Table 2. Themes and supporting quotes from participants who offer rapid hiv testing in the dental setting.

Theme 1: Attitudes

1.1 I feel that dentists are physicians in a place where they can interact with patients on a very regular basis, and they develop good rapport … I think that we can be almost on the first line of defense in terms of being able to interact with patients that may not want to go to their physicians, and have an HIV test. 1.2 We could be – for a lack of a better term – a portal of entry into a system and catch people that are not getting tested otherwise. 1.3 Us dentists are already in the mouth…to me it is no different than assessing a linea alba on the inside of the buccal mucosa.

Theme 2: Barriers

2.1 Certainly reimbursement is a big [barrier]….Because unfortunately there’s an overhead to be met, so I think that a dentist in general would look at this and say, ‘I guess I know it’s for the better good, but I can’t afford to take ten minutes out of every patient’s visit to do this.’ 2.2 It’s giving somebody life altering—potentially life altering news. Again, as dentist, we’re not really well trained to do that. 2.3 Well, how do I connect the dots. If I find someone who’s HIV positive…then how do I connect them to health care? Am I sort of responsible?’ To just have this big black cloud over their head of responsibility or, Will I be put in a litigious type of situation if I don’t find them—if I can diagnose it correctly or incorrectly, first of all. 2.4 The more mature dental practitioners that have been in their private practices and done things a certain way for so many years; there is just this…reticence of stepping into having a rapid test of that nature as an offering for their patient base.

Theme 3: Funding

3.1 When it was presented to me that I could get the tests for free because I was a trailblazer in this fight, I had no reason to say no.

Theme 4: Reactions

4.1 It takes [staff] one more step as part of the medical family, which really dentistry is part of anyway. I think that that gave them a certain satisfaction. 4.2 [The staff]’re excited, that they feel this is not just drill, fill, bill; that we’re making a difference. 4.3 They were like, “We can’t tell someone that they have HIV.” Cuz the worst thing we have to do in our professional lives in dentistry is, “You’re gonna hafta’ lose that tooth,” so this was a whole ’nother ballgame to them. 4.4 [Reciting staff response] “Wow, now that I’m doin’ this all the time, it’s nothing.” 4.5 There weren’t a lot [of testing], so I was like, “What’s going on?” They said, “Well, staff aren’t comfortable starting yet,” so I ran a contest to see if—we offered a gift card and said that this gift card goes to the person who offers the test the most times.

Theme 5: Strategies

5.1 I always say if you mention it in a matter of fact, and you’re not making it seem like a bad thing then they’re not gonna think it’s a bad thing. 5.2 That way we don’t feel like we’re kind of surfing for patients and that we don’t make patients feel like, “Oh, they’re asking me this because they think that I might be at a higher risk.” 5.3 I think it can be incorporated during what we call the comprehensive oral exam. Like if we’re going to offer oral cancer screening … I think patients are more respective of that and the fact that everyone is being tested.

Theme 6: Patient Reactions

6.1 Say one person might be defensive and say well, “What do you think I am, a woman of the street or something?” You’d be surprised how many people don’t know perhaps what their husband’s doing. 6.2 They all are pretty much surprised. I don’t think they were expecting that option when they went to the dentist. No one was offended though. 6.3 Casual in the sense that they say, “Fine. Where do I sign? Go ahead and test me.” 6.4 Once they think about it for a minute, they realize that the oral test is actually pretty appropriate to offer in a dental office 6.5 I think that’s probably the most interesting piece of this research, is that they are very accepting and willing to do this. We had more barriers when it came to institutional barriers, than we did from the actual patients themselves. 6.6 I was so surprised at the number of patients that agreed. I was almost questioning them like, “Really?” I was kind of like excited. 6.7 I think [for] a lot of people it’s like I’m here anyhow, and we were offering the testing for free, so free is always good. 6.8 The fact that this one is done by swipe, it makes it much easier. It isn’t uncomfortable. 6.9 I think cost is a huge factor, and the kits are not inexpensive, so it’s the same with the brush biopsies. If you can get the kits for free, people are more likely to do it. 6.10 I think that dentists have generally…really close relationships with their patients, and I think that they may feel more comfortable speaking to the dentist rather than a physician that they don’t see as often. 6.11 [Reciting patient response when declining test]: “That doesn’t really pertain to me. I just stay at home, I don’t bother anybody, I don’t date, I don’t take drugs. I’m not a drug abuser.” All those kind of things. They say, “I’m not any of that, why do I need it?” 6.12 I think because there’s a stigma and … the attitude of it’s a gay person’s disease … I also think that because they have these ideas they think that you’re saying something about them personally.

Theme 7: Positive Results

7.1 The first one was very difficult, for many reasons, because this happened the second day that we were doing [it]….The others were much easier….Yeah, I will say that definitely practice is important. I think that the more cases that you deliver, the better that you handle them. 7.2 I’m just thinking about all the positive treatments that are out there, and all the success that patients have with different medications, and things, the antivirals, and whatnot that they’re living successfully with HIV for a long time….The earlier that they can access that care—and if I’m a part of their access to that early care, I think I’m gonna feel good about that after I really think about it. 7.3 Well, I felt someone had to do it, and I was gonna be the most compassionate and make sure that they stayed in care 7.4 We have our medical champion. It’s just a flow, so if the test is positive, then the next step is immediate…we would tell the patient, “We will contact our champion in medical,” so that it’s a kind of seamless communication that they will come up. Then we would talk to the patient, that, “Although your test is positive, it does not mean that you are HIV positive. We will go into the next step, with a blood draw.” You kind of encourage the patient, “Don’t freak out, yet.” 7.5 The finger stick…has to be sent into The Department of Health. It opens up a whole bunch of problems. One is—you know, is the dentist going to be willing to do a finger stick on a patient that they know that they’ve just diagnosed as HIV. Then the second thing is if you send out that confirmatory test, then the results have to come back to you, and now you are in the position of now you have to communicate those results to the patient….The Department of Health wants, but it’s not modeling anything that is really reality. If you’re gonna do this, then you should really try to mimic a private practice setting as much as possible. 7.6 We have our mechanism that we need to basically we have our red bat phone that we should call for the folks over at—our resources over in the medical school who are participating with us in the study. They have counselors and people who we should contact if we do get a positive test, and then they will do the confirmatory testing over there… Once I get a positive, I call them and stall the patient so to speak, and then they’ll take the patient and let them know everything… 7.7 If there’s a preliminary positive result, we have, there are two, actually, counselors from the infectious disease clinic. We can page them; they will then come to our clinic and discuss the results with the dentist and the patient, and then either one, give them an appointment to come to the infectious disease clinic, or two actually walk them over, which is obviously the preferable method. Walk them over for the confirmatory test and also set up appointments for the follow up care.

Theme 8: Going Forward

8.1 I think once you see how easy the test can be incorporated into a traditional visit, it’s really very easy to accept it 8.2 You probably would want to observe the testing taking place somewhere or in some manner, so you feel comfortable with how you’re going to incorporate it in your own protocols or operation of your own, how you’re going to change it within your particular treatments. 8.3 I actually think that more dentists would be inclined to offer it if it was billable code, if it was more accepted in the dental insurance industry as a billable code, and they could get reimbursed … The more dentists that we have in it, doing it, the more accepted it will be in the dental industry and insurance industry, and overall become standard of care. 8.4 Our advice to that is to have a protocol in place so that if you do get a reactive test you know exactly what to do and how to guide this patient.