescent girls with PCOS.