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Background
Human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) continue to be among the leading causes of morbidity and mortality in the United States. The first cases of AIDS were reported more than 30 years ago in the June 5, 1981, issue of the Centers for Disease Control and Prevention’s (CDC) Morbidity and Mortality Weekly Report.1 Since then, the epidemic has claimed the lives of approximately 30 million people worldwide, and 34.2 million people currently live with HIV infection.
In 2006, the CDC released revised recommendations that all healthcare settings should offer people aged 13 to 64 years routine voluntary screenings for HIV infection, and should treat HIV like any other infectious disease.4,5 The recommendations advocate routine voluntary HIV screening as a normal part of medical practice, similar to screening for other treatable conditions. Screening helps to identify unrecognized health conditions so treatment can be offered before symptoms develop and interventions can be implemented to reduce the likelihood of continued transmission for communicable diseases.4 Research indicates that prevention efforts that include early screening and detection are critical because of the growing population of people living with HIV and AIDS. Early screening and detection can reduce morbidity and mortality associated with HIV as well as prevent transmission of the disease through risky behaviors.4
The CDC estimates that more than 1.1 million people in the United States are living with HIV infection and nearly one in five (18.1%) of those people are unaware of their infection.6 Despite increases in the total number of people in the United States living with HIV infection in recent years due to better testing and treatment options, the annual number of new HIV infections has remained relatively stable.6 Approximately 50,000 Americans become newly infected with HIV each year,6 with a disproportionately high number found among ethnic minorities. The CDC reported that in 2009, the estimated rate of new HIV infections among black men was 6.5 times as high as that for white men and more than 2.5 times as high as that for Hispanic/Latino men.3,6 In the same year, the estimated rate of new HIV infections among black women was 15 times that for white women and over 3 times that for Hispanic/Latina women.
Although an estimated 3.6 million Americans report a significant HIV risk, many have never been tested and receive no preventive medical care from any source.7 However, three quarters of these people at high risk for HIV infection reported that they have seen a dentist within the last 2 years.7 Therefore, dental offices present an excellent opportunity for early screening and detection for at-risk individuals who otherwise might have no access to other settings that offer HIV testing.7,8 HIV testing in the dental office has the potential to create a major breakthrough in public health that could benefit patients through earlier detection and help reduce the incidence of HIV. Both dental hygienists and dentists have the training and education to play a significant role in providing point-of-care HIV screening. It also offers an interdisciplinary approach to healthcare, integrating oral health with systemic health.
HIV and AIDS
HIV is a bloodborne pathogen contracted by contact with body fluids of infected individuals.10 After exposure, the retrovirus binds to CD4+ t-lymphocytes, a type of white blood cell. It infects by infusing to the cell membrane of the lymphocyte, and once inside the cell it uses the enzyme reverse transcriptase to convert RNA into DNA.11 As the retrovirus multiplies, the host’s immune system is compromised, allowing opportunistic infections to occur.11 If left untreated, these opportunistic infections will eventually lead to death.12 Opportunistic infections associated with HIV commonly observed in the oral cavity include oral candidiasis, hairy leukoplakia, Kaposi’s sarcoma, necrotizing ulcerative gingivitis, necrotizing ulcerative periodontitis, oral warts, and recurrent herpes simplex virus.11 However, since the development of Highly Active Anti-Retroviral Therapy (HAART), oral manifestations have decreased.
An infected person may experience mild flu-like symptoms 1 to 4 weeks after exposure that can include fever, rash, swollen lymph nodes, muscle aches, and joint pains.11 Seroconversion is the interval, several weeks after HIV infection, during which antibodies are first produced and rise to detectable levels.13 Antibodies generally begin to appear within 1 to 2 weeks of exposure, and antibody concentrations continue to increase for several months thereafter. The window period refers to the time after infection and before seroconversion, during which markers of infection, HIV-specific antigen and antibodies, are still absent or too scarce to be detectable.13 Standard screening tests cannot reliably detect HIV infection until after the window period has passed. Testing guidelines, therefore, recommend that a person who may have been recently infected should have a repeat test some weeks or months after the possible date of infection.13 Since both the window period and seroconversion time vary from person to person, it is important to ensure that clients understand that testing for HIV cannot be done immediately following a chance exposure.
Testing for HIV
Standard testing for HIV includes the enzyme-linked immunosorbent assay (ELISA) and the Western Blot test. Both use a blood sample to screen for HIV antibodies. Generally, the ELISA is used as the screening test and the Western Blot follows as a confirmatory test after two positive ELISA readings. When using the ELISA as a screening test, the client is required to return in 1 to 2 weeks to receive the results.14 Often, possibly out of fear or denial, clients do not return for their results and remain undiagnosed with the potential to infect others through risky behavior.14 This could be eliminated with the use of rapid HIV antibody screening tests. All of the rapid screening tests still utilize whole blood, serum or plasma except for the OraQuick Advance Antibody Test* (Ora Sure Technologies, Inc).14 This test, approved by the US Food and Drug Administration in 2004, uses oral fluids and provides results within 20 minutes.
The dental office provides a venue for implementing rapid HIV antibody screening tests utilizing oral fluids.7 It is estimated that 58% to 75% of the US population sees a dentist annually, so dentists may be the only healthcare provider that sees an asymptomatic HIV-infected person in any given year.15 In addition, dental offices already offer other screening tests such as those for oral cancer, blood pressure, and blood glucose, so rapid HIV testing is a natural extension for comprehensive care that could be incorporated into a standard dental examination.15 The initial test could be easily integrated into treatment as a part of routine care, with the clinician informing the patient of the option to decline the test by means of opt-out consent.
Oral mucosal transudate (OMT) is obtained by swabbing the buccal mucosa and tongue. This OMT sample is rich in antibodies and provides a better source of antibodies than does saliva.12 The swab is then placed in a vial with an enzyme solution. This test involves the use of nitrocellulose lateral flow strips that contain two capture zones: a control line that detects the presence of all antibodies in the sample and a test line that specifically reacts with HIV-1 or, ideally, with both HIV-1 and HIV-2.12 In 20 minutes, this test reveals if the person is presumably HIV positive or HIV negative. If the result shows a positive for HIV, then it must be confirmed by the ELISA test and the Western Blot.12 Once a result is obtained, negative or positive, a preliminary result has been formed—not a definitive diagnosis with an HIV infection. In the dental setting, the rapid HIV test represents a screening test only.
The rapid HIV screening test is highly sensitive and specific, with no federal requirements for personnel. It can be performed outside the traditional medical office by a clinician certified to perform and interpret accurate results.5 In general, any dental office that performs a rapid HIV test for the purpose of providing a patient with a result must comply with the Clinical Laboratory Improvement Amendments (CLIA) of 1988.16 The OraQuick Advanced test is a CLIA-waived test which means there are no federal requirements for personnel, quality assessment, or proficiency testing.16 CLIA-waived tests can be performed outside a traditional medical office only after the clinician obtains a certificate of waiver from the CLIA program.5,16 Dental offices can obtain the necessary waiver to perform rapid HIV oral screening tests and clinicians performing the testing must receive training and certification.
Rapid HIV Testing in the Dental Office
There are several issues and challenges to implementing HIV rapid testing in dental offices, including lack of knowledge/training to administer the test, fear of delivering bad news to the patient, lack of dentists’ interest or comfort, perception that HIV testing is outside the domain of dentistry, lack of patient acceptance, financial reimbursement and time constraints, and lack of referral sources.9 Any HIV test needs to be accompanied by patient counseling both before and after the test is conducted.16 Pretest counseling includes providing information about HIV/AIDS, routes of transmission and a plan for dealing with a positive test result as well as an understanding of prognosis and treatment of HIV disease.16 If the test comes back negative, posttest counseling should include a discussion of the concept of a “window period” and the consequences of behavior that may pose a risk of transmission.16 If the test comes back positive, posttest counseling and referral for follow-up is required,16 and the referral would have to be tracked.
From the patient perspective, studies support acceptance of rapid oral HIV screening. In a pilot study done by Dietz et al, the majority (62%) of patients in an urban free dental clinic reported that it did not matter who provided the screening result although some (37%) preferred their dentist above any other provider.17 It may be that the barriers exist only from the healthcare and dental establishments and not from within the population at large.
The CDC recommends the use of rapid HIV testing in community clinics and community-based organizations to increase the proportion of persons aware of their HIV status.4,18 While this is a start, it seems to suggest that only patients at community settings are at high risk for HIV. In reality, HIV infection can affect anyone from any socioeconomic level. Dental healthcare professionals need to understand that HIV infection is now a chronic illness, like diabetes, and is within their realm of treatment.
What will it take to make rapid HIV testing in the dental office a reality? It will require a shift from the traditional perception of what a dental practice should offer as part of comprehensive dental care. It will also require dental educators to look at ways dentistry can positively impact public health and to ensure that dental hygiene and dental education provides a strong foundation for understanding the role in prevention and detection of HIV. Once these changes shift the paradigm, we could truly begin to see a decrease in the morbidity and mortality associated with HIV.
References
1. Centers for Disease Control and Prevention. Epidemiologic notes and reports pneumocystis pneumonia Los Angeles. MMWR. 1981;37:1-3.
2. Centers for Disease Control and Prevention. World AIDS day. MMWR. 2012;61:957.
3. Prejean J, Song R, Hernandez A, et al. Estimated HIV incidence in the United States, 2006–2009. PLoS One. 2011;6(8):e17502.
4. Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. 2006;55:1-17.
5. Vernillo A. Routine opt-out HIV testing in dental health care—its implementation and the advancement of public health. Am J Bioethics. 2011;11(4):46-48.
6. Centers for Disease Control and Prevention. HIV in the United States: At a glance. Fact Sheet. 2012. Available at: www.cdc.gov/hiv/resources/factsheets/PDF/HIV_at_a_glance.pdf. Accessed March 22, 2013.
7. Pollack H, Metsch L, Abel S. Dental examinations as an untapped opportunity to provide HIV testing for high-risk individuals. Am J Public Health. 2010;100(1):88-89.
8. Blackstock O, King J, Mason R et al. Evaluation of a rapid HIV testing initiative in an urban, hospital-based dental clinic. AIDS Patient Care and STDs. 2010;24(12):781-785.
9. Vernillo AT, Caplan AL. Routine HIV testing in dental practice: Can we cross the Rubicon? J Dent Educ. 2007;71(12):1534-1538.
10. New Mexico AIDS Education & Training Center. What is AIDS? Fact Sheet Number 101. 2012. Available at: www.aidsinfonet.org. Accessed March 21, 2013.
11. Darby D, Darby M. Persons with human immunodeficiency virus infection. In Darby M, Walsh M (eds.): Dental Hygiene Theory and Practice. 3rd ed. St. Louis: Saunders Elsevier; 2010:888-999.
12. Corstjens P, Abrams WR, Malamud D. Detecting viruses by using salivary diagnostics. J Am Dent Assoc. 2012:143(10 suppl):12s-18s.
13. Understanding test results. Available at: www.aidsmap.com/Understanding-test-results/page/1320698/. Accessed March 22, 2013.
14. Pinkerton SD, Bogart LM, Howerton D, et al. Cost of oraquick oral fluid rapid HIV testing at 35 community clinics and community based organizations in the USA. AIDS Care. 2009;21(9):1157-1162.
15. Siegel K, Abel SN, Pereyra M, et al. Rapid HIV testing in dental practices. Am J Public Health. 2012;102(4):625-632.
16. Glick M. Rapid testing in the dental setting. J Am Dent Assoc. 2005;136:1206-1208.
17. Dietz C, Ablah E, Reznik D, Robbins D. Patients’ attitudes about rapid oral HIV screening in an urban, free dental clinic. AIDS Patient Care and STDS. 2008;22(3):205-212.
18. Centers for Disease Control and Prevention. Advancing HIV prevention: new strategies for a changing epidemic-United States, 2003. MMWR. 2003;52:329-332.
About the Authors
Montana Duncan, RDH, works full time as a registered dental hygienist for Dr. Tiffani Long at Farmington Dental Center in Farmington, Arkansas. She has been practicing since May 2013 and is licensed in both Oklahoma and Arkansas. A graduate of the University of Arkansas Fort Smith dental hygiene program, she is currently a member of the American Dental Hygienists’ Association.
Chelsea Holdren, RDH, a May 2013 graduate of the University of Arkansas at Fort Smith dental hygiene program, works full time as a dental hygienist for Dr. Brook Derenzy, DDS, and Dr. Emily Steininger, DDS, at My Dentist in Fayetteville, Arkansas. She has been practicing since June 2013 and is a current member of the American Dental Hygienists’ Association.
Taylor Rogers, RDH, is a May 2013 graduate of the University of Arkansas at Fort Smith dental hygiene program. She has been practicing since June 2013 and currently works full time as a registered dental hygienist for Dr. Ward W. Clemmons Implant and Comprehensive Dentistry in Fort Smith, Arkansas.
The faculty mentor for this article Pamela Davidson, RDH, MEd, University of Arkansas-Fort Smith College of Health Sciences.
