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ARTICLE ABSTRACT Detection of HIV infection provides an opportunity for transmission reduction and lifesaving treatment strategies. This study examined patients’ willingness to take a routine, rapid oral HIV test if offered at a dental school clinic. For fifteen days in 2011, an anonymous survey containing demographic information and willingness to be tested questions was offered to all patients awaiting treatment. A total of 383 of 443 people approached, answered the questionnaire (40.2% Hispanic, 27.2% Caucasian, and 19.3% African American) with 58.8% indicating that they had been previously tested for HIV (as compared to the California mean of 39.2%). Patients were highly likely to participate (84.0% of Hispanics, 63.6% of Caucasians, 80.0% of African Americans and 66.7% of Asians) in a free HIV rapid test when given the opportunity. Of respondents never tested before, 62.6% reported a willingness to be tested in this study. HIV screening in a dental clinic during routine visits may allow new undiagnosed cases to be detected with subsequent referral into medical treatment.
KEY WORDS: screening, HIV, serostatus, enzyme immunoassays, PLWHA
Attitude toward rapid HIV testing in a Dental School Clinic Piedad Suarez Durall, DDS;1 Reyes Enciso, PhD;2* Jiho Rhee, BS;3 Roseann Mulligan, DDS, MS4 1Assistant
Professor of Clinical Dentistry and Section Chair of Geriatrics and Special Patients; Professor of Clinical Dentistry; 3Research Assistant; 4Charles M. Goldstein Professor of Community Dentistry and Chair, Division of Dental Public Health and Pediatric Dentistry, Ostrow School of Dentistry, University of Southern California, Los Angeles, California. *Corresponding author e-mail: [email protected] 2Associate
Spec Care Dentist 35(1): 29-36, 2015
Introd uct ion According to the Center for Disease Control and Prevention (CDC), the number of people living with HIV infection in the United States is higher than ever before with estimates of over 1.1 million adults and adolescents as of February 2013.1 Moreover, an estimated 50,000 people become newly infected each year in the U.S.1 A total of 6,404 individuals were newly diagnosed with HIV in 2010 in California alone.2 There are approximately an additional one in five (18.1%) of those infected who are undiagnosed and thus not included in these numbers who account for 49% of all HIV transmissions and have three to seven times higher transmission rates than the aware group.1,3 Thus, increasing the number of individuals informed about their infections is good preventive strategy to reducing the spread of HIV. According to the revised 2006 CDC recommendations, routine, opt-out HIV screening should be offered in all healthcare settings.4
Benefits of rapid HIV testing Despite the efforts to expand testing through a routine, opt-out approach, getting patients to return for their HIV test results remains a significant problem with reasons including: fear, busy-ness, and apathy.5 Thus, more efficient and convenient HIV testing methods have been introduced that are rapid and require only a finger stick to acquire a blood sample or a swabbing of the oral mucosa. Test results are ready in 20 minutes with sensitivity similar to conventional HIV enzyme immunoassays.6 Rapid HIV testing has already been implemented in acute healthcare settings such as emergency departments with overwhelming support (247 agreeing out © 2014 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12096
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of 329 asked, 85.8%) from the patients.7 Implementation of the test in a jail setting also showed similar results (1,343 agreeing/1,364 asked, 98%).8
Rapid HIV screening in a dental setting Many patients infected with HIV are diagnosed late. In particular, in Los Angeles County, from 2000 to 2004, 72% of HIV infected Latino patients and 53% of African American HIV infected patients had very late detection (AIDS diagnosis within 1 year of their HIV diagnosis).9 Promptly identifying HIV infections and reducing the viral load are essential to delaying the onset of AIDS, resulting in increased survival rates and
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decreased healthcare costs.10 A dental setting provides early and frequent opportunities for patients to be screened in regular, routine dental visits and may be the only exposure to healthcare for those who are in seemingly good health. In fact, in the 2005 National Health Interview Survey, 50% of patients who had not visited a doctor in the prior year had visited an oral health provider during the same time period.11 As rapid HIV testing is quick and minimally invasive and oral mucosa samples are easily collected during a dental appointment, what better place to initiate a rapid HIV test than as part of a dental visit? It is also possible that many lowincome individuals do not have access to other forms of healthcare besides free or affordable dental clinics, thereby increasing access to rapid HIV testing were it to be provided as part of the services offered.
Hispanic ethnicity, who are well-represented (40.2%) in this study.15,16 Previous studies evaluated the feasibility of rapid HIV testing in dental clinics in Kansas City17 and New York City.18,19 The descriptive demographics of the first two studies showed that the majority of the subjects were African Americans (47% in Dietz et al., and 75.5% in Blackstock et al.), while in the study by VanDevanter et al.,19 there was a Caucasian majority (>50%). To our knowledge, this study will be the first to examine dental patients’ acceptance of rapid HIV testing in a widely Hispanic-populated area. Our study investigates patients’ attitudes and willingness to participate in rapid HIV screening in a private dental school clinic. Furthermore, it aims to determine if the interest to participate in such a test demonstrates any gender or racial/ethnic differences.
Implementation in Los Angeles
M et h od s
As of December 2012, Los Angeles County has 45,474 people living with HIV/AIDS (PLWHA) including 26,563 persons living with AIDS.12 In addition, in 2011, according to the CDC, the Los Angeles division area of residence had the second highest cumulative number of AIDS diagnoses and the second highest number of PLWHA in the U.S.13 Contributing factors to these prevalence rates could include a high poverty level (higher than any other metropolitan area in the U.S.) and limited access to HIV testing facilities.9,14 Thus, improved, widespread, and affordable HIV preventive measures are necessary in this geographic region. In addition to African Americans, Hispanics have recently been disproportionately affected by HIV. Representing 16% of the U.S. population in 2010, Hispanics accounted for 21% of new HIV infections in that year in the U.S.1 In 2010, the highest proportion of PLWHA in Los Angeles County was among Latino(a)s at 41%, compared to African Americans at 21% and Caucasians at 34%.12 Unlike many other metropolitan areas, the population of Los Angeles consists of 48.5% of people of
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The setting is a private dental school clinic in downtown Los Angeles, California. The dental school accepts patients with a few private or public dental insurances as well as cash patients. Patients are typically residents of the community surrounding the school or employees/students of the University. The distribution by race/ethnicity of the patients is 26.9% Hispanic, 15.3% Caucasian, 13.2% African American, 6.1% Asian and 37.9% other races or unknown. According to the patient’s records, for 84.0% the preferred language is English, 14.0% Spanish and 2.0% other languages. The survey was conducted for 1 hour in the early morning, Monday through Friday, for a total of 15 days (2 weeks in March and the first week of May 2011) by trained staff and research assistants from the Division of Public Dental Health and Pediatric Dentistry. Patients presenting for dental treatments in the school clinics were approached in the lobby of the dental school clinic and asked if they would like to participate in a short survey about a new service that was being considered for the clinic. The phrase “HIV testing” or any details about the survey were not
verbally communicated in order to respect the patients’ privacy and to prevent provoking unnecessary fear or anxiety. If the potential participant requested more details, he/she was given the survey and asked to look it over. A cover letter was attached to explain the strict confidentiality and anonymity of the responses. It also instructed the participants to place the survey into a sealed envelope and return it to the nearby box labeled “short survey.” Surveys were offered in either English or Spanish (two of the staff members were Spanish speakers). No identifying information other than age, gender, race, ethnicity, and sexual orientation was requested. The Institutional Review Board deemed the study exempt. Refer to Table 2 for the survey questions.
Statistical analyses Descriptive statistics, including frequencies, and Chi-square tests were used to study race/ethnicity and gender differences in the patient’s prior HIV screening history and his/her willingness to take a rapid test. Statistical analyses were performed with SAS Enterprise Guide 4.2 (SAS Institute Inc., Cary, NC, USA) with a significance value of 0.05.
R es ul t s In our survey, a total of 383 of 443 patients completed the questionnaire with a 13.5% (n = 60) refusing to participate. The study population was made up of 164 males (42.8%), 208 females (54.3%), and 11 (2.9%) individuals who declined to state a gender. Responses were sorted by decade of age with fairly equal distribution in each decade between those in their 30s, 40s, 50s, and 60s (17.5%, 21.9%, 17.5%, 17.0%, respectively). Hispanics represented the largest racial/ethnic group (n = 154, 40.2%) followed by Caucasians (n = 104, 27.2%) and African Americans (n = 74, 19.3%). Only 5.0% (n = 19) were Asians with 2.1% (n = 8) being Native Americans or Pacific Islanders (Table 1). The majority of respondents indicated that they were heterosexuals (n = 332, 86.7%).
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Table 1. Patient demographics for those who consented to participate in survey. Demographics
Frequency (percent)
Table 2. Patient responses. Question content Q1
Frequency (percent)
Have you ever been tested for HIV/AIDS? Yes, I’ve had one HIV test
140 (36.6%)
Yes, I’ve had more than one HIV test
85 (22.2%)
164 (42.8%)
No, I’ve never had an HIV test
154 (40.2%)
Female
208 (54.3%)
No answer
Transgender
0 (0.0%)
Gender Male
No answer
11 (2.9%)
Total
383 (100.0%)
4 (1.0%)
Total Q2
Age
383 (100%)
When you had your last HIV test, how soon after did you receive your results? 20 minutes later
62 (27.6%)
2 weeks later
149 (66.2%)
2 (0.5%)
Both
1 (0.4%)
18–29
53 (13.8%)
No answer
14 (6.2%)
30–39
67 (17.5%)
Under 18
40–49
84 (21.9%)
50–59
67 (17.5%)
60–69
65 (17.0%)
70–89
29 (7.6%)
No answer
16 (4.2%)
Total
383 (100.0%)
Total Q3
Q4
Race and ethnicity Asian
19 (5.0%)
Black/African American
74 (19.3%)
Hispanic
154 (40.2%)
Native American/Pacific Islander
8 (2.1%)
White/Caucasian
104 (27.2%)
More than one race
14 (3.6%)
No answer
10 (2.6%)
Total
Q5
Heterosexual
332 (86.7%)
Homosexual
15 (3.9%)
Bisexual
4 (1.0%)
No answer
32 (8.4%)
Total
383 (100.0%)
The survey consisted of six questions (see Table 2) with multiple choice answers possible for each of the questions. When asked about any prior HIV testing experience, a total of 140 of 383 (36.6%) respondents reported having previously had one HIV test, 85 (22.2%) respondents reported having had more
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Yes
272 (71.0%)
No
87 (22.7%)
No answer
24 (10.7%)
Total
383 (100%)
How much are you willing to pay for the test? $60
8 (2.1%)
$45
7 (1.8%)
$30
30 (7.8%)
$15
51 (13.3%)
$10
58 (15.1%)
$0
148 (38.6%)
More than one answer
383 (100.0%)
Sexual orientation
225 (100%)
If your dentist could offer you a Rapid HIV test so that you test results would be ready in 20 minutes, would you take the test?
Q6
4 (1.0%)
No answer
81 (21.2%)
Total
383 (100%)
Who would you prefer to give you your test results in private? My student dentist
40 (10.4%)
My personal physician
60 (15.7%)
The student hygienist
0 (0.0%)
A trained counselor
51 (13.3%)
By mail
37 (9.7%)
Does not matter
92 (24.0%)
More than one answer
18 (4.7%)
No answer
94 (24.5%)
Total
383 (100%)
If you would not want a Rapid HIV test during your dental appointment why not? I think I would be treated differently by my healthcare provider or friends if I have the test
11 (12.6%)
I’m afraid of finding out I’m HIV positive
0 (0.0%)
I would be afraid of other people knowing my HIV test results
2 (2.3%)
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Prior HIV testing experience
Table 2. Continued. Question content
Frequency (percent)
I would be in too much pain to have a test
5 (5.7%)
This test would make my dental appointment too long
14 (16.1%)
I don't think the test is accurate
2 (2.3%)
I would need to give my name
4 (4.6%)
More than one answer
3 (3.5%)
No answer
46 (52.9%)
Total
87 (100%)
Further analysis of the results demonstrated statistically significant differences in the number of respondents who had been tested for HIV by age (n = 361, p < .0001). Patients aged 30 to 59 had the highest percentages of respondents previously tested (>65%) while the youngest, 18 to 29, and the oldest, 70 to 89, had lower percentages (60.4% and 17.2%, respectively). There were no significant differences by race (p = .102) nor gender (p = .688) (Figure 1).
Willingness to take a rapid HIV test
Figure 1. Percentage and number of respondents previously tested by age (n = 361, p < .0001), race (n = 369, p = .102), and gender (n = 369, p = .688).
than one test and 4 (1.0%) declined to answer this question. The remaining 154 respondents (40.2%) indicated that they have never had an HIV test. A total of 149 of 225 (66.2%) respondents who had been previously tested, had received their testing results 2 weeks after taking the test. A majority of the respondents (n = 272, 71.0%) indicated that they would be willing to take a rapid HIV test if the
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dental clinic would offer one with 40.2% willing to pay for the test (the range of payments suggested was $10 to $60 per test). When offered a choice of a selection of individuals who would provide the testing results to the person tested, nearly equal numbers of respondents (n = 94, 24.5%) did not answer this question or indicated that it did not matter who provided the results (n = 92, 24.0%).
Statistically significant differences were found in the patients’ willingness to take a free rapid HIV testing by age (n = 343, p < .0001). Among patients 18 to 59, approximately 80% of the respondents were willing to be tested. However, past the age of 60, the willingness decreased, with 59.7% willingness for the 60 to 69 age group and 39.1% for the 70 to 89 age group. There were also statistically significant differences in patient’s willingness by race/ethnicity (n = 350, p = .010). A total of 84.0% of Hispanics, 63.6% of Caucasians, 80.0% of African Americans, and 66.7% of Asians were willing to be tested. There were no significant differences by gender (p = .264) (Figure 2). Statistically significant differences were also found in patients’ willingness to be tested by HIV screening history (n = 356, p < .0001). If the respondent had been tested once, 86.6% were willing to be tested again, compared to 81.9% of respondents with multiple testing and 62.6% who had never been tested (results not shown).
Willingness to be tested with no prior history For those respondents with no HIV testing experience who also stated their race/ ethnicity (n = 133), there were significant differences by race/ethnicity in patient’s attitudes toward HIV testing as compared to those who had prior testing experience (p = .001). Hispanics overwhelmingly reported they would be willing to take the test (85.7%). Similarly,
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Reasons for declining the test The predominant reasons for being unwilling to take a rapid HIV test, as reported on the survey by those who indicated that they would decline a free test (n = 87), were a concern that testing will make the dental appointment too long (n = 14, 16.1%) and the fear of being treated differently either by the healthcare provider or friends if tested positive (n = 11, 12.6%). Only five respondents (5.7%) indicated any worry about possible pain from the test. No respondent chose “I’m afraid of finding out I’m HIV positive;” however, (52.9%) of the decliners chose not to answer this question (Table 2).
D is cus s ion Figure 2. Percentage and number of respondents reporting willingness to take a rapid HIV test during a dental visit by age (n = 343, p < .0001), race (n = 350, p = .010), and gender (n = 350, p = .264).
Figure 3. Percentage and number of respondents, with no testing experience, reporting willingness to take a rapid HIV test during a dental visit by age (n = 129, p = .074), race (n = 133, p = .001), and gender (n = 137, p = .123).
African Americans were also more willing (65.0%) than not (35.0%) to take the test. On the other hand, the majority of Caucasians with no previous HIV testing
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experiences were less willing (56.5%) to take the test. There were no significant differences by age (p = .074) nor gender (p = .123) (Figure 3).
Overall, dental patients in the dental school clinic responded favorably (71.0%) to the offer of a rapid HIV test during their dental visit. Although the demographic makeup of our population differs from those in previous studies, this high overall acceptance rate is consistent with results from other dental settings performed by Dietz et al. (73%), and VanDevanter et al. (74%).17,19 Since both African Americans and individuals of Hispanic descent are being disproportionately affected by HIV, we compared our results with these population groups with those found in the Kansas City (KC) study. Our study demonstrated that the individuals of Hispanic descent were the most interested in taking a free rapid HIV test (84%); this was similar to the KC findings of 91% being interested in testing. These rates were similar even though there was a large difference in the proportion of Hispanics in each study: 40.2% Los Angeles (LA) and 7.4% KC, respectively. In the Kansas study, 47% of the survey population were of African American descent with 73% interested in participating as compared to our LA study where they made up only 19.3% of the study population yet 80% were willing to participate.20 In comparison, the Caucasians in the LA study (27.2%) and KC (38%) demonstrated interest in testing in both studies, at variable rates: in
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LA it was 63.6%, which was less than the other two groups and in KC it was 79% which was higher than the African Americans. Although 58.8% of the participants in the study reported that they had been previously tested for HIV, this is higher than the overall mean in the state of California, which is 39.2%.21 A little over half (51.9%) of Caucasian respondents reported having been tested compared to 68.5% and 64.5% of African American and Hispanics, respectively. In addition, the youngest age group in this study, 18 to 29 had a lower percentage of respondents previously tested (60.4%) than the 30 to 59 age group (>65%). Similarly, the oldest age groups had lower percentages of previously tested, with 43.1% for 60 to 69 and 17.2% for 70 to 89. Similar trends can be found in the literature. In Merchant et al. (2009), the youngest age group, 18 to 21, showed the lowest reporting of HIV testing (36.4%). The percentages of previously tested increase with age with a peak at 32 to 36 (66.1%), then there is also a clear trend of a decrease with age with 52 to 55 years old at 43.7% tested.22 Based on NHANES data showing HIV Testing Trends in the U.S. from 2000 to 2011, there was a significant decrease in the percentage of previously tested among persons aged 18 to 24.23 This is alarming since the 20 to 24 years old have the highest number of diagnoses of HIV infection (36.4%) followed by the 25 to 29 years old with 35.2%.13 In our population, 40.2% of the respondents answered that they have never been tested, compared to Dietz et al.’s 36%, meaning that they may not be aware of their serostatus. It is fortunate that the majority of those who have never been tested were more than likely (62.6%) to accept a rapid HIV test during their dental visit. If infected, they can unknowingly transmit the disease to others. In Blackstock et al. (2010) of 3,565 dental clinic patients in New York City, 19 were found to have previously undiagnosed HIV infection (an undiagnosed HIV prevalence rate of 0.5%) thus demonstrating the efficacy of such a rapid testing program in screening for
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HIV disease.18 Therefore, we conclude that the willingness of dental patients in our study to take the HIV rapid test confirms that there is a significant opportunity to implement widespread HIV testing in what would be considered nontraditional primary care settings such as dental clinics. It is also important to consider our overall results in light of the fact that the CDC has recommended annual HIV testing.4 Since 69.6% of all Californians report a dental visit in the past year and yet only 39.2% of Californians ever received an HIV test, the dental settings offer an excellent opportunity for access to HIV rapid testing.21,24 In our study, those participants who have never been tested were less likely to agree to screening than those who have been tested. When asked why, only 47.1% responded to one or more of the possible reasons provided. Whereas in our study the length of time that testing would add to dental appointments (n = 14, 16.1%), the issues of being treated differently by health care providers or friends after taking the test (n = 11, 12.6%), and being in too much pain to be tested (n = 5, 5.7%) were the most common responses in that order, Dietz et al., reported dental pain as the most common reason to decline being tested (n = 6, 17%), with being treated differently (n = 2, 6%) and the accuracy of the test (n = 2, 6%), as secondary reasons.17 It should be noted that in Dietz et al. as well as our study the overall response rates for these choices were quite low. In this study, willingness to pay for an HIV rapid test at various pricing points suggested that 38.6% of the patients would want the HIV rapid test to be free. Several participants in previous studies reported free testing as an important incentive.19 Only 28.4% were willing to pay $10 to $15 for the test with even lower percentages willing to pay more than that. Such a level of reimbursement may not be enough to support a widespread HIV rapid testing program in a dental school clinic without a supplemental infusion of funds. In addition, little is known about the cost effectiveness of implementing HIV testing in a
dental setting that would include ancillary costs such as additional staff, training and overhead. Unexpectedly when asked for a preference of whom should deliver the test results, nearly one-third were not concerned about who would delivered them (n = 92, 24.0%). Notably, more people selected their personal physicians (15.7%) over their student dentists (10.4%). For this question as well, 24.5% of the respondents did not answer. Some patients may be uncomfortable with their dental care providers conducting HIV screening because they are not aware of the minimally invasive, rapid oral testing method. In Siegel et al. (2012), many of the private practice dentists interviewed (n = 40) recognized the value of early HIV detection through dental screening. However, only one dentist knew of the availability of the rapid HIV tests. In addition, many were reluctant to actually implement the screening in their practices for reasons such as fear of false results, fear of offending the patients, and potential negative reputation HIV screening would bring to the practice.25 Thus, improving attitudes and competence of dentists toward HIV screening requires a larger cultural change. Moreover, dental schools should include HIV testing process and protocol in their curricula to break down the potential barriers to offering HIV screening. According to one study, although 1/3 of graduating dental students reported willingness to perform such services, many were reluctant to actually implement them in the clinics due to numerous issues and challenges.26 To implement HIV screening, it may require education, training, and careful oversight. Thus, dental school clinics versus private practice may be the optimal dental setting to introduce HIV screening. In addition to providing training, dental school clinics can more efficiently provide referrals and link patients to further treatment. Among the dental care providers, dental hygienists are ideal candidates to conduct rapid HIV screening since they already provide patient management screening, assessing, planning and implementing an individualized patient care plan.27,28
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Oral diagnostics is an emerging field in dentistry. The majority of the dental providers agree oral screening for HIV in dental settings is consistent with the professional scope of practice.29 With advancement and improvement of oral diagnostic technology, detection and diagnosis will move away from central laboratory facilities to point-of-care locations such as dental settings, helping dentists play a vital role in early detection and treatment for HIV.30
L i mitation s Since this is a pilot study the sample size was too small to conduct age and race interactions. Almost all of the respondents (379/383) answered the first question of the survey but as the questions progressed there were numerous questions left blank. This might introduce selection bias due to nonresponses. Another observation was that many subjects who responded favorably to rapid HIV testing also answered reasons as to why they would not take a rapid test. As a result we concluded that future studies should utilize a skip pattern of survey so that once a subject makes a choice, he/ she would be directed to move to the next appropriate question based upon the answer given rather than answering all questions in the survey. It is also possible that some of the questions or sequencing of the questions themselves could have been improved.
Conclusions In summary, roughly two of three patients, who previously were unaware of their HIV status and are attending a dental school clinic for oral healthcare, would like to receive a free Rapid HIV test if given the opportunity. A dental clinic provides a nontraditional site for patients to be HIV tested and may also be the only healthcare encounter for individuals who are otherwise healthy and also those individuals who are impoverished. Costs of the rapid test and fees charged must be considered to provide a sustainable program.
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In addition, it will be important to these patients to provide assurances of how the test will be managed throughout the normal dental appointment, so that there will be no additional time needed, and that the results will be held in strictest confidence. Additional information should be gathered from representatives of the clinic patient population, perhaps through focus groups, on other barriers that may impede acceptance of the test and strategies implemented to eliminate these barriers prior to beginning the testing. Additionally, oral health care providers should be thoroughly trained on the legal and moral requirements for privacy and confidentiality associated with HIV testing.31 Providing the appropriate referral services to help those who have a positive screening result must be part of the protocol of the rapid screening/testing process. If properly implemented to ensure patient safety, confidentiality, and linkage to overall care, rapid HIV testing would be feasible and well accepted in a dental school clinic.
Co nf l ict s of int er es t The authors have no conflicts of interest.
Acknowledgement The authors would like to thank the staff at the Ostrow School of Dentistry of USC Center for Community Oral Health for their assistance in collecting the data, in particular, Carolyn Bedoian-Malconian, Timothy Hughes, Carmen Rubenia Molina, Julio Martinez, Rosa Linda Muñoz and pre-doctoral student Diana Zhou.
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Los Angeles, CA: Los Angeles County Department of Public Health; 2013. http:// publichealth.lacounty.gov/wwwfiles/ph/hae/ hiv/2012AnnualHIVSurveillanceReport.pdf. Accessed May 22, 2014. Centers for disease control and prevention HIV surveillance report (Vol. 23). Atlanta, GA: Centers for Disease Control and Prevention; 2011. http://www.cdc.gov/hiv/pdf/statistics_2011_HIV_Surveillance_Report_vol_23. pdf. Accessed May 22, 2014. Grusky O, Duan N, Swanson AN, et al. Evaluating the accessibility of HIV testing organizations. Eval Health Prof 2004;27(2): 189-205. U.S. Census Bureau. State and county QuickFacts. Washington, DC: U.S. Department of Commerce; 2012. http:// quickfacts.census.gov/qfd/states/06/0644000. html. Accessed May 22, 2014. U.S. Census Bureau. Statistical abstract of the United States. Washington, DC: U.S. Department of Commerce; 2012. http:// www.census.gov/compendia/statab/2012/ tables/12s0023.pdf. Accessed May 22, 2014. Dietz CA, Ablah E, Reznik D, et al. Patients’ attitudes about rapid oral HIV screening in an urban, free dental clinic. AIDS Patient Care STDS 2008;22(3):205-12. Blackstock OJ, King JR, Mason RD, et al. Evaluation of a rapid HIV testing initiative in an urban, hospital-based dental clinic. AIDS Patient Care STDS 2010;24(12):781-5.
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19. VanDevanter N, Combellick J, Hutchinson MK, et al. Qualitative study of patients’ attitudes toward HIV testing in the dental setting. Nurs Res Pract 2012;2012:803169. 20. Missouri Department of Health & Senior Services. 2011 Epidemiologic Profiles of HIV/ AIDS and STDs in Missouri, pages 73–90. Kansas City, MO: Missouri Department of Health & Senior Services; 2011. http:// health.mo.gov/data/hivstdaids/pdf/ KCHIVSTD2011.pdf. Accessed May 22, 2014. 21. The Kaiser Family Foundation’s State Health Facts. (Source: Center for Disease Control and Prevention, Behavioral Risk Factor Surveillance System 2012 Survey Results). Menlo Park, CA: Kaiser Family Foundation; 2013. http://kff.org/hivaids/state-indicator/ hiv-testing-rate-ever-tested/. Accessed May 22, 2014. 22. Merchant RC, Catanzaro BM, Seage GR 3rd, et al. Demographic variations in HIV testing history among emergency department patients: implications for HIV screening in US emergency departments. J Med Screen 2009;16(2):60-6. 23. Centers for Disease Control and Prevention. HIV testing trends in the United States, 2000– 2011. Atlanta, GA: Centers for Disease Control and Prevention; 2013. http://www. cdc.gov/hiv/pdf/testing_trends.pdf. Accessed May 22, 2014. 24. Center for Disease Control and Prevention. Behavioral risk factor surveillance system.
25.
26.
27.
28.
29.
30.
31.
Prevalence and trends data, oral health—2010. Atlanta, GA: Centers for Disease Control and Prevention; 2010. http://apps.nccd.cdc. gov/brfss/list.asp?cat=OH&yr=2010&qkey= 6610&state=All. Accessed May 22, 2014. Siegel K, Abel SN, Pereyra M, et al. Rapid HIV testing in dental practices. Am J Public Health 2012;102(4):625-32. Patton LL, Santos VA, McKaig RG, et al. Education in HIV risk screening, counseling, testing, and referral: survey of U.S. dental schools. J Dent Educ 2002;66(10):1169-77. Santella AJ, Davide SH, Cortell M, et al. The role of dental hygienists in conducting rapid HIV testing. J Dent Hyg 2012;86(4):265-71. Santella AJ, Krishnamachari B, Davide SH, et al. Dental hygienists’ knowledge of HIV, attitudes towards people with HIV and willingness to conduct rapid HIV testing. Int J Dent Hyg 2013;11(4):287-92. Hutchinson MK, VanDevanter N, Phelan J, et al. Feasibility of implementing rapid oral fluid HIV testing in an urban University Dental Clinic: a qualitative study. BMC Oral Health 2012;12:11. Jacobson JJ. Is dentistry going to get into the salivary diagnostics game or watch from the sidelines? Todays FDA 2013;25(3):26-7, 29-33. Vernillo A. Routine opt-out HIV testing in dental health care—its implementation and the advancement of public health. Am J Bioeth 2011;11(4):46-8.
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ARTICLE ABSTRACT Detection of HIV infection provides an opportunity for transmission reduction and lifesaving treatment strategies. This study examined patients’ willingness to take a routine, rapid oral HIV test if offered at a dental school clinic. For fifteen days in 2011, an anonymous survey containing demographic information and willingness to be tested questions was offered to all patients awaiting treatment. A total of 383 of 443 people approached, answered the questionnaire (40.2% Hispanic, 27.2% Caucasian, and 19.3% African American) with 58.8% indicating that they had been previously tested for HIV (as compared to the California mean of 39.2%). Patients were highly likely to participate (84.0% of Hispanics, 63.6% of Caucasians, 80.0% of African Americans and 66.7% of Asians) in a free HIV rapid test when given the opportunity. Of respondents never tested before, 62.6% reported a willingness to be tested in this study. HIV screening in a dental clinic during routine visits may allow new undiagnosed cases to be detected with subsequent referral into medical treatment.
KEY WORDS: screening, HIV, serostatus, enzyme immunoassays, PLWHA
Attitude toward rapid HIV testing in a Dental School Clinic Piedad Suarez Durall, DDS;1 Reyes Enciso, PhD;2* Jiho Rhee, BS;3 Roseann Mulligan, DDS, MS4 1Assistant
Professor of Clinical Dentistry and Section Chair of Geriatrics and Special Patients; Professor of Clinical Dentistry; 3Research Assistant; 4Charles M. Goldstein Professor of Community Dentistry and Chair, Division of Dental Public Health and Pediatric Dentistry, Ostrow School of Dentistry, University of Southern California, Los Angeles, California. *Corresponding author e-mail: [email protected] 2Associate
Spec Care Dentist 35(1): 29-36, 2015
Introd uct ion According to the Center for Disease Control and Prevention (CDC), the number of people living with HIV infection in the United States is higher than ever before with estimates of over 1.1 million adults and adolescents as of February 2013.1 Moreover, an estimated 50,000 people become newly infected each year in the U.S.1 A total of 6,404 individuals were newly diagnosed with HIV in 2010 in California alone.2 There are approximately an additional one in five (18.1%) of those infected who are undiagnosed and thus not included in these numbers who account for 49% of all HIV transmissions and have three to seven times higher transmission rates than the aware group.1,3 Thus, increasing the number of individuals informed about their infections is good preventive strategy to reducing the spread of HIV. According to the revised 2006 CDC recommendations, routine, opt-out HIV screening should be offered in all healthcare settings.4
Benefits of rapid HIV testing Despite the efforts to expand testing through a routine, opt-out approach, getting patients to return for their HIV test results remains a significant problem with reasons including: fear, busy-ness, and apathy.5 Thus, more efficient and convenient HIV testing methods have been introduced that are rapid and require only a finger stick to acquire a blood sample or a swabbing of the oral mucosa. Test results are ready in 20 minutes with sensitivity similar to conventional HIV enzyme immunoassays.6 Rapid HIV testing has already been implemented in acute healthcare settings such as emergency departments with overwhelming support (247 agreeing out © 2014 Special Care Dentistry Association and Wiley Periodicals, Inc. DOI: 10.1111/scd.12096
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of 329 asked, 85.8%) from the patients.7 Implementation of the test in a jail setting also showed similar results (1,343 agreeing/1,364 asked, 98%).8
Rapid HIV screening in a dental setting Many patients infected with HIV are diagnosed late. In particular, in Los Angeles County, from 2000 to 2004, 72% of HIV infected Latino patients and 53% of African American HIV infected patients had very late detection (AIDS diagnosis within 1 year of their HIV diagnosis).9 Promptly identifying HIV infections and reducing the viral load are essential to delaying the onset of AIDS, resulting in increased survival rates and
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decreased healthcare costs.10 A dental setting provides early and frequent opportunities for patients to be screened in regular, routine dental visits and may be the only exposure to healthcare for those who are in seemingly good health. In fact, in the 2005 National Health Interview Survey, 50% of patients who had not visited a doctor in the prior year had visited an oral health provider during the same time period.11 As rapid HIV testing is quick and minimally invasive and oral mucosa samples are easily collected during a dental appointment, what better place to initiate a rapid HIV test than as part of a dental visit? It is also possible that many lowincome individuals do not have access to other forms of healthcare besides free or affordable dental clinics, thereby increasing access to rapid HIV testing were it to be provided as part of the services offered.
Hispanic ethnicity, who are well-represented (40.2%) in this study.15,16 Previous studies evaluated the feasibility of rapid HIV testing in dental clinics in Kansas City17 and New York City.18,19 The descriptive demographics of the first two studies showed that the majority of the subjects were African Americans (47% in Dietz et al., and 75.5% in Blackstock et al.), while in the study by VanDevanter et al.,19 there was a Caucasian majority (>50%). To our knowledge, this study will be the first to examine dental patients’ acceptance of rapid HIV testing in a widely Hispanic-populated area. Our study investigates patients’ attitudes and willingness to participate in rapid HIV screening in a private dental school clinic. Furthermore, it aims to determine if the interest to participate in such a test demonstrates any gender or racial/ethnic differences.
Implementation in Los Angeles
M et h od s
As of December 2012, Los Angeles County has 45,474 people living with HIV/AIDS (PLWHA) including 26,563 persons living with AIDS.12 In addition, in 2011, according to the CDC, the Los Angeles division area of residence had the second highest cumulative number of AIDS diagnoses and the second highest number of PLWHA in the U.S.13 Contributing factors to these prevalence rates could include a high poverty level (higher than any other metropolitan area in the U.S.) and limited access to HIV testing facilities.9,14 Thus, improved, widespread, and affordable HIV preventive measures are necessary in this geographic region. In addition to African Americans, Hispanics have recently been disproportionately affected by HIV. Representing 16% of the U.S. population in 2010, Hispanics accounted for 21% of new HIV infections in that year in the U.S.1 In 2010, the highest proportion of PLWHA in Los Angeles County was among Latino(a)s at 41%, compared to African Americans at 21% and Caucasians at 34%.12 Unlike many other metropolitan areas, the population of Los Angeles consists of 48.5% of people of
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The setting is a private dental school clinic in downtown Los Angeles, California. The dental school accepts patients with a few private or public dental insurances as well as cash patients. Patients are typically residents of the community surrounding the school or employees/students of the University. The distribution by race/ethnicity of the patients is 26.9% Hispanic, 15.3% Caucasian, 13.2% African American, 6.1% Asian and 37.9% other races or unknown. According to the patient’s records, for 84.0% the preferred language is English, 14.0% Spanish and 2.0% other languages. The survey was conducted for 1 hour in the early morning, Monday through Friday, for a total of 15 days (2 weeks in March and the first week of May 2011) by trained staff and research assistants from the Division of Public Dental Health and Pediatric Dentistry. Patients presenting for dental treatments in the school clinics were approached in the lobby of the dental school clinic and asked if they would like to participate in a short survey about a new service that was being considered for the clinic. The phrase “HIV testing” or any details about the survey were not
verbally communicated in order to respect the patients’ privacy and to prevent provoking unnecessary fear or anxiety. If the potential participant requested more details, he/she was given the survey and asked to look it over. A cover letter was attached to explain the strict confidentiality and anonymity of the responses. It also instructed the participants to place the survey into a sealed envelope and return it to the nearby box labeled “short survey.” Surveys were offered in either English or Spanish (two of the staff members were Spanish speakers). No identifying information other than age, gender, race, ethnicity, and sexual orientation was requested. The Institutional Review Board deemed the study exempt. Refer to Table 2 for the survey questions.
Statistical analyses Descriptive statistics, including frequencies, and Chi-square tests were used to study race/ethnicity and gender differences in the patient’s prior HIV screening history and his/her willingness to take a rapid test. Statistical analyses were performed with SAS Enterprise Guide 4.2 (SAS Institute Inc., Cary, NC, USA) with a significance value of 0.05.
R es ul t s In our survey, a total of 383 of 443 patients completed the questionnaire with a 13.5% (n = 60) refusing to participate. The study population was made up of 164 males (42.8%), 208 females (54.3%), and 11 (2.9%) individuals who declined to state a gender. Responses were sorted by decade of age with fairly equal distribution in each decade between those in their 30s, 40s, 50s, and 60s (17.5%, 21.9%, 17.5%, 17.0%, respectively). Hispanics represented the largest racial/ethnic group (n = 154, 40.2%) followed by Caucasians (n = 104, 27.2%) and African Americans (n = 74, 19.3%). Only 5.0% (n = 19) were Asians with 2.1% (n = 8) being Native Americans or Pacific Islanders (Table 1). The majority of respondents indicated that they were heterosexuals (n = 332, 86.7%).
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Table 1. Patient demographics for those who consented to participate in survey. Demographics
Frequency (percent)
Table 2. Patient responses. Question content Q1
Frequency (percent)
Have you ever been tested for HIV/AIDS? Yes, I’ve had one HIV test
140 (36.6%)
Yes, I’ve had more than one HIV test
85 (22.2%)
164 (42.8%)
No, I’ve never had an HIV test
154 (40.2%)
Female
208 (54.3%)
No answer
Transgender
0 (0.0%)
Gender Male
No answer
11 (2.9%)
Total
383 (100.0%)
4 (1.0%)
Total Q2
Age
383 (100%)
When you had your last HIV test, how soon after did you receive your results? 20 minutes later
62 (27.6%)
2 weeks later
149 (66.2%)
2 (0.5%)
Both
1 (0.4%)
18–29
53 (13.8%)
No answer
14 (6.2%)
30–39
67 (17.5%)
Under 18
40–49
84 (21.9%)
50–59
67 (17.5%)
60–69
65 (17.0%)
70–89
29 (7.6%)
No answer
16 (4.2%)
Total
383 (100.0%)
Total Q3
Q4
Race and ethnicity Asian
19 (5.0%)
Black/African American
74 (19.3%)
Hispanic
154 (40.2%)
Native American/Pacific Islander
8 (2.1%)
White/Caucasian
104 (27.2%)
More than one race
14 (3.6%)
No answer
10 (2.6%)
Total
Q5
Heterosexual
332 (86.7%)
Homosexual
15 (3.9%)
Bisexual
4 (1.0%)
No answer
32 (8.4%)
Total
383 (100.0%)
The survey consisted of six questions (see Table 2) with multiple choice answers possible for each of the questions. When asked about any prior HIV testing experience, a total of 140 of 383 (36.6%) respondents reported having previously had one HIV test, 85 (22.2%) respondents reported having had more
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Yes
272 (71.0%)
No
87 (22.7%)
No answer
24 (10.7%)
Total
383 (100%)
How much are you willing to pay for the test? $60
8 (2.1%)
$45
7 (1.8%)
$30
30 (7.8%)
$15
51 (13.3%)
$10
58 (15.1%)
$0
148 (38.6%)
More than one answer
383 (100.0%)
Sexual orientation
225 (100%)
If your dentist could offer you a Rapid HIV test so that you test results would be ready in 20 minutes, would you take the test?
Q6
4 (1.0%)
No answer
81 (21.2%)
Total
383 (100%)
Who would you prefer to give you your test results in private? My student dentist
40 (10.4%)
My personal physician
60 (15.7%)
The student hygienist
0 (0.0%)
A trained counselor
51 (13.3%)
By mail
37 (9.7%)
Does not matter
92 (24.0%)
More than one answer
18 (4.7%)
No answer
94 (24.5%)
Total
383 (100%)
If you would not want a Rapid HIV test during your dental appointment why not? I think I would be treated differently by my healthcare provider or friends if I have the test
11 (12.6%)
I’m afraid of finding out I’m HIV positive
0 (0.0%)
I would be afraid of other people knowing my HIV test results
2 (2.3%)
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Prior HIV testing experience
Table 2. Continued. Question content
Frequency (percent)
I would be in too much pain to have a test
5 (5.7%)
This test would make my dental appointment too long
14 (16.1%)
I don't think the test is accurate
2 (2.3%)
I would need to give my name
4 (4.6%)
More than one answer
3 (3.5%)
No answer
46 (52.9%)
Total
87 (100%)
Further analysis of the results demonstrated statistically significant differences in the number of respondents who had been tested for HIV by age (n = 361, p < .0001). Patients aged 30 to 59 had the highest percentages of respondents previously tested (>65%) while the youngest, 18 to 29, and the oldest, 70 to 89, had lower percentages (60.4% and 17.2%, respectively). There were no significant differences by race (p = .102) nor gender (p = .688) (Figure 1).
Willingness to take a rapid HIV test
Figure 1. Percentage and number of respondents previously tested by age (n = 361, p < .0001), race (n = 369, p = .102), and gender (n = 369, p = .688).
than one test and 4 (1.0%) declined to answer this question. The remaining 154 respondents (40.2%) indicated that they have never had an HIV test. A total of 149 of 225 (66.2%) respondents who had been previously tested, had received their testing results 2 weeks after taking the test. A majority of the respondents (n = 272, 71.0%) indicated that they would be willing to take a rapid HIV test if the
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dental clinic would offer one with 40.2% willing to pay for the test (the range of payments suggested was $10 to $60 per test). When offered a choice of a selection of individuals who would provide the testing results to the person tested, nearly equal numbers of respondents (n = 94, 24.5%) did not answer this question or indicated that it did not matter who provided the results (n = 92, 24.0%).
Statistically significant differences were found in the patients’ willingness to take a free rapid HIV testing by age (n = 343, p < .0001). Among patients 18 to 59, approximately 80% of the respondents were willing to be tested. However, past the age of 60, the willingness decreased, with 59.7% willingness for the 60 to 69 age group and 39.1% for the 70 to 89 age group. There were also statistically significant differences in patient’s willingness by race/ethnicity (n = 350, p = .010). A total of 84.0% of Hispanics, 63.6% of Caucasians, 80.0% of African Americans, and 66.7% of Asians were willing to be tested. There were no significant differences by gender (p = .264) (Figure 2). Statistically significant differences were also found in patients’ willingness to be tested by HIV screening history (n = 356, p < .0001). If the respondent had been tested once, 86.6% were willing to be tested again, compared to 81.9% of respondents with multiple testing and 62.6% who had never been tested (results not shown).
Willingness to be tested with no prior history For those respondents with no HIV testing experience who also stated their race/ ethnicity (n = 133), there were significant differences by race/ethnicity in patient’s attitudes toward HIV testing as compared to those who had prior testing experience (p = .001). Hispanics overwhelmingly reported they would be willing to take the test (85.7%). Similarly,
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Reasons for declining the test The predominant reasons for being unwilling to take a rapid HIV test, as reported on the survey by those who indicated that they would decline a free test (n = 87), were a concern that testing will make the dental appointment too long (n = 14, 16.1%) and the fear of being treated differently either by the healthcare provider or friends if tested positive (n = 11, 12.6%). Only five respondents (5.7%) indicated any worry about possible pain from the test. No respondent chose “I’m afraid of finding out I’m HIV positive;” however, (52.9%) of the decliners chose not to answer this question (Table 2).
D is cus s ion Figure 2. Percentage and number of respondents reporting willingness to take a rapid HIV test during a dental visit by age (n = 343, p < .0001), race (n = 350, p = .010), and gender (n = 350, p = .264).
Figure 3. Percentage and number of respondents, with no testing experience, reporting willingness to take a rapid HIV test during a dental visit by age (n = 129, p = .074), race (n = 133, p = .001), and gender (n = 137, p = .123).
African Americans were also more willing (65.0%) than not (35.0%) to take the test. On the other hand, the majority of Caucasians with no previous HIV testing
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experiences were less willing (56.5%) to take the test. There were no significant differences by age (p = .074) nor gender (p = .123) (Figure 3).
Overall, dental patients in the dental school clinic responded favorably (71.0%) to the offer of a rapid HIV test during their dental visit. Although the demographic makeup of our population differs from those in previous studies, this high overall acceptance rate is consistent with results from other dental settings performed by Dietz et al. (73%), and VanDevanter et al. (74%).17,19 Since both African Americans and individuals of Hispanic descent are being disproportionately affected by HIV, we compared our results with these population groups with those found in the Kansas City (KC) study. Our study demonstrated that the individuals of Hispanic descent were the most interested in taking a free rapid HIV test (84%); this was similar to the KC findings of 91% being interested in testing. These rates were similar even though there was a large difference in the proportion of Hispanics in each study: 40.2% Los Angeles (LA) and 7.4% KC, respectively. In the Kansas study, 47% of the survey population were of African American descent with 73% interested in participating as compared to our LA study where they made up only 19.3% of the study population yet 80% were willing to participate.20 In comparison, the Caucasians in the LA study (27.2%) and KC (38%) demonstrated interest in testing in both studies, at variable rates: in
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LA it was 63.6%, which was less than the other two groups and in KC it was 79% which was higher than the African Americans. Although 58.8% of the participants in the study reported that they had been previously tested for HIV, this is higher than the overall mean in the state of California, which is 39.2%.21 A little over half (51.9%) of Caucasian respondents reported having been tested compared to 68.5% and 64.5% of African American and Hispanics, respectively. In addition, the youngest age group in this study, 18 to 29 had a lower percentage of respondents previously tested (60.4%) than the 30 to 59 age group (>65%). Similarly, the oldest age groups had lower percentages of previously tested, with 43.1% for 60 to 69 and 17.2% for 70 to 89. Similar trends can be found in the literature. In Merchant et al. (2009), the youngest age group, 18 to 21, showed the lowest reporting of HIV testing (36.4%). The percentages of previously tested increase with age with a peak at 32 to 36 (66.1%), then there is also a clear trend of a decrease with age with 52 to 55 years old at 43.7% tested.22 Based on NHANES data showing HIV Testing Trends in the U.S. from 2000 to 2011, there was a significant decrease in the percentage of previously tested among persons aged 18 to 24.23 This is alarming since the 20 to 24 years old have the highest number of diagnoses of HIV infection (36.4%) followed by the 25 to 29 years old with 35.2%.13 In our population, 40.2% of the respondents answered that they have never been tested, compared to Dietz et al.’s 36%, meaning that they may not be aware of their serostatus. It is fortunate that the majority of those who have never been tested were more than likely (62.6%) to accept a rapid HIV test during their dental visit. If infected, they can unknowingly transmit the disease to others. In Blackstock et al. (2010) of 3,565 dental clinic patients in New York City, 19 were found to have previously undiagnosed HIV infection (an undiagnosed HIV prevalence rate of 0.5%) thus demonstrating the efficacy of such a rapid testing program in screening for
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HIV disease.18 Therefore, we conclude that the willingness of dental patients in our study to take the HIV rapid test confirms that there is a significant opportunity to implement widespread HIV testing in what would be considered nontraditional primary care settings such as dental clinics. It is also important to consider our overall results in light of the fact that the CDC has recommended annual HIV testing.4 Since 69.6% of all Californians report a dental visit in the past year and yet only 39.2% of Californians ever received an HIV test, the dental settings offer an excellent opportunity for access to HIV rapid testing.21,24 In our study, those participants who have never been tested were less likely to agree to screening than those who have been tested. When asked why, only 47.1% responded to one or more of the possible reasons provided. Whereas in our study the length of time that testing would add to dental appointments (n = 14, 16.1%), the issues of being treated differently by health care providers or friends after taking the test (n = 11, 12.6%), and being in too much pain to be tested (n = 5, 5.7%) were the most common responses in that order, Dietz et al., reported dental pain as the most common reason to decline being tested (n = 6, 17%), with being treated differently (n = 2, 6%) and the accuracy of the test (n = 2, 6%), as secondary reasons.17 It should be noted that in Dietz et al. as well as our study the overall response rates for these choices were quite low. In this study, willingness to pay for an HIV rapid test at various pricing points suggested that 38.6% of the patients would want the HIV rapid test to be free. Several participants in previous studies reported free testing as an important incentive.19 Only 28.4% were willing to pay $10 to $15 for the test with even lower percentages willing to pay more than that. Such a level of reimbursement may not be enough to support a widespread HIV rapid testing program in a dental school clinic without a supplemental infusion of funds. In addition, little is known about the cost effectiveness of implementing HIV testing in a
dental setting that would include ancillary costs such as additional staff, training and overhead. Unexpectedly when asked for a preference of whom should deliver the test results, nearly one-third were not concerned about who would delivered them (n = 92, 24.0%). Notably, more people selected their personal physicians (15.7%) over their student dentists (10.4%). For this question as well, 24.5% of the respondents did not answer. Some patients may be uncomfortable with their dental care providers conducting HIV screening because they are not aware of the minimally invasive, rapid oral testing method. In Siegel et al. (2012), many of the private practice dentists interviewed (n = 40) recognized the value of early HIV detection through dental screening. However, only one dentist knew of the availability of the rapid HIV tests. In addition, many were reluctant to actually implement the screening in their practices for reasons such as fear of false results, fear of offending the patients, and potential negative reputation HIV screening would bring to the practice.25 Thus, improving attitudes and competence of dentists toward HIV screening requires a larger cultural change. Moreover, dental schools should include HIV testing process and protocol in their curricula to break down the potential barriers to offering HIV screening. According to one study, although 1/3 of graduating dental students reported willingness to perform such services, many were reluctant to actually implement them in the clinics due to numerous issues and challenges.26 To implement HIV screening, it may require education, training, and careful oversight. Thus, dental school clinics versus private practice may be the optimal dental setting to introduce HIV screening. In addition to providing training, dental school clinics can more efficiently provide referrals and link patients to further treatment. Among the dental care providers, dental hygienists are ideal candidates to conduct rapid HIV screening since they already provide patient management screening, assessing, planning and implementing an individualized patient care plan.27,28
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Oral diagnostics is an emerging field in dentistry. The majority of the dental providers agree oral screening for HIV in dental settings is consistent with the professional scope of practice.29 With advancement and improvement of oral diagnostic technology, detection and diagnosis will move away from central laboratory facilities to point-of-care locations such as dental settings, helping dentists play a vital role in early detection and treatment for HIV.30
L i mitation s Since this is a pilot study the sample size was too small to conduct age and race interactions. Almost all of the respondents (379/383) answered the first question of the survey but as the questions progressed there were numerous questions left blank. This might introduce selection bias due to nonresponses. Another observation was that many subjects who responded favorably to rapid HIV testing also answered reasons as to why they would not take a rapid test. As a result we concluded that future studies should utilize a skip pattern of survey so that once a subject makes a choice, he/ she would be directed to move to the next appropriate question based upon the answer given rather than answering all questions in the survey. It is also possible that some of the questions or sequencing of the questions themselves could have been improved.
Conclusions In summary, roughly two of three patients, who previously were unaware of their HIV status and are attending a dental school clinic for oral healthcare, would like to receive a free Rapid HIV test if given the opportunity. A dental clinic provides a nontraditional site for patients to be HIV tested and may also be the only healthcare encounter for individuals who are otherwise healthy and also those individuals who are impoverished. Costs of the rapid test and fees charged must be considered to provide a sustainable program.
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In addition, it will be important to these patients to provide assurances of how the test will be managed throughout the normal dental appointment, so that there will be no additional time needed, and that the results will be held in strictest confidence. Additional information should be gathered from representatives of the clinic patient population, perhaps through focus groups, on other barriers that may impede acceptance of the test and strategies implemented to eliminate these barriers prior to beginning the testing. Additionally, oral health care providers should be thoroughly trained on the legal and moral requirements for privacy and confidentiality associated with HIV testing.31 Providing the appropriate referral services to help those who have a positive screening result must be part of the protocol of the rapid screening/testing process. If properly implemented to ensure patient safety, confidentiality, and linkage to overall care, rapid HIV testing would be feasible and well accepted in a dental school clinic.
Co nf l ict s of int er es t The authors have no conflicts of interest.
Acknowledgement The authors would like to thank the staff at the Ostrow School of Dentistry of USC Center for Community Oral Health for their assistance in collecting the data, in particular, Carolyn Bedoian-Malconian, Timothy Hughes, Carmen Rubenia Molina, Julio Martinez, Rosa Linda Muñoz and pre-doctoral student Diana Zhou.
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