Background: Cervical cancer is the second most common type of cancer among women worldwide. Women with human immunodeficiency virus (HIV) bear a disproportionate burden of cervical cancer and its precursor, cervical intraepithelial neoplasia (CIN), that result from persistent high-risk Human Papillomavirus (HPV) infection. HIV clinical practice guidelines recommend two Pap tests in the year following diagnosis, and if both are normal, yearly thereafter. Nationally, only 25% of women meet this recommendation. The mean annual Pap testing rate for federally-funded HIV centers is only 55.7%. In 2009, quality improvement statistics from the Johns Hopkins Hospital Adult HIV Clinic, a large urban HIV center, revealed an annual Pap testing rate of 59%. This occurred despite interventions to address adherence issues were implemented, including nurse case management, co-location of HIV and gynecology services, flexible scheduling, and continuity of care. Women keep their appointments for HIV primary care more often than for gynecology care in the adult HIV Clinic, so an intervention that takes place during a primary care visit could improve cervical cancer screening rates. The availability of HPV testing provides a unique opportunity to increase perceived susceptibility to and severity of cervical cancer among women with HIV, and to encourage follow-up Pap testing. Detection of high-risk strains of the virus indicates a higher risk for high grade CIN and cancer, while a negative HPV test predicts a less than 2% risk of developing CIN. Women can perform HPV testing easily through vaginal self-collection in a primary care visit. Studies of women without HIV who do not have regular Pap testing have demonstrated that self-collected HPV testing and results counseling increases the overall screening rate, and women who test positive for HPV have a high rate of follow-up Pap testing. Self-collected HPV testing and results counseling could be utilized in the HIV primary care setting to promote Pap testing among women with HIV. Objectives: This dissertation study was a randomized trial to test whether receiving self-collected HPV testing and results counseling in HIV primary care would increase completion of Pap testing in a group of women a hospital-based outpatient Adult Clinic for HIV Care. The study was informed by the Health Belief Model (HBM), which posits that screening behavior will increase if persons at risk for disease have a cue to action that increases their perception of susceptibility to and severity of the disease. In this study, the HPV test and results counseling were cues to action that also correctly identify women at increased for disease.Sampling, design and methods: To achieve these aims, 97 women who were late for Pap testing were recruited for participation while they were at an HIV care appointment. They were randomized to HPV self-collection and results counseling, or to a control group receiving usual care. Six months after enrollment, medical records were reviewed for completion of Pap testing in the intervening months. Findings: Self-collected HPV testing and results counseling did not improve Pap test attendance when compared with usual care as experienced by the control group. Overall, 35% of the entire sample completed their Pap tests within 6 months of the baseline visit. Perceived threat of cervical cancer did not change for the intervention group, even when the HPV test was positive. The follow-up interview rate for the Perceived Threat scale was 91%. Conclusions: Self-collection of cervico-vaginal cells for HPV testing was feasible in this population. Overall the study served as an effective intervention to promote Pap testing. High follow up rates overall demonstrated that intensive interventions to improve cervical cancer screening are effective.
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A TEST OF AN INTERVENTION TO PROMOTE PAP TESTINGIN A GROUP OF WOMEN LIVING WITH HIV
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