Rapid HIV Testing in Dental Practices

Abstract

Despite increasing discussion about the dental care setting as a logical, potentially fruitful venue for rapid HIV testing, dentists’ willingness to take on this task is unclear. Semistructured interviews with 40 private practice dentists revealed their principal concerns regarding offering patients HIV testing were false results, offending patients, viewing HIV testing as outside the scope of licensure, anticipating low patient acceptance of HIV testing in a dental setting, expecting inadequate reimbursement, and potential negative impact on the practice. Dentists were typically not concerned about transmission risks, staff opposition to testing, or making referrals for follow-up after a positive result. A larger cultural change may be required to engage dentists more actively in primary prevention and population-based HIV screening.

An estimated one fifth of Americans infected with HIV, approximately 250 000 individuals, are unaware of their status.¹ Consequently, individuals are often diagnosed only when their disease has progressed and they are symptomatic² or they already have AIDS. The advent of the rapid HIV test has made it possible to offer HIV testing in a much wider array of settings, thus creating the opportunity for more infected individuals to be identified earlier. Paltiel et al.³ estimated that widespread routine HIV screening would extend survival by 1.5 years for the average detected HIV-infected individual who enters care. Furthermore, studies have also shown that most persons who learn that they are HIV positive reduce sexual risk behaviors, resulting in reduced transmission to others.^4–6

The rapid HIV test is a fast, reliable, simple, and cost-effective method to screen for HIV,^7–11 yielding results typically in 20 minutes or less and relieving burdens on both patients and providers that arise from the need for tested persons to return later to obtain results. Although it is a screening test, and therefore a reactive-positive result must be confirmed with traditional testing, it has been shown to be comparable to the traditional Western blot in sensitivity and specificity.¹¹ The Food and Drug Administration approved the rapid HIV test using whole blood from a finger stick in 2002¹² and using oral fluid in 2004.¹³ Rapid testing is now the preferred method for many providers and clients. Oral fluid collection for testing has demonstrated high acceptability in preliminary studies with various risk groups.^14–18 Given the availability of a safe, reliable, and acceptable rapid test for HIV, and recognizing the value for both individuals and public health of identifying undiagnosed cases of HIV infection as early as possible, in 2006 the Centers for Disease Control and Prevention issued revised recommendations for HIV testing.¹⁹ In the recommendations, they advocated that all individuals aged 13 to 64 years be routinely tested in all private and public health care settings and that HIV testing be included among the routine prenatal tests pregnant women take.

THE DENTAL CLINIC AS A VENUE FOR HIV TESTING

The dental setting is a promising though largely unexplored venue in which to offer the HIV rapid test using oral fluid.^20–22 Additionally, individuals are likely to have more frequent visits to a dentist than to other health care providers.²³ With an estimated 58% to 75% of the US population seeing a dentist annually,^24–26 practicing dentists may be the only provider to see an asymptomatic HIV-infected person in any given year.^27,28 Furthermore, many dentists already offer other screening tests—such as those for oral cancer, high blood pressure, and elevated blood glucose—and refer patients for definitive diagnoses after screening.²⁹ If offered routinely to all patients, HIV screening could become a component of a standard dental examination that would be carried out along with x-rays, evaluations of caries and periodontal disease, and screening for oral cancers.²³ More generally, the field of dentistry is moving toward expanding the use of salivary-based diagnostic testing.³⁰ For example, efforts are underway to develop an oral rapid test for HCV. Other tests that are in development and being considered for salivary-based screening include screening for HSV-1, hepatitis B, measles, rubella, mumps, and cytomegalovirus.²⁹

BARRIERS TO OFFERING HIV TESTING IN THE DENTAL SETTING

Although published data addressing dentists offering HIV testing are limited, numerous concerns and potential barriers have been identified. Patton et al.²⁸ surveyed 46 dental school associate deans for clinical services (or their designates) about the feasibility of instituting HIV testing of at-risk individuals in dental settings. They were asked whether they thought offering HIV counseling and testing in the dental office should be part of the dentist’s role. Thirteen percent agreed that this was already part of their role, and another 33% thought it might become part of their role in the future. When asked if their graduates would have the skills to do HIV counseling and testing if a rapid chairside oral fluid HIV test became available, 24% thought they would, but only 11% thought that the dentists would be willing to do so. Lack of counseling skills and time constraints were the most frequently mentioned barriers (> 80%); others included low patient acceptance and lack of training with oral HIV testing. Furthermore, in a mail survey of 1945 US-based practicing dentists, Greenberg et al.³¹ found that 69% of respondents stated that it was “very important” or “somewhat important” for dentists to conduct chairside screening for HIV. Although this endorsement was higher for screening for hypertension (86%), cardiovascular disease (77%), diabetes mellitus (77%), and hepatitis (72%), this finding suggests broad receptivity to the idea.

Lack of experience communicating the diagnosis of a serious medical condition to patients, except in rare cases of oral cancer, is another concern dentists have expressed with regard to offering HIV testing.^28,32 Concerns about being able to link patients to appropriate follow-up care issues were identified as the most important concerns at meetings held by the Centers for Disease Control and Prevention and the National Association of Community Health Centers about expanding HIV testing in the dental setting.^33,34 Several studies have also identified low patient acceptance of HIV testing in the dental care setting as a potential barrier. Patton et al.²⁸ found that dental providers were concerned that patients might not accept HIV testing in the dental setting because patients would not expect it and would view it as an activity that is not within the traditional scope of dentistry.

Structural barriers to HIV testing in the dental care setting may also exist. Reimbursement has been identified as a possible barrier that needs further investigation.^23,33,34 In a national survey, Greenberg et al.³¹ found that in considering whether to incorporate medical screening (including HIV screening) into their practice, considerably fewer respondents ranked insurance coverage as “very important” (57%) compared with those who ranked patient willingness (84%), liability issues (82%), cost (76%), and time (75%) as “very important.” Numerous logistical issues also need to be considered. For example, dentists may require some additional training on the requirements of privacy and confidentiality surrounding HIV results²³ and on communicating with patients about test outcomes.

METHODS

The American Dental Association Survey Center gave us a list of 208 dentists in private practice randomly selected from their national sample frame of professionally active dentists, dental students, and retired dentists; this sample frame is independent of American Dental Association membership. We excluded dentists whose practices were limited solely to children and adolescents. As the order of names on the generated list was randomly organized, the interviewer contacted dentists sequentially to set up an appointment for a telephone interview. Interviewers made a minimum of 2 contacts with each dentist’s office to invite the dentist to participate. Interviewers typically made both contacts by telephone, but when a fax or e-mail address was obtainable, they also sent a letter inviting the dentist to participate in the study. We offered dentists a small monetary stipend for their time in participating in the telephone interview. We contacted 174 dentists, and 40 participants completed interviews. Of the remaining 134 dentists, 97 dentists did not contact the interviewer after 2 or more requests to do so; 20 dentists declined participation; and we could not contact 17 dentists because of retirement or a wrong or disconnected telephone number (and we were unable to locate a correct number from an online directory).

Participant characteristics are shown in Table 1. The majority of participants were older than 50 years (52%), men (80%), and White non-Hispanic (78%). Almost all dentists reported working full time (85%) and being owners of their practices (81%).

TABLE 1—

Characteristics of Qualitative Interview Participants: HIV Rapid Testing in Dental Care Settings: Miami, Florida, 2009–2012

Characteristic	No. (%) or Mean ±SD (Median; Range)
Age, y	53 ±13.3 (53; 29–77)
29–39	7 (18.9)
40–49	7 (18.9)
50–59	11 (29.7)
≥ 60	12 (32.4)
Years since graduation	24 ±14.3 (24; 2–51)
Gender
Male	32 (80.0)
Female	8 (20.0)
Race/ethnicity
Asian	3 (8.1)
Black	1 (2.7)
Hispanic	2 (5.4)
White	29 (78.4)
Other	2 (5.4)
Primary occupation
Full-time practice (≥ 30 hrs/wk)	34 (85.0)
Part-time practice (< 30 hrs/wk)	6 (15.0)
No. of full-time staff
1	32 (80.0)
2	5 (12.5)
3	1 (2.5)
≥ 4	2 (5.0)
No. of part-time staff
0	28 (70.0)
1	8 (20.0)
2	2 (5.0)
3	2 (5.0)
Secondary occupation
Armed forces	1 (2.7)
Hospital staff dentist	2 (5.4)
No secondary occupation	34 (91.9)
American Dental Association membership
Active	24 (60.0)
Active life	6 (15.0)
Nonmember	10 (25.0)
Ownership
Owner	29 (80.6)
Nonowner	5 (13.9)
Associate (nonowner)	1 (2.8)
Unknown	1 (2.8)
Location
Rural	4 (10.0)
Suburban	25 (62.5)
Urban	11 (27.5)

As we recognized that many dentists may not be familiar with the rapid HIV test, the introduction to the interview provided the following information:

The rapid test involves using an absorbent pad on a stick to take a swab of a patient’s upper and lower gums. The swab is then placed in a vial with a developing solution. In 20 minutes this test reveals if the person is presumably HIV positive or HIV negative. This is only a screening test, and a result that shows the person is presumably HIV positive must be confirmed with a definitive blood test.

All participants completed a 25- to 30-minute semistructured telephone interview that elicited their views regarding the idea of dentists offering rapid HIV testing to their patients. Before the interview, we read all dentists a statement that gave them the information needed to make an informed decision about participating in the interview (e.g., risks, benefits, procedures, and safeguards on confidentiality). They were then read the following statement:

I have been read this consent form. I have had my questions answered so that all parts are clear to me now. Completion of this interview implies consent to participate and be audio taped.

We digitally recorded all interviews with the participants’ knowledge and consent and subsequently transcribed the interviews for analysis. Data collection took place from mid-April 2010 through the end of September 2010.

One member of the team read a subsample of interviews and developed a provisional coding scheme that focused primarily on identifying what the dentists perceived as concerns or deterrents as well as facilitators to offering testing in their practices and among dentists in general. A second research team member reviewed a different subsample to validate the adequacy of the provisional coding scheme that was found to be very complete. We determined 2 categories initially proposed to be conceptually overlapping and collapsed them. Subsequently, using this finalized coding scheme, these 2 researchers independently coded all interviews. The research team excerpted text relevant to each barrier for analysis and interpretation. There was very high interrater agreement on the coding of the interview transcripts (κ = 0.89).

RESULTS

Virtually all the dentists reported that their office gathered information about a patient’s HIV testing history and their test results through a medical history questionnaire that all patients completed, usually at least annually. When patients reported being HIV-infected, dentists typically discussed this with the patient with the goal of understanding their current health status and what medications they were taking to determine which dental procedures were safe and which might carry risks for the patient. All dentists claimed that they followed universal precautions with all patients and therefore felt there was virtually no risk of them or their staff becoming infected, except possibly through a needle stick. Only 2 participants reported specifically assessing patients for oral lesions or symptoms that were indicative of HIV infection. All others indicated that they performed a general comprehensive oral examination of all their patients, which included oral cancer screening, and were looking for any abnormalities but not specifically those associated with HIV infection. Only 2 dentists had ever suggested to a patient that they seek HIV testing, and in both cases this was many years earlier and limited to 1 or 2 patients.

Attitudes About Offering Rapid Testing for HIV

Although the rapid oral test has been available since 2004, only 1 dentist appeared to know about the rapid test’s availability before being contacted about the study and was already routinely offering the test to her patients. Most dentists indicated that they accepted in principle the idea of their profession becoming involved in rapid HIV testing. They understood the logic of dentists’ participation in screening because of the nature of the test (i.e., taking an oral swab), and they understood that many dentists already did oral cancer screening and that some screened for other things, such as high blood pressure. Many recognized the value of early detection for infected individuals so that they could obtain needed treatment before the disease advanced. They also noted that a dentist’s knowledge of patients’ HIV infection would benefit patients by enabling the dentist to plan safer and better treatment for them. As an example, 1 dentist noted that infected patients had potential healing issues a dentist should be aware of when providing care. For those who tested negative, dentists said the benefit to the patient would be “peace of mind.” A substantial minority also noted that dentists’ taking on this role would be a service not just to their patients but also to their community and would contribute to public health efforts to control the spread of HIV. However, several also felt it made sense for dentists to offer the test to all their patients only if they lived in areas with a high prevalence of HIV infection; otherwise, they saw little reason to offer it or felt dentists should only offer it selectively to patients for whom there was a firm basis for assuming they were at risk or might already be infected.

Concerns Regarding Rapid Testing

Fear of false results.

The most frequently mentioned concern related to the accuracy of the rapid test results was fear of false results. Many dentists expressed worry about the possibility of false positive results or, to a lesser degree, false negative results. A substantial number noted the potential for liability issues to arise if they gave an uninfected person a false positive result, and they were unwilling to assume such risks. One stated, “Until I know for sure it is totally accurate, I wouldn’t want it in my office.”

Dentist participants offered various suggestions to protect the dentist. For example, 1 participant suggested that patients be required to sign an informed consent form before testing. Another believed that patients taking the test should have to sign a form that indemnified the dentist against any harm that might result from the testing results. Similarly, another dentist when asked about any liability concerns in relation to offering HIV testing to patients indicated that he would want certain protections in place. Specifically he said,

If the tests were available, I would want the provider of the test to probably come up with a very specific form that the patient fills out that specifies exactly what the test provides and does so there’s no coming back to the dentist as the source or problem with the false positive, like I said. I can see that being an issue.

Other dentists were primarily concerned about the unnecessary fear and anxiety a false positive result would cause their patients until it was disconfirmed, although associated liability was also present in some. As 1 dentist said,

My biggest concern with a test like that is potentially informing the patient they may have a positive test and having to refer them to a physician or another site for a definitive test and then having to carry that burden of potentially thinking they’re positive until the test clears them. So I’ve got questions as far as liability and some of the political things that may crop up with false positives and negatives.

Another dentist, when asked if he foresaw any problems offering HIV testing in this dental office, said,

I guess nervousness that it could create if there’s a false positive. The nervousness that it could create if it is positive and then they have to move on knowing that they didn’t know and wanted to be tested and they just—that general nervousness and then the anxiety of once the test is done if they’re sitting there having their teeth cleaned they might be thinking about the test results during that, and just the increased anxiety; I guess that would be what I would think about.

Two participants raised concerns about the possibility of false negative results. They felt that this too was very problematic, as those engaging in risky practices might assume it was safe to continue to do so. As 1 participant remarked,

If it shows negative, and it’s 100% negative, it would be nice for people. If it doesn’t show 100%, then it’s sort of useless. I know you have to have the positives confirmed, but if it says negative, it better be negative. Otherwise people would keep up with their activities thinking there’s no problem, and there is a problem.

Fear of offending the patient.

Another common concern among participants was that some patients might be offended if offered HIV testing because they would construe it as implying that they engage in high-risk behaviors (e.g., homosexuality, injection drug use, sexual promiscuity). Two dentist participants commented on the need to think about how to present the offer in a way that did not make patients feel they were being labeled as being infected or as having a lifestyle that put them at risk. One dentist commented,

I think checking the patients will be uncomfortable if they think you are accusing them of having HIV. And they will be uncomfortable in that regards. It might be that they won’t come to see you again because it was presented in the wrong way.

Another dentist indicated he did not ask patients about their HIV status because he felt the universal precautions his practice took with all patients were more than adequate to protect himself and his staff. Yet he too had concerns about offending patients by offering them the test. He stated,

We take the same precautions with them as we do with any patient and if you do that as a matter of routine for everybody that walks in the door there’s no worries, at least with me. So it’s an irrelevant question [to ask their serostatus]. It’s a political question; it’s a hot button; you may offend some people with that. It’s a can of worms sometimes to insinuate they have habits that aren’t really the greatest or asking someone what their sexual orientation is; it’s kind of a funny issue.

Dentists who served older populations or had their practices in more conservative sections of the country were particularly concerned about offending the patients. For example, 1 dentist remarked,

[o]ffering it [the HIV test] to everyone, that could be a problem because of just the rural setting that I live in. I really believe that and I think there are some people who are uneducated and would feel I was saying something about their sexual orientation.

Some participants felt the best way to minimize the risk of offending patients was to offer testing to patients that they felt were members of populations most affected by the AIDS epidemic, for example, gay men, or people with clinical signs of infection, whereas others felt offering it to all patients was the best way to normalize it and to not single people out.

Regarding HIV testing as outside their scope of licensure.

Some opposed to taking on HIV testing felt it was a medical matter that went beyond the scope of activities for dentists. Others felt they would have to refer a patient who tested positive to a physician anyway, so it was probably most efficient to be tested only by a physician. As 1 dentist argued,

I probably feel that the medical doctors are then better qualified to go ahead with the counseling and certainly with treatment and things like that. So a dentist just might not be able to give the patient as much pertinent information. If they did do testing, certainly they would still need to be referred to the medical doctor anyway. So I guess a person would probably be in a more qualified setting if it was done by the medical doctor.

Similarly, another participant expressed concern about his own and other dentists’ ability to adequately address the emotional reactions and questions patients receiving a positive result might have. He said,

Just having to deal with grief and not being able to completely answer all their questions—whatever questions that they do have. It would be like the equivalent to, I guess—I mean, I guess dentists know the disease and stuff like that—but the equivalent to having a nurse give a diagnosis of cancer to a patient and not being able to fully answer every single type of question as far as treatment and what the best approach is.

Some participants felt that although dentists were well qualified to do HIV testing, it would be more logical for a physician to do the test and a physician would be better suited to communicate a positive result. For example, 1 stated,

This is only my opinion, but it would seem very odd for the first person to tell the patient that they were HIV positive would be the dentist. That would seem odd to me. I can see that conversation coming more from a primary physician than from a dentist. Even if the dentist had the capability of doing it and giving them the information, it would just seem very odd that the dentist would be the first medical person giving them that information.

A few dentists indicated they would not want to have to be the “bearer of bad news” and tell a patient that she or he was HIV positive. They also said that they felt less equipped than are physicians to communicate such information. One who did not believe HIV testing should be offered in the dental setting stated,

I think if the test does come out positive, then I don’t want to be the person who is going to have to break the news to them. That is something I would like their primary care physician to be able to do.

A few indicated that they were too busy to take on HIV testing, or even other kinds of screening, and these activities could end up drawing them away from carrying out their central functions. One dentist, who had made a choice not to take on various kinds of screening tests, said,

It [screening patients for various medical problems] just opens up a whole can of worms—the whole anxiety phase for the patients sometimes. And we’re there to treat their oral cavity, and I think we do too many tests. The screenings are good but we are already overloaded with different tests, and different procedures, and questions, and health forms. So I don’t want to get to a point where we’re not treating their dental problems.

Similarly, another dentist who wasn’t doing other kinds of screenings said,

HIV-positive stuff I put in the same category as diabetes, cholesterol, hypertension. It’s a medical issue even though we’re here on the frontline and can screen for it; I’ve got enough stuff to worry about.

Notably, although some dentists contended that HIV testing was a medical matter and was best done by physicians, almost all felt quite confident they could link patients testing positive on the rapid test to follow-up care for a confirmatory blood test or medical treatment. Some noted they had already had experience setting up referrals, for example to oral surgeons, when they observed a lesion or some other abnormality in their patients’ mouth. Others were already in medical office buildings and had relationships with physicians there who they could refer to. Most, however, indicated they would simply refer patients back to their primary care physician.

Anticipating low patient acceptance of HIV testing in a dental setting.

Dentist participants offered a variety of reasons for why they expected that few of their patients would accept the HIV rapid test. A few believed that it would be a challenge to get patients to be comfortable with the idea of dentists screening people for HIV. Several thought their patients would be surprised and perhaps a little confused about why their dentist was offering this test to them. A couple even felt their patients would think it was inappropriate for them to be offering the test. As 1 dentist said, “I don’t think the patient acceptance—I think most of my patients would feel insulted or that I was overstepping my bounds.”

Other dentists made similar remarks. One said, “I don’t think they will share this information in a dental office. If they have an issue, they will share it with their medical doctor.” Another remarked, “I think most people would want to seek out medical advice, not dental advice, on that particular point.”

A few participants believed that their patients would prefer to be tested in a more anonymous setting, given that dentists often have long-standing and ongoing relationships with their patients, who, therefore, may not want them to know their status. For example, 1 stated,

I think you are putting it in a particular situation that they would rather go to a private clinic or something like that so that the dentist or whoever is anonymous, that they wouldn’t know whether they have it or not.

Cost was frequently mentioned as a likely barrier to patient uptake of testing. Many dentists felt that unless the test was free or the patient’s dental insurance covered it, patient acceptance would be very low. Participants believed that few of their patients felt they were at any real risk of being infected and therefore would see no reason to pay to take the test. As 1 participant related,

Our patient population is of the more conservative order. Not that that excludes them from being exposed to HIV, but I think in their mind they may not think it’s [the rapid test] necessary. So if it’s free or complimentary screening, I think they would be much more likely to do so.

Some even recognized the test could be obtained free at some clinics, and so they doubted their patients would be willing to pay for it. Others indicated that their patients were not inclined to accept anything new if they had to pay for it. One noted,

The only thing which most patients ask when something new is introduced is, “How much is this going to cost me? Is it going to cost me more.” Because I know we tried to introduce something new and almost everybody said, I heard, “If it is going to cost more, I don’t want it.”

Finally, some just felt that their patient population would not see themselves as at risk for HIV infection. For example, 1 participant remarked,

Do I have a target market that would be open and receptive to the service? And my answer is “no.” Who are the most likely candidates for wanting to know this information? People that are engaged in high-risk activities or high-risk lifestyles. You know, all my patients are members of the covenant. You know, they abstain from sex, they don’t do drugs. They’re not even candidates.

Concern about receiving adequate reimbursement.

A few dentists believed that the test required little time and should be offered to their patients as a complimentary service. Most, however, felt some compensation was appropriate because testing would take time out of their workday and thus reduce their opportunity to earn other fees. Many indicated that they would not be willing to do rapid HIV testing without compensation. For example, 1 stated,

I do have a problem with doing things for free because I pay taxes, I pay my employees, but I have not made a profit in dentistry in years. So doing things out of the goodness of my heart—I do them all the time; but I will tell you what, it is getting harder and harder to do that. Paying to run [a practice] right now is getting hard.

Another dentist, who also thought he should be compensated if he were to test patients, felt that being HIV positive did not deserve special status that morally obligated him to test patients for free. He remarked,

Yes, I have a problem not making some sort of—getting a reimbursement. I don’t mean to sound—a cavity is going to kill this person. Eventually that abscess will reach their heart and kill them. So I don’t think that this particular disease has any status over a bacterial infection. Here it is the 21st century, and these people are getting eaten up by bacteria. It is crazy. That is crazier than people getting eaten up by a virus.

What participants believed to constitute fair compensation varied greatly. Some felt offering the test was a service to their patients and the community and not dental care per se and therefore it should be offered free or for a minimal charge. Others suggested much higher fees and said they based their figure primarily on the time involved and what they would charge for procedures similar in nature or taking a similar length of time (e.g., a brush biopsy, taking a full set of x-rays). Although most felt some level of compensation was appropriate, when asked if they would still offer testing if the testing kits were provided free with no reimbursement, a substantial minority of them said they probably would.

Fear of a negative impact on their practice.

Some dentists felt that starting to openly offer HIV testing might lead patients to assume that there was a substantial infected or at-risk group of individuals seen at the practice. Some feared that this might make patients less comfortable there. As 1 dentist who worked in a nonurban area explained,

My population I find might be a little bit more hesitant [than 1 in urban areas] or might be alarmed if they found out there might be presumably HIV-positive patients that are in the practice. And therefore they might be more concerned about the safety or even simple sterility or cleanliness or spread of HIV in the practice.

Obviously, this dentist was concerned that if such worries were raised among his patients they might leave his practice. Similarly, another participant expressed concern that offering testing could lead to the loss of patients. Speaking about his patients’ likely reactions to his offering HIV testing, he said,

I think some of them would be offended, and also a lot of them would wonder if I was offering—that is, do I have a large patient base that would be positive for that and then they may go elsewhere.

A few dentists indicated that they did not want to get the reputation of being an “HIV practice,” as that could stigmatize them and lead to loss of patients. Two dentists even feared that some drug users and other at-risk individuals would come in only for the HIV test if they offered it and that seeing these individuals in the office could frighten off their steady patients.

Additionally, a few feared that if there was a charge for testing, some patients would think offering testing was just a “money-making gimmick” for the doctor, which could cause patients to view them negatively, undermining the patient–dentist relationship.

DISCUSSION

Dental care settings have been proposed as a potential new venue in which to carry out rapid HIV testing in an effort to identify infected individuals earlier so that they can initiate care sooner and hopefully take precautions to avoid HIV transmission.^35,36 Implementing HIV screening in this setting would also serve to further integrate the oral and medical health care systems and would be consistent with the dental profession’s movement in recent years toward offering rapid point screening and other oral diagnostics.³⁰

This study provides critical information on the perspectives and concerns a random sample of practicing dentists had about offering HIV testing to their patients. In general, HIV seemed to have little applicability in the day-to-day practices of participants. Surprisingly, only 1 out of 40 dentists interviewed had even heard about the rapid HIV test before we contacted them about this study. Thus it appears that HIV screening, and perhaps salivary diagnostics in general, has not yet been seen as an issue relevant to the dental private practitioner and that as a result many have not sought out the relevant information.

Unlike early in the HIV epidemic when dentists, along with other health professionals, were afraid to treat HIV-infected patients,^36–38 participants in this study had very little fear of transmission within the dental setting. The now long-standing practice of taking standard precautions seems to have reduced or eliminated this concern. Although all dentist participants were quite willing to care for HIV-positive individuals, a few did worry that if their practice came to be perceived as one that treated a large number of infected individuals—for example, through posting notices in their office that the HIV rapid test was offered—patients might become concerned for their own safety and seek care elsewhere.

Although many of the private practitioners interviewed understood the benefits to their patients of offering rapid HIV testing as well as the public health value of making the test widely available through dental settings, they also expressed a variety of reservations about offering testing in their own practices. Most prevalent were concerns about the accuracy of the test. These centered primarily on potential liability issues that could arise from giving patients false results and on the unnecessary patient worry and suffering that would accompany a false positive until it was disconfirmed. False negatives were also seen as potentially problematic, as they might allow infected patients who had been engaging in unsafe practices to feel complacent about continuing these behaviors and as a result spread infection. Clearly, education and reassurance about the test’s high level of sensitivity and specificity (which are both higher than 99% and higher than most other preventive screening tests) would be a critical component of any efforts to enable dentists to make an informed decision on whether to offer HIV testing to their patients.

Dentists also feared that if they offered selected patients HIV testing, it could be construed as an implicit assumption that their lifestyle was associated with elevated risk for HIV infection (e.g., homosexuality, promiscuity, substance use). They believed this could offend some patients, causing them to seek care elsewhere. Among dentists who were more receptive to offering testing, some felt the way to avoid this problem was by offering it to everyone.

Some dentists also felt uncomfortable with the concept of delivering an HIV-positive screening result to their patients. They either felt ill equipped to do so or simply chose to avoid the associated discomfort. As some participants themselves recognized, dentists will likely require additional training on pre- and posttest HIV counseling.

Others resisted the idea of dentists taking on HIV testing, believing it was outside the scope of dentistry. They believed patients would prefer to be tested by a physician and would be better served by doing so, as a physician could immediately do a confirmatory test if the rapid test was positive. Patients’ attitudes about receiving HIV and other salivary diagnostic tests in the dental setting is clearly an area requiring additional research.

Many dentists were also concerned that their time doing HIV testing would not be covered by adequate compensation. They argued that doing HIV testing would extend patients’ chair time and negatively affect productivity. Although some were not ready to experience this potential loss of income, others saw providing HIV testing as a service they wanted to offer their patients regardless of the compensation rate. How third-party payers perceive compensating dentists for performing HIV and other chairside medical screenings is an area that currently demands industry attention.

Numerous dentists commented that dentists generally resisted assuming new or unfamiliar tasks. A larger cultural change may be required to engage dentists more aggressively in primary prevention and population-based screening outside the traditional domains of primary care dentistry. Presentations at professional conferences and continuing education classes for dentists are obvious venues for such education for those already in practice. However, to broadly secure a fundamental transformation in the role of the dentist as a member of the primary care team, HIV testing and other chairside medical screenings must be included in the curriculum of dental schools. In this and other areas, altering the ethos of dental care to more fully embrace prevention would provide major opportunities for public health.