Barriers to recommended gynecologic care in an urban United States HIV clinic

Background: Despite an increased risk for cervical cytologic abnormalities, HIV-infected women frequently miss their gynecology appointments. We examined barriers to adherence with gynecologic care in an urban HIV clinic. Methods: We conducted a cross-sectional survey of 200 women receiving gynecologic services in an urban HIV clinic, followed by focus groups. Primary outcomes included (1) missed gynecology appointments and (2) receipt of a Pap smear in the previous year. Independent variables included sociodemographic characteristics, child care responsibilities, substance use, depressive symptoms, social support, interpersonal violence, CD4 count, and HIV-1 RNA. We conducted multivariable logistic regression to examine associations between independent variables and outcomes. We then held two focus groups designed to gather opinions on and increase our understanding of the key findings from the survey. Results: Of 200 women, 69% missed at least one gynecology appointment, and 22% had no Pap smear in the past year. In logistic regression, moderate (odds ratio [OR] 3.1, 95% confidence interval [CI] 1.4-6.7) and severe (OR 3.1, 95% CI 1.3-7.5) depressive symptoms and past-month substance use (OR 2.3, 95% CI 1.0-5.3) were associated with missing an appointment in the prior year. An education level of less than high school (OR 0.3, 95% CI 0.1-0.6) compared with high school diploma or greater was associated with not having a Pap smear in the previous year. When analyses were limited to women with a cervix (n = 166), moderate (OR 2.5, 95% CI 1.1-5.7) and severe (OR 2.5, 95% CI 1.0-6.3) depressive systems remained significantly associated with missing a gynecology appointment in the previous year and age >50 (OR 0.3, 95% CI 0.1-0.9), an HIV-1 RNA > 50 (OR 0.4, 95% CI 0.2-0.9), and education level less than high school (OR 0.2, 95% CI 0.1-0.5) were associated with not having a Pap smear in the past 12 months. Qualitative analysis of the focus group data suggested that fear, inclement weather, and forgetting appointments may contribute to missed gynecology appointments. Conclusion: Gynecologic healthcare is underused among HIV-infected women. We found that depressive symptoms, substance use, fear of the gynecologic examination, and simply forgetting about the appointment may be barriers to gynecologic care. Interventions targeting these barriers may improve use of gynecologic care among this population.