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Prevalence of sexually transmitted infections and risk factors among young people in
a public health center in Brazil: a cross-sectional study
Leyde Daiane de Peder, Claudinei Mesquita da Silva, Bruna Larissa Nascimento,
Josi Any Malizan, Heloise Skiavine Madeira, Josana Dranka Horvath, Eraldo Schunk
Silva, Jorge Juarez Vieira Teixeira
PII: S1083-3188(20)30161-3
DOI: https://doi.org/10.1016/j.jpag.2020.02.008
Reference: PEDADO 2456
To appear in: Journal of Pediatric and Adolescent Gynecology
Received Date: 29 June 2019
Revised Date: 1 February 2020
Accepted Date: 13 February 2020
Please cite this article as: Daiane de Peder L, Mesquita da Silva C, Nascimento BL, Malizan JA,
Madeira HS, Horvath JD, Silva ES, Vieira Teixeira JJ, Prevalence of sexually transmitted infections and
risk factors among young people in a public health center in Brazil: a cross-sectional study, Journal of
Pediatric and Adolescent Gynecology (2020), doi: https://doi.org/10.1016/j.jpag.2020.02.008.
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© 2020 Published by Elsevier Inc. on behalf of North American Society for Pediatric and Adolescent
Gynecology.
Prevalence of sexually transmitted infections and risk factors among young people
in a public health center in Brazil: a cross-sectional study
Leyde Daiane de Peder
1,4
,
Claudinei Mesquita da Silva
2,4
, Bruna Larissa Nascimento
3
,
Josi Any Malizan
4
, Heloise Skiavine Madeira
4
, Josana Dranka Horvath
5
, Eraldo Schunk
Silva
6
, Jorge Juarez Vieira Teixeira
1
1
Post-Graduate Program in Biosciences and Physiopathology, Maringá State
University, Maringá, Paraná, Brazil.
2
Post-Graduate Program in Health Sciences, Maringá State University, Maringá,
Paraná, Brazil.
3
Center of Medical and Pharmaceutical Sciences, State University of Western Paraná,
Cascavel, Paraná, Brazil.
4
Clinical Analyses Laboratory, University Center of Assis Gurgacz Foundation,
Cascavel, Paraná, Brazil.
5
Centro Especializado em Doenças Infecto Parasitárias, Cascavel, Paraná, Brazil.
6
Department of Statistics, Maringá State University , Maringá, Paraná, Brazil.
Corresponding author:
Leyde Daiane de Peder
Post-Graduate Program in Biosciences and Physiopathology, Maringá State University.
Phone: 55 (44) 30114805, Maringá, Paraná, CEP 87020-900, Brazil. E-mail:
leydepeder@yahoo.com.br
Number of summary words: 317 words
Number of text words: 3,028 words
Number of references: 33 references
Number of figures: 2 figures
Number of tables: 4 tables
We declare for the proper purposes that none of the authors of this study has any
type of interest, or others that configure the so-called conflict of interests.
We declare that the manuscript received no financial support from the industry
or other commercial source and none of the authors or any first-degree relatives have
financial/other interests in the subject matter covered in the manuscript.
1
Prevalence of sexually transmitted infections and risk factors among young people in a
public health center in Brazil: a cross-sectional study
Running head:
Sexually transmitted infections in young people
Abstract
Introduction: Sexually transmitted infections (STI) significantly impact the health of
sexually active people, especially young people, and can cause sexual dysfunction, infertility,
increased transmission of HIV, low self-esteem, and death. Methods: We reviewed the
medical records of a cross section of users of a public health services center and verified the
prevalence of STI and its associated predictors for male and female individuals aged 13–24
years in an interior county of southern Brazil. Results: The records of 1,703 adolescents and
young adults, stratified by age (13–18 and 19–24 years respectively) and sex, admitted
between April 1, 2012 and March 31, 2017, were reviewed in this retrospective study.
Epidemiological, clinical, and laboratory data of medical records were analyzed using the chi-
square test and odds ratio, with confidence interval of 95% by the Stata® 9.0 program. During
the study period, a total of 3,448 patients were attended, and of these, 1,703 (49.39%) were
aged 13–24 years, with 86.56% of those aged 19–24 years having at least one STI. The
prevalence of STI among men and women, respectively, was 35.40% and 47.67% for
condylomata, 8.46% and 7.00% for herpes, 26.35% and 18.80% for syphilis, and 20.06% and
6.27% for urethral discharge syndrome. The risk for STI acquisition was the highest in young
adults (OR 1.55, 95% CI 1.17-2.06, p=0.002), female individuals (OR 1.51, 95% CI 1.14-
2.00, p=0.004), those with multiple sexual partners (OR 1.62, 95% CI 1.22-2.16, p<0.001),
and those not or irregularly using prophyplactics (OR 1.62, 95% CI 1.22-2.16, p<0.001).
2
Conclusions: The findings revealed a significant prevalence of STI in young people in public
health service. The predictors associated with STI in these patients were being female, having
multiple partners in the last year, and not using or irregular use of prophyplactics. These
predictors confirm the necessity to implement more aggressive strategies to prevent the
occurrence of STI in specific populations with higher disease risk and minimizing costs and
damages caused by the infections.
Keywords: Sexually Transmitted Infections; Prevalence; Risk factors; Adolescent; Young
adult
Background
Adolescents are two to three times more likely to be affected by sexually transmitted
infections (STI) than are adults, with the highest prevalence among those aged 15–19 years.
1
Early sexual life, curiosity, and the need for affirmation in groups are the leading factors that
trigger adolescents to engage in risky sexual behaviors and not adhere to preventive measures,
a fact that makes them more susceptible to acquiring STI, also, adolescents and young adults
are at greater risk of contracting STI, like HIV due to variations in level of development,
psychological factors, social factors, and systems for providing care.
2, 3
In Brazil, the availability of publications on the prevalence of STI among adolescents
has been insufficient. Only Human Immunodeficiency Virus Infection or Acquired
Immunodeficiency Syndrome (HIV/AIDS), syphilis, and viral hepatitis are included in the
national list of diseases with compulsory notification (SINAN), a system that investigates
notifiable diseases, thus not requiring all STI to be reported (Portaria 204/2016).
4
In addition,
3
a higher prevalence should be considered due to asymptomatic patients. They usually do not
receive adequate guidance and treatment, carrying subclinical infection and being key links in
the transmission of STI.
According to the World Health Organization (WHO), adolescence comprises
individuals between 15 and 19 years of age and young adults are considered to be those
between 20 and 24 years of age.
5
It is estimated that there are more than 1 billion people in
this age group, representing almost 20% of the world population. In Brazil, there are about
16,991,000 adolescents aged between 15 and 19 years and 17,245,000 young adults, of both
sexes, according to data from the Brazilian Institute of Geography and Statistics, which
corresponds to approximately 18% of the total Brazilian population.
6
The concern regarding STI transmition among young adults is important both now and
in the future, which may lead to sexual dysfunction, pelvic inflammatory disease, cervical
cancer, infertility, spontaneous abortion, congenital malformation, premature births, ectopic
pregnancy, vertical transmission, and death, if they do not seek adequate treatment.
7,8,9
Simultaneously, these infections also increase the risk of acquiring HIV.
10,11
In low- and
middle-income countries, symptomatic STI are treated using syndromic management, with
presumptive treatment for symptomatic persons without the use of laboratory tests.
12
Using
syndromic management can make diagnosis difficult, as many patients may be
asymptomatic.
13
The number of STI cases among young people has increased, and between 2004 and
2013, 25% of the registered cases were of those aged <25 years, according to the World
Health Organization. It is also clear that adolescents are not a homogeneous population, they
have diverse needs that are related to the transition from childhood to adulthood, which
4
presents risks to their health.
5
By understanding the problems to which they are susceptible,
increased health services can contribute to the healthy development of these young people.
Considering that many adolescents start their sexual lives when they still have little
knowledge about STI and have misconceptions about the transmission of these infections, the
concern for this population group is of utmost importance. Prevention is the basic strategy in
controlling STI transmission. The use of condoms, early detection, and utilization of
educational measures, preventive counseling and activities through constant reminders are
factors that contribute to the reduction in the increasing rates of these diseases, thus reducing
the burden on the health system and complications that affect the quality of life of the young
population.
14,15
Providing preventive counseling is more likely to be effective when
implemented prior to the involvement of adolescents in sexual risk situations.
15
The aim of
the present study was to determine the prevalence of STI in adolescents and young adults who
visited a public health center in Southern Brazil..
Methods
A cross-sectional, descriptive, and retrospective study was conducted according to the
Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines
(S1 STROBE Checklist).
16
Study design, setting, and subjects
The study was a carried out in a public health center called Centro Especializado em
Doenças Infecto Parasitárias (CEDIP) located in Cascavel city, Paraná county, south of
Brazil. The CEDIP Cascavel unit, operates in the control and treatment of hepatitis,
leishmaniasis and other sexually transmitted diseases, toxoplasmosis, blastomycosis and
5
reduction of damage caused by alcohol/drugs. The public health center is accredited as a
hospital in the treatment of AIDS. This reference center serves 25 municipalities of the 10th
Regional Health (RS) Center of Paraná, with a total population of 502,591 and approximately
93,000 young people aged 13 to 24 years.
17
We reviewed the medical records of adolescents and young adults with STI, who
accessed the CEDIP service from April 1, 2012 to March 31, 2017. For study purposes, the
young people (13-24 years old) were divided between adolescents (13-18 years) and young
adults (19-24 years). For the present study, a census was used, that is, records of all patients
between 13 and 24 years old who attended the service for diagnosis, treatment or follow-up of
infections were studied. Patients aged 25 years or over were excluded because they were
already adults according to WHO
4
and those under 13 years of age, due to the great majority
of children, which is beyond the scope of the study. Individuals who are between 13 and 15
years old have similar general behavior, because of this, we decided to extend the study age of
adolescents, when compared to the one defined by the WHO so as to achieve a broader view
of the behavior of these individuals.
The medical records contained sociodemographic information and other relevant risk
factors which were recorded by trained physicians and nurses. A structured and pre-tested
questionnaire was used to document this information. Data on the following predictor
variables were collected: sex, age, marital status, behavior, occupation, date of diagnosis, time
of onset of symptoms/signs until diagnosis, STI history, STI partner, number of partners in
the last 12 months, alcohol use, tobacco use, illicit drugs use, reinfection, age at first sexual
intercourse, and use of condoms. The outcome variable was STI diagnosis. The records of all
young people with STI, who visited the reference center for diagnosis, monitoring, and/or
treatment during the study period, were reviewed for this study.
6
Diagnosis
All exams were performed according to the norms of the Ministry of Health of Brazil in
force at the time, following the instructions of the test manufacturers. For the
immunodiagnosis of syphilis, samples were analyzed with a non-treponemal test, Rapid
Plasma Reagin (RPR LABORCLIN/BRAS®), and reagent samples were analyzed with a
treponemal test, ELISA (Trepanostika® TP recombinant), as established in Ordinance
Number 2012 of the Ministry of Health's guidelines (Portaria 2012/2016).
18
Diagnosis of urethral discharge syndrome (UDS), herpes, and condylomata/Human
papillomavirus (HPV) are based on history and physical examination, including the presence
of suggestive lesions and discharge. For these conditions, the patient is offered and provided
medical treatment, without waiting for the results of confirmatory tests
19
; therefore, the
clinical characteristics of the patient were observed, and the visualization of suggestive
lesions or secretion reports were considered and validated by the medical team.
Data management and statistical methods
For UDS, those who had only urethral or vaginal discharge were considered as patients.
In order to calculate the prevalence of each disease, they were considered independent of the
presence of coinfection. To determine the prevalence of coinfections, a diagnosis of more than
one STI was considered in the patient, such as UDS and genital herpes, UDS and syphilis, and
genital herpes and syphilis or more than two coinfections. For the determination of the simple
quantitative prevalence (%) of each variable, only the medical records that had the variable
were considered.
7
The data were collected through Microsoft Excel® and statistical analysis was
performed using the Stata® software version 9.4 (StataCorp, College Station, Texas, USA).
The quantitative variables were categorized and results were expressed as median,
interquartile relation (IQR), or frequencies and percentages. The chi-square test, effect
measures by the odds ratio (OR) test, and confidence intervals (CI) of 95% were used. The p-
value of <0.05 was considered statistically significant.
Ethical approval
This study complied with the guidelines and requirements of Resolution No. 466/13 of
the National Health Council
20
and was approved by the Research Ethics Committee of the
University Center of Assis Gurgacz Foundation (report no. 1.206.008/2015).
Results
Between April 2012 and March 2017, 3,448 patients were attended to in public health
service and of these, 1,703 (49.39%) were aged between 13 and 24 years (young people), with
the median age of 20 years and IQR of 18–22. The prevalence of STI in these patients was
84.85% (1,445), and a large majority (73.08%) of young people attended to were aged
between 19 and 24 years. Among those aged 13 to 18 years of age (adolescents), the
prevalence of STI was 80.54% (389/483) and among those aged 19 to 24 years of age (young
adults), it was 86.56% (1.056/1.220). The most prevalent infection in both populations was
condylomata followed by syphilis (Figure 1). There was no significant difference between the
prevalences of the diseases under study among adolescents and young adults (p=0.901).
As CEDIP has the area of service for the 25 municipalities that make up the 10th RS,
all the young people referred by physicians from the municipalities in the area or who visited
8
the center for assistance/diagnosis were considered for the present study. The referral center is
responsible for the care of approximately 47,700 adolescents aged between 13 and 18 years
and 44,700 young adults aged between 19 and 24 years, and it was verified that the
prevalence of STI in 100.00 inhabitants was higher for those individuals aged between 19 and
24 years. In these patients, there was an increase in prevalence over time (348.9–545.7 per
100,000 population), except for the last year in which there was a slight decrease (471.9). In
relation to patients aged 13 to 18 years, the highest prevalence of STI (203.4/100,000
inhabitants) was visualized in 2013 (Figure 2).
The most common infections among young people was condylomata (40.34%)
followed by syphilis (23.31%). There was a significant difference (p<0.001) in the prevalence
of diseases between men and women, respectively being 35.40% and 47.67% for
condylomata, 8.46% and 7.00% for herpes, 26.35% and 18.80% for syphilis, and 20.06% and
6.27% for UDS. Among male and female adolescents and young adults, the differences
between the prevalences were significant (p<0.001 in both cases) (Table 1).
Among the young STI patients, 603/1,445 (41.73%) were female and 842/1.445
(58.27%), male. In the female patients treated, the prevalence of STI was 87.90% (603/686),
with the median age of 20 years and IQR of 17–21 and in male patients, the STI prevalence
was 82.79% (842/1,017), with median age of 21 years and IQR 19–22.
The most affected young people by STI were single; with a heterosexual orientation;
having secondary education; studying or employed; who reported no use or have already used
tobacco, alcohol, or illicit drugs; not using any contraception; having two or more sexual
partners in the last year; and more than 12 years old during the first sexual relationship (Table
2).
9
As described in Table 3, young adult (OR 1.55, 95% CI 1.17-2.06, p=0.002) and
female patients (OR 1.51, 95% CI 1.14-2.00, p=0.004) were at a higher risk of acquiring
infections than other covariates. In addition, 62.96% of the patients reported having multiple
partners and had a higher risk (OR 1.62, 95% CI 1.22-2.16, p <0.001) than those who had a
single partner. A large number of patients (86.05%) reported to have not used or occasionally
used condoms and had a higher risk of acquiring STI (OR 2.48, 95% CI 1.76-3.49, p<0.001)
(Table 3).
The risk for HPV acquisition was the highest in adolescents (OR 1.27, 95% CI 1.02-
1.57, p=0.027), female patients (OR 1.66, 95% CI 1.36-2.03, p<0.001), others marital status
(OR 1.54, 95% CI 1.21-1.967, p<0.001), those with heterosexual orientation (OR 1.99, 95%
CI 1.40-2.84, p<0.001), and those with single sexual partners in the last 12 months (OR 1.26,
95% CI 1.02-1.56, p=0.028). The risk for syphilis acquisition was the highest in young adults
(OR 1.42, 95% CI 1.09-1.84, p=0.008), male (OR 1.54, 95% CI 1.22-1.96, p<0.001), those
with homosexual or bisexual orientation (OR 4.82, 95% CI 3.41-6.82, p<0.001), those with
multiple sexual partners (OR 1.49, 95% CI 1.15-1.93, p=0.002), and those not using or
irregularly using prophylactics (OR 1.74, 95% CI 1.16-2.59, p=0.005); the risk for UDS
acquisition was the highest in male patients OR 3.75, 95% CI 2.64-5.33, p<0.001), those who
were single (OR 2.77, 95% CI 1.74-4.35, p<0.001), those having multiple partners in last 12
months (OR 3.18, 95% CI 2.22-4.55, p<0.001), and those who used tobacco (OR 1.64, 95%
CI 1.20-2.24, p<0.001) and illicit drugs (OR 1.52, 95% CI 1.06-2.194, p=0.023) (Table 4 and
Table 5).
About 7% (98) of the patients were confirmed to be pregnant or had pregnant partners;
7.96% (115) had a history of STI; 6.92% (100) had partners with STI; 12.56% (161)
presented reinfection; and approximately 55.98% (805) did not return after treatment.
10
Regarding the delay in medical care, 62.70% (684) of the patients sought diagnosis at least 1
month after the onset of symptoms, and 5.41% (59) of them had lesions lasting for more than
1 year.
Discussion
STI are common causes of morbidities in young individuals, which may lead to the
development of various complications, such as severe infection, chronic pain, infertility,
cancer, ectopic pregnancy, and deleterious effects on the uterus.
21
Several factors are
considered as important risky behaviors for acquiring STI among adolescents: onset of early
sexual activity, multiple sexual partners, sequential sexual partners of a limited duration,
increased biological susceptibility to infection due to other STI, and lack of adequate and
proper protection and access to the health system.
1,2,11
Studies have shown that individuals
who engaged in early sexual activities are exposed to risks related to unprotected sex, which
may result in an increased risk for STI and its consequences.
22,23
Of the total number of patients attended to at the reference center, and who had STI
(1,445), 389 (26.92%) were aged 13 to 18 years; 1,056 (73.08%) were aged 19 and 24 years;
842 (58.27%) were men; and 603 (41.73%) were women.
Data shows that in the United States, approximately 24% of young women aged 14–19
years have laboratory history of at least one of the following STI: HPV, Chlamydia
trachomatis, Trichomonas vaginalis, herpes, and Neisseria gonorrhoeae.
2
In our study, the
vast majority of adolescents were affected by condylomata (40.34%), which was also
consistent with a study conducted with adolescents in Greece, showing that 37.9% of the
patients had HPV.
24
11
A large number of cancer cases have been attributed to carcinogenic infections,
especially HPV
25
, cervical cancer is known to develop HPV persistence in the cervical
epithelium
26
and a systematic review and meta-analysis conducted in Brazil demonstrated
high pooled HPV prevalence in several other cancers, including penile cancer, colorectal
cancer, and vulvar cancer.
27
The high prevalence of HPV infection in cancers emphasizes the
importance of prevention measures, with emphasis on vaccination. In Brazil, two vaccines are
available to the population, the quadrivalent vaccine, Gardasil®/Silgard® (Sanofi Pasteur
MSD/Merck Sharp & Dohme), which protects against HPV infections 6, 11, 16 and 18, and
the bivalent vaccine, Cervarix® (GlaxoSmithKline Biologicals), that protects against HPV 16
and 18 infections
28
In 2015, the nonvalent Gardasil9 vaccine (Sanofi Pasteur MSD/Merck
Sharp & Dohme) was licensed in Europe for the prevention of cancers and precancerous
lesions of the cervix, vulva, vagina and anus, as well as genital warts caused by HPVs 6, 11,
16, 18, 31, 33, 45, 52 and 58 (European Medicines Agency). This vaccine protects against
five high-risk HPV types not included in first-generation HPV vaccines (HPV 31, 33, 45, 52
and 58).
29
Female adolescents are biologically more likely to be infected when exposed to STI due
to cervical ectopy, decreased local immunity, decreased introitus, and lack of lubrication that
can lead to trauma during sex. In men, increased susceptibility occurs in uncircumcised
individuals, regardless of age.
30
Information on the prevalence of STI among adolescents in Brazil is scarce and urgently
needded. Only HIV, syphilis, and viral hepatitis are compulsory notification in SINAN.
4
In this study, there was an increase in the prevalence of STI in the study population with
the passage of time, especially in individuals aged between 19 and 24 years. Literature shows
that STI/AIDS incidence in Brazil has increased in the general population and affected the
12
younger population, aged between 15 and 21 years.
31
A study conducted in Brazil with
patients seen between 2005 and 2016 at a health center showed a higher prevalence of
syphilis- HIV coinfection in patients aged 18–29 years compared to older patients.
32
In a study conducted in Europe and North America, the highest prevalence of STI in
adolescents was found in women (p<0.01). Higher prevalence of STI in women was also
found in a study of young people in South Africa.
13
Women, especially adolescents and
young adults, are more vulnerable to STI than are men due to biological, social, and gender
factors.
33,34,35
The relatively high prevalence in women may be related to gender and power
issues (submissiveness), moral issues, prejudices, taboos, and lack of female autonomy.
34
Regarding marital status, majority of young people were single (77.72%) and had multiple
partners (62.96%). Studies show that single teenagers are more inclined to relationships with
multiple partners, thereby increasing their chances of acquiring STI/HIV.
36
Approximately 86.00% reported not or irregularly using condoms. Condoms are the
most common preventive measures in reducing the rate of contamination, protecting STI
partners, and also preventing unwanted pregnancies.
37
Kenyon et al. also found that condom
use among adolescents was relatively low.
38
Non-adherence to regular condom use continues
to be one of the main vulnerability factors of young people worldwide.
39
About 7.00% of the patients were confirmed to be pregnant or had pregnant partners.
In 2015, data from the Ministry of Health in Brazil showed that pregnant women with STI
may develop problems that affect the child and cause complications, such as abortion, preterm
birth, congenital diseases, or even death of the newborn.
39
In addition, these infections can not
only be controlled by treating those who seek help in the health service centers but also by
testing and treating the partners of the patients with the guidance of a health professional.
Since 1990, the adolescent fertility rate has increased by 26%, thus showing a relevant health
13
problem when associated with high rates of pregnancy and STI in the youth.
40,41
Among the
total number of patients, 12.56% presented reinfection, 7.96% had a history of STI, and
approximately 56% did not return after treatment. Moreover, 62.70% of the patients sought
diagnosis at least 1 month after the onset of symptoms, and 5.41% of them had lesions for
more than 1 year. The delay in seeking health services is also found in other studies on people
with STI.
42
This fact can increase the transmission of STI, besides aggravating the patient’s
condition. Partner’s lack of adherence to treatment is one of the difficulties encountered and
triggers reinfection.
14
Strengths of this study include the subject studied, that is, sexually transmitted
infections are now a global public health problem with growing socioeconomic burden,
especially in adolescents, which can have important and serious consequences if not properly
diagnosed and treated. The increased use of prevention method among sexually active young
people can improve their quality of life. The large sample of young adults attended at public
health service is due to the fact that CEDIP is located in the largest municipality in the
western region of the state of Paraná. This service is considered as a reference, so all
suspected cases of STI are referred to this location. This increases the credibility of the study,
as the service does not only serve patients from the municipality of Cascavel, but also patients
from 25 municipalities. Although STI prevalence varies according to each region, the present
study can contribute in comparison with studies conducted in institutions with similar
characteristics, regardless of whether they are located inside or outside Brazil, clinics serving
patients with suspected sexually transmitted infections are very common in the vast majority
of patients in both developed and developing countries.
The limitations of this study include the nature of the information collection in terms
of secondary data, because it was based on the verbal report of signs/symptoms, and the
14
prevalence may be under- or overestimated. As the work was performed in a health service
focused on the diagnosis of infectious and parasitic diseases, which receives patients
suspected of having these infections, we may have had a higher prevalence in relation to what
was studied, when compared to a study with general population. Another important point was
the absence of some information in the patients' records, minimizing the comparison of the
predictors. It is believed that larger samples involving various specialized services could
provide more accurate information of the problem. However, our results are consistent with
those of other published studies.
In conclusion, the findings showed a high number of young people attended (41.90%)
in a public health service and a higher prevalence of STI in young people among them
(84.85%). The predictive variables related to these individuals were being female, having
multiple partners in the last year, and not or irregularly using prophyplactics. Considering the
high cost that STI can generate for the public health system and the terrible consequences they
may have on young people in the future, epidemiological studies can contribute in
determining the population most at risk and propose preventive and control measures.
Acknowledgements
We acknowledge the Centro Especializado em Doenças Infecto Parasitárias (CEDIP).
Funding
This research did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.
Competing interests
15
The authors declare that they have no conflict of interest.
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Table 1. STI Prevalence in young patients (13–24 years old) attended to at a public health service in an interior county of
southern Brazil, from 2012 to 2017
STI
Male
n (%)
1,017 (59.72)
Female
n (%)
686 (40.28)
Overall
n (%)
1,703 (100.00)
13
-
18
years
(n =234)
19
-
24
years
n = 783
Total
n =1,017
13
-
18
years
n = 249
19
-
24
years
n = 437
Total
n = 686
13
-
18
years
n = 483
19
-
24
years
n = 1,220
Total
n = 1,703
Condylomata
69 (29.49%) 291 (37.16%) 360 (35.40%) 146 (58.63%) 181 (41.42%) 327 (47.67%) 215 (44.51%) 472 (38.69%) 687 (40.34%)
Herpes
14 (5.98%) 72 (9.20%) 86 (8.46%) 19 (7.63%) 29 (6.64%) 48 (7.00%) 33 (6.83%) 101 (8.28%) 134 (7.87%)
Syphilis
56 (23.93%) 212 (27.08%) 268 (26.35%) 36 (14.46%) 93 (21.28%) 129 (18.80%) 92 (19.05%) 305 (25.00%) 397 (23.31%)
UDS
54 (23.08%) 150 (19.16%) 204 (20.06%) 18 (7.23%) 25 (5.72%) 43 (6.27%) 72 (14.91%) 175 (14.34%) 247 (14.50%)
Coinfection*
18 (7.69%) 74 (9.45%) 92 (9.05%) 21 (8.43%) 27 (6.18%) 48 (7.00%) 39 (8.07%) 101 (8.28%) 140 (8.22%)
Other**
6 (2.56%) 29 (3.70%) 35 (3.44%) 31 (12.45%) 92 (21.05%) 123 (17.93%) 37 (7.66%) 121 (9.92%) 158 (9.28%)
n, patients number; HPV, human papillomavirus; UDS, urethral discharge syndrome. *UDS and genital herpes, UDS and syphilis, genital herpes
and syphilis or more than two coinfections. **cervicitis, pelvic inflammatory disease, donovanosis, candidiasis, molluscum contagiosum, HTLV,
vaginosis, urethritis, epididymitis, balanitis, balanoposthitis
Table 2. Baseline characteristics of young STI patients (13–24 years old) attended to at a public health service in an
interior county of southern Brazil, from 2012 to 2017
Characteristics
Male
n (%)
842 (58.27%)
Female
n (%)
603 (41.73%)
Overall
n (%)
1,445 (100.00%)
13
-
18
years
n (%)
169 (43.33)
19
-
24
years
n (%)
673 (63.73)
Total
n (%)
842 (58.27)
13
-
18
years
n (%)
220 (56.56)
19
-
24
years
n (%)
383 (36.27)
Total
n (%)
603 (41.73)
13
-
18
years
n (%)
389 (26.92)
19
-
24
years
n (%)
1,056 (73.08)
Total
n (%)
1,445
(100.00)
Marital
status
Single
136/145
(93.79%) 541/650
(83.23%) 677/795
(85.16%) 155/217
(71.43%) 246/375
(65.60%) 401/592
(67.74%) 291/362
(80.39%) 787/1,025
(76.78%) 1,078/1,38
7 (77.72%)
Married
9/145
(6.21%) 109/650
(16.77%) 118/795
(14.84%) 61/217
(28.11%) 125/375
(33.33%) 186/592
(31.42%) 70/362
(19.34%) 234/1,025
(22.83%) 304/1,387
(21.92%)
Divorced
-- -- -- 1/217
(0.46%) 4/375
(1.07%) 5/592
(0.84%) 1/362
(0.28%) 4/1,025
(0.39%) 5/1,387
(0.36%)
Sexual
Orientation
Heterosexual
110/144
(76.39%) 486/589
(82.51%) 596/733
(81.31%) 197/200
(98.50%) 349/358
(97.49%) 546/558
(97.85%) 307/344
(89.24%) 835/947
(88.17%) 1,142/1,29
1 (88.46%)
Homosexual
25/144
(17.36%) 76/589
(12.90%) 101/733
(13.78%) 1//200
(0.50%) 5/358
(1.40%) 6/558
(1.08%) 26/344
(7.56%) 81/947
(8.55%) 107/1,291
(8.29%)
Bisexual
9/144
(6.25%) 27/589
(4.58%) 36/733
(4.91%) 2/200
(1.00%) 4/358
(1.12%) 6/558
(1.08%) 11/344
(3.20%) 31/947
(3.27%) 42/1,291
(3.25%)
Highest
level
of
education
Primary
56/154
(36.36%) 144/657
(21.92%) 200/811
(24.66%) 48/213
(22.54%) 60/380
(15.79% 108/593
(18.21%) 104/367
(28.34%) 204/1,037
(19.67%) 308/1,404
(21.94%)
Secundary
91/154
(59.09%) 395/657
(60.12%) 486/811
(59.93%) 154/213
(72.30%) 234/380
(61.58%) 388/593
(65.43%) 245/367
(66.76%) 629/1,037
(60.66%) 874/1,404
(62.25%)
Finished high
school*
7/154
(4.55%) 118/657
(17.96%) 125/811
(15.41%) 11/213
(5.16%) 86/380
(22.63%) 97/593
(16.36%) 18/367
(4.90%) 204/1,037
(19.67%) 222/1,404
(15.81%)
Study
ou
work
Yes
104/131
(79.39%) 569/620
(91.77%) 673/751
(89.61%) 145/180
(80.56%)
274/353
(77.62%) 419/533
(78.61%) 62/311
(19.94%) 130/973
(13.36%)
1,092/1,28
4 (85.05%)
No
27/131
(20.61%) 51/620
(8.23%) 78/751
(10.39%) 35/180
(19.44%)
79/353
(22.38%)t 114/533
(21.39%) 249/311
(80.06%) 843/973
(86.64%)
192/1,284
(14.85%)
Use
or
have
already
used
tobacco
Yes
60/169
(35.50%) 150/673
(22.29%) 210/842
(24.94%) 25/220
(11.36%)
48/383
(12.53%) 73/603
(12.11%) 85/389
(21.85%) 198/1,056
(18.75%)
283/1,445
(19.58%)
No
109/169
(64.50%) 523/673
(77.71%) 632/842
(75.06%) 195/220
(88.64%)
335/383
(87.47%) 530/603
(87.89%) 304/389
(78.15%) 858/1,056
(81.25%)
1,162/1,44
5 (80.42)
Use
or
have
already
used
alcool
Yes
10/169
(5.92%) 22/673
(3.27%) 32/842
(3.80%) 1/220
(0.45%) 5/383
(1.31%) 6/603
(1.00%) 11/389
(2.83%) 27/1,056
(2.56%) 38/1,445
(2.63%)
No
159/169
(94.08%) 651/673
(96.73%) 810/842
(96.20%) 219/220
(99.55%) 378/383
(98.69%) 597/603
(99.00%) 378/389
(97.17%) 1,029/1,056
(97.44%) 1,407/1,44
5 (97.37%)
Use
or
have
already
used
Ilicid
drugs
Yes
55/169
(32.54%) 101/673
(15.01%) 156/842
(18.53%) 15/220
(6.82%) 22/383
(5.74%) 37/603
(6.14%) 70/389
(17.99%) 123/1,056
(11.65%) 193/1,445
(13.36%)
No
114/169
(67.46%) 572/673
(84.99%) 686/842
(81.47%) 205/220
(93.18%) 361/383
(94.26%) 566/603
(93.86%) 319/389
(82.01%) 933/1,056
(88.35%) 1,252/1,44
5 (86.64%)
Current
use
of
any
contraception
Yes
17/121
(14.05%) 73/531
(13.75%) 90/652
(13.80%) 34/201
(16.92%) 43/344
(12.50%) 77/545
(14.13%) 51/322
(15.84%) 116/875
(13.26%) 167/1,197
(13.95%)
No
104/121
(85.95%) 458/531
(86.25%) 562/652
(86.20%) 167/201
(83.08%) 301/344
(87.50%) 468
(85.87%) 116/875
(84.16%) 759/875
(86.74%) 1,030/1,19
7 (86.05%)
Number
of
current
sexual
partners
None
-- 5/584
(0.86%) 5/737
(0.68%) 3/199
(1.51%) 2/341
(0.59%) 5/540
(0.93%) 3/352
(0.85%) 7/925
(0.76%) 10/1,277
(0.78%)
1
25/153
(16.34%) 148/584
(25.34%) 173/737
(23.47%) 105/199
(52.76%) 185/341
(54.25%) 290/540
(53.70%) 130/352
(36.93% 333/925
(36.00%) 463/1,277
(36.26%)
2 or more
128/153
(83.66%) 431/584
(73.80%) 559/737
(75.85%) 91/199
(45.73%) 154/341
(45.16%) 245/540
(45.37%) 219/352
(62.22%) 585/925
(63.24%) 804/1,277
(62.96%)
Age
of
the
first
sexual
relationship
≤ 12 years
13/95
(13.68%) 13/265
(4.91%) 26/360
(7.22%) 10/153
(6.54%) 4/199
(2.01%) 14/352
(3.98%) 23/248
(9.27%) 17/464
(3.66%) 40/712
(5.62%)
≥ 13 years
82/95
(86.32%) 252/265
(95.09%) 334/360
(92.78%) 143/153
(93.46%) 195/199
(97.99%) 338/352
(96.02%) 225/248
(90.73%) 447/464
(96.34%) 672/712
(94.38%)
n, patients number
Table 3. Predictor variables associated with STI in young people (13–24
years old) attended to at a public health service in an interior county of
southern Brazil, from 2012 to 2017
Predictor
variable
Patients
with
STI
n (%)
OR
(95%
CI)
P
value
Age
group
13 – 18 years 389/483 (80.54) 1
19 – 24 years 1,056/1,220 (86.56) 1.55 (1.17-2.06) 0.002
Sex
Male 842/1,017 (82.79) 1
Female 603/686 (87.90) 1.51 (1.14-2.00) 0.004
Marital status
Single 1,078/1,263 (85.35) 1
Others 309/352 (87.78) 1.23 (0.86-1.76) 0.246
Behaviour
Homosexual or
bisexual 149/166 (89.76) 1.48 (0.87-2.50) 0.140
Heterosexual 1,142/1,335 (85.54) 1
Number
of
partners
in
last
12
months
Single 473/582 (81.27) 1
Multiple 804/918 (87.58) 1.62(1.22-2.16) <0.001
Preservatives
use
Regular 167/229 (72.93) 1
Irregular or not
using 1,030/1,184 (86.99) 2.48 (1.76-3.49) <0.001
Age
of
first
sexual
intercourse
(years)
≤ 12 40/47 (85.11) 1
≥ 13 672/761 (88.30) 1.32 (0.57-3.04) 0.511
Tobaco
Yes 283/336 (84.23) 0.94 (0.67-1.31) 0.721
No 1,162/1,367 (85.00) 1
Ilicit drugs
Yes 193/220 (87.73) 1.31 (0.86-2.02) 0.202
No 1,252/1,483 (84.42) 1
n, patitent number, STI, Sexually Transmitted Infection, OR, odds ratio, CI,
confidence interval
Table 4. Predictor variables associated with condylomata and herpes in young patients (13–24 years old) attended to at a
public health service in an interior county of southern Brazil, from 2012 to 2017
Predictor
variable
Patients
with
condylomata
n (%)
OR
(95%
CI)
P
value
Patients
with
herpes
n (%)
OR
(95%
CI)
P
value
Age group
13 – 18 years 215/483 (44.51) 1.27 (1.02-1.57) 0.027 33/483 (6.83) 1.23 (0.82-1.85) 0.318
19 – 24 years 472/1220 (38.69) 1 101/1,220 (8.28) 1
Sex
Male 360/1017 (35.40) 1 87/1,017 (8.46) 1.23 (0.85-1.77) 0.272
Female 327/686 (47.67) 1.66 (1.36-2.03) <0.001 48/686 (7.00) 1
Marital status
Single 493/1,263 (39.03) 1 89/1,263 (7.84) 1
Others 175/352 (49.71) 1.54 (1.21-1.96) <0.001 29/352 (8.24) 1.05 (0.68-1.62) 0.806
Sexual
orientation
Homosexual or
bisexual 49/166 (29.52) 1 14/166 (8.43) 1.11 (0.62-1.99) 0.718
Heterosexual 608/1,335 (45.54) 1.99 (1.40-2.84) <0.001 102/1,335 (7.64) 1
Number
of
partners
in
last
12
months
Single 266/582 (45.70) 1.26 (1.02-1.56) 0.028 38/582 (6.53) 1
Multiple 367/918 (39.98) 1 77/918 (8.39) 1,31 (0.87-1.96) 0.187
Preservatives use
Regular 91/229 (39.74) 1 16/229 (6.99) 1
Irregular or not using 522/1,184 (44.09) 1.19 (0.89-1.59) 0.224 94/1,413 (7.94) 1.15 (0.66-1.99) 0.622
Age
of
first
sexual
intercourse
(years)
≤ 12 18/47 (38.30) 1 6/47 (12.77) 1.84 (0.75-4.53) 0.177
≥ 13 359/761 (47.17) 1.44 (0.78-2.64) 0.237 56/761 (7.36) 1
Tobaco
Yes 127/336 (37.80) 1.14 (0.89-1.46) 0.289 26/336 (7.74) 1.02 (0.65-1.60) 0.921
No 560/1,367 (40.97) 1 108/1,367 (7.90) 1
Ilicit drugs
Yes 89/220 (40.45) 1.00 (0.75-1.34) 0.970 19/220 (8.64) 1,12 (0.67-1.87) 0.650
No 598/1,483 (40.32) 1 115/1,483 (7.75) 1
n, patitent number, OR, odds ratio, CI, confidence interval
Table 5. Predictor variables associated with syphilis and UDS in young patients (13–24 years old) attended at a public
health service in an interior county of southern Brazil, from 2012 to 2017
Predictor
variable
Patients
with
Syphilis
n (%)
OR
(95%
CI)
P
value
Patients
with
UDS
n (%)
OR
(95%
CI)
P
value
Age gro
Age group
13 – 18 years 92/483 (19.05) 1 72/483 (14.91) 1
19 – 24 years 305/1,220 (25.00) 1.42 (1.09-1.84) 0.008 175/1,220 (14.34) 1.04 (0.77-1.40) 0.766
Sex
Male 268/1,017 (26.35) 1.54 (1.22-1.96) <0.001 204/1,017 (20.06) 3.75 (2.64-5.33) <0.001
Female 129/686 (18.80) 1 43/686 (6.27) 1
Marital status
Single 306/1,263 (24.23) 1.22 (0.91-1.63) 0.172 205/1,262 (16.23) 2.77 (1.74-4.35) <0.001
Others 73/352 (20.74) 1 23/352 (6.53) 1
Sexual Orientation
Homosexual or
bisexual 87/166 (52.41) 4.82 (3.41-6.82) <0.001 30/166 (18.07) 1.38 (0.90-2.11) 0.136
Heterosexual 248/1,335 (18.58) 1 184/1,335 (13.78) 1
Number
of
partners
in
last
12
months
Single 105/582 (18.04) 1 42/582 (7.22) 1
Multiple 227/918 (24.73) 1.49 (1.15-1.93) 0.002 182/918 (19.83) 3.18 (2.22-4.55) <0.001
Preservatives use
Regular 32/229 (13.97) 1 24/229 (10.48) 1
Irregular or not using 261/1,184 (22.04) 1.74 (1.16-2.59) 0.005 173/1,184 (14.61) 1.46 (0.93-2.30) 0.098
Age
of
first
sexual
intercourse
(years)
≤ 12 15/47 (31.91) 1.89 (1.00-3.59) 0.046 10/47 (21.28) 1.61 (0.78-3.35) 0.192
≥ 13 151/761 (19.84) 1 109/761 (14.32) 1
Tobaco
Yes 89/336 (26.49) 1.24 (0.94-1.63) 0.124 67/336 (19.94) 1.64 (1.20-2.24) 0.001
No 308/1,367 (22.53) 1 180/1,367 (13.17) 1
Ilicit drugs
Yes 56/220 (25.45) 1.14 (0.82-1.58) 0.420 43/220 (19.55) 1.52 (1.06-2.19) 0.023
No 341/1,483 (22.99) 1 204/1,483 (13.76) 1
n, patitent number, OR, odds ratio, CI, confidence interval
Figure 1. Flowchart of patients at a public health service, southern Brazil, 2012 to 2017. n,
patient number; UDS, urethral discharge syndrome; *cervicitis and/or pelvic inflamatory disease,
and/or donovanosis, and/or candidiasis and/or molluscum contagiosum and/or vaginosis and/or,
urethritis and/or epididymitis and/or balanitis and/or balanoposthitis; **UDS and genital herpes,
UDS and syphilis, genital herpes and syphilis or more than two coinfections.
Total adolescents and young adults
n=1,703 (49.39%)
Total young
people
Syphilis n= 305 (25.00%)
UDS n=175 (14.34%)
Herpes n=101 (8.28%)
Condylomata n= 472 (38.69%)
Other infections* n=121 (9.92%)
Two or more coinfections** n=101 (8.27%)
Syphilis n=92 (19.04%)
UDS n=72 (14.91 %)
Herpes n=33 (6.83%)
Condylomata n= 215 (44.51%)
Other infections* n=37 (7.66%)
Two or more coinfections** n=39 (8.07%)
Prevalence
Attended patients
n= 3,448
Total
attended
19-24 years
n=1,056
(73.08%)
19-24 years
n = 74
(28.68%)
Adolescents
(13-18 years)
n= 483 (28.36%)
Young adults
(19-24 years)
n= 1,220 (71.64%)
With STI
n=1,445 (84.85%)
Total adolescents and young adult
n=1,703 (49.39%)
13 – 18 years
n = 184
(71.32%)
Without STI
n = 258 (15.15%)
13–18 years
n = 389
(26.92%)
Figure 2. STI prevalence by 100.000 inhabitant adolescents (13-18 years) and
young people (19-24 years) attended to in an interior county of southern Brazil,
from 2012 to 2017
