Decreasing Cervical Cancer in Women Infected with HIV: A Nurse-Driven Approach to Preventive Screening

Purpose: The goal of this initiative was to improve the percent of HIV-infected women who received cervical cancer screening that was in alignment with the Centers for Disease Control’s (CDC) guidelines.

Relevance/significance: Cervical cancer-related mortality in the United States has decreased significantly with the application of cervical cancer screening. Screening is aimed at identifying and treating women with pre-cancerous lesions, thereby preventing the progression to cervical cancer. The initial screening tool used in the US is the papanicolaou (pap) test with or without the human papillomavirus (HPV) co-test. HPV positivity is associated with most cervical cancer diagnoses. Women living with HIV (WLWH) develop cervical dysplasia and advance to cervical cancer more rapidly than their HIV-uninfected counterparts. The CDC screening guidelines (“the guidelines”) have been adjusted to account for this disparity. It is recommended that WLWH continue to screen beyond age 65. Additionally, WLWH who are older than age 30 with a baseline negative pap and HPV co-test need follow-up screening every three years versus every five years. Our clinic provides HIV care to 1700 individuals, including 515 women; however, only 54% percent of those women received a pap test in alignment with the CDC guidelines.

Strategy and implementation: A multidisciplinary team was formed to address the low screening rates. The committee recommended creating a women’s health nurse position who would focus efforts on identifying women who did not meet guideline recommendations. On a weekly basis, the nurse reviewed the medical records of all scheduled female patients for the upcoming week. The date of last pap test, along with other demographic and clinical indicators including age, history of hysterectomy, history of tubal ligation, and whether the woman was post-menopausal was noted. Patients who were identified as not in accordance with the guidelines had a note entered in their medical record and their physician was notified. A note associated with an upcoming appointment was entered to remind the physician of the need to update the pap test. Patients without an upcoming appointment were contacted by phone, and a visit was scheduled for them. The women’s health nurse arranged for more extensive evaluation and testing if indicated based on the pap and HPV co-testing results. Additionally, all women who were eligible for pre-conception counseling were provided this education and given an appointment to see a specialty provider for pregnancy planning. Peri- and post-menopausal women were provided with education and offered an appointment in the women’s menopause clinic. The nurse developed a database to track which educational components and interventions each woman received and updated the medical record accordingly.

Evaluation/outcomes: In the year following the creation of the women’s health nurse position, cervical cancer screening rates for eligible WLWH improved from 54% to 84%. Patients reported improved understanding of the educational content received.

Implications for practice: A nurse-driven, targeted approach to improving cervical cancer screening was successful in improving quality outcomes in our clinic population. This type of approach can be applied in other screening areas.