Health Provider Checklist for Adolescent and Young Adult Males

Sexual and Reproductive Health

HIV/STI Risk Assessment and Reduction

Key Points

  • Adolescent and young adult males bear a disproportionate share of STIs relative to other age groups.
  • A substantial number of young men report engaging in high-risk sexual behaviors. Data from the 2009 Youth Risk Behavior Surveillance indicate that among male high school students, 25.9% reported using alcohol or drugs before last sex, 16.2% reported 4 or more lifetime partners, and 8.4% reported initiating sex at 13 years or younger .
  • Education about health and disease with regard to STIs is a key element of the clinical encounter. Young men in many cases still do not know the difference between the three-letter conditions: HIV, HPV and HSV.

Questions to ask young male patients about HIV/STI Risk Assessment and Reduction

Overview

Education about health and disease with regard to STIs is a key element of the clinical encounter. Young men in many cases still do not know the difference between the three-letter conditions: HIV, HPV and HSV. For many, a diagnosis of any of these three means a condition they must live with for the rest of their lives, and one that will necessitate a change in sexual behavior for their lifetime.1

Adolescent and young adult males bear a disproportionate share of STIs relative to other age groups. In a national sample of 18- to 22-year-olds, 3.7% were infected with Chlamydia, 1.7% with Trichomonas, and 0.4% with gonorrhea.2,3 The incidence rates of syphilis among males age 15-24 is from twice to five times that of females.4 As much as 40% of young men presenting with genital herpetic lesions are co-infected with HSV-1 from oral sex.5

A substantial number of young men report engaging in high-risk sexual behaviors. Data from the 2009 Youth Risk Behavior Surveillance indicate that among male high school students, 25.9% reported using alcohol or drugs before last sex, 16.2% reported 4 or more lifetime partners, and 8.4% reported initiating sex at 13 years or younger.6 Data from the 2002 NSFG also showed that among 15- to 19-year- old males, 28.6% reported no condom use at last vaginal sex, 11.1% reported engaging in anal sex with a female partner, and 5.6% reported having sex with a prostitute or an HIV-infected person or often/always being high during sex.7 (as cited in 8)

Each year, costs related to STIs/HIV infection and their complications are estimated to be $17 billion.9 (as cited in 10)

Syphilis

The average time between infection with syphilis and the start of the first symptom is 21 days, but can range from 10 to 90 days.  Syphilis has been called “The Great Pretender”, as its symptoms can look like many other diseases. However, syphilis typically follows a progression of stages that can last for weeks, months, or even years:

Primary Stage
The appearance of a single chancre marks the primary (first) stage of syphilis symptoms, but there may be multiple sores. The chancre is usually firm, round, and painless. It appears at the location where syphilis entered the body. Possibly because these painless chancres can occur in locations that make them difficult to find (e.g., the anus), smaller proportions of MSM are diagnosed in primary stage than men having sex with women only.11  The chancre lasts 3 to 6 weeks and heals regardless of whether a person is treated or not. However, if the infected person does not receive adequate treatment, the infection progresses to the secondary stage.

Secondary Stage
Skin rashes and/or mucous membrane lesions (sores in the mouth or anus) mark the second stage of symptoms. This stage typically starts with the development of a rash on one or more areas of the body. Rashes associated with secondary syphilis can appear when the primary chancre is healing or several weeks after the chancre has healed. The rash usually does not cause itching. The characteristic rash of secondary syphilis may appear as rough, red, or reddish brown spots both on the palms of the hands and the bottoms of the feet. However, rashes with a different appearance may occur on other parts of the body, sometimes resembling rashes caused by other diseases. Sometimes rashes associated with secondary syphilis are so faint that they are not noticed. Large, raised, gray or white lesions, known as condyloma lata, may develop in warm, moist areas such as the mouth, underarm or groin region. In addition to rashes, symptoms of secondary syphilis may include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue. The symptoms of secondary syphilis will go away with or without treatment, but without treatment, the infection will progress to the latent and possibly late stages of disease.12

HSV

Herpes is an infection caused by a herpes simplex virus 1 or 2, and it primarily affects the mouth or genital area.  There are two strains of herpes simplex viruses. Herpes simplex virus type 1 (HSV-1) is usually associated with infections of the lips, mouth, and face. It is the most common herpes simplex virus among the general population and is usually acquired in childhood. Herpes simplex virus 2 (HSV-2) is sexually transmitted and is usually associated with genital ulcers or sores. The highest incidence of HSV-2 is in young adults between the age of 18 and 25 years. Individuals may harbor HSV-1 and or HSV-2 and not have developed any symptoms.

HPV

The recommendation was adopted by the American Academy of Pediatrics and other organizations.  Gardasil is the only HPV vaccine for males.

Data indicate that HPV infections in young males are common, with HPV infection rates between 29% and 65% in different young adult (18 to 25 years of age) male populations [2226].13 In the August 30, 2013 edition of Mortality and Morbidity Weekly, The Centers for Disease Control and Prevention reported that the male HPV vaccination rate is 20% for the first dose of the three-dose regimen14, although data on the percentage that receive the full three-dose regimen is not yet available.

HIV

Men who have sex with men (MSM) remain the group most heavily affected by HIV in the United States. Gay and bisexual men make up nearly two-thirds of the 50,000 newly infected each year. The number of new infections among the youngest MSM (aged 13-24) increased 22 percent, from 7,200 infections in 2008 to 8,800 in 2010. Young black MSM continue to bear the heaviest burden, accounting for more than half (55 percent) of new infections among young MSM (4,800). In fact, young black MSM now account for more new infections than any other subgroup by race/ethnicity, age, and sex. There was a 12 percent increase in HIV incidence among MSM overall, from 26,700 in 2008 to 29,800 in 2010.15

The rate of new HIV infections is especially high among gay men recently diagnosed with a rectal sexually transmitted infection (STI), according to research conducted in New York City and published in the online edition of Clinical Infectious Diseases. The authors compared HIV incidence in both people diagnosed with rectal chlamydia (CT) and/or gonorrhoea (GC) infection at a baseline clinic visit between 2008 and 2010 and closely matched controls who were negative for these infections at their baseline visit. Over two-thirds of both the diagnosed people and the controls reported unprotected anal sex. During follow-up, 7% of men with rectal STIs at the initial clinic visit were diagnosed with HIV, compared to 3% of men without these infections at baseline.16

A 2008 UK study17 found that only about half of men who went to a doctor with symptoms of HIV seroconversion were diagnosed correctly.  The other half were misdiagnosed with some other ailment until they returned to the physician for the second or third time.

The majority of people infected by HIV develop a flu-like illness within a month or two after the virus enters the body. This illness, known as primary or acute HIV infection, may last for a few weeks. Possible symptoms include:

  • Fever
  • Muscle soreness
  • Rash
  • Headache
  • Sore throat
  • Mouth or genital ulcers
  • Swollen lymph glands, mainly on the neck
  • Joint pain
  • Night sweats
  • Diarrhea

Although the symptoms of primary HIV infection may be mild enough to go unnoticed, the amount of virus in the blood stream (viral load) is particularly high at this time. As a result, HIV infection spreads more efficiently during primary infection than during the next stage of infection.18


1 Farrow, James A, MD Male sexual health during adolescence and young adulthood: contemporary issues. Journal of Men’s Health. September 2009

2 Miller WC, Swygard H, Hobbs MM, et al.The prevalence of trichomoniasis in young adults in the United States. Sex TransmDis. 2005;32(10):593–598

3 Miller WC, Ford CA, Morris M, et al.Prevalence of chlamydial and gonococcal infections among young adults in the United States. JAMA. 2004;291(18):2229–2236

5 Farrow, James A, MD Male sexual health during adolescence and young adulthood: contemporary issues. Journal of Men’s Health. September 2009.

6 Centers for Disease Control and Prevention.Youth Risk Behavior Surveillance: United States, 2009. Morb Mortal Wkly Rep. 2010.

7 Marcell AV, Bell DL, Lindberg LD, Takruri A.Prevalence of STI/HIV counseling services received by teen males, 1995 to 2002. J AdolescHealth. 2010.

8 Marcell A, MD et al.Male Adolescent Sexual and Reproductive Health Care. Pediatrics. December 2011.

9 Eng TR, Butler WT, eds. Institute of Medicine, Committee on Prevention and Control of Sexually Transmitted Diseases.The Hidden Epidemic: Confronting Sexually Transmitted Diseases. Washington, DC: National Academies Press. 1997.

10 Marcell A, MD et al.Male Adolescent Sexual and Reproductive Health Care. Pediatrics. December 2011.

11 Centers for Disease Control and Prevention.Sexually Transmitted Disease Surveillance, 2011. Atlanta, GA: U.S. Department of Health and Human Services, 2012.

12 Centers for Disease Control and Prevention.Syphilis Fact Sheet. August 2013.

13 Ott, Mary A., MD.Examining the Development and Sexual Behavior of Adolescent Males. J Adolesc Health. 2010 April; 46(4 Suppl): S3–11.,doi: 10.1016/j.jadohealth.2010.01.017

15 New HIV Infections in the United States, Centers for Disease Control and Prevention. 2012

16 Pathela P et al. HIV incidence among men with and those without sexually transmitted rectal infections: estimates from matching against an HIV case registry. Clin Infect Dis, online edition, 2013. Report online here.

17 Sudarshi D, Pao D, Murphy G, Parry J, Dean G, Fisher M.Missed opportunities for diagnosing primary HIV infection. Sex Transm Infect. 2008 Feb;84(1):14-6. Epub 2007 Oct 30.

18 HIV/AIDS Symptoms. Mayo Clinic. August 2012.