Dentists' Willingness to Provide Expanded HIV Screening in Oral Health Care Settings

Results From a Nationally Representative Survey

Harold A. Pollack, PhD; Margaret Pereyra, DrPH; Carrigan L. Parish, DMD; Stephen Abel, DMD, MSO; Shari Messinger, PhD; Richard Singer, DMD, MS; Carol Kunzel, PhD; Barbara Greenberg, PhD, MSc; Barbara Gerbert, PhD; Michael Glick, DMD; Lisa R. Metsch, PhD

Disclosures

Am J Public Health. 2014;104(5):872-880. 

In This Article

Abstract and Introduction

Abstract

Objectives. Using a nationally representative survey, we determined dentists' willingness to provide oral rapid HIV screening in the oral health care setting.

Methods. From November 2010 through November 2011, a nationally representative survey of general dentists (sampling frame obtained from American Dental Association Survey Center) examined barriers and facilitators to offering oral HIV rapid testing (n = 1802; 70.7% response). Multiple logistic regression analysis examined dentists' willingness to conduct this screening and perceived compatibility with their professional role.

Results. Agreement with the importance of annual testing for high-risk persons and familiarity with the Centers for Disease Control and Prevention's recommendations regarding routine HIV testing were positively associated with willingness to conduct such screening. Respondents' agreement with patients' acceptance of HIV testing and colleagues' improved perception of them were also positively associated with willingness.

Conclusions. Oral HIV rapid testing is potentially well suited to the dental setting. Although our analysis identified many predictors of dentists' willingness to offer screening, there are many barriers, including dentists' perceptions of patients' acceptance, that must be addressed before such screening is likely to be widely implemented.

Introduction

The Centers for Disease Control and Prevention (CDC) estimates that more than 47 000 Americans are newly infected with HIV annually.[1] Early diagnosis and timely initiation of care with highly active antiretroviral therapy have been shown to reduce HIV transmission, facilitate rapid access to antiretroviral therapy, and reduce morbidity and mortality among HIV-infected persons.[2–7] Therefore, one of the goals of the National HIV/AIDS Strategy is to increase the percentage of people living with HIV who are aware of their status from 79% to 90%.[8]

In 2006, the CDC released revised national HIV testing guidelines to prioritize routine rapid screening of adults in US outpatient health care settings.[9] Routine HIV screening of all Americans aged 15 to 65 years, regardless of their level of risk, has been given an A rating by the US Preventive Services Task Force, and HIV screening is fully reimbursed under the Patient Protection and Affordable Care Act of 2010.[10–12] Despite these supportive guidelines, approximately one fifth of the 1.2 million Americans living with HIV are unaware of their status.[13] Widespread late testing limits the ability of prevention and treatment modalities to improve long-term prognosis, which, according to surveillance data taken from 40 states, caused 33% of persons who received an HIV diagnosis in 2008 to progress to an AIDS diagnosis within 1 year.[14] A need therefore exists to consider expanding to additional health care settings that will facilitate the identification of people undiagnosed with HIV.

The dental setting has been recognized as a venue to identify at-risk individuals who may not otherwise access medical and public health systems.[15–21] Prior research found that more than 70% of individuals who had never been HIV tested, yet who self-reported high HIV risk behaviors, had been in recent contact with a dental provider.[21] It is notable that dentistry is moving toward continued integration with other health care providers and expanding the incorporation of advanced and innovative diagnostic testing into dental practice, including salivary-based diagnostic testing.[22,23]

Healthy People 2020's Oral Health Objective 14 proposes to "increase the proportion of adults who receive preventive interventions in dental offices," specifically proposing to "increase the proportion of adults who are tested and referred for glycemic control from a dentist or dental hygienist."[24] Many dentists are already collaborating with other members of the primary care team by offering medical screening tests and referring patients for definitive diagnosis and treatment of prevalent chronic diseases.[20,25,26] Research efforts are also under way to develop salivary-based screening tests for hepatitis C, herpes simplex virus 1, hepatitis B, measles, rubella, mumps, and cytomegalovirus.[26–28] The contested nature of the dentist's role in HIV testing offers a valuable opportunity to expand the general role of oral health providers in screening for systemic diseases and in incorporating medical innovations into dental practice.

Recently conducted studies have explored patient and provider attitudes regarding HIV testing in the dental care setting. Data from patients suggest that many would be amenable to accepting the offer of a rapid oral HIV test in the dental setting.[17,22,29] A recent survey of 288 dental clinic patients at the New Jersey Dental School and 182 patients from private dental practices in New Jersey and Arizona showed that 80% and 55% of respondents, respectively, responded favorably to the inclusion of HIV testing in their dental visit.[22] This finding of potential acceptance among dental patients has also been validated by a New York University College of Dentistry study of patients' acceptance of HIV testing in a university clinic, through which 88.2% of patients completed testing during their dental visit when offered it by a faculty member or a dental student.[30] A Harlem Hospital demonstration project implemented HIV testing in the dental setting with much success; 97.6% of dental patients who were approached agreed to be tested, leading to more than 3500 patient screenings in less than 2 years.[31]

Less is known about dental providers' willingness to embrace HIV rapid oral testing. Qualitative research has suggested that dentists have reported their lack of counseling skills, time constraints, concerns about financial reimbursement, privacy and confidentiality concerns, and issues related to scope of practice as potential barriers to their offering HIV testing in the dental care setting.[20,25,32,33]

Within this context, our specific aims were to (1) identify barriers and facilitators associated with dentists' willingness to conduct HIV screening in the dental care setting and (2) investigate the perceived compatibility of HIV screening with dentists' professional role.

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