ENHANCING ADOLESCENT SEXUAL HEALTH

Transcription

1 ENHANCING ADOLESCENT SEXUAL HEALTH SERVICES BY CREATING AN ADOLESCENT MEDICAL HOME Gale R. Burstein, MD, MPH, FAAP, FSAHM Commissioner, Erie County Department of Health, Associate Clinical Professor, SUNY at Buffalo School of Medicine and Biomedical Sciences, Buffalo, NY Faculty, NYC STD/HIV Prevention Training Center Agenda Making the case: Why adolescent sexual health services matter Routinizing sexual health in 1º care: Creating an Adolescents Medical Home Questions 1

2 Disclosures Financial relationships : Dr. Burstein wishes to disclose she has no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. I would like to acknowledge NYCDOHMH and NYSDOH for their assistance and data. 2

3 WHY IT MATTERS Overview STD Burden >19 million STD cases occur in USA each year Disproportionately among young people and racial and ethnic minority populations Estimated $17 Billion in annual direct medical costs of treating STDs and sequelae Estimated $6.5 Billion in annual direct medical costs of treating STDs and sequelae among yo STDs can cause serious health problems Ectopic pregnancy, infertility, chronic pelvic pain risk of HIV infection CDC. STD Surveillance Atlanta: U.S.DHHS; Chesson HW, et al. Perspect Sex Reprod Health 36(1):

4 WHY IT MATTERS Adolescent Sexual Behavior NYS high school students who ever had sexual intercourse, 2011 % CDC YRBSS, 2011 Grade 4

5 Sexual behavior with opposite-sex partners among youth aged years, NSFG Age group Vaginal sex Oral sex Anal sex MALES yo 45% 48% 10% yo 82% 80% 32% FEMALES yo 46% 45% 11% yo 85% 81% 30% Sexual behavior with same-sex partners among males aged years, NSFG Age group Oral sex with Anal sex with yo 2% 1% yo 6% 3% 5

6 WHY IT MATTERS STI Burden Estimated Youth STI Incidence, 2000 ~25% Years ~75% Years Sexually Experienced Population Weinstock et al., Persp Sex Reprod Health,

7 Estimated Youth STI Incidence, 2000 ~25% Years Account for: ~48% New Infections ~75% Years ~52% New Infections Sexually Experienced Population Incident STIs* Weinstock et al., Persp Sex Reprod Health, Estimated Youth STI Incidence, 2000 ~25% Years Account for: ~48% New Infections 5% Gonorrhea 7% Genital herpes 16% Chlamydia 21% Trichomoniasis ~75% Years ~52% Sexually Experienced Population New Infections Incident STIs* 51% HPV *Also included <1% each HIV, Syphilis, Hepatitis B Weinstock et al., Persp Sex Reprod Health,

8 Prevalence of 5 STIs Among Females Aged 14 to 19 yrs: United States, All Sexually Experienced STI Weighted Prevalence (%) Weighted Prevalence (%) Any STI HPV* C trachomatis T vaginalis HSV N gonorrhoeae *HPV 6/11 & any of 23 oncogenic types Forhan SE, et al. Pediatrics 2009;124: NYS STIs AND TEEN PREGNANCY 8

9 Reported Chlamydia among Women, NYS, excluding NYC, 2011 Reported Gonorrhea among Women, NYS, excluding NYC,

10 Chlamydia Age and Sex-Specific Rates: NYS excluding NYC, 2011 Gonorrhea Age and Sex-Specific Rates: NYS excluding NYC,

11 50 Reported Cases of Chlamydia by Reporting Source NYS excluding NYC, % of Cases Private Provider Health Dept Family Planning Hospital CHC Other Men Women 35 Reported Cases of Gonorrhea by Reporting Source NYS excluding NYC, Private Provider % of Cases 25 Health Dept Family Planning 20 Hospital CHC Other 5 0 Men Women 11

12 WHY IT MATTERS Who is caring for adolescents? 12

13 WHO IS CARING FOR MORE TEENS NOW COMPARED TO 5 YEARS AGO? Raise your hands!! Clinical Care: Female Adolescents 25 Source: National Ambulatory Medical Care Survey, Hoover et al., J Adol Health,

14 26 Routinizing sexual health in 1º care Create an adolescent medical home Approach to the Adolescent Key Strategies Assess developmental level Discuss confidentiality with adolescent/parent Appropriately ensure confidentiality, time alone Brief risk assessment at most visits STI screening annually if sexually active Systems for follow-up of confidential results 27 14

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17 32 ADOLESCENT STI RISK ASSESSMENT Available tools 33 Comprehensive HEADSSS H: Home E: Education/Employment/Eating A: Activities D: Drugs S: Suicidality/Depression S: Sexuality/Sexual l Behavior S: Safety S: Spirituality 17

18 SSHADESS* Strength Assessment Tool for Psychosocial Screening 34 Strength or interests School Home Activities Drugs/substance use Emotions/depression Sexuality Safety *Clark and Ginsburg,

19 36 ASSESSING SEXUAL BEHAVIOR Include questions that direct testing CDC Recommendations Assessment: The 5 P s 37 PARTNERS Sexual PRACTICES PAST history of STIs PREGNANCY PROTECTION from STI 19

20 38 Guidelines for Adolescent STI Testing Bright Futures-American Academy of Pediatrics U.S. Preventive Services Task Force Centers for Disease Control and Prevention 39 Bright Futures (3 rd ed; 4 th ed in development) STI Screening for Adolescents Chlamydia and gonorrhea screening appropriate for patient population and clinical setting Offer HIV and syphilis testing based on: Clinical setting: STI Clinic, correctional facility, homeless shelter, TB clinic, clinic for MSM, clinic prevalence >1% STI risk factors: Unprotected sex with > 1 partner Ever been treated for STI Use or ever use intravenous drugs MSM Trades sex for money/ partner has ever Past/current partner bisexual, HIV positive, IVDU 20

21 Bright Futures STI Prevention via Immunization Human Papillomavirus Vaccines Gender neutral recommendation 2012 HEDIS HPV measure for Adolescents Hepatitis B Vaccine Hepatitis A Vaccine USPSTF Chlamydia Screening Recommendations Recommendations by CDC, United States Preventive Services Task Force (USPSTF), medical associations Screen all sexually-active active females aged <25 years annually Screen women aged 25 years if at increased risk USPSTF: A-rated recommended preventive service 21

22 What about males?! Insufficient evidence to recommend routine chlamydia screening in young men feasibility efficacy cost Correctional facilities Selective screening in high- prevalence populations may be beneficial: STD clinics Adolescent-serving clinics MSM Multiple partners How Well Are Providers Chlamydia Screening Annually? 2010 Chlamydia Screening HEDIS Rates Health Plan Type Age Commercial Medicaid (yrs) (%) (%) The State of Health Care Quality, 2011 National Center for Quality Assurance at: 22

23 USPSTF Gonorrhea Screening Recommendations Screen all sexually active if at risk for infection i.e., young (<25 yrs), previous gonorrhea or other STIs, new or multiple sexual partners, inconsistent condom use, sex work, drug use Risk factors for pregnant = non-pregnant African Americans and MSM have higher prevalence of infection than the general population in many communities and settings Insufficient evidence to recommend for or against routine gonorrhea screening in men at risk ik No routine gonorrhea screening and at risk Chlamydia/Gonorrhea Screening: Preferred Noninvasive Genitourinary Specimens Females: Vaginal swab Vaginal swab samples are as sensitive as endocervical swab specimens, with no difference in specificity Urine samples are acceptable, but urine may have performance when compared to genital swab samples Males: Urine In some studies, urethral swab samples sensitive than urine, though equivalently specific 23

24 CDC Adolescent STI Screening Recommendations Annual C. trachomatis (CT) screen all sexually active females aged 25 yrs Annual N. gonorrhoeae (GC) screen all at-risk sexually active females Females aged <25 years are highest risk for gonorrhea infection Discuss HIV screening with all adolescents and encourage testing for those at risk CDC Recommendations Screening for Other STIs 47 Routine screening of asymptomatic adolescents for certain STIs (syphilis, trichomoniasis, BV, HSV, HPV, HAV, HBV) not recommended Consider individual and population-based risk factors Pregnant adolescents require more thorough evaluation Begin cervical cancer screening at age 21 in most cases 24

25 Adolescent Prevention Encourage immunizations, including HPV, HAV and HBV Provide information on HIV infection, testing, transmission, and implications of infection to all adolescents as part of health care Integrate sexuality education into clinical practice USPSTF recommends high-intensity STD prevention behavioral counseling for all sexually active adolescents twice yearly 25

26 50 RESOURCES FOR PRACTITIONERS AAP/SOAH SAHM CDC NCC 26

27 Chlamydia Coalition ncc.prevent.org 53 Coalition includes AAP, CDC, SAHM, ACOG, non-profits, health plans, advocacy groups Aim to increase chlamydia screening Provides tools and resources for practitioners and patients 27

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31 60 The GYT om/gyt campaign is a youthful, empowering social movement to reduce the spread of STDs among young people Visit the web sites for provider resources, tools, and GYT materials to help support your local STD prevention efforts: provider.gytnow.org

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33 Changes You May Wish to Make In Your Practice Use adolescent EMR template Prompt on EMR/visit note for confidential contact # Risk behavior screening questionnaire before visit Universal urine collection Make primary care opportunities at sick visits STI Screening Immunizations Assess length of teen pt visit w/ flow study List of community resources for confidential reproductive health/mental health services Resources Useful Websites American Academy of Pediatrics Bright Futures NY State American Academy of Pediatrics Physicians for Reproductive Choice and Health Society for Adolescent Health and Medicine North American Society for Pediatric and Adolescent Gynecology American Civil Liberties Union Reproductive Freedom Project 33

34 Resources Useful Websites Advocates for Youth Guttmacher Institute Center for Adolescent Health and Law Sexuality Information and Education Council of the United States Association of Reproductive Health Professionals National Chlamydia Coalition Emergency contraception 34

35 QUESTIONS? 35