Oral health problems and use of dental services among HIV-infected adults. Supplement to HIV/AIDS Surveillance Project Group

Barriers and facilitators to dental care among HIV-Infected adults

Oral health problems can significantly compromise HIV-infected individuals' general health and well-being, yet many of them experience an unmet need for oral care. The barriers and facilitators of obtaining dental care in a sample of HIV-infected adults, all of whom were eligible for Ryan White Part A funding for their treatment, were investigated through qualitative interviews with HIV-positive individuals who had not received dental services in the prior 12 months (n = 44). Identified barriers were as follows: (1) dental anxiety and fear, (2) cumbersome administrative procedures, (3) long waits at the dental office, (4) problem focused care-seeking behavior, (5) transportation difficulties, (6) dentists' reluctance to treat people like them, and (7) psychological issues. Identified facilitating factors were as follows: (1) coverage for dental care, (2) being treated with respect and acceptance, and (3) having an assigned case manager or social worker. Many of the barriers uncovered in this qualitative study can be addressed and overcome by case management services, but other approaches are needed to address the additional psychological and stigma-related factors that are impeding access to oral healthcare in this population.

Stigma and disclosure as barriers to regular dental care for people living with HIV/AIDS in Kwazulu-Natal and Western Cape, South Africa

Purpose

– The purpose of this paper is to determine the oral health care experiences of people living with HIV in Kwazulu-Natal (KZN) and the Western Cape (WC) and also to identify the role of stigma and discrimination in the oral health care experiences for people living with HIV in KZN and the WC.

Design/methodology/approach

– This study was a survey among HIV-positive people attending selected Community Health Centres and regional hospitals, HIV clinics in KZN and WC provinces in South Africa. The sample consisted of people living with HIV that were 18 years or older and who had given written, informed consent. A cross-sectional study structure has been employed using a standardized format using a semi-structured interview and an administered questionnaire to collect data. The study classified participants as living in metropolitan or non-metropolitan areas.

Findings

– Apprehension of loss of confidentiality, stigma and discrimination were the barriers that deterred participants from seeking care. Respondents stated that they feared what the dentist and staff would think of them being HIV positive and feared being discriminated against by the dentist and staff. In some instances there appears to be a difference between policy and practice regarding the oral health care needs of and services rendered to people living with HIV in public health facilities as there are still patients who do not obtain care and for whom the attitudes of the health care provider constitutes the major barrier to accessing that care.

Research limitations/implications

– The results are specific to KZN and WC and have to be extrapolated with caution to the rest of South Africa. Additionally, this study did not have a control group of HIV-negative people which would have enabled one to determine whether certain barriers were unique to people living with HIV.

Practical implications

– To make recommendations with respect to addressing the issue of stigma and discrimination in the oral health care experiences for people living with HIV in KZN and the WC as there is a definite need for the government to address the resource needs of rural areas and less developed areas of South Africa. Health care is a much-needed resource in these high prevalence areas and governments must ensure that all their HIV/AIDS projects and policies should have a rural component built into them.

Social implications

– This study emphasizes the importance of embracing people that are being discriminated and marginalized by society such as people living with HIV to ensure that they feel a franchised member of society who can take the initiative to be in control of their own health and, with the necessary aid from public resources and societal support, join forces to reduce the public health burden and its impact on the socio-economic milieu.

Originality/value

– To the best of the author's knowledge, there is no other study that has compared differences in the use of oral health care services by people with HIV in South Africa and these results serve as an indication of some the important issues in this regard.

Dental care and HIV-infected individuals: are they equally treated?

OBJECTIVE

To investigate the problems in seeking dental care faced by HIV-positive individuals in Italy.

METHODS

A multicenter observational study was performed by distributing an anonymous self-administered questionnaire to patients of six public healthcare facilities specialized in the treatment of individuals with HIV infection. The questions concerned personal data potentially correlated with discrimination, the patient-dentist relationship before and after HIV diagnosis, and the reasons for seeking dental care in public facilities. We also evaluated the patients' discomfort in the patient-dentist relationship after HIV diagnosis, performing univariate and multivariate analyses.

RESULTS

Of the 1,500 questionnaires distributed; 883 were filled-out completely. A total of 630 persons received dental care after HIV diagnosis: 209 (33.2%) did not tell the dentist that they were seropositive. Of those who did, 56 were refused care. For patients treated by a private dentist, having been treated by the same dentist before diagnosis was a risk factor for great discomfort in the patient-dentist relationship (P < 0.002). Being treated in public facilities was associated with having received dental care after HIV diagnosis (P < 0.001) and a primary school education (P < 0.001).

CONCLUSIONS

There exist episodes of discrimination on the part of some dentists, and a relatively high proportion of HIV-positive persons do not disclose their seropositivity to the dentist. Dentists should be provided with training for promoting both ethically acceptable practices and suitable clinical management of HIV-positive persons.

Perceived discrimination in clinical care in a nationally representative sample of HIV-infected adults receiving health care

BACKGROUND

Perceived discrimination in clinical settings could discourage HIV-infected people from seeking health care, adhering to treatment regimens, or returning for follow-up.

OBJECTIVES

This study aims to determine whether HIV-infected people perceive that physicians and other health care providers have discriminated against them.

DESIGN, PARTICIPANTS

Cross-sectional data (1996 to 1997) from the HIV Cost and Services Utilization Study (HCSUS), which conducted in-person interviews with a nationally representative probability sample of 2,466 HIV-infected adults receiving health care within the contiguous U.S.

MEASUREMENTS

Reports of whether health care providers have been uncomfortable with the respondent, treated the respondent as an inferior, preferred to avoid the respondent, or refused the respondent service. Questions also covered the types of providers who engaged in these behaviors.

RESULTS

Twenty-six percent of HIV-infected adults receiving health care reported experiencing at least 1 of 4 types of perceived discrimination by a health care provider since becoming infected with HIV, including 8% who had been refused service. White respondents (32%) were more likely than others (27%) and Latinos (21%) and nearly twice as likely as African Americans (17%) to report perceived discrimination (P < .001). Respondents whose first positive HIV test was longer ago were also more likely to report discrimination (P < .001). Respondents who reported discrimination attributed it to physicians (54%), nurses and other clinical staff (39%), dentists (32%), hospital staff (31%), and case managers or social workers (8%).

CONCLUSIONS

Many HIV-infected adults believe that their clinicians have discriminated against them. Clinicians should make efforts to address circumstances that lead patients to perceive discrimination, whether real or imagined.

Perceived oral health status, unmet needs, and barriers to dental care among HIV/AIDS patients in a North Carolina cohort: impacts of race

OBJECTIVE

This prospective observational study examined differences in perceived oral health status, treatment needs, dental care utilization patterns, and barriers to care between HIV-infected non-Hispanic blacks and whites in North Carolina.

METHODS

632 adult HIV-infected medical clinic attendees provided information on their oral health status and dental care history during face-to-face interviews with a trained interviewer.

RESULTS

Compared to whites, blacks were significantly more likely to be female, older, less educated, have lower income, and have acquired HIV by heterosexual sex or injecting drug use. Although two-thirds of patients reported good oral health, blacks were significantly more likely to have loose teeth, need extractions, and be episodic dental care utilizers. Primary barriers to dental care were cost (30%), fear (19%), and low motivation (13%). Sixty-five percent of patients had unmet dental needs in the last three years. Race, cost, fear, and immune competence were significantly associated with unmet dental need in a multivariable model.

CONCLUSIONS

Disparities exist within this HIV-infected population in oral symptoms, utilization patterns, and perceived unmet dental need. Targeted interventions that address barriers to care are needed to help establish preventive dental care patterns in this region, especially among blacks.

Evaluation of the care of women living with HIV/AIDS in São Paulo, Brazil

To evaluate care provided to women living with HIV in São Paulo, Brazil, based on their own experiences, patients from HIV/AIDS reference clinics answered a questionnaire on circumstances of HIV testing, health personnel's attitudes at diagnosis, adherence to follow-up, services provided by care centers and access to laboratory monitoring. From September 1999 to February 2000, 1,068 women were interviewed. Most had over 8 years of education and reported having regular sexual partners, being mothers and family caregivers. They were diagnosed as HIV-infected for 4.36 +/- 3.15 years. The majority had been referred to testing without counseling. Post-test counseling was provided depending on the testing center. Neither pre-test nor post-test counseling were associated to time since diagnosis. Some patients reported having felt indifference, discrimination or criticism at diagnosis, depending on where testing occurred. Compliance to medical follow-up was associated to adherence to antiretrovirals and to shorter time since diagnosis, but not with having a primary caregiver or with commuting time to the care center. Psychological support, nutrition care and oral health were women's less addressed needs. Access to gynecological care was associated with counseling on mother-to-child transmission and on safe sex. Access to CD4+ cell counts and HIV viral loads was concordant with guidelines, but the understanding of their meaning was incomplete. We conclude that women living with HIV/AIDS in São Paulo, Brazil have limited HIV risk perception and unmet care needs. Better training of professionals in charge of diagnosis and integrating women's health and family-planning actions to AIDS programs may enhance care.

An update on HIV and periodontal disease

With the advent of newer pharmacological approaches to the treatment of human immunodeficiency virus (HIV) infection, the incidence and progression of both atypical and conventional periodontal diseases are changing. The incidence of necrotizing periodontitis and gingival diseases of fungal origin appears to be on the decline as a result of these therapies that have led to increased life spans for HIV patients. However, in cases where these therapies lose their effectiveness and HIV patients relapse into an immunosuppressed state, these conditions may recur. Recent evidence has shown that HIV patients with more conventional periodontal diseases such as chronic periodontitis may have increased attachment loss and gingival recession when compared to their HIV-negative counterparts. This pattern of loss of periodontal support may be due in part to a diffuse invasion of opportunistic bacterial infections, viruses, and fungi into the gingival tissue, leading to a more elevated and more diffuse destructive inflammatory response in the periodontal soft and hard tissues. While the accepted approaches to treating the spectrum of periodontal diseases in HIV patients remain essentially unchanged over the past 15 years, the impact of newer systemic therapies on patient immunocompetence may influence treatment decisions.

Access and use of specific dental services in HIV disease

OBJECTIVES

This study examined factors associated with the use of specific dental services by persons with HIV disease.

METHODS

The data were derived from 1,588 adults who participated in a series of up to six interviews as part of the AIDS Cost and Service Utilization Surveys. Use of dental services such as examinations, x-rays, cleaning, fillings, extractions, root canals, crown and bridge or dentures, and periodontal procedures were evaluated using logistic regression and generalized estimating equations were applied.

RESULTS

Multivariate analyses showed that medical insurance, an education beyond high school, income higher than $1,300 per month, high ambulatory visits, and receipt of psychological counseling were generally associated with higher service use. Blacks, those with an inpatient admission, and CD4+ cell counts less than 500 cells/microL were significantly less likely to use most types of dental services.

CONCLUSIONS

The study concludes that disparities exist in the use of several dental services similar to those seen in the general population.

Factors associated with utilization of care for oral lesions in HIV disease

OBJECTIVES

The purpose of this study was to examine factors associated with utilization of care for oral lesions in people with HIV disease.

STUDY DESIGN

The data were derived from 1424 adults who participated in a series of up to 4 interviews as part of the AIDS Cost and Service Utilization Survey. Treatment for thrush, oral sores, and other conditions was evaluated through use of logistic regression, with generalized estimating equations being applied.

RESULTS

In all, 9.1% of those in the study sample reported being treated. After adjusting for CD4 cell count and other variables, regression analyses indicated that blacks (odds ratio [OR], 0.54; 95% confidence interval [CI], 0.32-0.91) and Hispanics (OR, 0.59; 95% CI, 0.36-0.98) had significantly lower odds of reporting being treated. Respondents with more than a high school education (OR, 1.64; 95% CI, 1.08-2.51), clinical trial participants (OR, 1.92; 95% CI, 1.27-2.90), and those receiving counseling (OR, 2.22; 95% CI, 1.60-3.09) were more likely to report being treated.

CONCLUSIONS

Utilization of care for oral lesions is very low. Educational and racial differences exist among those respondents who received care for HIV-associated oral lesions.

Dental care access and use among HIV-infected women

OBJECTIVES

This study sought to identify predictors of dental care use in HIV-infected women.

METHODS

In a cross-sectional survey of HIV-infected women enrolled in the northern California site of the Women's Interagency HIV Study, dental care use and unmet need were assessed in relation to selected variables.

RESULTS

Among 213 respondents, who were predominantly Black and younger than 45 years, 43% had not seen a dentist and 53% (among dentate women) reported no dental cleaning in more than a year (although 67% had dental insurance coverage, mainly state Medicaid). Nine percent were edentulous. Among nonusers of dental care, 78% reported that they wanted care but failed to get it. Barriers included fear of and discomfort with dentists, not getting around to making an appointment, and not knowing which dentist to visit. Multivariate analysis showed that lack of past-year dental care was associated mainly with unemployment, a perception of poor oral health, and edentulism.

CONCLUSIONS

HIV-positive women appear to be underusing dental care services. Fear and lack of information regarding available resources, in addition to unemployment and perception of poor oral health, may be important barriers.

Do people with HIV/AIDS disclose their HIV-positivity to dentists?

This study documents behaviours of people with HIV/AIDS regarding the disclosure of their HIV-positivity when seeking dental care. An anonymous survey was conducted in Québec, Canada, from 1993 to 1995, using a sample of 463 people with HIV/AIDS recruited from different sources. Over 80% of respondents reported having sought dental care since becoming aware of their positivity. Of these, 54% reported having always disclosed their HIV-positivity to dentists, while 25% reported never having disclosed this information to dentists. However, 83% of all respondents preferred that the dentist be aware of their HIV status. Respondents gave reasons related to the sociopathological impact of HIV infection to explain their behaviours. The predictors of disclosure of HIV-positivity to the dentist were: gender, main source of payment for dental care, prior disclosure of HIV status to family members, prior disclosure of HIV status to co-workers, and trust in the maintenance of confidentiality by the dentist. These results emphasize the need to use universal precautions in the dental office and to promote dentist-patient relations free of discrimination, so that people with HIV/AIDS are not reluctant to disclose their health status and are confident that such disclosure will lead to care best adapted to their condition.