This special supplement of Public Health Reports fills a much-needed gap in research on oral health care for people living with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) (PLWHA). It presents findings from the Special Projects of National Significance (SPNS) Innovations in Oral Health Care Initiative (hereafter, Oral Health Initiative) as well as other studies that investigate ways to improve outcomes and oral health-care access for HIV-positive individuals. The results presented in this supplement offer strategies that can also be applied to other similarly vulnerable populations.
While good oral health is important to the well-being of all population groups, it is especially critical for PLWHA. Inadequate oral health care can undermine HIV treatment and diminish quality of life, yet many individuals living with HIV are not receiving the necessary oral health care that would optimize their treatment.1
Factors that may impede access to oral health care include presence of disability or chronic illness, lack of dental insurance, inability to pay for care, and lack of transportation.2 PLWHA also experience the barrier of discrimination by dentists as well as other types of providers.3,4 Many of these factors are common in communities with the highest reported cases of HIV. Indeed, most reported cases of HIV occur in communities where levels of oral health-care utilization are among the lowest in the nation.5
Due to the already compromised immune systems of PLWHA, lack of access to oral health care may affect the systemic health of these individuals. More than a decade ago, the first national study of HIV-positive adults in the U.S., the HIV Cost and Services Utilization Study, documented the high unmet need for oral health care among people living with HIV.6–10 The Institute of Medicine's April 2011 report, “Advancing Oral Health in America,” affirmed this continued dearth of oral health services, noting that while there has been a modest improvement in access to oral health care, those who are most vulnerable in the U.S. still have difficulty obtaining the oral health care they need. There continues to be limited recognition among non-dental clinicians about oral disease and how to promote oral health.11 Even with these national findings and associated calls for action, there continue to be barriers to accessing quality oral health services for PLWHA.
The Department of Health and Human Services provides the primary safety net for oral health care for PLWHA through the Ryan White HIV/AIDS Program and Medicaid. However, this coverage is limited. Comprehensive adult dental coverage under Medicaid is only available in approximately one-fifth of the states, and more than half of the states offer emergency or highly restricted dental services only.12 Thus, even Medicaid programs that offer some oral health benefits may not provide adequate coverage to eliminate oral disease. Further, Medicaid coverage for adult dental services has often been the victim of budgetary cuts during periods of fiscal retrenchment. For many low-income, under- or uninsured individuals living with HIV, the Ryan White HIV/AIDS Program is their only source of coverage for oral health care.
To expand access to comprehensive oral health care for underserved HIV-positive populations, in 2006, the Health Resources and Services Administration's HIV/AIDS Bureau funded the Oral Health Initiative through the SPNS program.13 The evaluations of projects during that five-year initiative explored whether they increased access to oral health care for PLWHA and whether participants experienced improvements in oral health outcomes. The evaluations also sought to identify best practices and replicable approaches that promote access to oral health-care programs. Findings from the Oral Health Initiative are presented in this supplement of Public Health Reports.
As we emphasize the importance of oral health in the National Prevention Strategy, we also aim to meet the Healthy People 2020 objectives for oral health.14 I encourage you to include oral health as an essential element of comprehensive primary care for people with HIV/AIDS. I urge you to strengthen the oral health-care safety net and to build upon the findings offered in this issue to develop innovative ways to engage and retain HIV-positive patients in oral health-care programs.
VADM Regina M. Benjamin, Surgeon General
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