|Home | About | Journals | Submit | Contact Us | Français|
In 2006 the CDC recommended routine HIV screening. This pilot study was developed in response to the suggestion that dental settings would be appropriate for expansion of HIV testing. This project included oral fluid HIV testing and a survey of acceptability by dental faculty. The survey assessed the attitudes of clinical faculty toward routine HIV testing within the context of a dental school clinic and HIV testing experience. Patient preferences for participating in oral fluid HIV testing were examined. 8.2% of subjects contacted by clinic admissions-clerical staff completed testing. When approached by a faculty member or student during the dental visit admission and tested during the dental visit, 88.2% completed testing. Of faculty members who took the survey, 27.4 % were neutral, 26.4% were somewhat in agreement and 32.1% were willing to incorporate HIV testing into routine dental care. In this pilot study HIV testing of dental patients was most successful when a dental care provider approached patients about testing. If consent was given the testing was performed during the visit. For faculty, the major barrier to testing was a lack of protocol familiarity.
Since the emergence of HIV infection in the early 1980s, new infections have continued despite continued prevention education efforts.1 Traditional HIV prevention programs have focused on testing of people considered at risk for HIV infection so that they could be linked to medical care and counseled for behavioral modification in order to prevent transmission to others.1 Focused testing of people considered at risk has not been a successful strategy for preventing new infections.2-4 In a 2004 report, the CDC estimated that of the approximately one million persons living with HIV in the United States, one quarter are unaware of their infection.5 In addition, a substantial number of people at risk for HIV infection do not perceive themselves to be at risk. Lagally and Mathies estimated transmission is 3.5 times higher among persons who are unaware of their infection than among persons who are aware.6 Persons who are HIV infected and who are unaware of their status are more likely to engage in high-risk behavior and unknowingly transmit HIV.7, 8 The CDC estimates that new sexually transmitted HIV infections could be reduced by more than 30% per year if all infected persons knew their HIV status.9 In addition, identification of HIV infection also allows appropriate initiation of antiretroviral therapy and the resulting reduction in viral load could also reduce the risk of transmission of HIV.8, 10-13
In September 2006 the Centers for Disease Control and Prevention (CDC) revised the recommendations for Human Immunodeficiency Virus (HIV) testing in health-care settings.14 The new recommendations include a dramatic change from testing focused on assessment of risk to routine HIV testing regardless of risk, and in addition, advise a broadening of health care settings, in which HIV testing is provided.14, 15 According to the CDC, more patients, and not just those who perceive themselves to be at risk, accept HIV testing when it is offered routinely.3, 16
The availability and reliability of oral fluid testing for HIV infection has led to the suggestion that dental care settings could be sites where HIV testing could be available.14, 17, 18 Pollack, Mench and Abel used data from the National Health Interview Survey to examine the potential for reaching untested individuals at risk for HIV infection and found that three quarters of these individuals had seen a dentist within two years.19 Although the prevalence of individuals who are unidentified HIV seropositive and who present to a dental school for care is unknown, providing rapid oral fluid HIV testing in the dental school setting has the potential for reaching individuals who might not otherwise be tested. However, incorporating HIV testing in a dental setting raises many issues including the willingness of patients to accept this testing as part of a dental school clinic appointment, the willingness of dental faculty to provide this testing, the training of faculty and students to perform this testing and inform patients of results, and issues related to 3rd party payment for this testing.20
New York University College of Dentistry (NYUCD), a pilot project was developed that included offering oral HIV testing to patients who presented for dental care and querying the faculty concerning their attitudes concerning oral HIV testing in the dental setting. The objectives of this project were to explore patient acceptance of HIV testing in a dental setting and to assess the perceptions and attitudes of oral health care providers regarding oral fluid HIV testing. The results of this pilot study are reported here.
The New York University Medical Center Human Subjects Institutional Review Board approved all components of this study. State law regulates HIV testing.21 For this study, HIV testing was provided by NYUCD faculty members who had received the training and credentials required by New York State to counsel individuals related to HIV testing. At least one counselor was on site when the testing was offered.
For this study, the OraQuick® Advance HIV-1/2 Test (http://www.webcitation.org/5mXdI41sE) was used for HIV assessment according to the manufacturer's instructions. The mucosa is wiped with the oral fluid collector for a total of 60 seconds. The collector is then inserted into a manufacturer-supplied vial that contains lateral flow buffer and after 20 minutes the test results are read by visualizing the results on the test device. If HIV antibodies are present in the collected sample (a “reactive” result), two reddish-purple lines appear in a small window on the device. A negative result will show only the one control line in the device window. The oral fluid test is a screening test and the results are appropriately reported as “reactive” not as “positive”. Reactive results require Western Blot confirmation in order for an individual to be considered HIV positive. For this study Western Blot confirmation was accomplished with the cooperation of the NYUCD Nursing Faculty Practice, which is located within the College of Dentistry.
Two different approaches were used to evaluate the effectiveness of HIV testing in the dental school environment. In our initial attempt, patients presenting to NYUCD for their appointment were given a questionnaire to complete by the clinic administrative clerical staff. The questionnaire asked if they were interested in participating in a study in which they would be tested for HIV antibodies using the oral fluid method and if they were willing to remain after their admissions appointment to have a faculty member describe the study to them. If the patient responded that they were unwilling to be tested they were asked to provide a reason or indicate if they had been previously tested in the last 3, 6, 12, or more months. If a patient did not wish to participate in this study, the dental visit proceeded as usual. When a patient expressed interest in HIV testing the study investigator was informed of the patient's interest. The admissions evaluation and the routine process for assigning a patient to a student was followed and the study investigator was informed of the patient's interest in participation. Patients who agreed to participate completed their routine dental admissions exam and at the conclusion of the admissions visit, the faculty investigator approached the patient and confirmed interest in oral HIV testing. If still interested, the patient was escorted to a private area for the informed consent process, HIV pretest counseling, and the oral HIV testing. The patient was asked to wait in the reception area and when the results were available was recalled to the private room to discuss the outcome. If the test result was negative, the patient was given the results and New York State's mandated post-test counseling. If the test result read “reactive”, the dental faculty member and the on-site nurse practitioner would provide the New York State mandated post-test counseling together and a serologic Western Blot test would be ordered to confirm the result. Referral to the NYU Medical Center/ Bellevue Hospital Medical Center Virology Clinic for HIV associated medical care was available for any patient whose test result was reactive and/or confirmed positive.
In the second approach, a faculty member or student asked patients at the beginning of their appointment if they were interested in HIV testing. Both the informed consent process and the New York State consent for HIV testing were completed and the oral sample taken at the outset of the dental visit. The results of the test were available to the patient at the end of the dental visit in a confidential setting.
An on-line questionnaire was sent to NYUCD clinical faculty to assess dental health care provider (dentist, dental hygienist, dental assistant) acceptance of HIV testing in the dental school setting. The questionnaire's demographics included professional title, gender, age, race/ethnicity and type of practice Sample questions included in the questionnaire are shown in Table 1.
Initially questionnaires asking patients if they were interested in HIV testing were given to 256 patients presenting for their initial admissions visit. These patients were required to remain after the dental visit for the testing procedure. Of the patients who received the questionnaires, only 21 patients completed testing. Subsequently of the 34 patients who were asked directly by a student or dental faculty member at the time of the dental visit if they would consent to rapid oral testing for HIV infection, 30 patients completed the test. No patient participating in this study had a reactive test result.
Of the 736 surveys that were e-mailed to faculty members, 106 were returned. Most of the respondents were dentists (102/106, 96.2%), dental hygienists, or assistants (10/106, 9.4%). Most of the respondents (68/106, 64.2%) were male and although many individuals of different race/ethnicities responded, the majority of these were Caucasian (89/106, 83.9%). Of the dentists who responded, 51.9% (55/106) were general dentists (Figure 1).
Most of the respondents (91/106, 85.9%) had no experience performing an HIV test, but were equally divided (50%) between those that had (53/106) or had not (53/106) personally experienced getting an HIV test. The mean age of those having prior experience with HIV testing was 43.6 years, while those who did not have experience was 55.3 years. It was also interesting to see that a majority of respondents (85.9%) either were neutral (29/106, 27.4%), somewhat agreeable (28/106, 26.4%) or willing (34/106, 32.1%) to incorporate HIV testing into routine patient care. However, a majority of respondents (56/106, 52.9%) felt that a lack of knowledge of the protocol or the logistics for testing would be a barrier to incorporating testing compared to only 12.3% (12/106) that felt it would not be a problem. When asked if the school had sufficient resources to deal with the extra paperwork and referrals, 62.3% (66/106) agreed or somewhat agreed that the school had sufficient resources while 22.6% (24/106) were neutral and 11.3% (12/106) disagreed. Factors such as clinician's cultural background, patients’ language, time and, concerns about offending the patient were not seen as major deterrents.
At NYUCD, we initiated this pilot study in response to the CDC's recommendation that HIV testing be offered routinely and expanded to sites that might include individuals who do not routinely see medical care providers. With the development of the oral fluid rapid HIV test, the dental care setting has been suggested as one of the expanded sites for testing.19, 22, 23 NYUCD is the first dental school in the United States to report the results of offering rapid HIV testing to a dental patient population. In this study two methods of contacting patients concerning their willingness to be tested for HIV in the dental school setting were explored. Although the numbers in each group of patients tested are small, our results suggest that patients are more likely to successfully complete HIV testing when they are contacted directly by a dental faculty member or student rather than an administrative staff member and that the test is completed during the dental visit. The acceptability of HIV testing by patients in a dental clinic setting in our study is consistent with the findings of the study by Dietz, et.al., that found 73% of the patients queried would be willing to take an HIV test if it were provided during their dental visit.22
A majority of faculty respondents accepted incorporating rapid HIV screening into routine care provided to patients at NYUCD. Although there were some concerns about incorporating HIV testing into our dental appointments, these results suggest that there was confidence by many faculty members that a new practice could successfully be implemented in the dental school and that there would be sufficient resources available to provide subsequent referral services and access to care for those patients that test positive. We recognize that the response rate to the provider questionnaire was low and could have resulted in a biased sample. However, these results are consistent with the findings of Greenberg et.al.,24 which showed willingness by the majority of dentists surveyed to participate in primary prevention screening.
Very few faculty members who completed the survey had prior experience performing an HIV screening test. “Not knowing the protocol” was cited as one of the barriers in conducting HIV tests. It is clear that incorporating HIV testing in the dental setting would require training of faculty members and students in both counseling and testing procedures. In the United States, all laboratory testing is regulated under the Clinical Laboratory Improvement Amendments of 1988 (CLIA). A CLIA waiver can be obtained in order to perform the rapid oral HIV test in the dental school environment. CLIA waived tests can be performed outside clinical laboratories by persons without formal laboratory training.25 The legal requirements for HIV testing are set by each state25. New York State requires “opt in” consent for HIV testing. As a consequence, individuals must consent to HIV testing before the test can be administered and pre and post test counseling is required. Other states utilize the “opt out” approach to HIV testing in which HIV testing is included as part of routine medical laboratory testing. In this approach, the patient is informed that the testing will be performed and the patient has the opportunity to decline testing. Written consent for HIV testing is not required.21
We followed the New York State Department of Health, AIDS Institute protocol for rapid HIV testing in settings where further testing of reactive results by a licensed clinical laboratory is required to confirm a reactive result. The training of our faculty involved the provision of accurate information for patients, including informed consent, before the test is performed and training in disclosure of both negative and reactive test results. For patients with negative test results, the time required for disclosure of the results is short. Patients are informed of the window period and if there is a high behavioral risk for HIV infection, they are advised concerning the need for subsequent testing. For patients with reactive test results, the time required for disclosure is considerably longer. Patients are provided with support for dealing with the test result and guided to a site to obtain confirmatory testing (http://www.health.ny.gov/diseases/aids/testing/rapid/protocol.htm, Accessed November 12, 2011).
A larger study is needed to confirm these preliminary findings. However, our results suggest that routine HIV testing of patients in a dental school setting could be a successful means of providing HIV testing to a broader population. Conducting routine rapid HIV testing and counseling in a dental school setting would provide this service to those individuals who, for various reasons do not access this testing in a medical setting. It is anticipated that oral fluid will be used for a number of different tests in the future.17, 18 In addition to the benefit to patients, incorporating rapid oral HIV testing in the dental school setting would provide experience in oral fluid testing for dental students.
While the study was in progress, a patient presented for admission to the clinic for dental treatment with oral lesions suggestive of HIV infection. Because the attending faculty member was aware of the availability of the rapid testing program, the patient was immediately tested on site and referred for appropriate confirmatory testing, counseling, and case management.
In this pilot study we found that patients who were approached were willing to be tested and many of the faculty members who responded to the questionnaire appeared to support the concept of testing in the dental school setting. Although no patients who participated in this study had a reactive test result, the presence of a nurse practitioner faculty practice in our dental school made the planning for confirmatory testing and follow-up of any patient who might have a reactive test result much easier than if the referral would have had to have been made to a more distant location.
This project was supported by an NYUCD Dean's Research Award to MG, a NYStar grant to DM, and NIH grants U01DE017855 and U19DE018385. The donation of OraQuick Advance® HIV-1/2 test kits from OraSure Technologies, Inc. is gratefully acknowledged.
David D. Nassry, Department of Oral and Maxillofacial Pathology, Radiology, and Medicine, College of Dentistry, New York University.
Joan A. Phelan, Department of Oral and Maxillofacial Pathology, Radiology, and Medicine, College of Dentistry, New York University.
Miganoush Ghookasian, University of California, Los Angeles.
Cheryl A. Barber, Basic Sciences, College of Dentistry, New York University.
Robert G. Norman, Epidemiology and Health Promotion, College of Dentistry, New York University.
Madeleine M. Lloyd, Department of Oral and Maxillofacial Pathology, Radiology, and Medicine, College of Dentistry, New York University.
Andrew Schenkel, Department of Cariology and Comprehensive Care, College of Dentistry, New York University.
Daniel Malamud, Basic Sciences, College of Dentistry, New York University.
William R. Abrams, Basic Sciences, College of Dentistry, New York University.