Preventive Health Screenings in High Risk Populations: The Case of a HIV Positive Refugee Woman

Background: Women infected with HIV are 5.4 times more likely to be diagnosed with cervical cancer than women without HIV. It is recommended that women with HIV have a pap test at the time of HIV diagnosis and every three years after 3 consecutive Pap tests are normal. This case study will describe the chronology of key events from resettlement in the U.S. to a high grade abnormal PAP test result in an HIV positive refugee woman. Building Bridges Initiative (BBI) is a cancer education and screening program for refugee women at the UNT Health Science Center and CPRIT. The program trains and employs lay health educators from refugee communities to provide culturally and linguistically appropriate outreach, education and navigation services. Methods: A review of existing medical records, BBI case files, and medical case management (MCM) files explored multilevel factors associated with missed opportunities for pap screenings and education. Data was collected on cancer knowledge and PAP test awareness from self-reported baseline assessments. Results: Our case study is an HIV positive refugee from Africa who reported to have become HIV positive as a result of rape in 2007. The patient reported a previous PAP test in January 2014 prior to arrival in the U.S. (February, 2014). At BBI enrollment (February, 2015), she specifically expressed interest in a follow-up PAP exam. Upon completion of cancer education classes (3/24/2015), a Well woman/PAP test appointment was scheduled and completed on 6/26/2015 at UNTHSC-OBGYN clinic. Patient was informed of high grade abnormal results and referred (7/6/2015) to MCM for follow-up. She subsequently underwent a colposcopy and cold knife cone biopsy. Patient was receiving treatment for her HIV status since March of 2014. Although a PAP referral was noted in her records (12/8/2014) she did not receive a PAP exam in that system, but received one through the BBI 6 months later. Patients are required to make the PAP appointment themselves. Conclusion: Records indicate that the BBI participant kept all appointments for her medical management of HIV. Failure to receive a PAP exam in the same medical system may be due to the requirement that patients make their own appointments. Language and cultural barriers may have prevented her from doing so. Refugee women face trauma, such as rape and the possibility of HPV, HIV and other infectious diseases. Given their vulnerability and high risk, it may be prudent to provide PAP exams upon arrival.