Kathleen L. Feroli, MS, RN, CPNP, and Gale R.

Burstein, MD, MPH

Adolescent Sexually Transmitted Diseases

New Recommendations for Diagnosis, Treatment, and Prevention
ABSTRACT Sexually transmitted diseases (STDs) are a major health problem among adolescents. In 2000, adolescent females 15 to 19 years old had the highest reported rates of chlamydia and gonorrhea. Adolescent biologic, cognitive, social, and behavioral developmental circumstances contribute to the high rate of adolescent STDs. New sensitive and noninvasive STD tests greatly improve our ability to diagnose asymptomatic infections. In May 2002, the Centers for Disease Control and Prevention (CDC) published revised guidelines for the treatment of STDs. The CDCs Treatment of Sexually Transmitted Diseases Guidelines 2002 is based on evidence from published literature and expert opinion. In this article, we review selected new recommendations that impact adolescent STD care. Providing care to adolescents can be a challenging but rewarding experience for primary care pediatric nurse practitioners. Nurses can be instrumental in reducing STD prevalence through screening interventions, prevention counseling, and health education. Key Words: Adolescent; Sexual risk behavior; Sexually transmitted diseases; Treatment guidelines.

Adolescent Risk Determinants

ach year approximately 3 million teenagers (1 in 4 sexually experienced adolescents) are infected with a sexually transmitted disease (STD) (AGI, 1994). Biologic, cognitive, social, and behavioral developmental circumstances contribute to adolescent STD susceptibility. Biologically, adolescent females are more susceptible to STDs compared to males and older females. Cervical ectopy (columnar epithelium present on the adolescent ectocervix) is the tissue susceptible to infection (Berman, 1999). Younger age at puberty places adolescent females at risk earlier in life compared to females who begin puberty later in adolescence. On average, African-American females begin puberty between 8 and 9 years of age and Caucasian females by 10 years of age (Herman-Giddens, 1997). Adolescents cognitive stage of development may render them at risk for STDs. Young adolescents are concrete thinkers who are less able to think abstractly, conceptualize, or determine long-term consequences of their actions (Elkind, 1992). Concrete thinkers find it difficult to consider potential adverse consequences of risky behaviors and may struggle with planning for condom use. As adolescents begin to develop abstract reasoning, a belief of uniqueness and their personal fable emerges (Elkind, 1992). Adolescents believe that no harm can befall them and that they are protected from any consequences of risky behaviors, including risky sexual behaviors. In addition, peer pressure, a powerful social influence throughout adolescence, may influence the decision to initiate sexual activity (Hamburg, 1992; Taylor-Seehafer, 2000). Almost one half (45%) of U.S. high school students have had sexual intercourse (CDC, 2002a). Among sexually experienced students, 14% report having had sex with four or more partners (CDC, 2002a). Adolescents often engage in serial monogamous relationships that are of short duration but high frequency (Berman, 1999). Even though these relationships are typically perceived as low risk due to their monogamous nature, over the course
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of a year an adolescent may have numerous monogamous relationships. Although 58% of high school students report using a condom with their last sexual intercourse (CDC, 2002a), these data do not measure consistent and correct condom use.

Barriers to Healthcare
Multiple barriers prevent adolescents from seeking STD care. Lack of health insurance or inability to pay for services are barriers to care (Newacheck, 1998). Fear of confidentiality breaches and disclosure to parents or friends negatively impacts adolescent health seeking behavior (Ford, 1999). Lack of transportation may pose a significant barrier to care. In addition, adolescents may be uncomfortable seeking services at facilities that are not teen friendly.

New diagnostic vaginitis tests have emerged on marthe ket. The Affirm VP III Microbial Identification Test (Becton Dickinson, Sparks, MD), is a DNA probe for the etiologic diagnosis of vaginitis, bacterial vaginosis (BV), candidiasis, and trichomoniasis. The FemExam pH and Amines Test Card (Cooper Surgical, Shelton, CT) detect an elevated vaginal pH and trimethylamine. The PIP Activity Test Card (Litmus Concepts, Inc., Santa Clara, CA) identifies an enzyme expressed by Gardnerella vaginalis. For trichomoniasis diagnosis, the InPouch TV Culture (BioMed Diagnostics, San Jose, CA) is an FDA-approved self-contained bag that can be inoculated with a vaginal fluid specimen from females or a first void urine specimen from males in the office setting and viewed under the microscope as a wet prep. If no trichomonads are seen, the specimen can be cultured and reexamined via microscopy for up to 5 days.

Adolescent biologic, cognitive, social, and behavioral developmental determinants contribute to the high rate of adolescent STDs. Health Consequences of STDs
Adolescent females 15 to 19 years of age have the highest reported rates of chlamydia and gonorrhea (CDC, 2002b). Pelvic inflammatory disease (PID), a serious sequela, can lead to chronic pelvic pain, increased risk of ectopic pregnancies, and tubal-factor infertility (Westrom, 1999). STDs are important cofactors in human immunodeficiency virus (HIV) transmission (Cohen, 1998; Fleming, 1999). Although mathematical modeling estimates that half of new HIV infections occur among persons younger than 25 years of age (Rosenberg, 1994), most HIV-infected adolescents are unaware of their status (NIH, 1999). STD coinfection increases HIV infectivity by increasing the viral load and viral shedding in the genital secretions (Cohen, 1998).

New STD Treatment Recommendations

Background

In May 2002, the CDC published revised guidelines for the treatment of STDs. The CDCs Treatment of Sexually Transmitted Diseases Guidelines 2002 (CDC, 2002d) updates the 1998 Guidelines for Treatment of Sexually Transmitted Diseases (CDC, 1998). These guidelines are based on evidence from published literature as well as expert opinion.
Chlamydia and Gonorrhea

New Diagnostic STD Tests

Nucleic acid amplification tests (NAATs) are a new class of highly sensitive and specific diagnostic tests for Chlamydia trachomatis and Neisseria gonorrhoeae infections. NAATs are the most sensitive chlamydia tests available (CDC, 2002c). Four NAATs are licensed for both gonorrhea and chlamydia testing (Polymerase Chain Reaction, Roche Molecular System, Branchburg, NJ; Ligase Chain Reaction, Abbott Laboratories, Abbott Park, IL; Transcription-Mediated Amplification, GenProbe, San Diego, CA; and Strand Displacement Amplification, Becton Dickinson, Sparks, MD). Advantages over older methods of testing include superior sensitivity, ability to test urine specimens, and practical convenience (CDC, 2002c). NAATs have made chlamydia and gonorrhea testing more acceptable for asymptomatic patients by eliminating the need for an invasive genital examination.
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Chlamydia and gonorrhea frequently present as an asymptomatic infection in females. In addition, many chlamydiainfected males do not offer a classic urethritis history. Although often asymptomatic, chlamydia and gonorrhea can present as various STD syndromes, depending on the site of infection. Both males and females may develop gonorrhea pharyngitis and gonorrhea or chlamydia urethritis, and proctitis. Females may develop cervicitis. Uncomplicated genital gonorrhea infections can be treated with single-dose therapy (Table 1) (CDC, 2002d). Adolescents infected with N. gonorrhoeae often are coinfected with C. trachomatis. Because the cost of a chlamydia treatment course can be less expensive than the cost of chlamydia testing, the CDC has recommended empirically treating gonorrhea-test positive persons for both gonorrhea and chlamydia (CDC, 2002d). However, providers may choose to treat only those who test chlamydia-positive with a sensitive NAAT in areas where chlamydia coinfection rates are low (CDC, 2002d). Providers may consult with their local health department to ascertain the proportion of gonococcal infections in their community that are accompanied by chlamydia. Because of high quinolone-resistant N. gonorrhoeae rates in California, Hawaii, Asia, and the Pacific, quinolones should not be used to treat gonorrhea infections acquired in these areas (CDC, 2002d).
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Table 1.
Fluoroquinolones have not been recommended for persons younger than 18 years because they damage articular cartilage in juvenile animal models. However, no joint damage attributable to therapy has ever been reported in children treated with extended fluoroquinolone courses (Burstein, 2002). Therefore, children who weigh more than 45 kg can be treated with any regimen recommended for adults. Although the recommended treatment regimens for chlamydia have not changed in the 2002 guidelines, new follow-up procedures are recommended. Because adolescents have a high risk of acquiring a repeat chlamydia infection within several months of the first infection (Burstein, 1998), providers should rescreen all chlamydia-infected females 3 to 4 months after treatment.
Vaginitis

The Centers for Disease Control and Prevention Recommended Treatment for Uncomplicated Genital C. trachomatis and N. gonorrhoeae Infections*
Pathogen Treatment

C. trachomatis

Azithromycin 1 g orally in a single dose or Doxycycline 100 mg orally twice daily for 7 days Cefixime 400 mg orally in a single dose or Ceftriaxone 125 mg IM in a single dose or Ciprofloxacin 500 mg orally in a single dose or Ofloxacin 400 mg orally in a single dose or Levofloxacin 250 mg orally in a single dose plus Treatment for C. trachomatis*

N. gonorrhoeae

*The Centers for Disease Control and Prevention recommends treating persons with a positive gonorrhea test result for both gonorrhea and chlamydia unless a negative result has been obtained with a sensitive nucleic acid amplification chlamydia test. Adapted from the Centers for Disease Control and Prevention. (2002). Sexually transmitted diseases treatment guidelines 2002 Morbidity and Mortality Weekly Report, 51(No. RR-6).

Trichomoniasis

Vaginitis is the inflammation of the squamous epithelial tissues lining the vagina. Three conditions cause most adolescent vaginitis: BV, trichomoniasis, and vulvovaginal candidiasis. All three treatable conditions can be diagnosed by examination of vaginal secretions during an office visit.
Bacterial Vaginosis

Bacterial vaginosis (BV) is a common cause of vaginitis resulting from replacement of H2O2-producing Lactobacillus with various anaerobic bacterial species. Although BV is not an STD, it occurs more frequently among sexually active compared to sexually inexperienced females. BV is diagnosed by the presence of a gray-white, homogenous vaginal discharge with at least three of the four Amsel criteria (thin, homogenous, white, uniformly adherent vaginal discharge; vaginal pH 4.5; positive whiff test; and 20% clue cells on microscopic exam). The new commercial BV diagnostic tests described earlier in this article are available, and may have clinical utility. The treatment goal is to decrease symptoms and signs and to eliminate excess reproductive risks. Treatment is recommended for symptomatic nonpregnant and all pregnant patients. Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days is a new recommended regimen (CDC, 2002d). Other recommended regimens include metronidazole 500 mg orally twice daily for 7 days, or clindamycin cream, 2%, one full applicator (5 g) intravaginally once a day for 5 days (CDC, 2002d). Clindamycin ovules 100 g intravaginally at bedtime for 3 days is a new alternative regimen (CDC, 2002d). Metronidazole 2 g orally in a single dose or clindamycin 300 mg orally twice a day for 7 days are other alternative regimens (CDC, 2002d). Abstinence from alcohol during and for 24 hours after metronidazole therapy should be stressed because of the drugs disulfiram-like effect. Clindamycin cream and ovules are oil-based and should not be used with latex barrier contraceptives.
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Trichomoniasis is an STD that is caused by a pathogenic, flagellated single-celled parasitic protozoan, Trichomonas vaginalis. It causes an impressive inflammatory response in females and infects the vagina, urethra, exocervix, and periurethral glands. In females, trichomoniasis classically presents with an irritating, profuse, yellow-green vaginal discharge with vulvovaginal itching and discomfort. In males, trichomoniasis is usually asymptomatic with fewer organisms and less inflammation. However, it is increasingly recognized as a cause of urethritis nonresponsive to the usual urethritis antibiotic regimens. The diagnosis of trichomoniasis is made by microscopic visualization on a wet prep of the organism with its flagellas characteristic erratic twirling motion. The InPouch TV Culture improves wet prep sensitivity. The recommended treatment regimen remains metronidazole 2 g orally in a single dose (CDC, 2002d).
Vulvovaginal Candidiasis

Vulvovaginal candidiasis (VVC) is not an STD. It commonly presents with acute vulvar pruritus and vaginal discharge of varying character and consistency. Other signs and symptoms include dysuria, vaginal soreness and irritation, vulvar burning, and dyspareunia. Physical exam may demonstrate redness and swelling of the vagina and vulva. Microscopic evaluation of vaginal discharge may support the diagnosis of candidiasis, but it is necessary to evaluate simultaneously for other causes of vaginal discharge. Vaginal pH is usually normal (4-4.5), germinated yeast (pseudohyphae) are easily identified in the saline or potassium hydroxide preparations, and a modest increase in white blood cells (WBCs) may be noted. Uncomplicated VVC can be managed with either short courses of topical azole preparations or fluconazole 150 mg orally in a single dose (CDC, 2002d). VVC that is recurrent, severe, caused by a non-albicans species, or infection in a compromised or pregnant host is classified as complicated VVC and may warrant more aggressive management, such as 1 to 2 weeks of topical azole
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Table 2.
preparations or fluconazole 150 mg orally repeated 3 days later (CDC, 2002d). For recurrent VVC, maintenance therapy is recommended for 6 months following acute treatment (CDC, 2002d). A variety of new treatment options are available, including clotrimazole 500 mg vaginal suppositories weekly, ketoconazole 100 mg daily, fluconazole 100 to 150 mg weekly, or itraconazole 400 mg monthly or 100 mg daily. Maintenance therapy should be discontinued after 6 months to reevaluate continued need for treatment. Patients receiving long-term ketoconazole should be monitored for hepatotoxicity.
Pelvic Inflammatory Disease

Pelvic Inflammatory Disease Diagnostic Criteria*

Minimal Requirements:

Uterine /adnexal tenderness (unilateral or bilateral) or Cervical motion tenderness

Additional criteria to increase specificity:

Oral temperature 38.3 C (101 F) Abnormal cervical or vaginal mucopurulent discharge Presence of WBCs on saline microscopy of vaginal secretions Elevated erythrocyte sedimentation rate or C-reactive protein Laboratory documentation of cervical N. gonorrhoeae or C. trachomatis
*Most females with PID have mucopurulent cervical discharge or evidence of WBCs on a microscopic evaluation of a vaginal fluid saline preparation. If the cervical discharge appears normal and there are no WBCs noted on the wet prep, the diagnosis of PID is unlikely and alternative causes of pain should be sought. Adapted from the Centers for Disease Control and Prevention. (2002). Sexually transmitted diseases treatment guidelines Morbidity and Mortality Weekly Report, 51(No. RR-6). WBC = white blood cells.

Pelvic inflammatory disease (PID) is a clinical syndrome caused by the spread of microorganisms from the lower genital tract (i.e., vagina or endocervix) to the upper genital tract (i.e., endometrium, fallopian tubes, and adjacent structures). PID is a polymicrobial infection where multiple pathogens are involved. Sexually transmitted organisms, particularly C. trachomatis and N. gonorrhoeae are often implicated. The altered vaginal flora that occurs with BV can often be found in the upper genital tract of women diagnosed with PID, implicating BV as an important cofactor in the development of PID. No pathogen is identified in many PID cases. Adolescents have the highest PID rates. PID is a serious consequence of STDs and an important cause of infertility, ectopic pregnancy, and chronic pelvic pain. The diagnosis of PID is made on the basis of history and clinical findings. Specific symptoms may include lower abdominal pain or cramping, vaginal discharge, irregular vaginal bleeding, or dysuria. Although infrequent, systemic signs may be present and include anorexia, nausea, vomiting, fever, or malaise.

lent cervical discharge or evidence of WBCs on a microscopic evaluation of a vaginal fluid saline preparation (CDC, 2002d). If cervical discharge appears normal and no WBCs are found on the wet prep, the diagnosis of PID is unlikely and alternative causes of pain should be sought (CDC, 2002d). Because PID is a clinical diagnosis, laboratory evaluations are used to support the clinical diagnosis and assist with management (CDC, 2002d). Negative gonorrhea and chlamydia test results are common because the specimen is not from the site of inflammationthe pelvis. Tests for other STDs should be performed because there is a high risk of coinfection. A pregnancy test should be performed because PID during pregnancy is an indication for hospitalization for intravenous therapy and close monitoring, and because ectopic pregnancy can mimic PID. Optional tests that may help support the diagnosis include tests for elevated acute phase reactants, such as white Nurses can be instrumental in blood cell count, erythrocyte sedimentareducing STD prevalence through tion rate, or C-reactive protein. An ultrasound may be helpful if the diagnosis is screening interventions, prevention in question, ectopic pregnancy is a counseling, and health education. strong consideration, or tubal-ovarian abscess (TOA) is considered. Laparoscopy is not recommended on a routine basis, although it may be reFindings on abdominal exam may include lower abdomquired for evaluation of treatment failures, to exclude surgiinal tenderness, peritoneal signs, such as rebound tendercal emergencies, or if TOA ruptures or does not respond to ness and guarding in severe cases, or right upper quadrant medical management within 48 to 72 hours. pain with associated perihepatitis (Fitz-Hugh-Curtis synTable 3 lists the CDC-recommended PID antibiotic treatdrome). Findings on pelvic exam may include abnormal ment regimens. PID antibiotic treatment regimens are genercervical or vaginal discharge, uterine tenderness, adnexal ally empiric and must be broad spectrum. All regimens tenderness, or cervical motion tenderness. should be effective against N. gonorrhoeae and C. traPID is a challenging syndromic diagnosis. CDC recomchomatis, even when endocervical tests are negative. Providmends that uterine or adnexal tenderness, or cervical moing coverage against anaerobes and other gram-negative ortion tenderness is required to consider the diagnosis (Table ganisms is also important. Treatment should be initiated as 2) (CDC, 2002d). Most females with PID have mucopurusoon as a presumptive diagnosis is made. Delays in initiat116
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Table 3.
ing antibiotic treatment until lab results are available should be avoided because this can adversely affect long-term outcomes. Addition of metronidazole or clindamycin to the oral doxycycline regimen improves anaerobic coverage at the risk of decreasing compliance. PID is often treated in the outpatient setting. Indications for hospitalization include suspicion of a surgical emergency (such as appendicitis or ovarian torsion), severe illness, pregnancy, TOA, and inability to tolerate or failure to respond to outpatient therapy (CDC, 2002d). A follow-up visit within 48 to 72 hours is necessary to ascertain adequate clinical improvement versus need for hospitalization. Sex partners should also be evaluated and treated.

The Centers for Disease Control and Prevention Recommended Treatment Regimens for Pelvic Inflammatory Disease*
Parenteral Regimens (one of the following):

Cefotetan 2g IV every 12 hours OR Cefoxitin 2g IV every 6 hours PLUS Doxycycline 100mg IV or po every 12 hours or Clindamycin 900mg IV every 8 hours plus Gentamicin loading dose IV or IM (2mg/kg body weight), followed by a maintenance dose (1.5mg/kg) every 8 hours. Single daily dosing may be substituted. Parental therapy may be discontinued 24 hours after clinical improvement: 1. Doxycycline 100 mg po twice a day or Clindamycin 450 mg orally four times a day continued for 14 days of total therapy 2. For TOA, addition of either Metronidazole 500mg po BID or Clindamycin 450mg po QID to oral Doxycycline provides better coverage against anaerobes

Nursing Implications

All sexually active adolescents are at risk for STDs. Oral Regimens (one of the following): Nurses play a key role in treating and preventing STDs. STD prevention requires focusing on identiOfloxacin 400mg po BID or Levofloxacin 500 mg po BID for 14 days fying risk (i.e., sexual activity). with or without Metronidazole 500mg po BID for 14 days or Screening asymptomatic individuals is a preCeftriaxone 250mg IM single dose OR Cefoxitin 2g IM and Probenecid ventive intervention to reduce the risk of STD se1g PO in a single dose once or Other parenteral third-generation quelae. Asking about sexual activity is a recomcephalosporin (Ceftizoxime or Cefotaxime) plus Doxycycline 100 mg mended part of the annual adolescent health PO BID for 14 days with or without Metronidazole 500mg po BID for maintenance visit (AAP, 2000). STD screening 14 days should be offered to all sexually active adolescents during that visit (AAP, 2000). Some experts *Adapted from the Centers for Disease Control and Prevention. (2002). Sexually transmitted diseases treatment guidelines Morbidity and Mortality recommend providing routine STD screening for Weekly Report, 51(No. RR-6). sexually active adolescents every 6 months (Burstein, 1998). Newer noninvasive urine-based STD screening is more acceptable for adolescents and easily teaching condom use skills or communication techniques implemented within primary care settings (Burstein, 1998). are important factors in sexual risk reduction (Taylor-SeeNurses should also focus on risk assessment and counhafer & Rew, 2000). The majority of condom failures are seling of all adolescents. Risk assessment includes inquiring due to inconsistent or incorrect usage, not breakage (Steinabout sexual behavior and being aware of adolescent sexuer, 1999). al behavior norms. When risk factors are identified, the Finally, nurses can assist adolescents in notifying their sexadolescent needs encouragement to develop safer sex pracual partners of their infection. Partner notification and treattices, such as STD testing of both partners prior to initiatment can prevent reinfection (CDC, 2002b). All adolescents ing intercourse. All sexually active adolescents should be treated for an STD should be instructed to abstain from sex advised to consider abstinence. Other prevention strategies until both the patient and the sex partner are fully treated. include advocating for mutually monogamous sexual relaSTDs are a serious adolescent health problem. Nurses can tionships and using condoms with each sexual act. be instrumental in STD prevention through providing risk Nonoxynol-9 is not an effective means to prevent infection assessment, disease screening, CDC-recommended treatwith HIV or cervical gonorrhea and chlamydia (CDC, ment, and developmentally appropriate health counseling. 2002d). Providers should clarify that oral contraceptive pills do not prevent STDs. Kathleen L. Feroli is an Instructor, University of Maryland An STD cure depends on compliance with established School of Nursing, Baltimore, MD. Gale R. Burstein is a medication protocols. Medication adherence is often a Medical Officer, Division of HIV and AIDS Prevention, challenge for adolescent patients. Reducing the treatment Centers for Disease Control and Prevention, Atlanta, GA. plan complexity may improve adherence. Many single-dose She can be reached c/o Division of HIV and AIDS PrevenSTD treatment options that can be directly observed are tion, Centers for Disease Control and Prevention, 1600 available. Some nursing experts suggest reducing the comClifton Road NE, Mail Stop E-46, Atlanta, GA 30333 plexity of the treatment plan by providing a plan in writing (e-mail: gib5@cdc.gov). (Divertie, 2002). Successful strategies to improve adolescent health-seekDisclaimer: Use of trademark names is for identification ing behaviors include a developmentally appropriate purposes only and does not constitute endorsement by the approach to STD care. Providing interventions such as Federal Government.
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