In our study of HIV gynecology clinic visit and Pap smear adherence, 68% of all women had missed a gynecology appointment in the previous year, and 22% of women had not had a Pap smear in the past year. From our previous study of the same clinic population, where HIV gynecology and primary care services are colocated, we knew that the rate of completed clinic visits was significantly lower for HIV gynecology (36%) than for HIV primary care (55%) (p
0.001). This study used mixed methods to elucidate reasons for missed HIV gynecology visits and recommended Pap screening. In this study, we found that factors associated with suboptimal gynecologic care included less than a high school education, substance use, depressive symptoms, older age, and detectable viral load. In addition, our focus groups revealed four major barriers to care: forgetting the appointment, inclement weather, discomfort/pain during the examination, and fear of a bad diagnosis. Our results are consistent with those of other studies examining gynecologic care among HIV-positive women.23,24
The prospective Swiss HIV Cohort Study (SHCS)7
examined factors associated with frequency of gynecologic follow-up in a cohort of 2186 HIV-positive women over 3 years; they found that 82% of those women reported having a Pap smear at some point in the 3 years, although 7.2% of women had not seen a gynecologist at all. In a more recent study of 2548 women infected with HIV in the United States, 1992 (78%) had a Pap smear in the previous year.9
We found that women with a lower education level were less likely to have had a cervical or vaginal pool Pap smear in the previous year. This association was strongly significant in all women and in women with a cervix. Our results are consistent with several studies of cervical cancer screening among ethnic minority women in the United States, where lower level of education and not understanding the need for a Pap smear were associated with not having had a cervical Pap smear within the past 12 months.25,26
In a study of 148 HIV-uninfected women with invasive cervical cancer, lack of knowledge about cervical cancer risk, fatalistic attitude (having cancer is just bad luck), and denial (did not want to know cancer diagnosis) were all associated with never having been screened by Pap smear.27
This literature and our findings suggest that basic education about the purpose and benefits of regular Pap smears for cervical cancer screening may improve adherence with screening.
In addition, our qualitative analysis of focus group data suggests that fear of or discomfort from the examination and fear of diagnosis may contribute to missed appointments and inadequate use of care. This was also found in a recent qualitative study of 35 low-income HIV-positive African American women who had not had cervical cancer screening in 5 years or more, in which psychological/emotional barriers were the most commonly reported barriers to care: specifically, fear of diagnosis, fear of pain or discomfort during the examination, low self-esteem, and denial were major reported barriers to care.28
The authors conclude that efforts to improve access to and use of healthcare services for these women should address their psychological and emotional needs.28
Andrasik et al.28
also found that a conflicting need, most commonly an active drug addiction, was a major reported barrier to care for those women. Our quantitative results showed that substance use is a barrier to having a cervical or vaginal pool Pap smear in the past year. This finding is consistent with a recent study of HIV-infected women in the Swiss Cohort Study,7
as predictors for fewer reported gynecologic examinations and Pap smears included current intravenous drug use and lower CD4 counts.
We also found that moderate and severe depressive symptoms are strongly associated with missing gynecology visits. Depression is common among people infected with HIV29,30
and has been associated with HIV appointment31
and medication nonadherence.32–36
Screening for and treating depression may improve gynecology clinic appointment attendance.
Given our findings, providers should also be cognizant of psychosocial and emotional barriers, such as depression, womens' fears, denial, low self-esteem, and competing needs, such as addiction, that may contribute to lower appointment adherence. Outreach programs incorporating education, explanation, and peer support may be effective methods for addressing these psychosocial and emotional barriers, thus improving adherence. A recent qualitative study of people living with AIDS in the United States examined the role of outreach programs in engaging and retaining patients in medical care; they found that almost all patients cycle in and out of care, and outreach programs of various kinds were able to reconnect patients to consistent care through education (dispelling myths and improving HIV knowledge), reducing barriers to care (arranging transport, helping with insurance paperwork, accessing drug and alcohol treatment programs), and providing support (connecting patients to support networks).37
In our study, the most common reason given for missing a gynecology appointment was simply forgetting. In the recent qualitative study,37
patients reported that phone calls and other reminder systems improved appointment and medication adherence. In addition, in a review of the literature on barriers to adherence for follow-up care for abnormal Pap smears, communication interventions, such as telephone reminders, counseling, and educational sessions, increased follow-up across several studies.38
In addition to addressing patient barriers to gynecology appointment adherence, structural or clinic system changes, such as consolidating or bundling HIV primary care with gynecology care (such as cervical cancer and sexually transmitted disease screening at the same visit), would likely improve Pap smear and gynecology appointment adherence. In one study of self-reported factors associated with cervical cancer screening among HIV-positive women, women who reported having a gynecologist and a primary care provider at the same clinic site were almost twice as likely to report having had a Pap smear in the previous 12 months.39
Having gynecology and primary care appointments scheduled for the same day may result in even greater adherence.
Our study has potential limitations. It was conducted at a single institution and consisted of a sample of women from an urban HIV care clinic; thus, results may not be generalizable to some settings. In addition, the quantitative component was cross-sectional; thus, causal inferences cannot be made. Given that the survey was self-report, there may have been some social desirability bias.
In conclusion, suboptimal adherence to routine gynecology care among HIV-infected women remains prevalent. Interventions targeting modifiable barriers to care, such as substance use, depressive symptoms, patient fears, and forgetting appointments, may improve participation in gynecology care and patient outcomes.