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

Discussion

We report the findings of the first nationally representative survey of dentists that examined their knowledge, attitudes, beliefs, and willingness regarding offering routine oral HIV rapid testing in the dental care setting. Our high response rate (70.7%) allows an especially complete description of the preferences and beliefs of the dental workforce. Our findings underscore the importance of survey designs that yield high response rates. Indeed, we found differential response rates among dentists with different attitudes toward our main dependent variables. Dentists who were most reluctant to respond (as evidenced by the need for more follow-up calls or letters along with a higher incentive payment) were significantly less willing to provide rapid oral HIV screening. Low-response-rate methodologies can easily overrepresent the views of dentists with the most positive views regarding HIV screening, who may also be most enthusiastic about completing related surveys.

Attitudes Toward HIV Testing and Knowledge of Guidelines

Rapid oral HIV testing is potentially an important and valuable extension of the traditional dental role. Sixty percent of surveyed dentists indicated at least some willingness to offer such screening to their patients. Forty percent stated that HIV testing should be part of the dental professional role.

Yet our descriptive and multivariate findings underscore multiple obstacles to broad implementation. Given a disease that disproportionately affects minority communities, it is perhaps unsurprising that non-White dentists professed a greater willingness (although the difference was statistically nonsignificant) to screen in our bivariate analysis, and African American dentists had more than twice the odds of accepting this as part of their professional role. These respondents may be more familiar with individuals affected by HIV in their own communities and in their professional practices.

We were surprised that, in our multivariable analysis, the odds ratio for professional role acceptance was greater than 1 for increasing age. Younger dentists appeared slightly less likely to support the provision of rapid oral testing as part of the dental role. In principle, this is the group most likely to experience the frontiers of current knowledge in their clinical training. It is possible that the topic of HIV testing has yet to be fully integrated into dental school curricula. It is also possible that older dentists have had greater exposure to individuals suffering HIV-related morbidities, which, in turn, may foster greater willingness to regard HIV population screening as part of the dental role.

Few dentists appeared to be familiar with the 2006 revised CDC HIV screening guidelines. These guidelines present the most prominent policy brief for widespread screening in relatively low-risk populations. These guidelines also underscore the potential importance of HIV screening in the dental setting. Dentists who were familiar with the 2006 CDC guidelines were more likely to see HIV screening as part of the dental professional role, although familiarity with these guidelines was not associated with increased willingness to offer such testing.

Normative Influences

Especially concerning were respondents' predictions of their colleagues' views of dentists who chose to offer HIV testing services. Fully 58.5% of respondents disagreed with the statement, "If I offered HIV screening, my colleagues' perception of me as a health care provider would improve." As noted, this response was strongly associated with decreased willingness to screen.

Most dentists (67.1%) also expressed concern regarding patients' acceptance of such population screening. Dental providers have previously identified low patient acceptance as a potential barrier to incorporating HIV screening in the dental setting.^[32] Dentists have also expressed concerns that offering HIV testing would be perceived as beyond the traditional role of the dental practitioner.^[32]

Although this study does not directly address patients' attitudes, patient surveys, including those carried out by members of this research team,^{[17,22,29–31]} suggest that dentists may overestimate patients' reluctance in this area. Continued research concerning patients' attitudes would be useful for identifying the determinants of patients' acceptance of such services.

Increasing HIV Screening in the Dental Setting

The survey results provide several findings that may be helpful in targeting public and professional information campaigns to increase screening. Public service announcements aimed at dentists, as well as those directed to the general population, may be helpful. Fewer than 12% of respondents were aware of the 2006 revised CDC guidelines, even though these guidelines contain pertinent recommendations about screening in relatively low-risk populations in all health care settings. Although the dental setting provides a feasible environment for chronic disease screening, the American public has been poorly prepared for these possibilities. The resulting lack of public acceptance becomes a further barrier to dentists' willingness or ability to embrace these clinical approaches. Initiating pilot programs within receptive pockets of the dental profession may also help to change professional norms.

If screening is the path to early HIV detection, prevention, and treatment, the dental setting may prove to be an important venue in addressing the HIV epidemic. The dental care setting provides an access point for individuals who would otherwise lack opportunities for routine HIV screening. This study underscores a number of barriers that need to be addressed before the dental setting's full potential in promoting population health can be realized.

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