It's Time to Act: Contextualizing the Prevalence of Sexually Transmitted Infections in Adolescents and Young Adults with Sickle Cell Disease
Authors: Walden Joseph , Stanek Joseph R , Nahata Leena , Creary Susan Elizabeth 
Published: December 2023

Background: Preventing sexually transmitted infections (STIs) is a key aspect of healthcare for adolescents and young adults (AYAs). Those with sickle cell disease (SCD) may be at particularly high risk given health disparities, knowledge gaps, negative reproductive health outcomes, and barriers to comprehensive sexual and reproductive healthcare for this underserved minority population. While studies show that risky sexual behavior is prevalent in AYAs with SCD (AYAs-SCD), it remains unclear how the prevalence of STIs in AYAs-SCD compares to STI prevalence seen in Black AYAs and AYAs in general. Contextualizing this problem will inform its urgency and potential mitigation strategies. As such, the aims of this study were to examine the prevalence of STIs in AYAs-SCD who were evaluated in the emergency department (ED) and/or admitted for any reason and to compare them to Black and non-Black AYAs in the same setting.
Methods: We used the Pediatric Health Information System (PHIS) database, an administrative database of clinical data from &gt;50 children's hospitals in the United States, to query ED and hospital discharges involving patients aged 13 - 25 years between 01/01/2022 - 05/31/2023. We identified patients with SCD (any genotype) using SCD diagnosis codes. Only the first encounter for each patient was used. STIs were identified using diagnosis codes for specific STIs, such as chlamydia trachomatis, neisseria gonorrhea, trichomonas vaginalis, syphilis, human immunodeficiency virus, and herpes simplex virus, as well as codes for non-specified STIs. STI prevalence was defined as the percentage of encounters with any STI diagnosis during the study period. STI prevalence in AYAs-SCD was compared to Black AYAs and non-Black AYAs without SCD controlling for age and sex. Descriptive statistics were used to summarize data. STI prevalence was summarized with 95% confidence intervals and logistic regression models were used to compare between groups. Significance was set at p-values of &lt;0.05.
Results: We identified 3,602 AYAs-SCD, 177,783 Black AYAs, and 534,495 non-Black AYAs (Table 1). In general, AYAs-SCD were older at the time of encounter (16.8 ± 2.6 years) compared to Black AYAs (16.0 ± 2.1 years; p &lt; .0001) and non-Black AYAs (16.0 ± 2.1 years; p &lt;.0001). AYAs-SCD had a higher prevalence of any STI diagnosis (17.1%) compared to controls (Black: 10.7%; p &lt;.0001, non-Black: 11.8%; p &lt;.0001) - even when controlling for age and sex (Figure 1).
Discussion: Our results suggest that more than one sixth of AYAs with SCD were diagnosed with STIs when seeking acute care for any reason and that they are diagnosed with STIs more frequently than their Black and non-Black counterparts, even when controlling for age and sex. While understanding testing practices is necessary to determine the true prevalence of STIs in AYAs with SCD, these findings indicate a potential disparity in STI risk for AYAs-SCD that is not accounted for by race.
We also identified that despite the potential for delayed physical sexual maturation among those with SCD, youth aged 13-15 years with SCD accounted for a substantial proportion of STI diagnoses. This finding, together with the higher prevalence of STIs among those with SCD aged 13-18 years highlights a potential need to increase STI testing in adolescents with SCD. Finally, females with and without SCD made up the majority of individuals diagnosed with STIs in this sample. Although this may be partially due to the increased STI testing frequency in females reported previously, this high STI burden is important to address, especially considering their disease-related risks of other negative reproductive health outcomes from unprotected sex (e.g., pregnancy).
This study was limited by its retrospective nature, inability to account for hospital-specific testing practices, focus on hospital-based encounters, and reliance on coding accuracy. Additional work is needed to explore rates of STI testing in AYAs with SCD, STI prevalence in ambulatory settings, the relationship between STI diagnosis and contraception use in AYAs with SCD, and strategies to address STIs in AYAs with SCD such as standardized testing practices for this population.