Screening for Chlamydia and Gonorrhea: U.S. Preventive Services Task Force Recommendation Statement

Screening for Chlamydia and Gonorrhea: U.S. Preventive Services Task Force Recommendation Statement FREE

Michael L. LeFevre, MD, MSPH, on behalf of the U.S. Preventive Services Task Force*

 Ann Intern Med. 2014;161:902-910. doi:10.7326/M14-1981

The USPSTF recommends screening for chlamydia in sexually active females aged 24 years or younger and in older women who are at increased risk for infection. (B recommendation)The USPSTF recommends screening for gonorrhea in sexually active females aged 24 years or younger and in older women who are at increased risk for infection. (B recommendation)The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydia and gonorrhea in men. (I statement)

---

The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without related signs or symptoms.

It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.

The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.

Asymptomatic Sexually Active Adolescents and Young Adults Should Not Be Screened for Herpes Simplex Virus

Hayley D. Mark, PhD, MPH, RN

JAMA Pediatr. 2013;():1-2. doi:10.1001/jamapediatrics.2013.462.

Herpes simplex virus (HSV) types 1 and 2 are highly prevalent in the general population of the United States. The seroprevalence of HSV-2 and HSV-1 were 17% and 58%, respectively, in a cohort aged 14 to 49 years who participated in the National Health and Nutrition Examination Survey from 1999 to 2004.1 Seroprevalence is substantially less among adolescents and young adults. Approximately 80% of infected individuals are unaware of their infection and the majority of infections are transmitted by these individuals.2

Type-specific serological assays for HSV became commercially available in 1999, making possible wide-scale screening for HSV-1 and HSV-2. However, the value of HSV screening is controversial. Proponents argue that on detection, asymptomatic carriers can be counseled to use prevention methods and, thus, reduce the possibility of transmission to uninfected partners. Opponents point out the possibility that large numbers of asymptomatic individuals may receive a diagnosis of a stigmatized, chronic infection, with substantial transmission potential, but there are no substantial data to support the effectiveness of HSV screening in changing sexual behaviors or preventing transmission.

The important questions that a clinician must consider in determining the value of HSV screening among asymptomatic sexually active adolescents and young adults are derived from the Wilson and Jungner classic public health report3 on criteria for use of a screening test and include the following: (1) Is the disease an important public health problem? (2) Is an accurate screening test available and is it acceptable to the population? (3) Does screening improve health outcomes and symptoms or reduce transmission of disease? (4) Are the costs and risks of screening less than the benefits?

Behavioural interventions for the prevention of sexually transmitted infectionsin young people aged 13-19 years: a systematic review. 

Health Educ Res. 2012 Jun;27(3):495-512. Epub 2012 Feb 20.
Picot J, Shepherd J, Kavanagh J, Cooper K, Harden A, Barnett-Page E, Jones J, Clegg A, Hartwell D, Frampton GK.
Southampton Health Technology Assessments Centre, University of Southampton, First Floor, Epsilon House, Enterprise Road, University of Southampton Science Park, Southampton, SO16 7NS, UK. j.picot@soton.ac.uk 

We systematically reviewed school-based skills building behavioural interventions
for the prevention of sexually transmitted infections. References were sought
from 15 electronic resources, bibliographies of systematic reviews/included
studies and experts. Two authors independently extracted data and
quality-assessed studies. Fifteen randomized controlled trials (RCTs), conducted 
in the United States, Africa or Europe, met the inclusion criteria. They were
heterogeneous in terms of intervention length, content, intensity and providers. 
Data from 12 RCTs passed quality assessment criteria and provided evidence of
positive changes in non-behavioural outcomes (e.g. knowledge and self-efficacy). 
Intervention effects on behavioural outcomes, such as condom use, were generally 
limited and did not demonstrate a negative impact (e.g. earlier sexual
initiation). Beneficial effect on at least one, but never all behavioural
outcomes assessed was reported by about half the studies, but this was sometimes 
limited to a participant subgroup. Sexual health education for young people is
important as it increases knowledge upon which to make decisions about sexual
behaviour. However, a number of factors may limit intervention impact on
behavioural outcomes. Further research could draw on one of the more effective
studies reviewed and could explore the effectiveness of 'booster' sessions as
young people move from adolescence to young adulthood. 

Interventions to reduce sexual risk for human immunodeficiency virus in adolescents: a meta-analysis of trials, 1985-2008.

OBJECTIVE: To provide an updated review of the efficacy of behavioral interventions to reduce sexual risk of human immunodeficiency virus (HIV) among adolescents.
DESIGN: We searched electronic databases, leading public health journals, and the document depository held by the Synthesis of HIV/AIDS Risk Reduction Project. Studies that fulfilled the selection criteria and were available as of December 31, 2008, were included.
SETTING: Studies that investigated any behavioral intervention advocating sexual risk reduction for HIV prevention, sampled adolescents (age range, 11-19 years), measured a behavioral outcome relevant to sexual risk, and provided sufficient information to calculate effect sizes.
PARTICIPANTS: Data from 98 interventions (51,240 participants) were derived from 67 studies, dividing for qualitatively different interventions and gender when reports permitted it.
MAIN OUTCOME MEASURES: Condom use, sexual frequency, condom use skills, interpersonal communication skills, condom acquisition, and incident sexually transmitted infections (STIs).
RESULTS: Relative to controls, interventions succeeded at reducing incident STIs, increasing condom use, reducing or delaying penetrative sex, and increasing skills to negotiate safer sex and to acquire prophylactic protection. Initial risk reduction varied depending on sample and intervention characteristics but did not decay over time.
CONCLUSIONS: Comprehensive behavioral interventions reduce risky sexual behavior and prevent transmission of STIs. Interventions are most successful to the extent that they deliver intensive content.

The impact of quadrivalent human papillomavirus (HPV; types 6, 11, 16, and 18) L1 virus-like particle vaccine on infection and disease due to oncogeni

The impact of quadrivalent human papillomavirus (HPV; types 6, 11, 16, and 18) L1 virus-like particle vaccine on infection and disease due to oncogenic nonvaccine HPV types in sexually active women aged 16-26 years.
J Infect Dis. 2009 Apr 1;199(7):919-22.

Wheeler CM, Kjaer SK, Sigurdsson K, Iversen OE, Hernandez-Avila M, Perez G, Brown DR, Koutsky LA, Tay EH, García P, Ault KA, Garland SM, Leodolter S, Olsson SE, Tang GW, Ferris DG, Paavonen J, Steben M, Bosch FX, Dillner J, Joura EA, Kurman RJ, Majewski S, Muñoz N, Myers ER, Villa LL, Taddeo FJ, Roberts C, Tadesse A, Bryan J, Lupinacci LC, Giacoletti KE, James M, Vuocolo S, Hesley TM, Barr E.

University of New Mexico, Department of Molecular Genetics and Microbiology, Albuquerque, NM 87131, USA. cwheeler@salud.unm.edu

BACKGROUND: We evaluated the impact of a quadrivalent human papillomavirus (HPV) vaccine on infection and cervical disease related to 10 nonvaccine HPV types (31, 33, 35, 39, 45, 51, 52, 56, 58, and 59) associated with >20% of cervical cancers. The population evaluated included HPV-naive women and women with preexisting HPV infection and/or HPV-related disease at enrollment. METHODS: Phase 3 efficacy studies enrolled 17,622 women aged 16-26 years. Subjects underwent cervicovaginal sampling and Pap testing on day 1 and then at 6-12-month intervals for up to 4 years. HPV typing was performed on samples from enrollment and follow-up visits, including samples obtained for diagnosis or treatment of HPV-related disease. All subjects who received 1 dose and returned for follow-up were included. RESULTS: Vaccination reduced the rate of HPV-31/33/45/52/58 infection by 17.7% (95% confidence interval [CI], 5.1% to 28.7%) and of cervical intraepithelial neoplasia (CIN) 1-3 or adenocarcinoma in situ (AIS) by 18.8% (95% CI, 7.4% to 28.9%). Vaccination also reduced the rate of HPV-31/58/59-related CIN1-3/AIS by 26.0% (95% CI, 6.7% to 41.4%), 28.1% (95% CI, 5.3% to 45.6%), and 37.6% (95% CI, 6.0% to 59.1%), respectively. Although a modest reduction in HPV-31/33/45/52/58-related CIN2 or worse was observed, the estimated reduction was not statistically significant. CONCLUSIONS: These cross-protection results complement the vaccine's prophylactic efficacy against disease associated with HPV-6, -11, -16, and -18. Long-term monitoring of vaccinated populations are needed to fully ascertain the population-based impact and public health significance of these findings.

Natural History of Genital Warts: Analysis of the Placebo Arm of 2 Randomized Phase III Trials of a Quadrivalent Human Papillomavirus (Types 6, 11, 16

Garland SM, Steben M, Sings HL, et al. Natural History of Genital Warts: Analysis of the Placebo Arm of 2 Randomized Phase III Trials of a Quadrivalent Human Papillomavirus (Types 6, 11, 16, and 18) Vaccine. J Infect Dis. 2009 Jan 2

Background. The placebo arm of human papillomavirus (HPV) vaccine trials helps define the natural history of genital warts (GW). Methods. Women enrolled in the placebo arm ([Formula: see text]) of 2 randomized trials of a quadrivalent vaccine were examined for the presence of GW for up to 9 visits over approximately 4 years. A comprehensive examination of the perianal area, vulva, and vagina prompted biopsy. Biopsy samples were analyzed by a blinded panel of up to 4 histopathologists and tested for 14 HPV genotypes (6, 11, 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, and 59) by use of a polymerase chain reaction-based assay. Risk factors for the development of GW were assessed. Results. Women were followed up for an average of 3.6 years (range, 0-4.9 years). Overall, 298 (3.4%) of 8800 participants developed GW related to HPV-6 or HPV-11 (incidence rate, 0.87 cases per 100 person-years-at-risk). In total, 520 distinct lesions were diagnosed as GW. HPV DNA was detected in 472 (90.8%) lesions, with HPV-6 and HPV-11 detected in 447 (86.0%) of these lesions (94.7% of 472 HPV DNA-positive lesions). We found high-risk HPV types in 161 (31.0%) of 520 lesions. Risk factors for HPV-6- and HPV-11-related GW included infection at baseline, acquisition of new sex partners, a higher number of sex partners, and DNA positivity at baseline for a high-risk HPV type. Conclusions. We confirm the major role played by HPV-6 and HPV-11 in GW, as well as associated risk factors. A vaccine that includes these types of HPV could substantially reduce the overall burden of HPV disease.

Behavioral counseling to prevent sexually transmitted infections: U.S. PreventiveServices Task Force recommendation statement.

U.S. Preventive Services Task Force.
Collaborators: Calonge N, Petitti DB, DeWitt TG, Dietrich AJ, Gordis L, GregoryKD, Harris R, Isham G, Leipzig R, LeFevre ML, Loveland-Cherry C, Marion LN, MoyerVA, Ockene JK, Sawaya GF, Yawn BP.

Ann Intern Med. 2008 Oct 7;149(7):491-6, W95.

DESCRIPTION: New U.S. Preventive Services Task Force (USPSTF) recommendations about behavioral counseling of adolescents and adults to prevent sexuallytransmitted infections (STIs).
METHODS: The USPSTF reviewed the evidence on the benefits and harms of counseling. The review included studies evaluating behavioral counseling interventions conducted in primary settings, those judged feasible in primary care, and those to which patients might be referred from primary care.
RECOMMENDATIONS: The USPSTF recommends high-intensity behavioral counseling for all sexually active adolescents and for adults at increased risk for STIs. (B recommendation) Current evidence is insufficient to assess the balance of benefits and harms of behavioral counseling to prevent STIs in non-sexually active adolescents and in adults not at increased risk for STIs. (I statement).