Comprehensive Adolescent Sexual Health: An Unmet Prevention Need

With sexual activity comes the risk of unintended pregnancy and the risk of acquiring a sexually transmitted infection (STI). Despite these dual risks, prevention efforts often focus on only one piece of the dyad. This failure to address comprehensive prevention needs related to the sexual health of adolescents is due to both communication gaps and a lack of tools to reduce the risk of pregnancy and STI acquisition.

Because of the clear lifelong outcome of most pregnancies—a living child—reducing the risk of unintended pregnancy often takes the forefront. This understanding leads women, particularly adolescents, to prioritize pregnancy prevention, sometimes at the cost of STI prevention. ¹ Sexual abstinence is the only way to eliminate any risks associated with penetrative sex. Short of abstinence, the only prevention mechanism that exists to effectively lower both pregnancy and STI risk is the condom, a method that requires consistent, correct use to work well. ²

In this issue of the Journal of Women's Health, Hunter et al. attempt to shed light on the ongoing problem of STI risk among contraception users. ³ Using a population of women aged 15–29 years who accessed services through a publicly funded California program aimed at addressing family planning needs, the authors analyzed chlamydia positivity (the proportion of women with a positive Chlamydia trachomatis test divided by all women tested) by contraception type. Women were grouped into tiers of contraception use based on the most effective method that they were using. All three groups of contraception users had clinically similar positivity, but women who were prescribed shorter acting hormonal methods (e.g., oral contraception, injectable contraception, patch, and vaginal ring) had statistically higher positivity (5.3%) than the other two groups of contraception users (permanent or long-acting reversible contraception [LARC] methods, 4.5%; barrier methods/emergency contraception/natural family planning, 4.9%) (p < 0.001). When analyzed separately, women who were given condoms had higher positivity than women who were not given condoms (adjusted prevalence ratio: 1.32, 95% confidence interval: 1.24–1.40).

The data used in this analysis reflect a population that may not be largely generalizable to the overall U.S. population of sexually active young women, given that the study population from California consisted of young women who had an economic need (living at ≤200% of the federal poverty level) and who sought free family planning services. However, chlamydia positivity has been shown to be a reasonable proxy for prevalence, ⁴ and the positivity reported by Hunter et al. is in line with national statistics that estimate chlamydia prevalence to be about 5% among sexually active women aged 14–24 years. ⁵ This suggests at least a partially shared risk profile between the U.S. population and the study population, despite some study limitations.

Use of cross-sectional data, while uniquely combined to look at both contraception provision and STI positivity, does not allow for conclusions about directionality. This might be particularly relevant for condom provision. The authors were not able to determine the timing of condom distribution relevant to a positive chlamydia test result. Condom distribution after a positive chlamydia test may reflect sexual risk associated with the diagnosis (more distribution due to high risk as evidenced by diagnosed STI risk). Likewise, condom distribution before a positive chlamydia test may also be reflective of a higher patient risk (whether indicated through conversations with the provider or provider perception). Regardless of the timing, the authors demonstrated that condom distribution was inadequate and targeted to women with a higher risk of STI acquisition. Only 39% of the study population had documentation of condom receipt. Although some patients may have accessed condoms elsewhere, there is likely an opportunity to enhance discussions around condom use and ensure uniform condom access in the clinic setting.

Overall, the findings reported by Hunter et al. suggest an ongoing unmet STI prevention need among contraception users. Some experts expressed early concern that users of LARC methods (intrauterine devices and subdermal hormonal implants) may be at a greater STI risk, ⁶ but the data presented by Hunter et al. do not support that concern. Instead, the results highlight the continued need for comprehensive sexual education and health for all adolescents, merging the prevention of unplanned pregnancies and the prevention of STIs together. Multipurpose prevention technologies (MPTs), products designed to address more than one prevention need, may help address this gap. ⁷ The need for novel MPTs is particularly pronounced given the limitations of condoms in reducing STI and pregnancy risk. When used perfectly, condom effectiveness is very high; only 2 in 100 women would experience an unintended pregnancy within a year. ⁸ However, perfect use is rare. Typical condom use confers much lower effectiveness, 18 in 100 women would experience an unintended pregnancy within a year. The effectiveness of condoms in preventing STIs varies substantially, with relatively high effectiveness at preventing bacterial infections, like chlamydia, and lower effectiveness at preventing viral infections, like HPV. ² Typical condom use in combination with overall population-level inadequate use lends further evidence to the value of additional MPTs.

Addressing the shared risk of pregnancy and STIs demands a cohesive effort around fully contextualizing the larger risk of unprotected sex and working toward a fully informed population of at-risk young women. Work by Hunter et al. lays the groundwork for future studies in this area.