Overcoming cancer screening barriers in HIV infected women
Due to their impaired immune function, HIV-positive women have a much higher risk of developing cervical and uterine cancers than do women without the disease.1 However, many women with HIV do not receive necessary cancer screening due to a reluctance to seek care or other barriers such as psychosocial factors.
One program has stepped up its care by integrating gynecologic care into overall HIV management. The Christiana Care Health Services HIV Program, based in Wilmington, DE, has implemented a weekly women's clinic, where HIV-infected patients can receive necessary screening, such as Pap tests, as well as pregnancy management and contraceptive/reproductive counseling in a comfortable setting.
Numbers for the women's clinic have risen from 178 in 2008 to 380 in 2009, according to Arlene Bincsik, RN, MS, CCRC, ACRN, program director. To meet the increased demand, the clinic has been expanded to include two days per month at one of the program's southern satellite clinics in Smyrna and has added an additional half day per week at the program's main site in Wilmington.
The program has increased cervical cancer screening rates, which in turn has led to the identification and treatment of many cervical cancer cases. More than half of HIV program patients receiving a Pap test in the first 10 months of the women's clinic had abnormal results; of these patients, 60% have received colposcopy and follow-up care at the Christiana Care Women's Health Clinic.
Before the implementation of the women's clinic, 90% of the women seen in the Christiana Care HIV Clinic were referred annually for routine Pap tests, yet less than 10% actually followed through with the screening. Many women, especially working, single mothers, found it difficult to make the time for appointments, as well as arrange transportation, clinic officials say. Others might have been reluctant to reveal their HIV-positive status to outside gynecologic providers, they note.
To operate the women's clinic, officials have allocated funding for an obstetrician/gynecologist who works one-half day per week, as well as a full-time nurse practitioner and nurse, who devote 50% of their time to direct gynecologic patient care and the other 50% to the HIV primary care clinic. Program expenses include labor; equipment such as a colposcope, ultrasound machine, and associated tools; and disposable gynecologic care supplies. The equipment cost about $45,000.
"We have all seen women who have developed cervical cancer, so we are all very committed to prevention," says Bincsik. "This is particularly true of my nurse practitioners, who are very willing to do pelvic exams and Pap [tests] during routine clinical visits."
Two of the program's nurse practitioners have become certified to do on-site colposcopies to follow up on abnormal results, says Bincsik. She also notes the leadership provided by clinic medical director Lisa Phillips, MD, who has demonstrated commitment to quality patient care and is involved in the program's implementation and evaluation.
How does it work?
To schedule clinic visits, HIV program nurses review patients' medical records before each physician visit to determine whether certain components of preventive gynecologic care are needed, including annual cervical cancer screening. If a screening has not been done in the past year, the nurse asks the patient if she has obtained screening elsewhere or if she would like an appointment at the weekly clinic. If the patient desires an appointment, the front office staff schedules the next HIV appointment for a Friday morning so that HIV care can be provided in conjunction with a gynecological exam. Patients receive a reminder call from a peer educator one or two days in advance of the appointment.
Women who attend the clinic are provided with a routine gynecology exam, including a pelvic exam and Pap test; an evaluation for sexually transmitted diseases; education on breast health, mammography, and breast self-exam; and family planning services, including birth control and education on reproductive health and safe sexual practices including condom use, based on a standardized treatment protocol. Women who attend gynecology appointments also receive a 'goodie' bag with small soaps, shower gels, and other products.
Other health professionals are involved in the weekly clinic. A clinical social worker is available to address patients' psychosocial needs, while a female peer educator is available in the waiting room to provide comfort and support. Transportation to the clinic is provided, if needed.
To provide follow-up care for those with abnormal findings, the gynecology nurse telephones patients with abnormal Pap smear results to schedule an on-site colposcopy. If results suggest the need for more comprehensive follow-up care, patients are referred to Christiana Care's Women's Health Center, where the women's clinic physician is on staff and can provide or coordinate necessary care.
The Christiana Care HIV Program, as a Ryan White Part D grantee, supports the provision of family-centered care to HIV-infected women who are pregnant, abusing drugs, have advanced HIV disease, or have mental illness. The women's clinic program was developed in response to research indicating that many women referred for cervical cancer screening did not obtain that screening. The on-site clinic now allows women to easily and sensitively access needed services.
"We are very pleased with the clinical outcomes associated with this program and feel that it truly meets the needs of our patient community," says Bincsik.
- Oster A, Sullivan P, Blair J. Prevalence of cervical cancer screening among HIV+ women in the United States, 2000 to 2004. Presented at the 16th Conference on Retroviruses and Opportunistic Infections. Montréal, Canada; February 2009.