Are we ready for HIV screening in dental clinics?

Of approximately 65,000 Canadians living with HIV, it is estimated that 1 out of 4 is unaware of their HIV-positive status and is infectious.¹ Early diagnosis and access to treatment are of paramount importance in reducing rates of transmission, comorbidity and mortality, as well as public health costs. Yet, according to the 2007–09 Canadian Health Measures Survey, many Canadians do not access primary care physicians because they do not feel sick or show any symptoms of illness.²

In contrast, private and public health dentists may see the public on a more consistent basis. Approximately 64% of Canadians older than 12 years of age had visited a dental office once a year.¹ Among that group are the 25% who are unaware of their HIV status. Oral care has been an important component of primary care since the early days of the HIV epidemic, when up to 80% of all HIV-positive patients would present with an oral manifestation related to disease progression.³ Often, dental professionals can be the first to recognize signs and symptoms consistent with HIV infection and can be important allies in early diagnosis.

In the U.S., a shift in public policy took place in 2006 when the Centers for Disease Control and Prevention recommended that various health care providers, including dental personnel, offer an HIV screening test to all age-eligible patients. ⁴ The rapid screening test looks for HIV antibody and uses a finger prick or oral swab method. Both methods are administered by trained dental personnel on pre-and post-counselling and referral and offer a result within minutes. As an antibody test, it is mostly effective after 3 to 4 weeks following the HIV infection, but not on the day after the infection. In cases of a non-negative result, a confirmatory blood test is required, which looks for the HIV virus. Follow up with a medical provider is required.  In Canada, where the level of patient acceptance for HIV screening and potential barriers to implementation are unclear, the feasibility of implementing HIV rapid screenings in dental settings remains unknown.

In 2011, we explored this issue by engaging in partnerships with the Vancouver Coastal Health Authority's Seek and Treat for Optimal Prevention of HIV/AIDS (S.T.O.P.) Program and the "Does HIV Look Like Me?" International Society in Vancouver. Our 7-month pilot project introduced routine dental provider-initiated HIV screening in community dental clinics and addressed the following question: Will patients be receptive to point-of-care HIV screening as part of dental care?

The HIV screening option was given to all patients receiving dental care at designated community clinics for the duration of the pilot study. They included those older than age 19 and with HIV-negative or unknown status. Both males and females were given the screening options, irrespective of sexual orientation and whether they were exposed to known risk factors for HIV infection according to their medical history.

With research ethics approval from the University of British Columbia, we also developed and applied an anonymous 10-item self-administered questionnaire to assess the reasons for accepting (convenience, free of charge, fast, etc.) or declining (unprepared, uncomfortable setting, not at risk for HIV infection, etc.) the HIV rapid screening. The questionnaire also aimed to determine patients' attitudes about dentists performing HIV screening and identify barriers in offering HIV rapid screening in a dental setting.

During the first 3 months of the pilot study, we saw a total of 546 age-eligible patients who were offered the HIV screening test and the survey questionnaire. One hundred and fifty-four patients completed the questionnaire: 32 consented to be screened and 122 did not.

Of the 32 patients who consented to screening, the majority were young heterosexual males. All screenings were negative. 61.5% of patients screened reported at least one identifiable risk of contracting HIV. All respondents who accepted the HIV screening did so because it was convenient, free-of-charge, and offered results on the spot. Nearly 70% of the individuals who accepted the HIV screening expressed that they would like to include screening as part of their regular oral exam while 92.3% felt that dental offices are appropriate venues for HIV screening.

Of the 122 who did not consent to HIV screening, 83 were males of various sexual orientations between the ages of 19 and 85. From these 122 patients, almost 70% had identifiable risk factors for contracting HIV. Forty-five percent reported they were tested within the last 3 months, while 23% felt they were not at risk of contracting HIV. However, 75.2% felt that HIV screening was within a dentist's scope of practice.

As a result of our pilot study, we now include HIV screening as part of routine care in at least one community clinic, and at the UBC Dental Hygiene program. We felt that patients and the public would support such an initiative, but when will organized Canadian dentistry do the same? More than 70% of patients accept HIV screening in dental settings in the U.S.⁵ What has prevented us from adopting this procedure in Canada? Perhaps we are not ready to fully embrace the HIV screening test. But why? Is it because HIV as a health condition remains stigmatized? Perhaps more education is needed to emphasize that HIV is no longer considered a "death sentence" but can be viewed as a manageable chronic condition.

Without buy-in from the dental profession, there is little hope of successfully implementing HIV rapid screening in a dental setting. Anecdotally, we have heard from our colleagues about some of the potential barriers to implementing HIV screening: the fear of having their clinics or practices labeled as an "HIV clinic," not being able to bill for time spent administering the screening and counseling patients psychologically, and feeling unprepared to deal with a possible HIV-positive result. Moreover, other major factors influencing the use of HIV screening in dental settings include concerns around privacy issues related to testing, and the need to link the patient to proper medical care.

Because there are a limited number Canadian studies related to HIV screening in dental settings, comparisons across the country are difficult to make. Nonetheless, HIV screening in a dental setting remains a feasible and promising way to reach a proportion of the population infected by the virus but not accessing conventional primary care. Widespread acceptance of the practice requires an attitudinal change by the public and within the dental profession. The reluctance to conduct HIV screening at dental appointments is similar to the hesitation some dentists feel about oral cancer screening, particularly when oral cancer is associated with HPV, a sexually transmitted virus.⁶

We believe that HIV screening in a dental setting can have a real public health benefit to the Canadian population, as long as it is performed according to guidelines and with support from dental personnel that includes referrals to appropriate medical care and counseling. Furthermore, the conversation does not need to be limited to HIV testing. Other infectious diseases with implications to dentistry include hepatitis C and influenza A and B, which also have rapid testing methods available in the U.S. These testing methods will likely soon reach Canada and it will be up to our profession to take the lead on rapid testing in health care settings.

THE AUTHORS

	Dr. Brondani is assistant professor, department of oral health sciences, division of preventive and community dentistry, and prosthodontics and dental geriatrics, and director of the combined MPH/dental public health graduate program, University of British Columbia.
	Dr. Chang is a private practice dentist in Surrey, British Columbia.

Correspondence to: Dr. Brondani, Faculty of Dentistry, University of British Columbia, JBM 122/2199 Wesbrook Mall, Vancouver, BC  V6T 1Z3. Email: brondani@dentistry.ubc.ca

The views expressed are those of the authors and do not necessarily reflect the opinions or official policies of the Canadian Dental Association.

This article has been peer reviewed.