Analysis Sexual Health

The Role of Community Health Centers in Reducing Cervical Cancer Inequities

Amelia MacIntyre

Cervical cancer incidence rates vividly demonstrate inequities in our health care systems and in health outcomes. Women in rural areas, the elderly, those with less formal education, and women of color, for example, experience disproportionately high rates of cervical cancer. Meanwhile, in rural communities, uninsured white women have some of the poorest access to routine screening of any patient population.

This article is cross-posted from and in partnership with the National Latina Institute for Reproductive Healthand is published as part of a series on cervical cancer.

See all our coverage of Cervical Cancer Awareness Month 2012 here.

The uninsured, the underinsured and those living in underserved communities in which health care services are scarce are the segments of the U.S. population that are disproportionately affected by cervical cancer. These populations include women in rural areas, the elderly, those with less formal education, and women of color. For example, the mortality rate for African-American and Vietnamese women continues to be twice as high as for white women – and about 50 percent higher for Latinas. Meanwhile, in rural communities, uninsured white women have some of the poorest access to routine screening of any patient population. Thus, cervical cancer incidence rates vividly demonstrate inequities in our health care systems and outcomes.

Community health centers supported by the Health Resources and Services Administration (HRSA) address this disparity by providing preventive health services – including Pap tests and HPV vaccinations – to any woman, regardless of insurance status and/or ability to pay. As such, health centers play a vital role in redressing health disparities and delivering care to groups excluded in the health care system, such as immigrants.

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For example, in 2010, more than 11 million patients served in community health centers were women and girls, or 6 out of every 10 patients. Of that population, 69% were women over 20 – comprising the largest single patient-category in the system. In addition to HPV vaccines, health centers administered Pap tests to about 1.8 million women, resulting in 120,167 abnormal cervical findings. Of the 9,592 attending physicians in health centers, almost 1 in 10 was an OB-GYN specialist, accounting for more than 3 million patient visits-or 9% of the 34 million visits to health centers annually.

The passage of the Affordable Care Act will allow community health centers to make an even greater impact on access to preventive health services. Under the Affordable Care Act, cervical cancer screenings are already covered with no cost sharing for new health plans. Furthermore, the Affordable Care Act created the Community Health Center fund which will provide $11 billion over a five-year period to assist in the expansion, improvement and creation of new health centers throughout the country. In September 2011, the Department of Health and Human Services (HHS) made $700 million in funds available to health centers: $600 million for current community health centers to expand operations and serve more patients and $100 million to help health centers address immediate needs. And in August 2011, HHS awarded nearly $30 million to create the New Access Points program, which will help health centers delivery primary and preventive care to an additional 286,000 patients.

Community health centers are poised to play a large role in increasing access to preventive and primary health care. Other provisions of the Affordable Care Act, including no-cost sharing for preventive services under private health insurance plans and non-discrimination protection for women with pre-existing conditions, also serve to bring down barriers to health care for women. Additionally, while greater research is needed, a recent study at the National Cancer Institute suggests that the HPV vaccine seemed to be about as effective whether women had 1, 2, or 3 doses; a development which may increase access to the HPV vaccine for women who seek it.

With the nation spending over $1.4 billion a year on cervical cancer treatment, these basic preventive services not only provide crucial access to care to the most vulnerable of populations, but also serve to reduce health care costs overall by emphasizing prevention and reducing the need for costly disease treatment and emergency room costs.

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

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A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.

Analysis Politics

New Hampshire Sen. Kelly Ayotte’s Record on Women’s Health at Center of Heated Race

Ally Boguhn

Sen. Kelly Ayotte's defenders have made claims about her commitment to "strengthening women's health" through action on various measures; reproductive rights advocates point out, however, that most of these measures would have done more harm than good.

The tight race between incumbent Sen. Kelly Ayotte (R-NH) and challenger Gov. Maggie Hassan (D) could help determine which party takes control of the U.S. Senate after the November elections. In recent months, a key point of contention has emerged among Ayotte’s supporters and critics: the senator’s record on reproductive rights and women’s health.

Planned Parenthood Votes released an ad in April claiming Ayotte is “bad for New Hampshire women,” signaling the continuation of the heated narrative in the lead-up to the election. Ayotte’s defenders have responded to the accusations with claims of her commitment to “strengthening women’s health” through action on various measures; reproductive rights advocates point out, however, that most of these measures would have done more harm than good.

“For months, Senator Kelly Ayotte has followed party bosses, refusing to fill the Supreme Court vacancy. And for years, Ayotte has waited for an opportunity to push for someone to end access to safe, legal abortion and overturn Roe v. Wade,” claims the Planned Parenthood Votes ad, before playing an August 2010 clip of Ayotte advocating for the Supreme Court to overturn Roe. “For New Hampshire women, the consequences of letting Kelly Ayotte play politics with the Constitution could last a lifetime.”

The $400,000 ad buy, slated to run on broadcast and cable in New Hampshire, has been Planned Parenthood Votes’ first on-air ad targeting a Senate race in the 2016 election cycle. The organization, a national independent expenditure political committee, is criticizing Ayotte for claiming to protect women but failing to protect reproductive rights, also drawing on her pledge to obstruct filling the vacant Supreme Court seat in the aftermath of Justice Antonin Scalia’s death.

“Kelly Ayotte may try to paint herself as pro-woman, but her record tells a very different story. Every chance she’s gotten she’s voted to ‘defund’ Planned Parenthood and cut women off from essential health care like birth control and breast and cervical cancer screenings,” said Deirdre Schifeling, executive director of Planned Parenthood Votes, in a statement on the organization’s new ad. “She has been advocating for years to ban women’s access to safe, legal abortion, and it’s clear she now sees her chance in the Supreme Court process. Kelly Ayotte is refusing to do her job, and abdicating her constitutional duty, in order to push an extreme agenda that no one in New Hampshire wants.”

Ayotte’s campaign manager, Jon Kohan, meanwhile, defended the senator’s record on women’s health and rights in a press release. He wrote, “Kelly’s long record of standing up for New Hampshire women and families is clear, and she cares deeply about ensuring all women have access to health services.” The release included a bulleted list providing examples of Ayotte’s work “strengthening women’s health care,” “supporting working women,” and “protecting domestic or sexual assault victims.”

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The claims may be familiar to those following the New Hampshire race. After Hassan announced her candidacy in October, for example, One Nation, an issue-advocacy organization that does not need to disclose where their funding comes from and is affiliated with Karl Rove’s American Crossroads super PAC, pushed a 17-day, $1.4 million ad campaign touting Ayotte’s record on women’s health.

Hassan, on the other hand, has the support of organizations such as EMILY’s List, whose stated mission is to help elect pro-choice women into office. After endorsing the governor in the Senate race, the group added Ayotte to its “On Notice” list for “voting for anti-woman legislation and standing in the way of policies that give working families a fair shot.”

But with both sides of the race simultaneously claiming opposing positions on whether Ayotte has been good for women and reproductive rights, what is the truth?

Ayotte has made no secret of her desire to defund Planned Parenthood, and she “has shown support for defunding the organization or opposition to continued funding in at least six votes,” according to PolitiFact, though some of those votes were procedural. Though she famously chided Sen. Ted Cruz (R-TX) for attempting to shut down the government over his crusade to strip the reproductive health provider of money in the wake of anti-choice front group Center for Medical Progress’ deceptively edited videos, it was because she didn’t view his methods as a winning strategy for accomplishing that goal—not because she didn’t believe in the cause.

In a letter to Cruz, Ayotte told the Republican presidential candidate that she too is “deeply disturbed by” CMP’s videos and doesn’t believe Planned Parenthood should have federal funding.”This callous disregard for the dignity of human life is heinous, and I do not believe taxpayer dollars should be used to fund a private organization that performs hundreds of thousands of abortions each year and harvests the body parts of unborn children,” wrote Ayotte. She went on to ask what Cruz’s “strategy to succeed in actually defunding Planned Parenthood” really was, given that their mutual efforts to redirect the organization’s funding to other clinics had failed.

Planned Parenthood does not use its federal funding to provide abortions; its fetal tissue donation program has been cleared of wrongdoing in multiple state and federal investigations. And despite claims from conservatives, including Ayotte, that other facilities could provide Planned Parenthood’s patients with health care should the organization lose funding, the Guttmacher Institute found that “credible evidence suggests this is unlikely. In some areas, Planned Parenthood is the sole safety-net provider of contraceptive care.”

“Our analysis shows unequivocally that Planned Parenthood plays a major role in delivering publicly supported contraceptive services and supplies to women who are in need of such care nationwide,” the Guttmacher Institute concluded.

Ayotte has also supported numerous other anti-choice restrictions and legislation, including a 2015 20-week abortion ban based on the medically unfounded claim that fetuses feel pain at this point in pregnancy.

According to NPR, Ayotte has “been a hero to anti-abortion activists since 2005, when as New Hampshire attorney general she defended a parental notification law all the way to the U.S. Supreme Court.” The law required doctors to notify parents of minors seeking an abortion at least 48 hours prior to the procedure, and contained no exceptions for the health of the patient. The Court ultimately ruled against Ayotte, affirming that states may not enact abortion laws that don’t protect women’s health and safety.

National Right to Life found that the New Hampshire senator voted “with” the anti-choice organization in all 14 of the scored votes from 2012 to 2015 it examined.

In 2012, Ayotte co-sponsored the failed “Blunt Amendment,” which would have allowed exemptions from the Affordable Care Act’s birth control benefit for any employers or insurers that had moral objections to providing contraceptive coverage to their employees. And in a 2014 commentary for the Wall Street Journal, Ayotte and Sen. Deb Fischer (R-NE) defended the Supreme Court’s ruling in Burwell v. Hobby Lobby, which grants some employers the right to deny contraceptive coverage to their staff based on the owner’s religious beliefs, falsely claiming that the ruling did “not take away women’s access to birth control.”

Ayotte’s campaign is quick to point to legislation sponsored by the senator that would have allowed over-the-counter contraception as proof that she cares about women’s health. Reproductive health advocates, however, called Ayotte’s Allowing Greater Access to Safe and Effective Contraception Act a “sham” when it was introduced in 2015. Though the American Congress of Obstetricians and Gynecologists (ACOG) generally supports over-the-counter birth control, the organization’s president Dr. Mark S. DeFrancesco, said in a statement that Ayotte’s measure “would actually make more women have to pay for their birth control, and for some women, the cost would be prohibitive.”

Paid leave is yet another issue in which Ayotte has put forth legislation in the name of helping women. Ayotte introduced the Family Friendly and Workplace Flexibility Act of 2015 in March of that year, claiming it would “allow greater flexibility for workers who are looking to better balance their work-life demands.” Analysis by ThinkProgress, however, found that the measure “could weaken already weak rules that require workers to be paid extra for working extra hours, thus ensuring that workweeks don’t grow out of control and employees are compensated fairly.”

Earlier in 2015, Ayotte signed on as a co-sponsor of the Working Families Flexibility Act. According to a statement from the National Partnership for Women and Families (NPWF) condemning the legislation, the act claimed to “give hourly workers more flexibility and time with their loved ones by allowing them to choose paid time off, rather than time-and-a-half wages, as compensation for working more than 40 hours in one week.” However, the bill did “not promote family friendly or flexible workplaces,” explained the nonprofit organization in a fact sheet. “Instead, it would erode hourly workers’ ability to make ends meet, plan for family time, and have predictability, stability, and true flexibility at work.”

Ayotte’s record on equal pay has been similarly debunked by advocates. One of the policies highlighted by Ayotte’s campaign in the wake of Planned Parenthood Votes’ ad was the senator’s introduction of the Gender Advancement In Pay (GAP) Act in September 2015, which she reintroduced ahead of Equal Pay Day this April. The measure was meant to make clear that “employers must pay men and women equal wages for equal work, without reducing the opportunity for employers to reward merit,” according to a press release from Ayotte’s office upon the initial release of the bill.

Critics argued that Ayotte’s bill was nothing other than an election-year stunt. New Hampshire state Sen. Donna Soucy (D-Manchester) told NH1 News that Ayotte’s move was an attempt to look “for some cover … in an effort to be more in line with” New Hampshire voters, after Ayotte voted against other fair pay measures. However, Soucy said, the legislation didn’t really address the issue of pay equity. “Sen. Ayotte’s bill attempts to create paycheck fairness but doesn’t in fact do so because employers could preclude their employees from discussing what they make with their fellow employees,” claimed Soucy.

Similar arguments were made when Ayotte co-sponsored another equal pay measure, the Workplace Advancement Act, with Sens. Deb Fischer (R-NE), Susan Collins (R-ME), Joni Ernst (R-IA), Thad Cochran (R-MS), and Shelley Moore Capito (R-WV) in April 2015. Though the legislation would ban employers from retaliating against their staff, it failed to garner support from Democrats. According to the National Women’s Law Center, the bill would have done “more harm than good” as it “entirely [ignored] the many loopholes and inadequacies in current equal pay laws and simply [stated] that pay discrimination ‘violates existing law.'”

Their arguments are bolstered by Ayotte’s repeated votes against the federal Paycheck Fairness Act, though as Politifact again pointed out, some of these votes were procedural and not against the bill itself. Ayotte did cast one vote in favor of ending debate on the measure and advancing it; the fact-checking site noted, though, that Ayotte’s office reportedly did so in the ultimately denied hopes of changing the bill.

Had it passed, the legislation would have updated the Equal Pay Act of 1963 to include protections such as prohibiting retaliation against employees who share their salary and strengthening penalties for those who violate the law. Ayotte claims she voted against the measure because it “could reduce the ability of employers to award merit pay for good performance and limit the opportunity for women to have flexible work schedules,” according to a press release on the matter.

Speaking at a town hall event in 2013, Ayotte had previously justified her vote against equal pay legislation by asserting that it “created a lot of additional burdens that would … make it more difficult for job creators to create jobs.” The New Hampshire senator went on to add that there were already laws in place that could help address the issue.

There are, however, some examples of Ayotte supporting and introducing legislation that would help women. In June 2015, Ayotte co-sponsored the Pregnant Workers Fairness Act to protect pregnant people from workplace discrimination. Though the legislation never came to a vote, it would have helped “end … discrimination and promote healthy pregnancies and the economic security of pregnant women and their families,” according to the NPWF. That same year, the New Hampshire senator co-sponsored the Protect Access to Lifesaving Screenings (PALS) Act, bipartisan legislation that would have safeguarded access to free annual mammograms for women ages 40 to 74. Ayotte co-sponsored the bipartisan Campus Accountability and Safety Act in 2014 and 2015, which, according to Democratic New York Sen. Kirsten Gillibrand’s website, would “protect students and boost accountability and transparency at colleges and universities” when it comes to sexual assault. Ayotte also co-sponsored the Combating Military Sexual Assault Act of 2013 to address the issue in the military.

Overall, Ayotte has signed onto or supported numerous pieces of legislation that at face value seem to promote reproductive health and women’s rights. Further examination shows, however, that—with a few exceptions—they largely failed to hold up to scrutiny. While Ayotte’s campaign alleges that many of her measures would have helped women and families, analysis suggests that her conservative solutions to addressing these issues often would have made the problems worse. This, coupled with the senator’s fierce anti-choice advocacy, will no doubt keep this portion of Ayotte’s record under tight observation as November’s election approaches.