LOS ANGELES — Many women do not go for recommended Pap testing after being diagnosed with the human immunodeficiency virus, despite being at elevated risk for cervical cancer.
Chart reviews of 428 women at an urban HIV clinic found 48% had Pap tests within a year of enrollment at the clinic. Yet the clinic's physicians had referred all the women for testing, many of them repeatedly, Laurie C. Zephyrin, M.D., reported at the annual meeting of the Society for Gynecologic Investigation.
“Those women who had other social factors or who tended to be sicker tended not to have their Pap tests. But they were referred. The primary care physicians were definitely doing their job in referring patients,” said Dr. Zephyrin of the department of obstetrics and gynecology at Johns Hopkins University in Baltimore.
Guidelines call for Pap testing every 6 months in the first year after diagnosis with HIV, and once annually thereafter, according to Dr. Zephyrin. With so many women not being screened in the first year, she called for simplifying the health care delivery system to make tests more accessible at primary care sites.
“I really think there needs to be a reorganization of how we deliver care, particularly to women with conditions such as HIV,” she said.
Dr. Zephyrin and her coinvestigators followed women who enrolled in a large urban HIV clinic affiliated with Johns Hopkins from January 1998 to November 2002. The population was predominantly African American and low income with a median age of 38. More than a third, or 36%, were intravenous drug users.
One in four patients had normal CD4 counts of at least 500. Dr. Zephyrin said more than 30% had “a diagnosis consistent with AIDS,” as reflected in CD4 counts below 200.
About three-fourths of the women, 74%, were on highly active antiretroviral therapy (HAART).
The proportion that had a Pap test increased with time spent in the program. Nearly two-thirds, 63%, were screened within 2 years and 75% were screened within 3 years. By the end of 6 years, 87% had at least one Pap test.
In the first year, black women were 37% more likely to have a Pap test and women on HAART were 38% more likely, compared with their nonblack and non-HAART counterparts.
Dr. Zephyrin speculated that the patients receiving HAART were in the clinic more often and might have been more compliant.
Compared with women with normal CD4 counts, women with counts of 200–500 were 39% less likely to have a Pap test during the first year.
Similarly, intravenous drug users were 32% less likely than were those who were not users.
Dr. Zephyrin reported that while 61% of Pap tests were normal, women who had been diagnosed with AIDS were four times more likely to have an abnormal Pap test result within the first year.
The clinic has 20 primary care physicians and six midlevel practitioners, according to Dr. Zephyrin. The staff was qualified to do Pap tests but often did not have the proper equipment and, therefore, referred patients to a gynecology clinic, she said.
“You can't do the Pap test unless you have the stirrups and the speculum and a chaperone. The provider may be willing and able to do it, but cannot do it because of the system variables that are in place,” she said.
“It becomes very challenging when you have to refer these women to other areas to get care. Because there is so much going on in their lives, making delivery of care as simple as possible will really allow them to get the screening they need,” Dr. Zephyrin said.
She also questioned whether the guideline should be stratified to reduce the first year screening requirement from two tests to one for women with normal CD4 counts.