Sexually Transmitted Diseases:
Association of Adolescents’ History of Sexually Transmitted Disease (STD) and Their Current High-Risk Behavior and STD Status: A Case for Intensifying Clinic-Based Prevention Efforts
DICLEMENTE, RALPH J. PhD*†; WINGOOD, GINA M. ScD, MPH*; SIONÉAN, CATLAINN PhD*‡; CROSBY, RICHARD PhD*; HARRINGTON, KATHY MPH, MAEd§; DAVIES, SUSAN PhD§; HOOK, EDWARD W. III, MD∥; OH, M. KIM MD¶
From the *Rollins School of Public Health, Department of Behavioral Sciences and Health Education, and †School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Epidemiology, and Immunology, Emory University, Atlanta; ‡Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia; and §School of Public Health, Department of Health Behavior, and School of Medicine, ∥Department of Medicine, Division of Infectious Diseases, and ¶Department of Pediatrics, University of Alabama, Birmingham, Alabama
Use of trade names and commercial products is for identification only and does not imply endorsement of the Centers for Disease Control and Prevention.
Reprint requests: Ralph J. DiClemente, PhD, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, BSHE/Room 520, Atlanta, GA 30322. E-mail: firstname.lastname@example.org
Received for publication July 27, 2001,
revised December 5, 2001, and accepted December 7, 2001.
Background: Adolescents are at high risk of sexually transmitted disease (STD)/HIV infection, and one vulnerable subgroup is African American females. The association between adolescents’ previous experience of STD and recent sexual risk behaviors has been ill-defined.
Goal: The goal was to examine the associations between adolescents’ self-reported history of STD diagnosis and current sexual risk behaviors, prevention knowledge and attitudes, and STD infection status.
Study Design: This was a cross-sectional survey. Recruitment sites were in low-income neighborhoods of Birmingham, Alabama, characterized by high rates of unemployment, substance abuse, violence, and STDs. Participants were sexually active adolescent females (N = 522) 14 to 18 years of age. Information on STD history and current sexual behaviors (within the 30 days before assessment) was collected in face-to-face interviews. Less sensitive topics, such as STD prevention knowledge, attitudes about condom use, and perceived barriers to condom use, were addressed via self-administered survey. DNA amplification of vaginal swab specimens provided by the adolescents was performed to determine current STD status. Outcomes associated with past STD diagnosis were determined by means of logistic regression to calculate adjusted odds ratios (AORs) in the presence of observed covariates.
Results: Twenty-six percent of adolescents reported ever having an STD diagnosed. Although past STD diagnosis was associated with increased STD prevention knowledge, it was not associated with increased motivation to use condoms. Compared with adolescents who had never had an STD, adolescents with a history of diagnosed STD were more likely to report not using a condom at most recent intercourse (AOR = 2.54; 95% CI = 1.64–3.93;P = 0.0001), recent unprotected vaginal intercourse (AOR = 1.79; 95% CI = 1.15–2.79;P = 0.010), inconsistent condom use (AOR = 2.27; 95% CI = 1.46–3.51;P < .0001), sexual intercourse while drinking alcohol (AOR = 2.09; 95% CI = 1.33–3.28;P = 0.001), and unprotected intercourse with multiple partners (AOR = 3.29; 95% CI = 1.09–9.89;P = 0.034). Past STD diagnosis was associated with increased risk for current biologically confirmed gonorrhea and trichomoniasis (AOR = 2.48; 95% CI = 1.09–5.23;P = 0.030; and AOR = 2.05; 95% CI = 1.18–3.59;P = 0.011, respectively). Past STD diagnosis was not significantly associated with increased risk of current biologically confirmed chlamydia (AOR = 0.78; 95% CI = 0.45–1.37;P = 0.38).
Conclusion: Among this sample of female adolescents, past STD diagnosis was an indicator of current high-risk sexual activity and increased risk for two common STDs: gonorrhea and trichomoniasis. Although adolescents may gain factual knowledge from the experience of having an STD diagnosed, they are not applying that knowledge to their current sexual behaviors. Thus, these adolescents remain at risk for subsequent STD infection. Therefore, the findings suggest that there is a need to intensify clinic-based prevention efforts directed toward adolescents with a history of STDs, as a strategy for reducing STD-associated risk behaviors and, consequently, the likelihood of new STD infections.
IN THE UNITED STATES, sexually transmitted diseases (STDs) are disproportionately diagnosed in adolescents. 1 It is estimated that 1 in 4 adolescents has ever had an STD. 2 Moreover, recent findings indicate that as many as 40% to 50% of adolescent females with an STD may become reinfected within a short follow-up period. 3,4
Adolescents are not a homogeneous population, however. Even among adolescents, the prevalence of STD has been shown to vary markedly by ethnic/racial subgroup. One vulnerable subgroup at high risk of STD/HIV infection is African American females. 5–7 Compared with that among white adolescents, the prevalence of chlamydia and gonorrhea is substantially higher among same-age African American adolescent females. 8 In a recent study of teen clinic attendees, Boyer et al 9 identified African American ethnicity/race and female sex as two key factors significantly associated with a history of STDs. Furthermore, Fortenberry et al 3 observed that among African American females, even after adjustment for diverse behavioral and sociodemographic risk indices, the reinfection rate was threefold that among white peers.
STD reinfections may be avoided by adopting STD-preventive behaviors such as consistently using condoms and otherwise avoiding unprotected intercourse. According to widely applied theoretical models of health behavior, adolescents’ previous STD experience may serve as a cue to action or a motivating factor promoting their adoption and maintenance of STD-preventive behaviors, such as consistent condom use. 10 However, the association between adolescents’ previous experience with an STD and recent sexual risk behaviors has been ill-defined. In addition, the association between previous STD experience and reinfection, although studied among ethnically mixed populations, remains understudied among African American adolescent females.
A number of previous studies have examined the association between self-reported history of STD and current sexual risk behaviors among adult populations; however, the results have been inconclusive, inconsistent, and at times contradictory. For instance, after a study of adult females, Fleisher et al 11 reported that self-reported STD history was associated with more frequent current use of condoms. However, a similar study revealed no association between previous STD and current sexual risk behaviors among samples of pregnant women. 12 In a recent study of a nationally representative sample of adults, Warszawski et al 13 noted an association between self-reported history of STD and greater sexual risk behavior among men but not among women. Findings of a recent analysis of data from the National Longitudinal Study of Adolescent Health suggested that adolescents’ self-reported STD history is a primary predictor of self-reported STD incidence. 14 However, to the best of our knowledge, studies have not focused specifically on African American female teens and have not utilized laboratory-confirmed STDs as an outcome.
This study examined the associations between adolescents’ self-reported history of STD and their current sexual risk behaviors, STD status, prevention knowledge, and attitudes.
Materials and Methods
From December 1996 through April 1999, project recruiters screened 1130 African American female teens across different community and clinical venues in Birmingham, Alabama. These recruitment sites included adolescent medicine clinics, health department clinics, and school health classes. These venues were located in communities characterized by high rates of poverty, STDs, and drug use. Eligibility criteria included being between the ages of 14 and 18 years, being sexually active in the past 6 months, and providing written informed consent. Of those screened, 609 adolescents were eligible to participate in the study. Of those adolescents not eligible to participate (n = 521), the majority (98%), were not sexually active. The current study involved 522 eligible adolescents (85.7%) who were enrolled and completed baseline assessments. The majority of eligible teens who did not participate in the study were unavailable because of conflicts with their employment schedules. The study protocol was reviewed and approved by the University of Alabama Institutional Review Board.
The current study involved analysis of only the baseline data collected in a randomized, controlled HIV prevention trial for female adolescents, in which intervention efficacy was assessed on the basis of biologically confirmed STD diagnoses. Data collection consisted of completion of a self-administered survey, completion of a structured personal interview that determined sexual risk behaviors and history of STD, and biological specimen sampling for STD testing.
At baseline, before collection of specimens for STD analysis, adolescents completed a self-administered survey that assessed STD-prevention knowledge and attitudes about condom use. The self-administered survey was conducted in a group setting, with monitors providing assistance to those with limited literacy and assuring participants of the confidentiality of their responses. Next, each adolescent was taken to a private examination room, where a structured, face-to-face interview was conducted by a trained African American female interviewer to assess the adolescent's lifetime history of STDs and current sexual behaviors (within the past 30 days). Adolescents were then asked to provide vaginal swab specimens for STD testing. Adolescents were reimbursed $20.00 for their participation. Adolescents were informed of their STD status nearly 1 week after completion of their baseline assessments. Because the STD status was unknown when an adolescent completed the baseline assessments, both the adolescent and the interviewer were blind to the STD test results.
Adolescents provided two vaginal swab specimens, which were evaluated for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis. 15 The first swab was placed in a specimen transport tube (Abbott LCx Probe System for N gonorrhoeae and C trachomatis assays; Abbott Laboratories, Abbott Park, IL) and tested for chlamydia and gonorrheal DNA by ligase chain reaction. 16 The second swab was used to inoculate culture medium for T vaginalis (InPouch TV test; BioMed Diagnostics, Santa Clara, CA). This culture was incubated at 37 °C and examined daily by light microscopy (magnification, ×100) for 5 days for the presence of motile trichomonads. 17 All STD assays were conducted at the University of Alabama at Birmingham Division of Infectious Diseases STD Research Laboratory.
Measures: Primary Independent Variable
Adolescents were asked “Have you ever been told that you have one of the following STDs?” and were read the following list: gonorrhea, syphilis, chlamydia, herpes, genital warts, and trichomoniasis. To facilitate adolescents’ recall, we also used common slang whenever possible to describe the STDs assessed. Adolescents who gave at least one affirmative response were categorized as having a history of STDs.
Measures: Outcome Variables
STD knowledge and attitudes.
STD prevention knowledge was assessed on the basis of 18 items. The knowledge test was developed and extensively pretested to be culturally, linguistically, and developmentally appropriate for the study population. The test assessed knowledge of transmission routes, misconceptions about ineffective preventive strategies, and knowledge of effective strategies for preventing STDs. A total score was calculated by adding the number of correct responses to the 18 items. Knowledge scores ranged from 0 to 17, with a median of 10 correct responses. Scores were dichotomized according to a median distinguishing high and low knowledge.
Motivational barriers to condom use were assessed on the basis of a modified version of the Condom Barriers Scale. 18 Adolescents responded to 7 items, each on a 5-point Likert-type scale, ranging from 1 (“strongly disagree”) to 5 (“strongly agree”). Higher scores on the scale indicate higher perceived motivational barriers to using condoms (e.g., “I don't need to use a condom because I never catch anything.”) This scale had adequate internal consistency (α = 0.64). Adolescents’ scale scores were categorized as high or low motivational barriers on the basis of a median split.
Current sexual risk behaviors.
Current sexual risk behaviors were assessed according to a recall period of the previous 30 days. Unprotected vaginal sex was assessed for the most recent intercourse episode, for any episode in the previous 30 days, and for multiple episodes with different sex partners in the previous 30 days. Consistent condom use was assessed by dividing the total number of times adolescents used condoms for vaginal sex by the total number of episodes of vaginal sex. Consistent condom use was defined as use of condoms for 100% of vaginal intercourse episodes. Two additional measures assessed sexual activity while under the influence of alcohol. Adolescents reported the number of intercourse episodes during which they, their partner, or both had been drinking alcohol. Adolescents reporting at least one episode of vaginal intercourse while either they or their male partner was drinking alcohol were categorized as having had any vaginal intercourse while drinking. In addition, we assessed the number of alcohol-associated intercourse episodes for which a condom was used. Adolescents reporting at least one episode of vaginal sex unprotected by a condom while either they or their partner was drinking alcohol were categorized as having had unprotected vaginal sex while drinking alcohol.
Current sexually transmitted disease status.
The primary outcome of interest was current infection with N. gonorrhoeae, C. trachomatis, and T. vaginalis. STD status was confirmed by laboratory assay, as described in the Laboratory Methods section.
Several variables were statistically identified as potential confounders of the analysis in which psychosocial factors were compared with sexual risk behaviors among adolescent females reporting any versus no history of STD: age, age of typical sex partner, current pregnancy status, and relationship length. Older adolescents, those with older male sex partners, those currently pregnant, and those in longer relationships were more likely to report a history of STD and at least one of the current outcomes.
The data analyses were comprised of several sequential steps. First, we compared adolescents reporting a history of STD with adolescents reporting no history of STD for psychosocial and behavioral outcomes. Prevalence ratios, their 95% CIs, and corresponding P values were calculated to assess the direction, magnitude, and statistical significance of associations between history of STD and hypothesized outcomes. Subsequently, we examined the association between history of STD and the potential covariates. Outcomes and covariates associated with history of STD in the bivariate analyses (P < 0.10) were included in logistic regression analyses. Logistic regression was used to calculate adjusted odds ratios, their 95% CIs, and corresponding P values for associations between history of STD and the outcomes in the presence of observed covariates.
The participating adolescents were 14 to 18 years of age (mean, 16.0; SD, 1.2). Approximately 26% of the adolescents reported a lifetime history of STD infection; 28% had a laboratory-confirmed positive test for one or more current STDs. Approximately 17% of the adolescents tested positive for chlamydia, 5% tested positive for gonorrhea, and 13% tested positive for trichomoniasis; 5% tested positive for at least two of these infections.
In the bivariate analyses, having a history of STDs was associated with high current STD-prevention knowledge and high scores on the scale assessing motivational barriers to condom use as well as greater likelihood of current sexual risk behaviors (Table 1). In logistic regression analyses, with adjustment for observed covariates, having a history of STDs was associated with high STD-prevention knowledge, greater likelihood of currently (within the previous 30 days) engaging in a variety of sexual risk behaviors, and testing positive for N. gonorrhoeae and T. vaginalis (Table 1). Although significant in bivariate analyses, motivational barriers to condom use were not associated with history of STD when covariates were controlled for.
In order to determine if the observed associations between self-reported history of STD and current infection were due to the increased sexual risk behaviors among those with a history of STD, we conducted additional logistic regression analyses, controlling for adolescents’ report of any unprotected vaginal sex and unprotected vaginal sex with multiple sex partners in the previous 30 days. A reduction in the odds ratio after controlling for sexual behaviors would support the possibility that the effect of self-reported history of STD on increased risk for current biologically confirmed STD was mediated by current high-risk sexual behavior. However, the associations between self-reported STD and current biologically confirmed gonorrhea and trichomoniasis (data not shown) were unchanged and remained statistically significant, even after controlling for the higher frequency of current sexual risk behaviors among individuals with a self-reported history of STD.
Contrary to previous research, 11,12 our study showed that adolescents who had ever had an STD diagnosed were more likely to report current high-risk sexual behaviors. Adolescents who reported a lifetime history of STD were less likely to have used condoms at most recent intercourse and were more likely to use condoms inconsistently, have unprotected intercourse with multiple partners, and have intercourse while either they or their partners were drinking alcohol. Similar findings have been reported among adult males but not adolescent females. 13 Moreover, adolescents who reported ever having an STD diagnosed were more than twice as likely to have a laboratory-confirmed positive test for gonorrhea and trichomoniasis. These associations persisted even after controlling for the higher current sexual risk behaviors of adolescents with a history of STD.
The results of the current study support a growing empirical literature indicating that increased STD prevention knowledge is insufficient to motivate the adoption or maintenance of safer sex behavior. 10 Adolescents with a history of STD had greater knowledge of STD prevention issues, but this did not translate to safer behavior. This greater knowledge may be a function of counseling received at the time of treatment for their previous STD(s). The experience of an STD may also heighten adolescents’ receptivity to and motivation to seek out information about STDs. However, as suggested by the observed higher risk behaviors among adolescents with a history of STD, knowledge gained from this experience may not be sufficient to promote the adoption and maintenance of effective STD-preventive behaviors. Indeed, in the current study, adolescents with a history of STD were no more likely to report high motivation for condom use than were those with no history of STD.
Clinical Practice Implications
The results of the current study underscore the necessity of screening for STDs. Because adolescent females may not experience or identify symptoms of an STD, preventive screening is an important early detection strategy. 4 Current guidelines for adolescent preventive services recommend annual screening for sexual risk behaviors and STD testing of sexually active adolescents. 19 However, recent data suggest that adolescent preventive screening practices may not meet recommended levels. 20,21 Moreover, for high-risk populations, more frequent routine STD testing may be required. 4 The frequency and methods of screening should be determined on the basis of the prevalence of infection and the available resources. 22
Recently advanced laboratory methods for STD diagnosis, such as nucleic amplification methods, although more sensitive and less invasive, may be costly. For some clinics, the added cost of such techniques may present financial barriers to more frequent STD screening of all sexually active adolescent females. The results of the current study suggest that pediatricians’ knowledge of adolescents’ lifetime history of STD could help identify those adolescents at greatest risk for reinfection. Thus, assessing adolescents’ lifetime STD history by carefully documenting their sexual history could help pediatricians identify those adolescents most in need of more frequent STD screening. Further research is needed to investigate the utility and cost-effectiveness of this proposed strategy.
In addition to microbiological advances in STD screening, new and innovative clinic-based interventions for adolescents with STDs are urgently needed. Theory-based, tailored, individual counseling in clinical settings has been shown to reduce sexual risk behaviors and STD reinfection rates. Kamb et al, 23 in a recent randomized, controlled trial, found that individualized counseling delivered in relatively brief sessions significantly reduced STD reinfection rates. In fact, the intervention was more effective for adolescents (≤20 years of age) and those with a self-reported history of STDs. 23 Similar interventions need to be designed, implemented, and evaluated for efficacy and cost-effectiveness in changing sexual risk behaviors and STD outcomes among adolescents.
Pediatricians face many obstacles to providing comprehensive screening and counseling for adolescents, 24 particularly a lack of time. Increased use of technology and ancillary services to screen and educate adolescents could help identify and provide counseling to those adolescents most at risk. For instance, computer-based systems that combined a behavioral risk assessment and the provision of developmentally appropriate and individually tailored behavior-change messages have demonstrated acceptance among adolescents 25,26 and are effective for identifying adolescents with high-risk behaviors. Use of a patient-guided computerized health-behavior assessment as a precursor to the clinical examination can be time-effective and may enable a more reliable assessment of adolescents’ risk behaviors, which consequently may guide the clinician in exploring adolescents’ risk history.
Technological advances in computerization also allow for the delivery of individually tailored risk-reduction messages to adolescents seeking care at busy clinical practices. Such programs have advantages over written materials in that adolescents may receive guidance tailored to their risk behaviors and readiness for change, corrective feedback about knowledge acquisition, and self-paced instruction. When combined with counseling provided by other health care professionals, such as health educators or nurses, such computerized assessment and counseling may be a cost- and time-effective risk-reduction strategy. 26
Public Health Implications
Knowledge-based counseling accompanying STD treatment may not be sufficient to motivate the adoption and maintenance of effective STD-preventive behaviors. Skills-based counseling for prevention of reinfection may not occur regularly or may not be delivered in a manner conducive to application on the part of the adolescent. Even when post-STD treatment counseling does occur, high reinfection rates suggest that standard-of-care prevention messages may have little effect on subsequent risk behaviors of adolescents. 3,4,27 Although clinic-based brief counseling may reduce STD risk behaviors, 28,29 the effects may be of insufficient magnitude 29 or duration 28 to reduce risk for reinfection, particularly among adolescents in high-risk environments where STD prevalence is high. 30
In this sample of adolescent females, a history of STD was associated with current gonorrhea or trichomoniasis, irrespective of current sexual risk behaviors. This finding is consistent with a growing body of literature about the importance of sexual and social network dynamics for risk of STDs. 31–34 Innovative prevention strategies such as intensive prevention counseling for “core transmitters”32 are needed to reduce the prevalence of infection and thereby reduce the potential number of sex partners who will be exposed.
This study has several methodological limitations. First, the data on lifetime history of STD diagnosis and current sexual behaviors were derived from adolescents’ self-reports. Of necessity, data on sexual behaviors must always be collected via self-report. STD history was also, of necessity, collected by self-report. Use of medical records review was not feasible because it was possible that participants had received prior treatment at a variety of clinics locally or outside the study area. We also cannot rule out the possibility that the cases of current, biologically confirmed STD represented failures of treatment for previously diagnosed STDs. Furthermore, in the current study we were unable to assess adolescents’ social networks or history of partner-mixing patterns. Given the potential of these factors to influence STD acquisition, future studies will need to focus specifically on social networks and partner-mixing patterns and their association with STDs.
In addition, although appropriate temporal sequencing was inherent in the data, they were collected at the same point in time. Future studies utilizing STD testing and behavioral assessment over repeated time points are needed to determine the stability of the observed associations over time and to further clarify the nature of these associations. For instance, in the current study, adolescents with a history of STD were more likely to currently practice high-risk sexual behaviors. However, it is possible that their risk behaviors had decreased after a previous STD diagnosis yet remained relatively frequent in comparison with risk behaviors among those who had never had an STD. Finally, the study was based on a sample of African American female adolescents, and the findings may not be generalizable to other populations.
The findings suggest that adolescents with a history of STD may be more likely than those who have never had an STD to currently engage in high-risk sexual behavior and are more likely to have biologically confirmed gonorrhea or trichomoniasis. However, increased risk of current infection was not attributable to higher rates of risk behavior. Thus, prior history of STD may be a marker for involvement in high-risk sexual networks. Health-risk behaviors, including sexual behaviors, may become long-lasting and increasingly difficult to modify over time. 35 Thus, future research is needed to develop and implement clinic-based counseling strategies that increase adolescents’ adoption and long-term maintenance of consistent STD/HIV-protective behavior.
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