Oral rapid HIV testing in the dental setting: Experiences from three dental hygiene clinics

Abstract

Background

Oral rapid HIV testing (ORHT) is implemented in the dental setting to make individuals aware of their possibly undiagnosed HIV infection. The testing process and characteristics of clients willing to receive ORHT has yet, however, to be systematically collected.

Case description

Three dental hygiene clinics located in academic institutions implemented ORHT from March 2016 to April 2017.

Results

231 persons received ORHT; all had non-reactive results. Most had seen a primary care provider in the past year (n = 130), had had a previous ORHT (n = 111), and described themselves as extremely likely or likely to accept a chairside screening in the future (n = 169). The main reason cited for accepting ORHT was that it was free (n = 138).

Conclusion

In order to ensure everyone living with HIV is aware of their infection, HIV testing should be expanded into non-traditional settings. The dental setting may help achieve this important public health milestone.

WHY THIS ARTICLE IS IMPORTANT TO DENTAL HYGIENISTS .

• Dental hygienists are often the first to interview clients and obtain their health history, including HIV status, in a dental office

• Oral rapid HIV testing using saliva is a quick and low-risk means of determining HIV status.

• Expanding HIV testing into the dental setting may increase the number of clients who are aware of their HIV infection and can thus begin treatment. It also has population health benefits through the potential reduction in community viral load.

INTRODUCTION

Currently, there are over 1.1 million people in the United States (US) living with human immunodeficiency virus (HIV). According to the Centers for Disease Control and Prevention (CDC), 1 in 8 individuals are unaware of their HIV status and almost 40% of newly diagnosed individuals with HIV have advanced stages of the disease.^{1, 2} Despite continued prevention and education efforts, the incidence of new infections has continued to rise.¹ CDC reported 923,777 persons living with diagnosed HIV in 2013, 948,494 such persons in 2014, and 973,866 such persons in 2015.³ Significant race-related disparities exist among individuals infected with HIV; the rates of new HIV diagnoses among non-Hispanic Blacks and Hispanics are 7.3 and 4.9 times higher, respectively, than the rate for non-Hispanic Whites.¹ In addition to race-related disparities, there are notable differences in HIV mortality and survival rates among individuals living in impoverished neighbourhoods.¹

Public health policy has shifted towards early diagnosis and treatment.^4,5 CDC recommends offering HIV testing for all individuals ages 13 to 64 in all health care settings on an opt-out basis as opposed to waiting for them to request testing.² These recommendations, along with the widespread availability of rapid HIV testing (RHT), now enable HIV testing and screening to be conducted in other venues. The use of HIV screening in these venues may assist in finding those persons living with HIV who are unware of their status.⁵

The dental setting has been introduced as a venue to conduct HIV testing using saliva.^2,4,6-7 Scientific research shows that HIV and its antibodies can be detected in the saliva of people living with HIV.^6,8 The oral rapid HIV test (ORHT) is a screening tool that delivers results in less than 20 minutes. It can detect HIV antibodies as early as 3 weeks after exposure to the virus.⁶ All reactive/positive HIV antibody tests must receive a confirmatory blood test.⁶ HIV antibodies can be found in cells along the cheeks and gums. The ease of sample collection, increased client acceptability, and a greater compliance in higher risk groups are all advantages to ORHT.^4,9 Furthermore, the use of the dental setting has a potential to reduce occupational hazards, considering that there is no need for needles and lancets.⁹ The risk of HIV transmission during testing is also reduced with this method of testing, because there are lower amounts of HIV antigens and antibodies in saliva than in blood.⁹

Another reason that dental practices are suitable places for disease screening and testing is that systemic diseases affect the oral cavity.^1-2,4,8,10 This includes diabetes, chronic kidney disease, heart disease as well as HIV-related diseases.¹¹ The use of routine evaluation of hemoglobin A1c and the monitoring of blood pressure along with other medical screenings may help identify individuals with chronic diseases and could help prevent future disease complications.¹² People living with HIV often are diagnosed with opportunistic oral diseases, which can be indicators of the progression of HIV to AIDS.^10,13 The use of risk assessment in the presence of these systemic conditions, as well as detailed medical histories and chairside screening, places the dental professional, specifically the dental hygienist, in an optimal position to offer education, interventions, and referrals.^4-9,11

The US federal government's Healthy People 2020 agenda proposes to “increase the proportion of adults who receive preventive interventions in dental offices.”² While the agenda references testing for glycemic control, it is clear that preventive interventions are not limited to diabetes. Preventive interventions are essential for managing all chronic infections including HIV. Dental providers can play a significant role in administering screening for early detection and treatment.^2,4 One reason is the frequency of visits; approximately 58% to 75% of the US population seek dental care annually, potentially putting dental professionals in contact with clients who are living with HIV yet are asymptomatic.^2,4-5,7 A survey of dental clients also showed that they approve of disease screening in the dental setting.¹⁴

The current case study documents the ORHT process and captures characteristics of dental clients who received ORHT in the dental setting.

CASE DESCRIPTION

This case study took place in 3 university-based dental clinics in a major metropolitan area. The program proceeded as follows at all 3 testing sites: flyers were placed in the reception area on designated HIV testing days, which ranged from 1 to 3 days a week, to inform both new and returning clients of the study. Interested clients over the age of 18 were instructed to approach their dental provider (a senior dental hygiene student or dental hygiene faculty member) about receiving ORHT. The provider reviewed the test process and the consent form with the participant. After giving consent, the client was escorted to a remote cubicle or private office setting where an oral swab was taken with a test kit. Twenty minutes later the dental hygienist interpreted the result as reactive, non-reactive or indeterminate, while another trained student or faculty study team member provided a second reading before results w,ere shared with the client.

Each study participant completed a questionnaire while waiting for the ORHT results. The questionnaire consisted of demographic questions, risk behaviours, attitudes towards testing, and a self-assessment of overall and oral health. All clients tested were informed immediately that their result was non-reactive. Had any been reactive/positive, the provider would have taken a dried blood spot specimen by fingerstick to be sent overnight to the State Public Health Laboratory for Western Blot processing. An appointment would have also been made within 48 hours of receiving the preliminary reactive result with an HIV physician at a local Designated AIDS Center (where each site had an executed Memorandum of Understanding) and the client would have received the results of the confirmatory Western Blot test as well as follow up care, if needed. The Designated AIDS Center would have had the responsibility of providing the HIV diagnosis and providing HIV care and treatment services, assuming the client was ready and willing to initiate treatment. An HIV prevention brochure was distributed upon completion of the visit to all participants. Institutional review board approval was received from the participating institutions.

RESULTS

Across the 3 university-based dental clinic sites, 231 persons received ORHT. As described in Table 1, the majority of study participants identified as White (48.9%), non-Hispanic (68%), and female (74%). Only about half (56%) had seen a primary care provider in the past year, and just under half (48%) had been tested for HIV in the past. The majority (58.4%) had rated their overall health as "excellent" or "very good," and approximately half (46.3%) rated their oral health as "excellent" or "very good." The majority (73.2%) described themselves as likely or extremely likely to accept another health screening in the dental setting.

Table 1.

Demographics of study participants (N = 231)

Demographic		n (%)
Mean age (SD): 31.7 (10.46)
Race (n = 190)
White	113 (48.9)
African American	32 (13.9)
American/Alaskan Native	2 (0.9)
Asian	43 (18.6)
Ethnicity (n = 187)
Hispanic/Latinx	74 (32.0)
Gender identity (n = 230)
Female	171 (74.0)
Male	58 (25.1)
Transwoman	1 (0.9)
Saw primary care provider in last 12 months (n = 207)
Yes	130 (56.3)
Previous HIV test
Yes	111 (48.1)
Self-rated overall health (n = 216)
Excellent or very good	135 (58.4)
Good	69 (29.9)
Fair or poor	12 (5.2)
Self-rated oral health (n = 218)
Excellent or very good	107 (46.3)
Good	75 (32.5)
Fair or poor	36 (15.6)
Likelihood of accepting a health screening in dental setting in the future (n = 209)
Extremely likely or likely	169 (73.2)
Neutral	23 (10.0)
Extremely unlikely or unlikely	17 (7.4)

Table 2 describes the reasons participants accepted ORHT in the dental setting. The main reasons were that the test was free (59.7%) and that they believed the dental clinic was an appropriate setting to have testing done (42%).

Table 3 describes the reasons participants had not received an HIV test in the past, if they indicated they had not received one. The main reasons included being confident that they did not have a reactive/positive diagnosis (13.9%) and not having enough time to take the test and/or wait for the results (9.5%).

DISCUSSION

This case highlights the process for implementing ORHT by dental hygienists and dental hygiene students in the dental setting. Data collected from participants align with prior research findings that low- or no-cost testing in the dental setting appeals to clients.^7-8,15 Another key finding is that most participants (73.2%) said they were "likely" or "extremely likely" to have testing conducted in the dental setting in the future.

Results of previous studies involving dental hygienists ’ and dentists ’ attitudes towards medical chairside screening have been favourable. Continuing education targeted to practising dental hygienists and dentists who did not receive any HIV testing and training in their formal dental education and the incorporation of ORHT training into the educational curriculum would support dental professionals’ acceptability and readiness to conduct ORHT.^15-16 Currently dental and dental hygiene curricula include training and screening for hypertension, oral cancer, periodontal infection, and dental caries risk assessment. ORHT can easily be an additional service incorporated into the curricula.

In another study assessing physicians’ attitudes towards medical screening in the dental setting, the majority of respondents believed medical screening for a variety of diseases would be valuable.¹⁷ These results highlight the value of this chairside screening. Previous studies have noted a need for inclusion of rapid testing training and education to prepare dental professionals such as dental hygienists and dentists for these additional screening roles.^17-20 Taking on the role of administering HIV testing is aligned with the many professional roles of the dental hygienist: clinician, advocate, administrator, researcher, and educator.⁴

In a similar study at a Canadian dental school, a majority of the study sample (n = 80, 82%) agreed that HIV screening was within the scope of practice of a dental professional, while many in our study (n = 169, 73.2%) were “extremely likely” or “likely” to accept a screening in a dental setting the future. Moreover, most Canadian study participants (n = 52, 91%) believed dental settings are an appropriate venue for RHT compared to only half (n = 97, 42%) in our study. Finally, participants in both studies largely agreed to receive the HIV screening because it was free. No positive/reactive results were found in either the Canadian study or ours.²¹

This study has limitations that need to be addressed before wide-scale implementation. First, the study was limited geographically to the dental clinics in one major metropolitan area. Second, university dental clinics may not be typical, and future research might examine such programs in private practices and dental medicine departments within clinics and hosptials.²² Third, while 60% of participants stated the reason for acceptance of RHT was that it was free, this result could be biased due to the mode of data collection. Attention should be given since participants’ rate of acceptance would conceivably be affected if there were a cost associated with ORHT. Finally, data should have been collected on individuals who refused the ORHT offer to see how similar or different they were from those who accepted the offer.

Table 2.

Reasons study participants accepted rapid HIV testing in the dental clinic (N = 231)

Reason for accepting ORHT	n (%)
Test is free	138 (59.7)
Believes dental clinic is an appropriate setting to have testing done	97 (42.0)
Has never been tested before	76 (32.9)
Wants to appease/reassure a partner or family member	58 (25.1)
Feels more comfortable knowing	43 (18.6)
Last HIV test was a long time ago	40 (17.3)
Trusts the dentist/dental hygienist	38 (16.5)
Suspects partner had been unfaithful	8 (3.5)
Considers him or herself at risk	7 (3.0)
Doesn't know	46 (19.9)

Table 3.

Reasons study participants had not previously received an HIV test (N = 231)

Reason for not having had an HIV test previously	n (%)
Confident he/she does not have a positive diagnosis and does not feel the test is necessary	32 (13.9)
Not enough time to take test and/or wait for results	22 (9.5)
Has already been tested recently	18 (7.8)
Is fearful of the test results	8 (3.5)
Does not feel comfortable taking the test	7 (3.0)
Too embarrassed to take the test	7 (3.0)
Is concerned about his/her confidentiality	7 (3.0)
Does not want to know the test result	4 (1.7)
Does not feel that the test is important	3 (1.3)
Does not want to discuss his/her sexual history	1 (0.4)
Is fearful of the procedure (if using finger stick method)	1 (0.4)
Does not believe dental clinic is an appropriate setting in which to have testing performed	0 (0)
Does not trust dentist/dental hygienist	0 (0)
Doesn't know	24 (10.4)

Further research is also needed. Insurance coverage and reimbursement are concerns and barriers that must be addressed in order to implement ORHT as a routine part of dental care.^15-16 Additionally, use of valid and reliable measures to collect data on socioeconomic status, residence, and dental/healthcare coverage of participants is needed to offer greater perspective on the client population Also, data on clients who refuse the ORHT offer should be collected in order to compare measures between groups. Finally, an economic evaluation of the dental setting’s ability to identify undiagnosed HIV in a more cost-effective manner than more traditional venues such as primary care and inpatient hospital settings is needed.

CONCLUSION

This case demonstrates that dental clinics may be an appropriate venue for ORHT. The ORHT process is quick, simple, and non-invasive, which should encourage client participation, even in non-traditional settings. The dental setting has wide potential as point of care screening; however, dental providers need to be made aware of the testing process and population health benefit of ORHT. With additional research and evaluation, ORHT may help end the HIV/AIDS epidemic.

CONFLICT OF INTEREST

The authors have no conflict of interest to report.