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Chlamydia Infection Among Adolescent Long-Acting Reversible Contraceptive and Shorter-Acting Hormonal Contraceptive Users Receiving Services at New York City School-Based Health Centers

Published:September 19, 2019DOI:https://doi.org/10.1016/j.jpag.2019.09.006

      Abstract

      Study Objective

      One concern regarding long-acting reversible contraceptive (LARC) use among female adolescents is the potential for sexually transmitted infection acquisition. Few studies investigate chlamydia infection among adolescent LARC users compared with other hormonal contraceptive method (non-LARC) users. We hypothesized that incident chlamydia infection would be similar in these 2 groups and that it would not be associated with adolescent LARC use.

      Design, Setting, and Participants

      Secondary data analysis of electronic health records of adolescents who started using LARC (n = 152) and non-LARC methods (n = 297) at 6 New York City school-based health centers between March 2015 and March 2017.

      Interventions and Main Outcome Measures

      Demographic characteristics, sexual risk factors, and occurrence of chlamydia infection over a period of 1 year were compared in the 2 groups using χ2 tests and t tests. Multivariable logistic regression was used to test the association between LARC use and chlamydia infection adjusting for relevant covariates.

      Results

      Among 422 adolescent patients tested the year after method initiation, 48 (11.4%) had at least 1 positive chlamydia test. The proportions of LARC users and non-LARC users with chlamydia infection were not statistically significantly different (10.9% vs 11.6%; P = .82). Multivariable analysis showed that LARC use was not associated with greater chlamydia risk (adjusted odds ratio, 0.84; 95% confidence interval, 0.41-1.43).

      Conclusion

      Adolescent LARC users did not have significantly higher chlamydia infection occurrence compared with non-LARC users the year after method initiation. Concern for chlamydial infection should prompt recommending condom use but should not be a barrier to recommending adolescent LARC use.

      Key Words

      Introduction

      Because of their high efficacy and safety, long-acting reversible contraceptive (LARC) methods, which include intrauterine devices (IUDs) and the subdermal contraceptive implant, have been recommended as the first-line contraceptive methods for adolescents by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics.
      ACOG Committee Opinion No
      735: adolescents and long-acting reversible contraception: implants and intrauterine devices.
      ,
      Committee on Adolescence
      Contraception for adolescents.
      Although LARC use among sexually active adolescents is estimated to be low (3.2%-5.8%),
      • Abma J.C.
      • Martinez G.M.
      Sexual activity and contraceptive use among teenagers in the United States, 2011-2015.
      ,
      • Pazol K.
      • Daniels K.
      • Romero L.
      • et al.
      Trends in long-acting reversible contraception use in adolescents and young adults: new estimates accounting for sexual experience.
      it is expected to continue to increase as interest in LARC increases and as barriers to LARC uptake decrease.
      • Pazol K.
      • Daniels K.
      • Romero L.
      • et al.
      Trends in long-acting reversible contraception use in adolescents and young adults: new estimates accounting for sexual experience.
      Although LARCs are the most effective reversible contraceptive methods in preventing unintended pregnancy, they do not protect against sexually transmitted infections (STIs).
      Committee on Adolescence
      Contraception for adolescents.
      Correct and consistent condom use remains the most effective method for preventing STIs.
      • Holmes K.K.
      • Levine R.
      • Weaver M.
      Effectiveness of condoms in preventing sexually transmitted infections.
      One of the concerns regarding offering LARCs to female adolescents is the potential for an increase in STI infections due to lower rates of condom usage and/or an increase in sexual risk-taking behaviors.
      • McNicholas C.P.
      • Klugman J.B.
      • Zhao Q.
      • et al.
      Condom use and incident sexually transmitted infection after initiation of long-acting reversible contraception.
      • Rose S.B.
      • Garrett S.M.
      • Stanley J.
      • et al.
      Chlamydia testing and diagnosis following initiation of long-acting reversible contraception: a retrospective cohort study.
      • Steiner R.J.
      • Liddon N.
      • Swartzendruber A.L.
      • et al.
      Long-acting reversible contraception and condom use among female US high school students: implications for sexually transmitted infection prevention.
      • Kortsmit K.
      • Williams L.
      • Pazol K.
      • et al.
      Condom use with long-acting reversible contraception vs non-long-acting reversible contraception hormonal methods among postpartum adolescents.
      Prior studies have reached mixed conclusions regarding whether adolescent LARC users report lower condom use compared to non-LARC users, with some studies finding lower rates of condom use among LARC users while others suggest a similar rate.
      • Steiner R.J.
      • Liddon N.
      • Swartzendruber A.L.
      • et al.
      Long-acting reversible contraception and condom use among female US high school students: implications for sexually transmitted infection prevention.
      ,
      • Bastow B.
      • Sheeder J.
      • Guiahi M.
      • et al.
      Condom use in adolescents and young women following initiation of long- or short-acting contraceptive methods.
      • Berenson A.B.
      • Wiemann C.M.
      Use of levonorgestrel implants versus oral contraceptives in adolescence: a case-control study.
      • Bernard C.
      • Zhao Q.
      • Peipert J.F.
      Dual method use among long-acting reversible contraceptive users.
      • Darney P.D.
      • Callegari L.S.
      • Swift A.
      • et al.
      Condom practices of urban teens using Norplant contraceptive implants, oral contraceptives, and condoms for contraception.
      • Gallo M.F.
      • Warner L.
      • Jamieson D.J.
      • et al.
      Do women using long-acting reversible contraception reduce condom use? A novel study design incorporating semen biomarkers.
      A recent large cross-sectional study among postpartum adolescents reported condom use was half as common in LARC users compared with non-LARC users.
      • Kortsmit K.
      • Williams L.
      • Pazol K.
      • et al.
      Condom use with long-acting reversible contraception vs non-long-acting reversible contraception hormonal methods among postpartum adolescents.
      This has raised the concern among some that LARC use might lead to increased STIs in the female adolescent population.
      • McNicholas C.P.
      • Klugman J.B.
      • Zhao Q.
      • et al.
      Condom use and incident sexually transmitted infection after initiation of long-acting reversible contraception.
      ,
      • Rose S.B.
      • Garrett S.M.
      • Stanley J.
      • et al.
      Chlamydia testing and diagnosis following initiation of long-acting reversible contraception: a retrospective cohort study.
      ,
      • Darney P.D.
      • Callegari L.S.
      • Swift A.
      • et al.
      Condom practices of urban teens using Norplant contraceptive implants, oral contraceptives, and condoms for contraception.
      Chlamydia is the most common STI among adolescents in the United States.
      • Phillips J.A.
      Chlamydia infections.
      There are few studies of a solely adolescent population that investigate whether STI rates are higher among LARC users compared with adolescents using other shorter-acting hormonal contraceptive methods (non-LARC users).
      • Darney P.D.
      • Callegari L.S.
      • Swift A.
      • et al.
      Condom practices of urban teens using Norplant contraceptive implants, oral contraceptives, and condoms for contraception.
      The objective of this study was to compare the chlamydia infection incidence proportion among adolescent LARC and non-LARC users receiving reproductive health care at 6 New York City (NYC) school-based health centers (SBHCs). Over the past decade, the percentage of SBHCs that distribute contraception to adolescents has increased.
      • Summit A.K.
      • et al.
      Integration of onsite long-acting reversible contraception services into school-based health centers.
      ,
      • Lofink H.
      • Schelar E.
      • Taylor K.
      • et al.
      School-Based Health Alliance Census Report.
      Because of their ability to offer adolescents accessible, convenient, and free reproductive health care services, SBHCs are in an important position to provide LARC services to the adolescent population.
      • Sangraula M.
      • Garbers S.
      • Garth J.
      • et al.
      Integrating long-acting reversible contraception services into New York City school-based health centers: quality improvement to ensure provision of youth-friendly services.
      ,
      • Gilmore K.
      • Hoopes A.J.
      • Cady J.
      • et al.
      Providing long-acting reversible contraception services in Seattle school-based health centers: key themes for facilitating implementation.

      Materials and Methods

      This secondary data analysis of electronic medical records identified sexually active female adolescents who initiated LARC (levonorgestrel IUD, copper IUD or etonogestrel contraceptive implant) or non-LARC contraceptive methods (oral contraceptive pill [OCP], depot medroxyprogesterone injection [Depo], transdermal patch, or vaginal ring) between March 2015 and March 2017 at 6 NYC SBHCs. These academic center-affiliated SBHCs expanded their repertoire of reproductive health services to start providing no cost LARC services to adolescents in March 2015.
      • Sangraula M.
      • Garbers S.
      • Garth J.
      • et al.
      Integrating long-acting reversible contraception services into New York City school-based health centers: quality improvement to ensure provision of youth-friendly services.
      Deidentified demographic information (age, grade, race/ethnicity, insurance), SBHC medical visit notes, medication lists, medication orders, billing diagnoses, and STI testing results (including chlamydia, gonorrhea, HIV, and syphilis) were extracted from the electronic medical record and the Online School Clinic Data Repository (OSCR). Access to OSCR, an online repository with more complete demographic information of student-patients who attend SBHCs, was granted by the NYC Department of Health. The study was approved by the Columbia University Medical Center institutional review board with a waiver for informed consent.
      Adolescent patients who initiated LARC and non-LARC methods between March 2015 and March 2017 were identified (n = 819; Fig. 1). Patients who initiated LARC were identified by the presence of a LARC placement note within their medical chart in the time period of interest (n = 262). Patient medication lists and billing diagnoses were used to identify any additional cases of LARC placement that were missed by using only the medical visit notes. Any LARC discontinuation or expulsion (with no replacement of a LARC method within a month) occurring within the year after method initiation was determined by identifying LARC removal notes or notes describing expulsion (n = 9). LARC users with LARC use before March 2015 were excluded (n = 3). Non-LARC users were identified by the presence of at least 1 non-LARC method on the medication list or medication order list within the period of interest. Adolescents with a LARC method listed under health diagnosis or on their medication list before March 2017 but no SBHC procedure note (n = 66) were excluded because these patients had LARC placed at another site. We attempted to divide non-LARC users into OCP, Depo, transdermal patch, or vaginal ring users but opted not to after noting that non-LARC patients switched between methods very frequently. We defined method initiation as the date of LARC placement for LARC users and as the date of first prescription or order for non-LARC method for non-LARC users between March 2015 and March 2017. Of the 152 adolescent patients who initiated LARC, most chose the IUD (27.6% levonorgestrel IUD and 28.3% copper IUD) whereas most non-LARC initiators (n = 297) selected OCPs (60.3%) followed by Depo, the vaginal ring, and the transdermal patch in that order (Fig. 1).
      Figure thumbnail gr1
      Fig. 1Sexually active school-based health center female adolescents who started long-acting reversible contraception (LARC) and non-LARC (non LARC) methods between March 2015 and March 2017. IUD, intrauterine device.
      The primary outcome of this study was determined by identifying the first positive chlamydia test within 1 year after method initiation. Chlamydia testing at the SBHCs was performed at least annually during medical or reproductive health visits for asymptomatic sexually active patients and as necessary to diagnose symptomatic patients, to screen 3 months after chlamydia treatment, and to screen whenever a patient requested testing. Only a small percentage of patients had multiple chlamydia infections diagnosed the year after method initiation (1.8%, n = 8), therefore only the first infection was counted. Chlamydia cases diagnosed on method initiation date were counted as occurring before method use. Patients who did not have any chlamydia tests the year after method initiation were excluded from the final study sample (LARC users, n = 107; non-LARC users, n = 195; Fig. 1). Reasons for individuals not having chlamydia tests the year after method initiation include declining or not being offered testing at subsequent SBHC visits, no further visits to the SBHCs because of graduation or moving to another school or following up for STI testing at outside clinics.
      Demographic and sexual risk factors were determined directly from the electronic medical record and OSCR. Number of sexual partners in a lifetime and age at first intercourse were determined directly from the “number of sexual partners in a lifetime” and “age at first sex” fields on the last medical visit note within the year after method initiation. The STI history variable was determined by using the response to the “positive STI tests in past?” field on the day of the first positive test for individuals who had at least 1 positive chlamydia test and on the last note within 1 year after method initiation for individuals with no positive chlamydia tests. Previous lab results for HIV, syphilis, gonorrhea, and chlamydia were also reviewed and individuals who had any positive lab result for any of the aforementioned STIs were determined to have a positive STI history even if there was no reported history on the note field. Age at method initiation was calculated by using the date of birth and the date of method initiation. Number of chlamydia tests within 1 year after method of initiation were determined and categorized as 1, 2, 3, 4, or more. All variables were treated as continuous in the analysis except for STI history (which was categorized as 1 for positive STI history and 0 for negative STI history, which was used as reference).
      Baseline demographic characteristics and potential STI risk factors were compared between LARC and non-LARC users using χ2 tests for categorical variables and t tests for continuous variables. Chlamydia infection incidence between LARC and non-LARC adolescents was compared using χ2 test. Multivariable logistic regression was used to determine the association between chlamydia infection and contraception method use (LARC vs non-LARC), adjusting for potential confounding factors including STI history, age at first intercourse, age at method initiation, number of chlamydia screening tests the year after method initiation, and number of reported lifetime sexual partners. A covariate was identified as a confounding factor if there was more than 10% change in the parameter estimate when it was added to the model.
      Demographic and sexual risk factors of the aforementioned excluded patients (n = 371) were identified and compared with those of patients in the study sample. A model excluding the 8 patients whose LARC was discontinued or expelled within 1 year after initiation was also run for comparison to ensure that any LARC discontinuation/expulsion did not affect the comparison of chlamydia infection incidence among the 2 groups. All analyses were performed using SAS, version 9.4 (SAS Institute Inc).

      Results

      Table 1 shows the demographic and sexual risk factors of adolescent patients who initiated a LARC (n = 152) or a non-LARC (n = 297) method from March 2015 to March 2017 at the 6 NYC SBHCs. Adolescent patients were predominantly Hispanic/Latino (74.2%) and black/non-Hispanic (23.8%) and most had Medicaid (67.3%) or no insurance (27.6%). Most (97.3%) of the study sample were ages 9-19 years, whereas the rest were ages 20 and 21 years. The 2 groups were statistically significantly different in insurance (P = .03), age at method initiation (16.9 vs 16.4 years; P < .001), and number of lifetime partners (2.4 vs 1.9; P = .004). Of the 449 subjects, 49 (18.5%) had a positive STI history with no statistically significant difference between the 2 groups (P = .98; Table 1).
      Table 1Demographic Characteristics and Sexual Risk Factors of Sexually Active Female Adolescents Who Started LARC and Non-LARC Methods at 6 New York City School-Based Health Centers
      CharacteristicTotal (n = 449)LARC (n = 152)Non-LARC (n = 297)P
      Race/ethnicity.51
       Hispanic/Latino of any race333 (74.2)116 (76.3)217 (73.1)
       Black, non-Hispanic107 (23.8)32 (21.1)75 (25.3)
       Other, non-Hispanic9 (2.0)4 (2.6)5 (1.7)
      Insurance type.03
       Medicaid302 (67.3)114 (75.0)188 (63.3)
       Other insurance23 (5.1)8 (5.3)15 (5.0)
       Uninsured124 (27.6)30 (19.7)94 (31.7)
      Age at method initiation in years (mean ± SD, range)16.6 ± 1.4 (12-21)16.9 ± 1.2 (14-21)16.4 ± 1.5 (12-21)<.001
      Age at first intercourse in years (mean ± SD, range)15.0 ± 1.3 (9-19)14.8 ± 1.4 (9-18)15.0 ± 1.3 (10-19).093
      Number of lifetime partners (mean ± SD, range)2.1 ± 1.5 (1-12)2.4 ± 1.9 (1-12)1.9 ± 1.3 (1-11).004
      History of STI
      Determined according to reported STI history and review of previous STI laboratory results.
      83 (18.5)28 (18.4)55 (18.5).98
      Number of chlamydia screening tests within 1 year of method initiation.25
       1240 (53.5)73 (48.0)168 (56.6)
       2123 (27.4)49 (32.2)74 (24.9)
       364 (14.3)21 (13.8)43 (14.5)
       4 or more21 (4.7)9 (5.9)12 (4.0)
      LARC, long-acting reversible contraception; STI, sexually transmitted infection.
      Data are presented as n (%) except where otherwise noted.
      Determined according to reported STI history and review of previous STI laboratory results.
      In the year after contraceptive method initiation, the overall proportion of adolescents in the sample with at least 1 new chlamydia infection was 48/422 (11.4%) (Table 2). There was no statistically significant difference between chlamydia incidence proportion in LARC users compared with non-LARC users (10.9% vs 11.6%; P = .82). In addition, there was no significant association between LARC use and chlamydia infection in the year after contraceptive method initiation even after adjustment for STI history, number of sexual partners in a lifetime, age at method initiation, age at first intercourse, insurance, and number of chlamydia tests (adjusted odds ratio, 0.84; 95% confidence interval, 0.41-1.73; Table 2). Similarly, excluding patients whose LARC was removed or expelled (n = 8; 7 removals and 1 expulsion) within 1 year after method initiation did not change these findings (data not shown).
      Table 2Odds Ratios of Incident Chlamydia Infection in LARC Users Compared With Non-LARC Users
      Excludes 27 female adolescents with missing data on required variables of interest (age at first intercourse, n = 13 missing; number of sexual partners in a lifetime, n = 8 missing; and number of sexual partners in a lifetime, n = 6 missing).
      MethodChlamydia Infection (n = 422)
      χ2 P = .82.
      CrudeAdjusted
      Adjusted for STI history, number of sexual partners in a lifetime, age at method initiation, age at first intercourse, insurance, and number of chlamydia tests. P = .64.
      OR95% CIaOR95% CI
      YesNo
      n (%)n (%)
      LARC16 (10.9)131 (89.1)0.930.49-1.750.840.41-1.73
      Non-LARC32 (11.6)243 (88.4)ReferenceReference
      Total48 (11.4)374 (88.6)
      aOR, adjusted odds ratio; CI, confidence interval; LARC, long acting reversible contraception; OR, odds ratio; STI, sexually transmitted infection.
      Excludes 27 female adolescents with missing data on required variables of interest (age at first intercourse, n = 13 missing; number of sexual partners in a lifetime, n = 8 missing; and number of sexual partners in a lifetime, n = 6 missing).
      χ2 P = .82.
      Adjusted for STI history, number of sexual partners in a lifetime, age at method initiation, age at first intercourse, insurance, and number of chlamydia tests. P = .64.
      Individuals excluded from the analyses because they did not receive any STI testing the year after method initiation or because of previous LARC use (n = 371) were compared with individuals in the study sample. Excluded patients were not statistically significantly different from individuals in the study sample in race/ethnicity, insurance type, or in number of lifetime partners but were significantly older at method initiation (17 years vs 16.6 years; P < .001), significantly older at first intercourse (15.2 years vs 15 years; P = .02), and less likely to have a history of a previous STI (9.2% vs 18.5%; P = .0001). Among the excluded, there was no statistically significant difference in history of previous STI between LARC and non-LARC individuals (9.1% vs 9.2%; P = .97; Supplemental Table 1).

      Discussion

      In this secondary data analysis, we compared chlamydia infection incidence proportion over a period of 1 year after LARC and non-LARC method initiation among an urban population of female adolescents, served by NYC SBHCs, who were predominantly low-income, publicly insured, and Hispanic. The chlamydia incidence proportion was not statistically significantly different among LARC initiators compared with non-LARC initiators in the year after method initiation and LARC use was not associated with chlamydia infection.
      There are very few studies on the association between LARC and STIs in either adult or adolescent populations. Our findings, however, concur with a study of urban adolescents in the San Francisco area, which also did not show a higher incidence of reported STIs after implant initiation compared with those using non-LARC methods.
      • Darney P.D.
      • Callegari L.S.
      • Swift A.
      • et al.
      Condom practices of urban teens using Norplant contraceptive implants, oral contraceptives, and condoms for contraception.
      Two recent studies that assessed STI rates have been published in which adolescent LARC users were a small percentage of the total study population. Although 1 study reported no difference in chlamydia infection between LARC and oral contraceptive users at 1 and 2 years after method initiation, the other study reported a small increase in STIs (chlamydia, gonorrhea, and trichomonas) after 1 year of LARC initiation compared with non-LARC initiation.
      • McNicholas C.P.
      • Klugman J.B.
      • Zhao Q.
      • et al.
      Condom use and incident sexually transmitted infection after initiation of long-acting reversible contraception.
      ,
      • Rose S.B.
      • Garrett S.M.
      • Stanley J.
      • et al.
      Chlamydia testing and diagnosis following initiation of long-acting reversible contraception: a retrospective cohort study.
      These differences in conclusions may be because of differing patient populations and/or study design. Furthermore, several studies show that the absolute risk of pelvic inflammatory disease is very low (0-5%) after IUD insertion
      • Sufrin C.B.
      • Postlethwaite D.
      • Armstrong M.A.
      • et al.
      Neisseria gonorrhea and Chlamydia trachomatis screening at intrauterine device insertion and pelvic inflammatory disease.
      • Goodman S.
      • Hendlish S.K.
      • Benedict C.
      • et al.
      Increasing intrauterine contraception use by reducing barriers to post-abortal and interval insertion.
      • Mohllajee A.P.
      • Curtis K.M.
      • Peterson H.B.
      Does insertion and use of an intrauterine device increase the risk of pelvic inflammatory disease among women with sexually transmitted infection? A systematic review.
      even after adjusting for age.
      • Sufrin C.B.
      • Postlethwaite D.
      • Armstrong M.A.
      • et al.
      Neisseria gonorrhea and Chlamydia trachomatis screening at intrauterine device insertion and pelvic inflammatory disease.
      Our study has several strengths. To the best of our knowledge it is one of the few studies that has investigated chlamydia infection among LARC and non-LARC users with the inclusion of an entirely adolescent population. This analysis focused specifically on the unique setting of SBHCs, of which there are more than 2500 nationally, with the capacity to reach underserved youth.
      • Love H.E.
      • Schlitt J.
      • Soleimanpour S.
      • et al.
      Twenty years of school-based health care growth and expansion.
      ,
      • Arenson M.
      • Hudson P.J.
      • Lee N.
      • et al.
      The evidence on school-based health centers: a review.
      Confounding was limited by adjustment of the aforementioned multiple potential confounders and by comparing LARC and non-LARC users coming from the same source population in whom contraceptive method initiation occurred in the same time period. Similar to previous studies, we attempted but were not able to identify users who continuously used a particular non-LARC method during the period of interest
      • Vaughan B.
      • Trussell J.
      • Kost K.
      • et al.
      Discontinuation and resumption of contraceptive use: results from the 2002 National Survey of Family Growth.
      and noted that these patients frequently switched between methods. Consequently, our non-LARC population represents a sample of adolescents with frequent switching between short-acting contraceptive methods as reported previously.
      Study limitations include a relatively small sample size compared with previous studies, as well as limited generalizability because the sample is comprised of mostly urban, Hispanic female adolescents attending NYC SBHCs. The retrospective nature of this study may have introduced information bias because several sexual risk factors were self-reported. However, this bias would have been likely nondifferential among the 2 groups. We likely overestimated chlamydia incidence by including only patients who completed screening. Although excluded patients reported a statistically significant lower rate of history of STI (9% vs 18%), there was no difference between STI history when LARC and non-LARC patients were compared, thus overestimation would have occurred equally in both groups (8.4% vs 9.2%; P = .81). Excluded patients (n = 371), comprised of mostly patients with no chlamydia testing the year after method initiation (n = 302), were statistically significantly different from the study sample in age of method initiation and age at first intercourse. However, this difference is clinically negligible (0.4 months or 4.8 months for age at method initiation and 0.2 months or 2.4 months for age at first intercourse). Thus, we do not expect those differences to have resulted in differences in incidence of chlamydia among the 2 groups. Finally, because sexual risk factors were determined from electronic medical record visit note fields, it is possible that notes were not updated at each visit; however, this would have affected both types of users similarly. Because of this reason, we were unable to reliably determine condom use, an important factor when considering STIs. Our study did not assess differences in the incidence of other STIs such as gonorrhea, trichomonas, or syphilis. In addition, chlamydia infections were followed only for 1 year after method initiation. A larger multisite prospective study with longer follow-up years on whether adolescent STI rates are different between LARC and non-LARC users is needed to overcome the aforementioned limitations.
      In addition, our study highlights the feasibility and success of providing adolescent LARC services at SBHCs, a unique environment, which eliminates many known barriers to adolescent LARC uptake including cost, accessibility, inconvenience, and fear of lack of confidentiality.
      • Summit A.K.
      • et al.
      Integration of onsite long-acting reversible contraception services into school-based health centers.
      Although not assessed in the current study, a previous qualitative study in NYC SBHCs, reported a high satisfaction level with LARC services among adolescents.
      • Sangraula M.
      • Garbers S.
      • Garth J.
      • et al.
      Integrating long-acting reversible contraception services into New York City school-based health centers: quality improvement to ensure provision of youth-friendly services.
      Approximately one-third of our adolescent sample who met the study criteria chose LARC as their contraceptive method, which is higher than the national average (3.2%-5.8%).
      • Abma J.C.
      • Martinez G.M.
      Sexual activity and contraceptive use among teenagers in the United States, 2011-2015.
      Being a first-line contraceptive method for adolescents, LARC use is expected to continue to increase in the adolescent population.
      • Pazol K.
      • Daniels K.
      • Romero L.
      • et al.
      Trends in long-acting reversible contraception use in adolescents and young adults: new estimates accounting for sexual experience.
      This study suggests that LARC use is not associated with a higher rate of chlamydial infection among adolescents served by SBHCs in NYC and supports the promotion of LARC use among female adolescents as a public health effort to reduce teenage pregnancy.
      • Finer L.B.
      • Zolna M.R.
      Declines in unintended pregnancy in the United States, 2008-2011.
      ,
      • Onyewuchi U.F.
      • Tomaszewski K.
      • Upadhya K.K.
      • et al.
      Improving LARC access for urban adolescents and young adults in the pediatric primary care setting.

      Acknowledgments

      The authors thank Jianhua Li and Jacek Slowikowski for data extraction, Lorraine Tiezzi for support in the access to the OSCR system data and Steven Shea, Richard Younge, and Yifei Sun for mentorship and support.
      Funding was provided by the Columbia University Primary Care Clinician Research Fellowship in Community Health, Fellowship T0BHP293020100 (Health Resources and Services Administration).

      Supplementary Data

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