HIV Screening in Dental Clinics

Introduction

“We care about more than just your oral health.”

In the 1980s, dentists were often the first to signal to patients that they should consult their doctors about getting tested for HIV or AIDS, based on oral manifestations of the disease like thrush and Kaposi’s sarcoma. Today, three dentists in Vancouver, together with their staff, are reinvigorating dentists’ role in HIV care by offering point-of-care HIV screening (rapid testing) to their patients. As part of the Seek and Treat for Optional Prevention of HIV/AIDS (STOP) Project, the Vancouver STOP Project partnered with Does HIV Look Like Me? International to train and support three dental clinics to initiate the routine offer of HIV screening to patients in their practices.

Dentists and clinic staff use point-of-care rapid tests to screen patients for HIV antibodies. Negative results are considered conclusive, though patients are counselled about the window period for HIV infection and encouraged to test again in three months if they experience ongoing risk. People who test preliminary positive are connected with the STOP Outreach Team, an interdisciplinary clinical team responsible for improving engagement and linkage for people with the most complex barriers to care, and with nearby medical clinics for immediate support.

To promote the initiative among patients, Does HIV Look Like Me? International developed a campaign using the tagline, We care about more than just your oral health. Posters and brochures in the waiting room and the operatories encouraged patients to ask about screening and to update their knowledge about HIV. At Mid-Main, the entire staff asked to be screened for HIV. Dr. Mario Brondani, one of Mid-Main’s dentists says that “this might have helped to spread the word about screening to the incoming patients and demystify what screening actually is.”

Patients have been overwhelmingly supportive of the initiative. “People were pretty positive about it. People were pretty happy,” said Dr. Sean Sikorski, the PHS Community Services Society Clinic’s dentist. “They were surprised, but they were kind of happy because a lot of people don’t have a regular physician or they aren’t comfortable plugging into that infrastructure.”

According to Brandy Svendson, Does HIV Look Like Me? International’s executive director, the introduction of HIV screening may be most appropriate for dentists with a large clientele from communities with a higher prevalence of HIV such as the gay community.

What is the Program?

Does HIV Look Like Me? International¹, with funding from the STOP Project, designed the program, and trained and supported three low-cost dental clinics and numerous residents from the UBC Faculty of Dentistry to routinely offer HIV screening using rapid point-of-care (POC) tests to all of their patients.

The goals of the pilot project were to support and train dental clinic staff to offer and administer point-of-care HIV tests in their practices; expand access to HIV testing; increase timely diagnosis; improve engagement in care; and reduce HIV stigma among dental health practitioners. Pilot dental clinics were chosen that serve the general population and communities at risk for HIV, including newcomers from endemic countries, people who experience episodic homelessness and people who live with mental health issues and addictions.

Does HIV Look Like Me? International, with support from the Vancouver STOP Project trained dentists, certified dental assistants and hygienists to offer and perform the point-of-care test. The project, which was considered a feasibility pilot to determine if testing could be offered in dental clinics, took place over eight months in 2011. Though the pilot has ended, the three sites continue to offer HIV screening to their patients as part of their regular care.

Confirmatory testing for people who receive a reactive (preliminary positive) test is offered by adjacent medical clinics or the STOP Outreach Team, an interdisciplinary clinical team responsible for improving engagement and linkage for people with the most complex barriers to care. Partnerships between medical clinics close to each testing site allow people newly diagnosed to seek immediate post-test counselling, support and linkage to care if they want it.

1. Does HIV Look Like Me? International Society is a non-profit organization that works locally and globally to reduce the stigma associated with HIV and AIDS. It raises awareness by producing cutting-edge media and print campaigns, and by providing projects, education and leadership opportunities to people infected and affected by HIV.

Why Was the Program Developed?

The high number of HIV positive individuals who are unaware of their HIV status indicates the need for expanded opportunities for testing, and in new settings. Traditional healthcare is missing people who do not have a physician or nurse they see regularly, but who have an ongoing relationship with a dentist. Evidence from an HIV screening pilot project in a dental clinic in New York City bears this out. Over a 22-month period, the dental clinic diagnosed 19 people with HIV; nine of those individuals had visited an emergency department, family physician or dental clinic in the past year but had not been offered an HIV test.¹

Traditional healthcare is also missing people who may avoid the medical system altogether as a result of complex psychosocial challenges, but for whom severe dental pain may drive them to seek dental care. For these individuals, dental care is an important point of contact with the healthcare system.

In addition, dental professionals have been an important part of HIV primary care since the onset of the epidemic, when up to 80 percent of all HIV-positive patients would present with an oral manifestation (e.g., oral thrush, Kaposi’s sarcoma) related to disease progression. Dental professionals are often some of the first healthcare professionals to recognize symptoms consistent with HIV and refer patients to other healthcare providers to learn their status. In this model, however, dental professionals cannot be sure that patients received a test.

The emergence and ease of use of rapid HIV-screening technologies allows individuals to learn their HIV status in minutes, well within the timeframe of a routine dental visit. People are more than twice as likely to receive their results when rapid HIV-testing technologies are used. Given this, VCH and Does HIV Look Like Me? International developed partnerships with local dental clinics and University of British Columbia Faculty of Dentistry to pilot-test the feasibility of HIV screening as part of the scope of dental practice in Vancouver.

1. Blackstock OJ et al. Evaluation of a Rapid HIV Testing Initiative in an Urban Hospital-based Dental Clinic. AIDS Patient Care and STDS. 2010; 24( 12): 782.

How Does the Program Work?

Confirming that HIV testing was within the scope of dental practice

Meetings were facilitated between Does HIV Look Like Me? International, the Vancouver STOP Project, the College of Dental Surgeons of British Columbia, the College of Dental Hygienists of British Columbia and the British Columbia Dental Association to determine if providing HIV screening in the dental setting was within the scope of dental practice. 

The support of these bodies was essential to getting buy-in and approval for scope of practice from dentists, certified dental assistants (who are regulated by the College of Dental Surgeons), and hygienists. The rationale for routine testing of HIV more broadly was presented by Vancouver’s medical health officer. The Registrar of the College of Dental Surgeons of British Columbia, already a supporter of a broader role for dentists in healthcare, was key to gaining the support of both the Colleges. 

To raise awareness of HIV testing and this pilot in the dental community and solicit feedback on the project’s design, the Registrar of the College of Dental Surgeons hosted a round table discussion with interested dentists. Dentists from both private and public health practice were invited to determine feasibility of introducing HIV screening in a number of settings.

While dentists in private practice were present for these initial discussions, it was determined that private practices were not ideal for the pilot project. Ultimately, dentists in private practice could not bill for HIV screening, and this undermined workflow and cost-effectiveness in private businesses with tight timelines for patient turnover. At one site, the lack of a confidential space in which to offer the test was also cited as a barrier to implementation.

Clinic pre-assessment

Each interested clinic had to demonstrate that a person’s confidentiality could be maintained through the HIV screening process. This meant ensuring that a private area in the clinic could be used if a patient requested it.

The dental clinics

Mid-Main Community Dental Clinic

Mid-Main Clinic is situated above the Mid-Main Community Health Centre, allowing patients receiving preliminary positive results to access immediate medical care if they request it. Unlike the other clinics in the pilot, Mid-Main does not operate in the Downtown Eastside and although low-income, serves the general population.  At Mid-Main, HIV screening was offered to all patients by a dentist and by a certified dental assistant, one day a week when that dentist was in the clinic.

First United Community Dental Clinic

First United Community Dental Clinic is an inner city clinic that operates once a week and is run by the University of British Columbia’s Faculty of Dentistry’s General Practice Residency Training Program. Most of the clinic’s patients do not see a dentist regularly, are often in need of emergency dental work and often live with mental health issues and addictions. Screening was offered by a dentist and by a certified dental assistant to all patients who sought the clinic’s services. The dental clinic was open one day a week.

PHS Community Services Society Community Dental Clinic

The PHS Community Services Society offers dental care to residents of the Downtown Eastside. Like First United, most of the clinic’s patients do not see a dentist regularly, are often in need of emergency dental work and often live with mental health issues and addictions. Screening was offered by dentists, certified dental assistants and a hygienist.  

Competency training and resource development

Competency training

Staff training needed to be flexible in order to complement the schedules of clinic staff. Depending on the clinic, the three-hour training was offered as a series of lunch-and-learns or during a half-day training. All clinic staff were required to be present, even those who would not be offering the test. This ensured that everyone in the clinic had some basic competency to answer questions about HIV and the point-of-care test.

The workshops were led by Does HIV Look Like Me? International and HIV nurse educators from the Vancouver STOP Project. Sessions covered the basics of HIV, including transmission, prevention, care, treatment and the most common oral manifestations of HIV/AIDS. Training also focused on the role that dentists have historically played in HIV/AIDS care and the expanded role they are beginning to play in preventive healthcare more broadly. This helped dentists situate performing HIV screening within the scope of their professional mandate.

Practical training on how to use the rapid testing kit was done and all staff offering the test had to pass a competency exam demonstrating that they could offer, perform and read a point-of-care test accurately. This competency exam was administered by an experienced HIV nurse educator from the Vancouver STOP Project.  The curriculum was adapted from the BC Centre for Disease Control Point-of-Care HIV Test Guidelines and included input from the dental advisory board made up of representatives from Positive Living BC, British Columbia Centre for Excellence and BC Centre for Disease Control as well as bioLytical, the manufacturer of the rapid test.

Resource development

In addition to offering onsite training, Does HIV Look Like Me? International developed resources for practitioners to facilitate the learning process.  Its Rapid HIV Testing for Dental Clinics, a resource designed for practitioners, covers the basics about the point-of-care test, what informed consent constitutes, how to offer the test, how to interpret the result, a cheat sheet (with diagrams) that shows all possible testing outcomes, and finally a workflow diagram that lists all of the steps in the process of delivering an HIV test. To view this resource, please see Program Materials.

Does HIV Look Like Me? International also developed posters and pamphlets geared toward patients that raised awareness about HIV testing. Resources using the tagline, We care about more than just your oral health, were posted in the clinics to encourage patients to ask about HIV testing. These materials are available in the Program Materials section of this case study.

The HIV screening process

Offering the test

Screening is offered routinely by a certified dental assistant, a hygienist or a dentist to all eligible patients. Patients who are not yet 18, who come to the clinic with another person, who already know they are HIV-positive or cannot give informed consent (those that the tester feels are too intoxicated or display signs of untreated mental illness) are not offered screening. For people living with HIV, dental clinic staff are trained to facilitate linkage to the STOP Outreach Team if they are not already engaged in HIV primary care.

Depending on the site, the patient and the type of appointment, screening is offered before, during or after the appointment. When discussing HIV screening, clinicians are encouraged to underscore the fact that all patients are being offered the test as part of routine healthcare. They further highlight that the only way for a person to know their HIV status is to get tested.

When offering screening and getting informed consent, testers make sure that patients understand that should the test reveal a preliminary positive, they will be contacted for follow up by a public health nurse from the STOP Outreach Team. For those who want to be screened, but who do not consent to be contacted by a public health nurse, the test will not be administered. This protocol decision was made to ensure that no one would test positive without a strong link to confirmatory testing and care.

Promotional material about HIV screening is available in the bathrooms, waiting room and operatories and has led to an increase in the number of patients who ask to be screened even before the dentist makes the offer.

Administering the test

Screening is performed at the end of the appointment using a point-of-care test kit, following the provincial guidelines with a site-specific protocol developed by Does HIV Look Like Me? International and the STOP Outreach Team. This protocol outlines what dental professionals are to do in case of a reactive (preliminary positive) test.

Communicating results and referrals

Negative results are communicated immediately to patients. Testers answer any questions patients have and discuss the window period of an HIV test to ensure that patients with ongoing risk, or who have experienced a risk event, know to get tested again in three months to confirm their negative results.

The three dental clinics involved in this pilot have tested 60 people and had zero HIV positive results. However, a protocol is in place to support a positive result, should there be any.

Reactive results on a point-of-care test are considered an indication that HIV antibodies are present in a person’s blood. Dentists are trained to offer this result as a preliminary positive to patients. Confirmatory testing through a blood test is required to confirm HIV infection, as false positives, though rare, can occur.

Because dental clinic staff are offering screening without confirmatory testing, testers would not tell patients who tested preliminary positive on the rapid test that they were very likely HIV positive. If asked, testers are trained to be honest and to say that a confirmed positive is possible.

Dentists are trained and are bound by professional responsibility to inform patients of symptoms (lesions, oral thrush) they observe that may be indicative of cancer, HIV/AIDS or other illnesses and encourage them to seek care from a physician. Offering HIV screening—but not diagnosis—is perceived to fall within this professional responsibility and preliminary positives are communicated as an indication that an HIV infection may be present. This practice is similar to the way oral cancer screening results are communicated by dentists in British Columbia.

Both professional colleges and individual dental clinicians were reluctant to take on the responsibility of offering a positive diagnosis based on the point-of-care test.  They are not trained to do so, and though dentists can order confirmatory blood work for patients, they preferred to defer this responsibility to the STOP Outreach Team. As an added linkage to treatment, care and support, Does HIV Look Like Me? International met with medical clinics in close proximity to each dental practice to ensure that anyone receiving a preliminary positive result could see a healthcare provider immediately for a confirmatory blood test.

As per the protocol, once the STOP Outreach Team is contacted for follow up and reporting to Vancouver Coastal Health Communicable Disease Control is done, the dental clinic’s role in the testing process would be complete. Individual clinicians, depending on their relationship with the patient, would be free to follow up to offer support.  

Next steps

The question about whether HIV screening should be rolled out on a wider scale in dental clinics in Vancouver remains unanswered. There are several reasons for this: not enough screening tests have been performed to determine cost-effectiveness; billing codes for public and private insurance have not been developed; many dental clinics lack private space for testing; and the remaining reluctance, for a variety of reasons, on the part of many practitioners to offer HIV screening as part of dental care.

There are also concerns, moreover, that establishing HIV screening in dental practices, covered by insurance, will lead to unnecessary and inappropriate HIV screening in some clinics. Given that widespread HIV screening using the point-of-care test in the general population increases the likelihood of false positives,¹ arguments can be made for confining access to HIV screening in dental clinics to practices serving populations and communities with a higher prevalence of HIV.

For example, practices that cater to a large population of gay men may be one context in which it would be appropriate to introduce HIV screening by dental professionals. Gay men have the highest incidence and prevalence of HIV transmission in Canada. Offering HIV screening in dental clinics serving the gay community would add one more context in which gay men could get tested.

1. Gilbert M, et al. Recommended use of point-of-care HIV tests. BCMJ. 2007 ; 49 (4) : 77. Available from: http://www.bcmj.org/bc-centre-disease-control/recommended-use-point-care-hiv-tests.

Required Resources

Human resources

• Dentists, certified dental assistants and dental hygienists trained and certified to offer and perform point-of-care testing. All other staff in the clinic, even those not offering the test, should be asked to attend the training to develop HIV competency and knowledge.
• Public health nurses, nurse educators, HIV clinicians and community partners available for training, referral services and establishing clinic work flow.
• Strong advisory board with community and provincial stakeholders.
• Support of the Colleges who regulate the work of dentists, certified dental assistants and hygienists in the jurisdiction.

Material resources

• Clear guidelines and curriculum for the use of the point-of-care test.
• Rapid point-of-care testing kits.
• Logs to track the number of kits received and used, the number of tests performed and the number of new positives reported to the local health authority.

Challenges

1. Education. Dentists and other clinic staff have limited, and often outdated, information about HIV. Their professional training on the topic covers how they can protect themselves from HIV and other blood-borne infections rather than offering a holistic perspective on what it means to live with HIV.  In some cases, this has led to deep misconceptions about the virus and significant stigma of those who live with it among dental professionals.
2. Billing Codes. There is no billing code in the provincial dental schedule for HIV screening so dentists are offering rapid screening for free. Currently, private insurance companies do not reimburse for HIV screening in dental settings. 
3. Workflow and Time. The community clinics keep tight appointment schedules in order to meet the demand for their services. Finding the time (about ten minutes to deliver the test and offer the results) that did not overburden already busy staff was a significant challenge. Because the service is known to be available, an increasing number of patients are requesting it, which puts further pressure on time.
4. Testing Technology. While POC testing kits are easy to use, testing kits that use oral swabs to collect samples to test for HIV are available in other jurisdictions and may be more acceptable to dental practitioners and patients. They are not, however, currently available in Canada. This technology would be more familiar to dental practitioners who are more experienced with oral swabs than they are with finger pricks. Using this technology might reduce resistance to performing HIV screening among dental practitioners.

Evaluation

As part of the STOP HIV/AIDS initiative, clinics are required to provide monthly reports on the number of tests performed and the number of positives yielded.

In addition, research has been conducted among patients at Mid-Main Dental Clinic and First United Dental Clinic to

• assess patient response to the incorporation of rapid HIV testing in routine dental appointments;
• determine patient attitudes toward dentists performing HIV testing; and
• identify barriers in offering rapid HIV testing in dental settings from the patients’ perspective.

Between October 2011 and February 2012, patients were recruited to complete exit surveys of their experience of HIV screening. Twenty-two participants completed the survey.

Although limited by the small number of participants, the study demonstrated that people who were comfortable being tested in a dental setting would prefer to do so as part of their routine care. Among those who declined to be tested, 78 percent nevertheless strongly agreed or agreed that diagnosing HIV is part of a dentist’s job. The study also concluded that an oral swab test, such as Orasure, might increase uptake of the test in the dental setting.

Impact

Although the project has not screened enough patients to determine its effectiveness, it has demonstrated its value in other ways. The project allowed the Vancouver STOP Project and the STOP Outreach Team to build stronger links with Vancouver’s dentists. As a result of the relationships that developed from this feasibility pilot, all students in their final year of dentistry at the University of British Columbia—the only school of dentistry in the province—attend HIV-specific workshops led by the STOP Outreach Team and Positive Living BC.

These workshops cover HIV basics, including prevention, transmission, treatment, and explain how HIV screening is now being offered in some public health practices in Vancouver. The workshops update the knowledge dentists have about HIV, and dispel myths and misconceptions regarding who contracts HIV and how. The training also reduces stigma associated with taking on patients living with HIV, and offers clinicians strategies to encourage and support patients who have been lost to care to re-connect with a healthcare provider.

Lessons Learned

1. Building relationships. Building the necessary relationships between HIV services and the dental professions, even if they choose not to provide HIV screening in their practices, improves knowledge of HIV and reduces stigma among dentists, certified dental assistants and dental hygienists. These strong relationships have resulted in HIV education for all dental students in their final year at the University of British Columbia. This ultimately reduces barriers for people living with HIV who want to access dental care.
2. Support of Dental Colleges and Associations. The pilot project received the support of the College of Dental Surgeons of British Columbia and the College of Dental Hygienists of British Columbia, both of whom sat on the project’s advisory committee. The support of these associations was critical in confirming that providing HIV screening was within the scope of dental practice and contributed significantly to moving this initiative forward.
3. Comprehensive Staff Education. All clinic staff must be provided comprehensive HIV education to reduce stigma and dispel misconceptions. Dentists and other clinic staff are not receiving the latest information about HIV transmission and treatment and thus have outdated ideas about the virus and those who live with it.  Some dentists have not been updated on HIV since their graduation in the 1980s.
4. Staff Screening. At one site, the entire clinic staff screened voluntarily for HIV. This may have helped to spread the word about the availability of screening to incoming patients and demystify the process. This also increased reception staff’s comfort level when answering questions regarding the test.
5. Expanded Access. Testing in dental clinics offers an alternative setting for testing to those who experience significant barriers to access in other healthcare settings, or do not have a primary healthcare provider.
6. Patient Acceptability. Offering point-of-care testing in a dental setting is acceptable to patients. The response to testing has been overwhelmingly positive. At PHS Community Services Society’s Clinic, most tests that are administered are requested by patients, rather than offered by a practitioner.

Program Materials

• Rapid HIV Testing for Dental Clinics
• Patient resource
• Training Powerpoint
• Oral Manifestations of HIV

Contact Information

For more information, please contact

Brandy Svendson, Executive Director

Does HIV Look Like Me? International Society
#210 – 289 Alexander Street
Vancouver, B.C  V6A 4H6
CANADA

1.800.601.0191

brandy@doeshivlooklikeme.org

What is the STOP HIV AIDS Project?

Seek and Treat for Optimal Prevention of HIV/AIDS (STOP) was a $48 million, four-year (2010-2013) pilot project funded by the government of British Columbia. This project aimed to increase the quality of life of people living with HIV and reduce the number of new HIV infections by taking a proactive public health approach to finding people living with HIV, linking them to HIV care and treatment programs and supporting them to stay in care. STOP aimed to improve the experience of people living with HIV or AIDS in every health and social service interaction and significantly improve linkage and engagement across the full continuum of services in HIV prevention, testing and diagnosis, treatment, and care and support.

STOP was rolled out in Vancouver and Prince George. It was made up of numerous interconnected and discrete clinic-based, hospital-based, community-based and policy-focused programs implemented through the collaboration of a significant number of stakeholders. In Vancouver, Vancouver Coastal Health and Providence Health Care partnered to form the Vancouver Project. Through this partnership, these two organizations shared governance, funding and reporting for most of the initiatives that took place in Vancouver between 2011 and 2013.

With funding from STOP, the IDC expanded its clinic hours to include evenings from Monday through Thursday; added specialized nursing, dietitian and social work staff; introduced point-of-care testing; and added peer navigation services in partnership with Positive Living BC.