Source: Ibrahim Dandakoye Part A/MAI Grant and Quality Management Coordinator at the Marion County Public Health Department.
Published November 12, 2018
The Marion County Public Health Department’s Ryan White HIV Services Program (RWSP) manages Part A, Minority AIDS Initiative (MAI), and Part C funding to address the needs of people living with HIV (PLWH) in central Indiana, including those out of care or historically underserved or uninsured. The program helps out-of-care clients gain access to points of entry; provides a comprehensive HIV continuum of care; and complies with the National HIV/AIDS Strategy (NHAS). This article sought to encourage HIV providers to offer Papanicolaou (Pap) tests for all adult (18 years and older) HIV infected female patients seeking care.
About Cervical Cancer
Cervical cancer caused by Human Papillomavirus (HPV) is the most common gynecological cancer in women infected by HIV. Knowledge regarding cervical cancer cause and pathogenesis is rapidly expanding. Persistent infection with one of about 15 genotypes of carcinogenic HPV causes almost all cases. There are four major steps in cervical cancer development: infection of metaplastic epithelium at the cervical transformation zone, viral persistence, progression of persistently infected epithelium to cervical pre-cancer, and invasion through the basement membrane of the epithelium. Infection is extremely common in young women in their first decade of sexual activity. Persistent infections and pre-cancer are established, typically within 5–10 years, from less than 10% of new infections. Invasive cancer arises over many years or decades, in a minority of women with pre-cancer, with a peak or plateau in risk at about 35–55 years of age. Each genotype of HPV acts as an independent infection, with differing carcinogenic risks linked to evolutionary species.
In spite of medical advances, cervical cancer continues to be the second most common cancer in women worldwide. With People Living with HIV (PLWH) the risk of having abnormal cervical cytology (precursor to cervical cancer) is ten times higher than that of the general female population. Propitiously, screening for cervical cancer by cytology is reducing the incidence of invasive cervical cancer in PLWH, with its panoply of poor quality of life and high healthcare associated cost. Therefore, as an HIV/AIDS Bureau (HAB) performance measure, all HIV infected female patients ought to have a Pap test less than one year after initial HIV diagnosis and every six months thereafter if they are less than 30 years of age for 3 consecutive times. If the three Pap tests are normal then the patient will get screened every year for life. As a clinical quality improvement project, the Eskenazi Infectious Disease Clinic (an HIV clinic in the Indianapolis TGA) is offering Pap tests to all female HIV patients.1,2,
Pap Smear Screening for All Females HIV Patients at Eskenazi Clinic:
Improving cervical cancer screening rates has been a priority in the TGA since 2009, and will continue in 2018. The Eskenazi Infectious Disease Clinic has developed a Performance Improvement Project (PIP) surrounding cervical cancer screening for women with HIV infection.
Clinical Issue: Abnormal cervical cytology is nearly 11 times more common among women with HIV infection compared with the general female population, and is associated with the presence of HPV infection and immune dysfunction. Cervical cancer screening recommendations for women living with HIV differ from those in the general population, as outlined below in the Health and Human Services (HHS) Guidelines for the Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents. The guidelines fail to fully address screening in transgender individuals. For screening purposes, cervical cancer screening should be based on the presence of a cervix rather than on a person’s identified gender. Sexually active women with HIV infection should undergo cervical cancer screening at initial entry to HIV care and again twelve months later. Some experts also repeat cervical cancer screenings every six months. This is consistent with previous guidelines. The screening test use should be determined by the woman’s age.
Although initiation of cervical cancer screening is recommended at age 21 in the general population, providers should screen for cervical cancer in adolescents and young women with HIV infection within one year of onset of sexual activity, and by age 21 at the latest, due to concerns about more rapid progression of cervical abnormalities in women with HIV infection. Cervical cancer screening should continue throughout the life of a woman with HIV infection, as opposed to the recommendation to stop after age 65 in the general population.
Screening for 30 years of age and younger: Annual Pap testing is recommended in this population, but if three consecutive screens are normal, Pap tests can be performed every three years. Co-testing with HPV is not recommended for routine screening in this age group due to the high HPV prevalence, but HPV testing can be done reflexively on abnormal Pap results to direct further evaluation.
Screening for 31 years of age and older: Co-testing with Pap and HPV is recommended, and if both tests are negative, the recommended screening interval is every three years. If HPV testing is not available, screening recommendations are the same as those in women younger than 30 years of age.
Management of Normal Pap test results vs. Positive HPV test results: If HPV genotype testing is performed and is positive for HPV 16 or 18, colposcopy is recommended. If genotype testing is not performed or is negative for HPV 16 and 18, repeat co-testing in one year is acceptable. If either of the repeat Pap or HPV test results is abnormal, colposcopy should be performed.
Management of abnormal Pap test results: For any Pap test result of low-grade squamous intraepithelial lesion (LSIL) or worse, colposcopy is recommended, regardless of HPV status. If the Pap test demonstrates Atypical Squamous Cells of Undetermined Significance (ASC-US), HPV testing should be performed in women of all ages infected with HIV. If the HPV test is positive, the woman should be referred for colposcopy. Women with ASC-US in whom HPV testing is negative or not done may be rescreened with Pap smear and reflex HPV test in six to 12 months. If the subsequent result is ASC-US or worse, or if the HPV test is positive, referral to colposcopy is indicated. For further management of abnormal screening tests, additional guidelines and algorithms are available through the American Society for Colposcopy and Cervical Pathology (ASCCP).
AIM of Cervical cancer screening PIP: The aim of the IDC Performance Improvement Project [PIP] is to: Ensure that women with HIV infection who receive care at the Eskenazi Health IDC are receiving cervical cancer screening in accordance with current clinical guidelines.
Primary Goal: By December 31, 2018, 80% of women with HIV infection who are managed by the Eskenazi Infectious Disease Clinic [IDC] Travel Team will have cervical cancer screening in accordance with current clinical guidelines. The IDC Travel Team is comprised of a nurse practitioner, a pharmacist, an HIV care coordinator and an HIV screening coordinator. This team provides expert HIV care in nine Eskenazi Health community centers, eight of which are Federally Qualified Health Center (FQHC). The IDC Travel Team continues to bill for Ryan White services.
Secondary Goal: By December 31, 2019, 80% of women with HIV infection who are managed by providers at the Eskenazi IDC on the main campus will have cervical cancer screening in accordance with current clinical guidelines.
Phase One: IDC Travel Team
Description: Percentage of female patients with a diagnosis of HIV who were screened for cervical cancer according to current clinical guidelines.
Numerator: Number of patients in the denominator who were screened for cervical cancer in accordance with current clinical guidelines.
Denominator: Number of female patients with a diagnosis of HIV who had at least one visit with a provider who has prescribing privileges in the past 12 months;
Baseline Data: On December 31, 2017, 56.7% of patients had appropriate cervical cancer screening; on April 30, 2018, the number of patients with appropriate cervical cancer screening increased to 77.5%; based on increase of nearly 21%, the Travel Team decided to maintain their course of intervention; on July 31, 2017, 83% of female patients with HIV infection followed by the Travel Team have had appropriate cervical cancer screening documented.
Conclusion: Next Steps: Use the Plan-Do-Study- Act (PDSA) model to increase the cervical cancer screening rates at the main campus to at least 80%. Baseline data is currently being processed. At this time, Eskenazi is examining the records of women with HIV infection who are being managed by IDC on the main campus [n=277]. The following data was extracted from Epic (Eskenazi Health’s electronic medical record system EMR): 2015 Pap Date and Result, 2016 Pap Date and Result, 2017 Pap Date and Result, 2018 Pap Date and Result, HPV Date and Result, Colposcopy Date and Result, Hysterectomy [Yes or No – plus comments].
Since cervical cancer was recognized as an AIDS-defined opportunistic disease, Pap test for HIV-positive females is gaining attention on the national level. As a required HAB measure for all HIV infected women Pap test is offered to all female adults six months after HIV diagnosis.
In the past, in Indianapolis TGA, Pap tests have been offered to HIV positive patients but the turnout was not rosy and data was scattered. With this project all females HIV-positive are educated on the risks of cervical cancer as an HIV opportunistic disease. They are then offered the Pap test with an opt-out option. Data will be entered in Epic and CAREWare (Ryan Service Program database). The IDC Travel Team ability to reach out HIV-positive females to their nearest FQHC, coupled with the health education provided on the tandem HIV/HPV to them HIV–positive females are showing interest in the Pap test.
Tips and Resources to Increase Pap Tests in the Indianapolis TGA
Numerous studies point out the benefit of Pap tests to prevent cervical cancer in the general female population and especially in immunocompromised patients, such as HIV-positive patients. According to Dal Maso and colleagues, 80% of HIV-positive female patients reported receiving at least one Pap test in the United States. The remainder 20% that never received a Pap test face various challenges; lack of education on cervical cancer as an HIV-defined illness, logistical issues at the primary care HIV clinic, including missing a gynecologist, lack of insurance, lack of transportation. Other studies cited in Dal Maso and colleagues’ article noted other factors hindering Pap testing, such as language barriers, older age, race, and substance abuse. The aim of this newsletter is to provide tips for encouraging HIV-positive females to be willing to accept the Pap test or even to ask for it as part of their care.
To increase the number of Pap tests in female HIV-positive patients in Indianapolis TGA: (1) efforts have been made to update the TGA’s Clinical Quality Management plan for the next fiscal year to include Pap tests for all female adults; therefore clinical providers are aware of the plan; (2) education on the benefits of receiving a Pap test will be covered as a medical case management so providers will be incentivized for educating female clients; (3) education on how to navigate or how to access health insurance to cover the cost of Pap tests because Ryan White dollars are the payer of last resort; (4) clients in need of medical transportation will be assisted for Pap test visits to and from their home; (5) other barriers preventing HIV-positive females from getting Pap tests, such as language barriers and substance abuse will be addressed by non-medical case managers; (6) finally, clinical providers will have the logistics and personnel to provide onsite Pap tests, thus mitigating the risk of referral for Pap tests.
 Pontus N, Walter R, Sven T et al. Human Papillomavirus and Papanicolaou Tests to Screen for Cervical Cancer. https://www.nejm.org/doi/full/10.1056/NEJMoa073204
 Goldie S, Kuhn L, Denny L et al. Policy Analysis of Cervical Cancer Screening Strategies in Low-Resource SettingsClinical Benefits and Cost-effectiveness. https://jamanetwork.com/journals/jama/fullarticle/193957
 Dal-Maso L, Franceschi S, Lise M, et al. Self-reported history of Pap-smear in HIV-positive women in Northern Italy: a cross-sectional study. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2904281/
 Leece P, Kendall C, Pottie K et al. Cervical Cancer screening among HIV-positive women Retrospective cohort study form a tertiary care HIV clinic. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3001950/