Updated October 2007

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INTRODUCTION

This booklet is designed to supply healthcare practitioners who provide or design healthcare services for women with HIV/AIDS with practical solutions to the problems of attracting and retaining women in GYN care.

Performance of an annual pelvic exam which includes a Pap test has long been a standard of care for women infected with HIV, yet a review of performance data from 1992-1999 showed that many HIV ambulatory care facilities throughout New York State had not fully met this standard. As a result, the New York State Department of Health/AIDS Institute’s (NYSDOH/AI) Quality of Care Program launched a Pelvic Exam Performance Improvement Campaign.

Through its Performance Improvement Campaign, the NYSDOH/AI conducts numerous interventions which are designed to assist facilities to improve their performance, including dissemination of data to recognize facilities with high performance; technical assistance to other facilities to improve their performance; targeted mailings to remind providers about the importance of routine GYN care; free Continuous Quality Improvement (CQI) consultation; and the distribution of a free software program, HIVQUAL, to assist facilities in tracking their progress in standards related to GYN care and other clinical indicators.

This brochure identifies some best practices and creative solutions that have been found to attract and retain women infected with HIV into routine GYN care. They have been culled from a series of face-to-face and telephone interviews with seventeen clinicians and administrators working in hospitals, community health centers, and drug treatment programs. It is hoped that by sharing the insights and perspectives of these successful colleagues, readers will develop and implement similar programs in their facilities. Providers are encouraged to adapt the strategies outlined in this booklet to most effectively meet the needs of different medical settings.

This booklet is divided into several sections:

Recommendations – In this section recommendations regarding routine GYN care are summarized.

Best Practices – In the second section, we present a variety of best practices that have been demonstrated to be effective at healthcare facilities across New York State. Best practice topics include increasing patient access to education and convenience to GYN care, getting patients to their appointments, utilizing staff resources effectively, creating patient-friendly examining rooms and providing services for women and children.

Case Studies – In the third section, we take a more in-depth look at issues affecting the delivery of GYN care at healthcare facilities and what individuals have done to counteract those problems. Issues addressed include focusing on patient comfort, co-location of services, and scheduling of appointments.

Quality Improvement – In the fourth section, we demonstrate the use of a storyboard. This visual tool can be useful in quality improvement activities.

Resources and Tools – The final sections of this booklet provide clinicians and administrators with tools that can be used during the office visit as well as free or low-cost educational materials targeted to patients.

WHY ROUTINE PELVIC EXAMS ARE IMPORTANT

Routine GYN care has been demonstrated to be especially important for women living with HIV/AIDS. While cervical cancer is an important AIDSdefining illness and may be the most common AIDS-related malignancy in women, its relationship to HIV is still being studied. It is known that HIVinfected women have much higher rates of persistent infection with human papillomavirus (HPV), even after treatment. This is particularly true for those types most strongly associated with the development of invasive cervical and anal cancer. HIV-infected women also have significantly higher rates of cervical intraepithelial neoplasia (CIN) with increasing prevalence as the severity of immunodeficiency advances as compared to non-HIV-infected women. Furthermore, women with abnormal cervical cytology are also at increased risk for abnormal anal cytology. Other risk factors for cervical cancer include lower socioeconomic status, tobacco smoking, early onset of sexual intercourse, and a history of multiple sex partners. Other risk factors for anal cancer include 10 or more sexual partners, history of anal or genital warts or gonorrhea, sexual partners who have a history of an STI, and a history of receptive anal intercourse before 30 years of age or with multiple partners.

Screening for sexually transmitted infections (STIs) is an important aspect of the pelvic examination for two reasons. First, risk behaviors for HIV infection are similar to those which place women at risk for STIs. Second, the presence of untreated, but curable, STIs increases the probability of HIV transmission.

The Medical Care Criteria Committee (MCCC) and the Women’s Health Committee (WHC) are advisory groups of clinicians from across New York State with expertise in treating HIV-infected patients. The Committees develop clinical practice guidelines and consider the following areas to be part of routine GYN care for HIV-infected women. The MCCC and WHC recommend that clinicians treating HIV-infected women complete the following for each identified area:

PELVIC EXAMINATION

Perform a routine pelvic examination in women or refer them to a gynecologist at baseline and at least annually. A routine pelvic examination should consist of the following:

• Visualization of the external vulva, including the anus and urethra, to evaluate for any lesions
• A speculum examination that includes visualization of all sides of the vagina
• Visualization of the cervix (or upper vaginal cuff after hysterectomy)
• A bimanual examination to evaluate the pelvis
• A digital rectal examination that includes evaluating the pelvis
• Cervical and anal cytology, and STI screening as follows

CERVICAL CYTOLOGY

Obtain cervical Pap tests at baseline, 6 months after baseline, and then repeat annually, as long as results continue to be normal. Perform colposcopy for women with any abnormal Pap tests (ASC-US, ASC-H, LSIL, or HSIL, or the WHO or CIN equivalent; see Table 1). Abnormal Pap tests should be repeated every 3 to 6 months thereafter until there have been two successive normal cervical Pap tests. Women with HSIL also should be referred for high-resolution anoscopy.

ASC-H: atypical squamous cells, HSIL cannot be excluded; ASC-US: atypical squamous cells of undetermined significance; CIS: carcinoma in situ; LSIL: low-grade squamous intraepithelial lesion; HSIL: high-grade squamous intraepithelial lesion.

For women who have undergone hysterectomy:

Obtain at least an annual Pap test in HIV-infected women who have undergone a hysterectomy when:

• The hysterectomy was performed because of high-grade dysplasia, HPV-related anogenital dysplasia of the cervix, or carcinoma
• A supracervical hysterectomy (uterus removed and cervix left in place) was performed
• The reason for the hysterectomy cannot be determined by patient self-report or other means
• Any cervical tissue remains
• If the cervix has been removed, a vaginal Pap test should be obtained

(Annual Pap tests are not recommended for HIV-infected women who have undergone a total hysterectomy for reasons not related to cervical abnormalities and have no history of cervical abnormalities.)

ANAL EXAMINATION AND CYTOLOGY

Complete the following at baseline and as part of the annual physical examination for all HIV-infected women, regardless of age:

• Inquire about anal symptoms, such as itching, bleeding, diarrhea, or pain
• Perform a visual inspection of the perianal region
• Perform a digital rectal examination

Refer women with abnormal anal physical findings, such as warts, hypopigmented or hyperpigmented plaques/lesions, lesions that bleed, or any other lesions of uncertain etiology, for high-resolution anoscopy and/or examination with biopsy of abnormal findings.

Obtain anal cytology at baseline and annually in the following populations:

• Any woman with a history of anogenital condylomas
• Women with abnormal cervical/vulvar histology

Refer women with abnormal anal cytology findings for high-resolution anoscopy and possible biopsy (see Table 2).

ASC-US, atypical squamous cells of undetermined significance; ASC-H, atypical squamous cells (HSIL cannot be excluded); LSIL, low-grade squamous intraepithelial lesion; HSIL, high-grade squamous intraepithelial lesion; AIN, anal intraepithelial neoplasia; CIS, carcinoma in situ.

SCREENING FOR SEXUALLY TRANSMITTED INFECTIONS (STIs)

Examine all women for vaginal discharge, vaginal pain, and ulcerative genital lesions as part of the annual comprehensive physical examination. If results show one STI, screen for other STIs.

Syphilis

Screen women for syphilis by obtaining a non-treponemal test (RPR or VDRL) with verification of reactive test by confirmatory fluorescent treponemal antibody absorbance (FTA-Abs) or treponema pallidum particle agglutination (TP-PA) tests at baseline and at least annually. Women with continued high-risk behavior should be screened for syphilis every 3 months.

Gonorrhea and chlamydia

Screen sexually active women under the age of 25 for gonorrhea and chlamydia at baseline and at least annually. A sexual history should be obtained to determine the sites of possible exposures, and all sites of exposure should be screened. Culture or nucleic acid amplification tests (NAAT) should be used to screen for gonorrhea. Immunofluorescence or DNA amplification should be used for chlamydia.

Screen women 25 years of age or older for gonorrhea and chlamydia at baseline and at least annually if they have or have had a recent STI, have multiple sexual partners, have had a new sexual partner, or have a sexual partner with symptoms of an STI.

HPV VACCINE

The HPV vaccine should be offered to HIV-infected females between the ages of 9 and 26 years. HPV typing prior to administering the vaccine is not necessary nor recommended. Patients with a history of HPV or abnormal Pap test results may still benefit from the vaccine.

Continue to obtain cervical Pap tests on the recommended schedule in HIV-infected women who have been vaccinated with HPV vaccine. Vaginal and vulvar visual inspection should be continued at regularly scheduled pelvic examinations.

BREAST HEALTH

Order annual mammograms for women aged ≥40.

Instruct all women on how to perform breast self-examinations, and conduct breast examinations at annual visits.

PREVENTION

Discuss safer sexual practices with women at each visit and include the following topics:

• The correct and consistent use of latex or, when latex allergies exist, polyurethane male condoms
• The option of using polyurethane female condoms
• Avoiding use of condoms and creams containing nonoxynol-9
• The proper use of dental dams as barrier protection during oral sex
• Counseling that transmission of HIV may occur during unprotected sex, even when women or their partners have undetectable HIV plasma viral loads
• The importance of disclosure to partners, including education about the options for voluntary partner notification

FAMILY PLANNING

Discuss family planning with women, and include the following topics:

• Risks to the mother and fetus during pregnancy
• Use of contraception until pregnancy is considered
• Importance of discussing all medications the patient is taking
• Ways to optimize health and minimize viral load before becoming pregnant
• Information about finding a provider with experience in caring for HIV-infected pregnant women
• Potential interactions between HIV medications and hormonal contraceptives

BEST PRACTICES IN GYN CARE

The GYN service providers and administrators interviewed for this booklet have identified methods for engaging and retaining women into routine GYN care. Their comments and suggestions regarding best practices are summarized below. Not all of these activities may work in every facility. The listings below represent a “menu” of options from which to choose the most appropriate method(s) for your facility.

Increasing Patient Knowledge and Access to Information

Patient knowledge and access to information may be increased through utilizing the suggestions outlined below. Many educational materials may be ordered free or at low cost from organizations listed in Appendix A.

• Create one-page information sheets at a range of literacy levels and in languages that reflect your patient population. Fact sheets should include the importance of GYN care for women infected with HIV, what to expect during a GYN exam, and the importance of follow-up care.
• Create a lending library of GYN-oriented health education videos which clients may take home and watch on their own or with a partner.
• Turn waiting rooms into “education rooms” by playing educational videotapes promoting GYN care or by providing health education presentations.
• Invite speakers, after having secured the group’s permission, into support groups and other settings where clients can be reached. Speakers can provide valuable information about women’s health issues, including GYN care.
• Offer individualized, one-on-one patient education on GYN care for all clients. Brochures, drawings and diagrams can visually reinforce the information discussed.
• Reinforce general prevention messages, including reminders about routine GYN screening, through case managers, nurses, doctors, social workers, and others who work with patients.

Increasing Patient Access and Convenience to GYN Care

• Make GYN care available on a same-day or walk-in basis (See Focus on Enhancing Access to Care).
• Coordinate GYN care with other clinic appointments so that patients do not have to make a special trip to obtain GYN services. For example, incorporate GYN care into routine HIV primary care visits, and/or provide GYN care at the initial visit or during the return visit for blood test results and medical evaluation.
• Enhance accessibility by (1) offering transportation or bus/subway fare to and from GYN services and (2) providing case management escorts to and from appointments as needed.

Getting Patients to Their Appointments

Prevent Missed Appointments:

• Schedule an integrated appointment that includes a pelvic exam as part of the periodic physical exam. This makes an additional appointment unnecessary.
• Train staff who schedule appointments to avoid scheduling GYN appointments during times when a client is menstruating or has conflicting medical or business appointments.
• Implement patient reminder systems, including:
  • Memory “triggers” to help patients remember appointments by associating appointments with certain milestones or times of year, such as saying to the patient, “I’ll see you again at Christmas time.” or “The next time I see you it will be spring, and the flowers will be in bloom.”
  • Reminder letters and/or telephone calls prior to the appointment. Patient confidentiality regarding communication with other family or household members who may not be aware of the patient’s diagnosis should always be taken into consideration. Clear with the patient during scheduling whether or not it is okay to send a letter or make a call.

Following Up on Missed Appointments:

• Make phone calls and send letters or postcards to clients who have missed an appointment, reminding them to reschedule. Ensure confidentiality, as stated on previous page, prior to communication with the patient.
• Use multi-disciplinary case conferencing to develop coordinated strategies for clients who repeatedly miss their GYN appointments.
• Ask clients what the medical provider/clinic can do to improve their access to care.

Utilizing Staff Resources Effectively

• Staff leadership should encourage routine GYN care. As one provider wisely counseled, “A couple of highly motivated individuals can alter the entire environment for the better.” Staff meetings and medical conferences should be used to reinforce staff awareness about the importance of regular pelvic exams for women living with HIV/AIDS.
• Ideally the HIV primary care provider should be able to perform the pelvic exam. If referral to another provider is needed, more than one should be available. The availability of two or more clinicians capable of delivering GYN care at any given time helps avoid scheduling delays. These delays can result in increased stress for patients and providers, backup for providers, long waiting periods for clients, dissatisfaction with the facility, decrease in return visits, or other unfavorable outcomes. Hiring and/or cross-training of nurse practitioners and other providers to deliver GYN care will help ensure that various healthcare providers are available to offer GYN care at all times.
• Female providers should be available. Most of the providers interviewed agreed that offering patients the option of being examined by a female provider is an important element of patient-friendly GYN care. Since patients are often hesitant to explicitly request a female provider, facilities should take the initiative of informing patients that this option is available to them.
• Bilingual providers should be available. The availability of staff members who are bilingual and of diverse ethnic backgrounds facilitates communication with various patient populations.
• Case Managers can promote routine GYN care by:
  • functioning as trusted “intermediaries” between patient and medical provider by reminding patients of upcoming GYN appointments, encouraging them to return for care, and reinforcing the importance of routine GYN care;
  • escorting patients to GYN care and/or follow-up services, and
  • acting as patient advocates.

Locating case management services near the medical team facilitates continuous communication between staff from both units.

Making Documentation Easier

Documenting information during the clinic visit

• Develop easy-to-read HIV flow sheets and checklists to promote ease of documentation and to prompt clinicians to deliver routine GYN care. GYN data should include, but certainly not be limited to, the following:
  • Date and results of last Pap test;
  • First and last date of the patient’s most recent menstrual period;
  • Date and results of last mammogram;
  • Birth control methods; and
  • STD (e.g. chlamydia, gonorrhea, syphilis) test results and dates.

• Create a special GYN section in patients’ charts. Use a divider to clearly separate this section from the rest of the chart to facilitate quick and easy access to each patient’s GYN information.
• Develop and have available a list of resources to facilitate prompt referrals to other services. This resource list may include specialty referrals such as endocrine, colposcopy and mammography, as well as social service, prenatal care, or abortion providers, domestic violence hotline numbers, legal services, and HIV counseling and testing services for partners.

Documenting information after the clinic visit

• Use a “Pap Log” to track Pap test results and to ensure provider folow-up. Designate a central contact person (e.g., a clerk or clinician) to be responsible for using the log to keep track of the date of each patient’s exam and Pap results. Enter results into the Pap Log, and flag abnormalities for provider follow-up. A similar log could be created to track follow-up and treatment of STIs.

Examining Room Considerations

• Make all examining rooms GYN-compatible. This will allow for more efficient use of the provider’s and patient’s time. For example, as one patient is being examined, medical staff can be working with the next patient regarding other medical issues, answering any questions, or assisting with exam preparations. Making all examining rooms GYN-compatible eliminates the need for patients to move between examining rooms for different parts of their medical visit.

• “Patient-friendly” examining rooms should be created.
  • Put locks on doors or a curtain in the room to ensure privacy during the exam;
  • Ensure that examining rooms are well heated and otherwise comfortable;
  • Provide well-made patient gowns that do not fall off or tear during the exam;
  • Situate examining tables so that patients face away from the doorway during their examination;
  • Use examining lamps that do not have steel shades as these become quite hot and can cause patients discomfort;
  • Cover foot rests with cloths so they are not cold, or encourage women to keep their socks on;
  • Stock exam rooms in advance with the necessary supplies to allow the GYN exam to proceed as quickly and efficiently as possible;
  • Have sanitary pads available for women in case of vaginal spotting after the exam;
  • Keep a range of speculum sizes on hand to make the exam as physically comfortable for the client as possible; and
  • Warm the speculum prior to use.

• Patient comfort should be fostered.
  • Devise ways to help your patient relax through verbal reassurance, breathing exercises, visualization, or other techniques;
  • Verbally prepare your patient by explaining each upcoming step in the examination process before carrying it out;
  • Ask your patient what you can do to make the exam more comfortable for her; and
  • Communicate with the patient about findings. Use neutral, asexual words, such as “Your cervix looks normal” as opposed to “Your cervix looks great.”

Providing Services for Women with Children

• Explore offering on-site child care through cooperative linkages with local organizations. Since patients may be uncomfortable being examined or discussing private matters such as sexual history and/or HIV with their children present, on-site child care is an important part of offering “mother-friendly” GYN services. Women who prefer to have their children with them for the duration of their appointment should be allowed to do so.
• Co-locate GYN services and pediatric services so that women can obtain medical care for their children and themselves under one roof. The availability of on-site pediatric services can also help attract women into care (see Focus on Enhancing Access to Care).

 
FOCUS ON ACCESS AND CLIENT COMFORT

Highlights of Best Practices at This Site

• Full-time staff is available to provide GYN care
• GYN exams are available daily on a walk-in or scheduled basis
• Patient privacy and comfort are prioritized during the GYN examination process

Background

The HOPE Center, the HIV program at St. John’s Riverside Hospital, is in a Designated AIDS Center (DAC) located in Westchester County. Southwestern Yonkers, the area where the hospital is based and its services directed, is a disenfranchised community with one of the highest rates of homelessness in the nation and the highest rate of HIV/AIDS in the county as a whole.

The HIV Program, initiated in 1993, has implemented a variety of strategies to optimize its delivery of routine GYN care to the women it serves. Two full-time Nurse Practitioners (NP) see about 90% of all clients within the program, which provides a spectrum of integrated HIV primary care services including GYN care. The HIV Program delivers care on-site at the hospital as well as at a nearby satellite clinic.

Increasing Access for the Patient

The HIV Program’s standard of care is to conduct two pelvic exams per client each year. To maximize accessibility, the HIV Program accommodates both scheduled appointments and walk-ins for GYN exams at both its hospital- based and satellite clinics. Should a patient in need of GYN care arrive at the hospital site on a day when the Nurse Practitioner is at the satellite clinic, that client is escorted to the clinic for care. “Flexibility is very important,” explains the HIV Program Coordinator, “We try to make GYN care as easy to access as possible so that we can encourage women to obtain the service.”

Focusing on Client Comfort

The HIV Program works hard to promote the delivery of routine GYN care by minimizing the unpleasantness and fear that can be associated with pelvic exams and by creating an atmosphere that conveys respect for its clients. For many clients, that means taking the GYN examination process one step at a time. “If on the client’s first visit, I encounter resistance to the GYN exam, I avoid being heavy-handed,” explains the Nurse Practitioner (NP). “I say to the patient, ‘Let’s go as far as you’re comfortable with. Today I’m just going to talk to you and ask you some questions. And here’s what we’ll cover today and over the next two visits.’ Then I take a comprehensive GYN history and set up a preliminary examination for the next time. I make a point of dealing first with whatever issues the patient has established as a priority. I also let the client know that I do the GYN exam very gently, and I encourage her to talk to the other women clients to confirm this.”

The NP’s techniques for increasing client comfort during the exam itself involve continuous verbal and nonverbal communication, as well as helping the client to acclimate to the examination process incrementally: “I begin the examination with the breast exam so the patient can start off sitting up,” the NP says, “I drape her legs, so they’re completely covered, tucking the sheet down, so the patient isn’t exposed until she needs to be. Next, I have the patient lie flat on the table, and I complete the breast exam. Once we are done with the breast exam, I cover the patient’s breasts before moving on to the pelvic exam. The point is to only expose the area that needs to be exposed at any given point in the exam. When I’m ready to have her scoot forward toward the leg rests, I give her my hand to help her into the footrest. Now I am ready to begin the pelvic exam. I touch her on the leg or knee first to desensitize her. I talk her through the examination, letting her know what to expect throughout.” Keeping the exam as brief as possible also eases the experience for clients. “I make sure all my collection devices are ready ahead of time, so I’m not looking around for my equipment during the pelvic exam itself,” says the NP.

Considering the patient’s physical and emotional comfort is also key. “When doing the exam, I use the smallest speculum I can,” the NP explains, “And I do the exam without anyone else in the room, so there’s no gawking. At the end, I help the patient up from the table. The key, I think, is anticipating the woman’s needs and what will make her comfortable. I talk her through what I’m doing, and I explain what I’m going to do next before I do it. At the end of the process, most women walk away saying ‘That wasn’t so bad!’”

FOCUS ON ENCHANCING ACCESS TO CARE

• GYN exams are available daily and can be scheduled on a same-day basis
• GYN appointments are scheduled with respect to clients’ individual needs and circumstances
• Healthcare services for women and their children are co-located on-site

Background

For 38 years, the South Brooklyn Health Center has provided comprehensive medical services to Brooklyn’s Red Hook community. The HIV Program serves approximately 150 active clients, the majority of whom — like the Health Center’s client population as a whole — are African-American and Hispanic. Forty-five percent of the HIV Program’s clients are women.

Routine GYN care for women with HIV/AIDS and other patients is provided by two Health Center staff members: a full-time OB/GYN physician and a Family Practitioner.

Enhancing Patient Access to Care

As with most of the programs mentioned in this booklet, the Health Center continually grapples with appointment cancellations and “no-shows” as major barriers to delivering routine GYN care. As one of the Health Center’s physicians observed, “The problem of breaking appointments is further complicated by substance abuse or by being in a relationship with substance abusers.” For women coping with their own substance use problem or dealing with a partner’s drug use, the daily challenges of life can often eclipse their determination to keep clinic appointments.

Methods for overcoming this barrier include scheduling appointments to match clients’ needs. “We don’t schedule appointments on check-cashing days or when clients have meetings at their methadone program,” explains the Program Director of the HIV Program. Ongoing contact and rapport with patients yields the personalized information needed to schedule care during times when the patient is most likely to access it. While advance appointments are preferred, pelvic exams are also available daily with same day appointments offered to accommodate “walk-ins.”

Another aspect of drawing clients into care involves the co-location of on-site pediatric services at the Health Center. As the staff here observe, “Women with children are more likely to access GYN care when they bring their children in for pediatric services. We make an active effort to recruit these women into getting care for themselves, as well as for their children.” Ongoing coordination and communication between the pediatric program and primary care program facilitates this process.

Other factors which draw clients into care and keep them coming back to the South Brooklyn Health Center include its full integration of a wide spectrum of on-site health services, its multilingual staff (English, Spanish, French/ Creole, and Tagalog are spoken), and its long history and solid reputation in the community. “The pediatricians here are now seeing the children of people who came here as children,” observes the HIV Program Director, “so there’s a strong basis of trust.”

FOCUS ON OFFERING INCENTIVES

Highlights of Incentives to Attract Women into HIV Care

• Activities such as women’s socials and cultural events are offered
• Hospital offers food vouchers as an incentive to engage women in GYN care
• Food and beverages are offered to women in an effort to make the clinic comfortable and inviting
• Women’s support groups, counseling, and pastoral care activties supplement clinic efforts

Background

For almost 80 years, the Erie County Medical Center (ECMC), a large, urban 550-bed public hospital, affiliated with the State University of New York at Buffalo, has served Western New York. The medical center is the Designated AIDS Center serving the eight-county Western New York region. Since 1996, the ECMC Designated AIDS Center has served approximately 70% (920 patients) of Western New York’s estimated AIDS cases. The Designated AIDS Center’s client population reflects the growing population of African-Americans and Hispanics who are at risk of becoming infected with HIV. The Center offers a spectrum of incentives to women to attract and retain them in routine GYN care.

Offering Incentives

Most providers agree that creating an environment designed to meet women’s needs is vital to attracting women into GYN care. “Perks” or incentives can be a part of this package. With creativity, a variety of incentives may be offered without straining budgets and staff time.
Incentives offered by various facilities include lunch, snacks, tokens, social events, women’s support groups, movie tickets, and on-site peer counseling. They can serve a variety of purposes. Serving snacks and beverages, for example, helps create an inviting, caring atmosphere in which clients are more likely to remain engaged. On-site peer education and support groups create a supportive psychosocial and informational environment. An on-site pharmacy team provides one-to-one treatment adherence counseling.

Erie County Medical Center also uses grocery store vouchers as an incentive to engage women in care. “We set up criteria for dispensing the food vouchers based on the specific problems we were encountering,” says the Program Administrator. “For example, some women were not coming in for routine pelvic exams or follow-up colposcopies, so the case manager would talk to them and offer a food certificate if they’d come in for two GYN exams or for their colposcopy.”

Creating a Comfortable Environment

The clinic itself is also set up to be comfortable and inviting. Tea, coffee, and lunch are provided for women who must remain at the clinic for long
procedures.

It’s worth remembering that even small courtesies can be beneficial. Whether simple or involved, perks and incentives can, as one provider remarked, give clients “something to look forward to,” something that encourages them to come in for care. ECMC offers flexible clinic options for women, including evening clinic sessions, and combined HIV primary care and OB/GYN on a weekly basis to meet the access needs of patients.

QUALITY IMPROVEMENT STORYBOARD PRESENTATION

Storyboards are visual tools that can be useful for quality improvement team members. They help the team focus on its goals and methods for improvement and concentrate on how to measure whether improvement is taking place. Storyboard presentations can:

• Be an effective method for communicating progress on a quality improvement project;
• Be updated over time to reflect current stages in the quality improvement process; and
• Allow team members and other personnel to follow the process being used to arrive at a solution and the improvements being made by team members and the organization at large.

A GYN storyboard from a New York City hospital’s project is presented below. In this presentation, clear goals are stated, data reflecting prior performance are displayed, implemented improvement measures are described, and follow-up data are reported. While this facility used the “FOCUS Approach” to performance improvement, a different but similar process could be used by any facility to improve the delivery of GYN or other care. For more information on quality improvement methods, please contact the Director of Quality Initiatives, NYSDOH/AIDS Institute, at 1 (212) 417-4730.

Improvement of GYN Care for HIV-Infected Women: North General Hospital

New York City

CONCLUSION

Routine GYN care is an essential component of a complete healthcare plan. We hope that this booklet will assist providers as they continue to strive to provide women with HIV infection with the highest quality of care.

It is hoped that the best practices, solutions, and quality improvement tools outlined in this booklet will be useful to healthcare practitioners who provide or design healthcare services for women with HIV/AIDS. Each of the facilities identified in this booklet went through the process of identifying which interventions or tools worked best at their sites. Readers of this booklet are encouraged to do the same.

Additional information about GYN care for HIV-infected women, including diagnosis and treatment, can be found at:

• Primary Care Approach to the HIV-Infected Patient
• Neoplastic Complications of HIV Infection
• Care for the HIV-Infected Female Adolescent

APPENDIX A – CLIENT EDUCATION MATERIALS

Many publications, videos, and online resources are available to the public explaining the importance of routine GYN care. Some organizations with patient educational materials are listed here.

American Social Health Association

https://www.ashastd.org/commerce/webstore/index.cfm
1 (800) 783-9877
Outside US: 1 (919) 361-8430
Publishes a variety of easy-to-understand brochures about women’s health, including: “Pap Tests: What Every Woman Should Know,” “HPV and Cervical Cancer Screening,” and “HPV Vaccine.” Many are available in Spanish.

Planned Parenthood of New York City

www.plannedparenthood.org/health-topics/stds-hiv-safer-sex-101.htm
1 (212) 274-7281
Publishes free brochures about sexual and reproductive health; some are available in Spanish as well as English. Many are specifically for teens. Several can be downloaded from their website, others are available by written request or by calling.

National Cancer Institute, NIH

http://www.cancer.gov
1 (800) 422-6237
Provides brochures which discuss Pap tests and GYN care in languages other than English, including Spanish and Vietnamese. A few are: “Pap Tests: A Healthy Habit for You,” “Every Woman Should Know about These 2 Tests,” and “The Pap Test: Questions and Answers.”

American College of Obstetricians and Gynecologists

http://www.acog.org/bookstore
1 (800) 762-2264
Offers comprehensive patient education materials, such as: “The Pap Test,” “Abnormal Pap Test Results,” “Colposcopy,” and much more.

Centers for Disease Control and Prevention (CDC)

http://www.cdc.gov/hiv
http://www.cdc.gov/hiv/topics/women/index.htm
1 (800) 232-4636
Presents extensive information about HIV/AIDS, in both English and Spanish, in different formats (fact sheets, brochures) and by specific categories, such as Women and African Americans.

AIDSinfo

http://www.aidsinfo.nih.gov
1 (800) 448-0440
Outside US: 1 (301) 519-0459
A service of the US Department of Health and Human Services, offers information about a wide-range of HIV-related topics, including guidelines, ARV medications, general information for HIV-infected women, mother-to-child transmission, and pregnancy.

National Cervical Cancer Public Education Fund

http://www.cervicalcancercampaign.org
1 (800) 444-4441
Offers information in Spanish and English about the importance of Pap tests, facts about cervical cancer, HPV facts, information about cervical cancer vaccine, and provides on-line brochures covering cervical cancer information for patients.

American Cancer Society

http://www.cancer.org
1 (800) 227-2345
Provides extensive information about all types of cancer, including breast, cervical, ovarian, and colorectal cancers. Explains some of the issues of risk, prevention, and treatment of these cancers. The American Cancer Society, in conjunction with the National Comprehensive Cancer Network (http://www.nccn.org), has produced easy-to-understand guidelines on treatment options for different cancers.

APPENDIX B – SAMPLE OFFICE SYSTEM TOOLS

Sample GYN Progress Note Page

GYNECOLOGY

A. History

G P

LMP:

Menses:

STD History:

Last PAP: Results: HPV:

Last Mammogram:

Surgical History:

Sexual Activity:

Contraception/Protection:

B. Pelvic Exam

Breasts:

Pelvic:

Wet mount/KOH:

C. Assessment/Plan

Follow-up Appointment:
Sample GYN Sticker