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Human papillomavirus (HPV) infection is the most common sexually transmitted infection (STI) in the United States. An estimated 6.2 million U.S. residents acquire the HPV virus each year, and at least half of sexually active women and men become infected at some point.1
While there are hundreds of types of HPV, a select few are associated with 70% of cervical cancers and 90% of genital warts. HPV is transmitted via sexual activity and contact with skin or mucous membranes - whether the infected partner has symptoms or not. Risk factors associated with HPV include young age, early onset of sexual activity, high number of lifetime sexual partners, immunosuppression, smoking and oral contraceptive use.1
The majority of men and women who become infected with HPV never experience symptoms, and the infection commonly clears without medical intervention. But roughly 10% of women who contract high-risk HPV types develop persistent infections that may lead to cervical cancer.1 Although cervical cancer rates have decreased as a result of more widespread Pap screening, 9,700 cases of cervical cancer are diagnosed each year.2 The disease results in 3,700 deaths annually.2
Vaginal, vulvar, anal, penile, urethral, tongue, tonsil, mouth and sinus cancers are also associated with oncogenic HPV types.2,3 Even low-risk HPV types can cause mild Pap test abnormalities.3,4
Adolescents are at particularly high risk for HPV. New evidence suggests that the prevalence of HPV infection is 25% among 14- to 19-year-olds and 45% among 20- to 24-year-olds.5 These data are not surprising given that nearly half (47%) of high school students report being sexually active, and 28% of adolescent girls and 31% of adolescent boys report having more than one partner.6
Of the 19 million new STIs diagnosed in this country each year, almost half occur among young adults between the ages of 15 and 24.7 One in two sexually active adolescents and young adults will contract an STI by age 25, and half of all new HIV infections occur among adolescents.8
Decision Making in Adolescence
Adolescence is the longest developmental stage. It begins with the onset of puberty and often extends through the college years into the early 20s.9 During this important stage, adolescents begin to make independent health care decisions, as well as judgments about their own sexual practices. This age group is vulnerable to STIs for a number of biological, cognitive, behavioral and cultural reasons.8
Adolescent women may be physiologically more susceptible to certain STIs, especially Chlamydia trachomatis, due to increased cervical ectopy during puberty.10 Among young women, cervical immaturity and upward movement of bacteria from the lower genital tract have a significant impact on the severity of chlamydia disease.
Many STIs are asymptomatic in women, which may lead to a delay in diagnosis and treatment. Severe long-term health consequences for women can include pelvic inflammatory disease (PID), ectopic pregnancy, infertility and chronic pelvic pain.
Many adolescents and young adults have difficultly predicting the consequences of their actions. As a result, they often underestimate their risk for adverse consequences.11 Recent neuroscience research into adolescent brain development supports the theory that decision-making skills continue to develop throughout older adolescence. Because the developing brain, cognitive and behavioral systems each mature at different rates, adolescence is often a period of increased vulnerability and adjustment.12
Acknowledging the existence of gaps among emotion, cognition and behavior is fundamental to understanding the effect of age on differences in judgment, risk taking, decision making and sensation-seeking behaviors.13 The impact of this continued cognitive maturation on the older adolescent population has yet to be fully explored, especially with regard to emotion regulation, inhibition and risk-versus-reward behaviors.12
Recent studies of condom use and sexual activity outside a traditional dating relationship (known as "hooking up") suggest that adolescents underestimate risk.14,15 Many studies have focused on adolescents' decision making and its relationship to perceived risk of sexual activity. Findings include the following:16-18
Adolescents underestimate the personal risk of health hazards in relation to peers.
Adolescents tend to have the misperception that they are not personally susceptible to pregnancy or health risks. They also tend to believe that their peers are more sexually active than they actually are.
Adolescents tend to equate long-term relationships with trust and safety, even when the evidence does not support this connection.
Neither younger adolescents (ages 16 to 18) nor older adolescents (ages 18 to 22) have a complete or accurate appreciation of their exposure to harm.
The concept of underestimated or misperceived sexual risk has also been examined in an older adolescent population alone. Interviews of college students between the ages of 18 and 20 determined that more than half had inaccurate perceptions about safer sex: They believed they had practiced safer sex when they had not.19 Also, more than half of the reported sexual encounters were unplanned, increasing the risk for unprotected sex. Reports of multiple partners, inconsistent condom use and drug and alcohol use during sex were also consistent findings among older adolescents, despite reports of assertion, feeling in control of the sexual situation and awareness that substance use causes impaired judgment.20 Although available research is limited, a consistent pattern suggests that the inability to correctly assess risk in sexual situations is pervasive across age groups. This is a potential contributor to the negative health outcomes of unplanned pregnancy and STIs.
At least two trends put today's adolescents at sexual risk for a longer period of time than any preceding generation: earlier onset of puberty and delay of marriage past the early 20s.21 Abstinence and long-term mutual monogamy with an uninfected partner are the most effective ways to prevent HPV. Many adolescents who presume they are in a mutually monogamous relationship underestimate their risk of STIs because they are mistaken about their partners' true sexual activities.22
Other risk reduction methods include limiting sex partners, regular Pap testing, STI screening and treatment, and the use of condoms. The effectiveness of condom use against HPV is not yet fully known, but it has been associated with decreased rates of cervical cancer and other HPV-associated disease, as well as higher rates of cervical intraepithelial neoplasia regression and clearance.1
Vaccination
The first vaccine to prevent cervical cancer, Gardasil, is recommended for girls and women ages 9 to 26. Gardasil is effective against four HPV types: 6 and 11 (which cause genital warts) and 16 and 18 (which are responsible for the majority of cervical cancers). Gardasil is a recombinant vaccine (containing no live virus) and is given in three separate intramuscular injections over 6 months. The second dose should be administered 2 months after the first dose, and the third dose should be administered 6 months after the first dose.1,23
Gardasil should be administered to girls before the onset of sexual activity or to women who have not already been infected with the targeted virus strains. It has been classified as a category B drug and is not recommended in pregnancy or for anyone with a history of hypersensitivity to yeast or any component in the vaccine. The safety of the vaccine has been evaluated in thousands of women, and only mild or moderate local reactions, such as discomfort at the injection site, have been noted. The duration of effectiveness is not known, but studies are demonstrating length of at least 5 years. Determination about the need for booster vaccines will depend on the ongoing research. Importantly, routine screening for cervical cancer should continue for all women, regardless of vaccination status.1,3,23
Gardasil is priced at approximately $120 per dose, and this amount does not include fees from clinics and providers. Many insurance entities are covering the cost of the vaccine, including Vaccines for Children (VFC), a federal health program.
Gardasil is indicated only for girls and women, but studies of HPV vaccination for boys and men are under way.1 Men do not have symptoms of HPV unless the infection is with the HPV types that cause genital warts. Approximately 1% of sexually active men in the United States have genital warts.24 No laboratory test can detect HPV in men, but certain strains of HPV have been linked to cancers in men, particularly penile and anal carcinoma. In 2006, approximately 1,530 men were diagnosed with penile cancer, and 1,910 men were diagnosed with anal cancer. An HPV vaccine for men could provide direct and indirect health benefits to sexual partners.
A second vaccine, Cervarix, is under consideration by the Food and Drug Administration. It is a bivalent vaccine that targets HPV types 16 and 18. A recently published study documented high efficacy for Cervarix when it was assessed for its ability to prevent cervical dysplasia.25
The PA's Role
PAs are uniquely positioned to help adolescents make behavioral changes to help control HPV spread through the provision of direct care, age-appropriate education and nonjudgmental support. Given the sensitive nature of sexual behavior, the establishment of rapport and trust is fundamental to a successful provider-patient relationship in which sexual issues can be addressed. Understanding adolescent growth and development is crucial to successful teaching strategies. Teens are primarily concrete thinkers who are oriented to the present, and this often extends to older, college-age adolescents as well. Education must be tailored accordingly.
The importance of safer sex behaviors such as consistent condom use, the need to limit and screen sexual partners, and the need to avoid drug and alcohol use are topics that warrant repeated exploration with adolescents. Rather than a one-time discussion, these issues should be part of every visit - along with a detailed sexual history that includes questions about the patient's number of sexual partners in the past year and whether he or she has changed partners since the previous visit.
When discussing HPV, remind vaccinated adolescents that although Gardasil is a useful tool for disease prevention, it only covers four of more than 100 HPV strains, and more than 30 strains are transmitted via sexual contact.1 Gardasil is not a substitute for abstinence or responsible sexual behavior. Even after vaccination, it is still possible to have an abnormal Pap smear result or an outbreak of external genital warts caused by an HPV strain not covered in the vaccine. This is especially true for patients with a history of multiple current or lifetime sexual partners. For all adolescents, emphasize the importance of yearly or routine cervical cancer and STI screening.
A significant concern for PAs who administer the HPV vaccine is compliance with the vaccine regimen. The full benefits of the vaccine are not achieved without completion of the vaccination series.1 Adolescents of all ages have busy school and work schedules, and older adolescents may spend months away at college, thus limiting their availability for office visits. Reducing the percentage of teens lost to follow-up is a challenge that needs to be addressed within each practice setting.
Make a specific plan with each patient to facilitate completion of the series. Involvement of parents is always desired, but for adolescents who want confidential care, phone calls to the home or reminder cards may not be possible. Identify alternate contact methods, such as private e-mail or cell phone numbers. Adolescents may frequently change cell numbers and e-mail accounts and forget to update demographic information in their medical records. Ask about current contact information at every visit.
Putting It Into Practice
HPV infection is prevalent among adolescents. Due to biological vulnerability of the immature cervix, cognitive inability to fully comprehend consequences of personal actions, and social and cultural norms about sexual activity, this group represents a priority audience for education about STI prevention and about HPV vaccination. Understanding adolescents and their decision-making abilities, educating them about safer sexual practices, providing HPV information, and offering the HPV vaccine are all critical aspects of adolescent health care today.
Holly Fontenot is a women's health nurse practitioner who is director of the women's health nurse practitioner program at Boston College. She is also a clinical instructor for the program and a sexual assault nurse examiner for the Massachusetts Department of Public Health.
Heidi Collins Fantasia is a women's health nurse practitioner at Health Quarters, a Title X family planning clinic in Beverly, Mass., and a doctoral student at Boston College.
Jennifer Allen is an RN with a doctorate degree and a master's degree in public health. She is an assistant professor of nursing at Boston College and a scientific associate at the Dana Farber Cancer Institute in Boston.
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