STD-Prevention Counseling Practices and Human Papillomavirus Opinions Among Clinicians with Adolescent Patients --- United States, 2004

In 2000, an estimated 18.9 million new cases of sexually transmitted diseases (STDs) occurred in the United States (1). Although young persons aged 15--24 years represented only 25% of the sexually active population, approximately 48% of STD cases in 2000 occurred in this age group (1). The most common sexually transmitted infection in persons aged <24 years was attributed to human papillomavirus (HPV) (1). Although the natural immunity of most young persons can clear HPV infections with no clinical consequences, certain infections persist and result in warts, precancerous changes, and invasive cancers of the anogenital region in both males and females. In 2000, an estimated 4.6 million new HPV infections occurred among persons aged 15--24 years (1), resulting in expected direct medical lifetime costs of $2.9 billion (2). In June 2006, the Food and Drug Administration licensed the first HPV vaccine for females aged 9--26 years for the prevention of cervical cancer (U.S. 2000 incidence rate: 9.4 cases per 100,000), precancerous genital lesions, and genital warts associated with HPV types included in the vaccine (HPV 6, 11, 16, and 18). Protection has been demonstrated for genital infections associated with HPV types included in the vaccine; therapeutic efficacy for persons already infected has not been demonstrated.* To assess 1) STD risk assessment, counseling, and education practices of U.S. health-care providers during routine adolescent^† check-ups and 2) provider opinions regarding methods to prevent HPV acquisition, CDC and Battelle Centers for Public Health Research and Evaluation surveyed clinicians who provided adolescent primary care. The results of this survey indicated that most of the clinicians assessed STD risk in their adolescent patients, addressed STD prevention, and recommended various STD-prevention methods; however, clinician opinions varied regarding the effectiveness of methods for preventing HPV infection and whether their patients would adopt these methods for the long term. Clinicians periodically should assess STD risk in their adolescent patients and provide STD counseling and education to reduce the incidence of STDs in this age group at high risk.

The analyses described in this report resulted from a broader assessment of the knowledge, attitudes, and practices among U.S. clinicians regarding HPV infections and general STD practice (3). In May 2004, CDC mailed surveys to 5,386 clinicians in seven specialties who commonly provide STD diagnosis, treatment, and prevention services.^§ Nationally representative samples were drawn from databases that included members and nonmembers of the American Medical Association, American Association of Physicians' Assistants, American College of Nurse Midwives, and American Association of Nurse Practitioners. Clinicians were eligible for the survey if they practiced >8 hours per week in an outpatient setting, they provided routine checkups, and >20% of their patients were aged 13--65 years. Stratified sampling by specialty was conducted to enable comparisons among specialties. The survey collected data on clinician demographic, practice, and patient characteristics; STD risk assessment, counseling, and education practices; and opinions regarding HPV infection prevention methods. Analyses were weighted to adjust for disproportionate sampling by specialty and nonresponse. Survey methods have been more fully described previously (3).

To increase the response rate, the initial survey mailing included $50 cash, and up to four additional reminders were sent to the 5,386 clinicians sampled. After adjusting for ineligibility, the overall response rate was 82%. For this study, analyses were restricted to the 2,958 (87%) respondents who reported providing routine adolescent checkups.

Among the 2,958 clinicians, 84% reported practicing in a private setting, 83% were white, and 55% were male. Those surveyed reported practicing a median of 14 years; the majority of their patients were female (mean: 69%), white (mean: 69%), and privately insured (mean: 53%). Nearly all the clinicians (94%) reported previous experience in diagnosing STDs, with reported medians of five and six diagnoses of Chlamydia trachomatis infection and genital herpes during the preceding 12 months, respectively. Among the respondents, 81% reported usually or always asking about the sexual behavior of their adolescent patients to assess STD risk. To prevent STDs, 90% of clinicians reported usually or always recommending that their adolescent patients use condoms, 76% recommended practicing monogamy or limiting the number of sex partners, and 54% recommended abstaining from sex.

Surveyed clinicians were asked their opinions regarding use of condoms, practicing monogamy/limiting number of sex partners, and abstinence as methods for both their sexually active adult and adolescent patients to prevent acquisition of HPV infection or HPV-related conditions (Table).^¶ Nearly all (95%) respondents believed that practicing monogamy or limiting the number of sex partners was highly effective, and 81% thought these practices were worthwhile to recommend to most patients. In response to another question, although 91% believed that abstinence was highly effective for prevention of HPV infection, 45% thought that abstinence was worthwhile to recommend. Among the clinician groups sampled, adolescent medicine and family practice physicians were significantly more likely to agree that abstinence was worthwhile to recommend than clinicians in all the other specialties combined (56% [95% confidence interval (CI) = 51%--61%] versus 36% [CI = 33%--39%]; odds ratio = 2.3 [CI = 1.8--2.9]; p<0.05). In addition, 78% believed that consistent and correct condom use was effective, and 89% thought that condom use was worthwhile to recommend. However, 96% agreed with the statement, "Condoms may not be 100% effective due to slippage, breakage, leakage or pore size," and 97% agreed with the statement, "Condoms cannot prevent transmission of infections during skin-to-skin contact in areas not covered/in contact with a condom." Among respondents, 23% believed consistent condom use would be adopted for the long term by most of their patients, compared with 21% for monogamy/limiting number of sex partners and 6% for abstinence (Table).

Practices of a subset of 352 clinicians who reported >75% of their patients were aged <18 years also were analyzed. Of these, 97% reported usually or always during adolescent check-ups recommending that their patients use condoms for STD prevention, 62% recommended practicing monogamy or limiting the number of sex partners, and 51% recommended abstinence. In addition, 93% reported routinely providing STD-prevention education, and 69% reported routinely providing education about genital HPV infection to adult and adolescent patients whom they believed were sexually active. Among the clinicians who provided STD-prevention education, in-person education (73%) was more common than delegating to staff (15%) or providing written materials (5%).

Reported by: D Montaño, PhD, D Kasprzyk, PhD, L Carlin, PhD, A Greek, PhD, C Freeman, PhD, Battelle Centers for Public Health Research and Evaluation, Seattle, Washington. K Irwin, MD, R Barnes, MPH, N Jain, MD, C Walsh, DrPH, Div of STD Prevention, National Center for HIV, Viral Hepatitis, STDs, and Tuberculosis Prevention (proposed); Z Henderson, MD, EIS Officer, CDC.

Editorial Note:

As recommended by national STD treatment guidelines (4), 81% of the clinicians surveyed in this study reported taking advantage of the routine check-up to assess STD risk in their adolescent patients. In addition, 93% of those with >75% of their patients aged <18 years reported educating patients they believed were sexually active about prevention of STDs, and 69% reported specifically addressing HPV infection. Clinician counseling of adolescents regarding STD prevention has been determined to reduce the incidence of STDs (5). Current national recommendations encourage clinicians to periodically assess adolescents for STD risk and provide STD counseling (6).

Although abstinence is the surest method to reduce the risk for acquiring HPV infection and other sexually transmitted infections, monogamy, minimizing the number of sex partners, and condom use also can reduce the risk (4,7). Large proportions (78%--95%) of clinicians believed that consistent condom use, abstinence, monogamy, and limiting number of sex partners were highly effective methods to prevent acquisition of HPV infection or HPV-related conditions. However, only 6%--23% believed that the majority of their patients would adopt these methods for the long term.

In this study, clinicians were more likely to rate abstinence, monogamy, and limiting number of sex partners as highly effective compared with condom use; however, they rated condoms as the method their patients most likely would use long term. These findings are consistent with studies suggesting that clinicians are more likely to recommend STD prevention and contraceptive methods such as condoms, which are not as effective as abstinence but more likely to be used (8). A limited number of prospective studies have evaluated the effect of condom use on the acquisition of genital HPV infection; a recent prospective study among college women demonstrated that consistent condom use was associated with a 70% reduction in the acquisition of genital HPV infection (7). In addition, previously published data indicate that condom use might reduce the risk for both genital warts and cervical cancer (4).

Although the majority of clinicians surveyed did not believe that most of their patients would use effective STD-prevention methods long term, they nonetheless thought recommending these methods was worthwhile. Such recommendations might not reach the estimated 40% of adolescents in the United States who do not receive routine medical check-ups and might be at higher risk for STDs (9). However, STD risk assessment, screening, and counseling also can be provided during urgent-care visits and nonroutine visits required for sports, camp, and school participation (9,10).

The findings in this report are subject to at least four limitations. First, although estimates were weighted for nonresponse bias, whether practices of responders differed substantially from those of nonresponders is unknown. Second, survey responses were not compared with medical or counseling records that might document actual practices; surveyed clinicians might have reported practices that were more consistent with guidelines than were documented in their medical records or reported by their patients. Third, certain questions about prevention methods did not distinguish between sexually inexperienced and sexually active patients, and prevention messages likely differed by patient sexual experience. Finally, general pediatricians who did not indicate a specialty of adolescent medicine were not included in the sample, although their patients might include large proportions of adolescents.

Scientific data link HPV infection to cervical cancer (4). Screening tests for HPV infection and the new vaccine to prevent infections from HPV genotypes that cause most cases of cervical HPV infection are now available, in addition to traditional Pap tests for precancerous and cancerous cervical lesions. The Advisory Committee on Immunization Practices issued provisional recommendations that this vaccine be routinely administered to girls aged 11--12 years and used for catch-up immunization in females aged 13--26 years.** Clinicians should be prepared to discuss with their adolescent patients prevention of HPV infection and other viral and bacterial STDs.

To support clinician risk assessment and prevention counseling for HPV infection, CDC and others have updated online training and support materials. A webcast, HPV and Cervical Cancer: An Update on Prevention Strategies, is available at http://www.phppo.cdc.gov/phtn/hpv-05; a netconference, Human Papillomavirus (HPV), Cervical Cancer, and HPV Vaccine and Recommendations, is available at http://www.cdc.gov/nip/ed/ciinc/hpv.htm. Materials regarding HPV infection also have been updated for patients and the general public to increase awareness of these topics and various prevention strategies. An overview of HPV infection and information regarding STDs is available at http://www.cdc.gov/std/hpv, and information regarding HPV vaccine is available at http://www.cdc.gov/nip/vaccine/hpv/default.htm.

Acknowledgments

The findings in this report are based, in part, on contributions by D Burkom, MS, Battelle Centers for Public Health Research and Evaluation, Seattle; L Koutsky, PhD, W Phillips, MD, Univ of Washington. T Cox, MD, G Sawaya, MD, Univ of California, San Francisco. D Saslow, PhD, American Cancer Society, Atlanta, Georgia. D Harper, MD, Norris Cotton Cancer Center, Manchester, New Hampshire. K Noller, MD, Tufts New England Medical Center, Boston, Massachusetts. J Dixon, W Teal, T Grant, J Douglas, MD, E Dunne, MD, K Stone, MD, H Lawson, MD, M Saraiya, MD, D McCree, PhD, A Friedman, M Sternberg, PhD, CDC.

References

1. Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspect Sex Reprod Health 2004;36:6--10.
2. Chesson HW, Blandford JM, Gift TL, Tao G, Irwin KL. The estimated direct medical cost of sexually transmitted diseases among American youth, 2000. Perspect Sex Reprod Health 2004;36:11--9.
3. Irwin K, Montano DE, Kasprzyk D, et al. Cervical cancer screening, abnormal cytology management, and counseling practices in the United States. Obstet Gynecol 2006;108:397--409.
4. CDC. Sexually transmitted diseases treatment guidelines, 2006. MMWR 2006;55(No. RR-11).
5. Bolu OO, Lindsey C, Kamb ML, et al. Is HIV/sexually transmitted disease prevention counseling effective among vulnerable populations? A subset analysis of data collected for a randomized, controlled trial evaluating counseling efficacy (Project RESPECT). Sex Transm Dis 2004;31:469--74.
6. Elster A, Kuznets N. AMA guidelines for adolescent preventive services (GAPS): recommendations and rationale. Baltimore, MD: Williams & Wilkins; 1994.
7. Winer RL, Hughes JP, Feng Q, et al. Condom use and the risk of genital human papillomavirus infections in young women. N Engl J Med 2006;354:2645--54.
8. Grimley DM, Lee PA. Condom and other contraceptive use among a random sample of female adolescents: a snapshot in time. Adolescence 1997;32:771--9.
9. Burstein GR, Lowry R, Klein JD, Santelli JS. Missed opportunities for sexually transmitted diseases, human immunodeficiency virus, and pregnancy prevention services during adolescent health supervision visits. Pediatrics 2003;111(5 Pt 1):996--1001.
10. Shafer MA, Tebb KP, Ko TH. Extending preventive care to pediatric urgent care: a new venue for CT screening. Presented at the National STD Prevention Conference, Philadelphia, PA, March 8--11, 2004.

* Available at http://www.fda.gov/cder/offices/oodp/whatsnew/gardasil.htm.

^† An age range for adolescents was not defined in this survey.

^§ Family/general physicians; general internists; adolescent medicine physicians; obstetrician/gynecologists; nurse practitioners specializing in family, adult, or women's health; certified nurse midwives; and physician assistants practicing primary care.

^¶ Participants were asked to respond to a series of statements (e.g., "For most of my patients, it is worthwhile to recommend consistent condom use." or "Abstinence is highly effective.") by choosing one response from a five-point scale (i.e., strongly agree, agree, neither agree nor disagree, disagree, and strongly disagree).

** Available at http://www.cdc.gov/nip/recs/provisional_recs/hpv.pdf.

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Date last reviewed: 10/19/2006