Mitigating the Impact of COVID-19 on Adolescent and Young Adult Sexual Health Care

AYA have unique challenges in accessing care that were exacerbated by the pandemic and not explicitly considered or addressed in the pandemic response. The Centers for Disease Control and Prevention released guidances and resources to address clinical STI services disruption during the pandemic.⁹  These guidances focused on delivering specialized sexual health care when in-person visits were limited and focused on treating symptomatic individuals with oral medications. Although critical to maximizing sexual health care during the pandemic, these guidelines failed to address the unique challenges that AYA patients face.

Although the guidelines prioritized oral treatment of symptomatic patients, obtaining medications is one challenge for AYAs. In one study, only 70% of AYA patients who received STI medication prescriptions from a pediatric emergency department filled their prescriptions.¹⁰  The closing of sexual and public health clinics, where uninsured and underinsured patients could receive medicines at no cost, represents a barrier that could prevent AYAs from obtaining treatment. Even insured AYAs, who are often covered on their parents’ insurance plan, may be concerned about their privacy with explanation of benefits sent to their parents, and may be hesitant to fill a prescription. Home-based medication delivery faces similar privacy concerns, with potential parental questions about arriving packages. The 21st Century Cures Act, requiring health information to be shared directly with patients, may exacerbate these privacy concerns if institutions do not develop specific record release policies that incorporate adolescent confidentiality protections per state laws. Furthermore, the recommended oral empirical treatment of syndromic management results in less precise diagnoses and could result in inadequate treatment, especially for pharyngeal gonorrhea. Inadequate treatment paired with testing challenges among youth could further propagate disease because youth may be less likely to return for a test of cure.

One solution to these challenges is to create community treatment or medication pickup sites that could remain open during a pandemic. Local pharmacies, supported by public health dollars, may be the ideal location for pharmacists to dispense oral medications or administer the intramuscular injections required for STI treatment. Opening community-based sites where patients could walk in for treatment may allow for limited interactions while still providing AYA standard-of-care treatment.

Providing empirical treatment may help those with symptomatic STIs, yet closing testing sites also reduces routine testing access. Many asymptomatic patients likely were not diagnosed or were diagnosed late because of testing site closures or STI test shortages. Missed or delayed STI diagnosis may lead to long-term complications of untreated STIs and additional opportunities for STIs to spread to others. Some clinics initiated home testing programs to address the lack of routine testing during the pandemic. However, without financial support, home-based testing remains out of reach and exacerbates inequalities because private companies often provide testing at a considerable individual cost, charging $39 to $522 without accepting insurance.¹⁰  Even if financially supported by local health departments, home-based STI testing presents a challenge for maintaining privacy because AYAs may fear parental inquiry regarding packages received or mailed from home.

Before the pandemic, there were efforts to expand sexual health care to community sites, such as school-based health centers in high schools and college health centers; however, many of these services closed during the pandemic. Although the pandemic increased interest in telemedicine, it also presents unique challenges for adolescent patients because confidentiality concerns remain a significant barrier to using STI services.^11,12  AYAs living at home may not find the private space needed to conduct a telemedicine visit. Lack of privacy may increase hesitancy to disclose sexual health issues or sensitive topics, such as intimate partner violence. Although telemedicine is one approach to providing care outside the clinic setting, attention to redesigning telemedicine to meet adolescent needs is warranted. Reducing communication barriers by incorporating electronic surveys either before or during patient visits may provide a means to obtaining sensitive personal information within the home settings’ limitations. Text messaging or web-based interfaces could be approaches to effectively reach youth and provide the required privacy to complete an assessment while living in the family home.

Creating community-based express STI services sites is one option to improve access to STI services and prepare for future pandemics. Express services that use kiosks or questionnaires for triage and encourage self-testing may enhance STI screening and treatment access. These limited contact sites offer quick visits and limited patient-provider interactions and are perfect for providing sexual health to adolescents who may have limited needs and may have another pediatric provider. Furthermore, establishing STI services in communities may allow for the ongoing provision of regular sexual health services even during a pandemic because of limited patient-provider interactions. Sites could have modern testing methods such as nucleic acid amplification tests, but they could also be stocked with older, less costly methods of diagnosis such as the wet prep for Trichomonas vaginalis and Gram stain for diagnosis of Neisseria gonorrhea in case of supply chain limitations during future pandemics.

Finally, as patients return to in-person care at clinical facilities, medication access could be expanded through Title X programs, including Expedited Partner Therapy. These sites could also offer critical sexual health vaccinations, such as human papillomavirus, which was neglected during the pandemic. The COVID-19 pandemic could be seen as an opportunity to redesign the delivery of AYA STI care and optimizing it for future pandemics.

AYAs experience unique barriers to accessing STI care that were amplified during the COVID-19 pandemic, including the closure of care sites such as schools, and increased concerns around privacy that make telemedicine, home-based testing, and medication delivery less appealing. With guidelines supporting empirical treatment over screening and the need to pivot resources away from STI testing, many STIs likely went undetected during the pandemic. Identifying approaches to provide youth-friendly STI services as we emerge from the COVID-19 pandemic and plan for future pandemics will be critical to reversing increasing US STI rates and reducing STI-related health disparities facing youth.

AYA

adolescents and young adults

STI

sexually transmitted infection