Advancing HIV/AIDS Research at the Intersection of Mental and Oral Health

HIV/AIDS and Oral Health Research Program
Center for Clinical Research
Division of Extramural Research

Goal

The objective of this initiative is to seek interdisciplinary research to better understand basic biologic, psychosocial, and behavioral factors and mechanisms that contribute to mental and oral health interactions in people living with HIV and help advance implementation science. This initiative encourages multidimensional (e.g. cognitive/perceived, clinical, biological) assessment of mental and oral health/disease/symptoms/well-being/quality of life and the use of theoretical frameworks to build evidence on broad but precise aspects of the influences of mental health on oral health in the context of people living with HIV.

Background

Severe and common mental illnesses such as depression have been linked to poorer oral health outcomes^1,2. Although the underlying mechanisms remain largely unknown, available evidence shows that self-reported mental health status and symptoms are associated with higher caries experience³, lower oral health-related quality of life⁴, and inadequate use of dental care among people living with HIV⁵.

While mental illnesses occur among the general population, people living with HIV are at higher risk for mental health conditions than people who do not have HIV^6,7. Not only is the prevalence of HIV substantially higher among adults with a serious mental illnesses in the United States, people living with HIV are reportedly twice as likely to have depression as people who do not have HIV^6,7. Substance use disorders, such as injection drug abuse, which frequently co-occur with mental illnesses, elevate risk for contracting HIV, and one in 10 new HIV infections in the United States reportedly occurs among people who inject drugs⁸. In the context of HIV, mental illnesses and co-occurring behavioral disorders are associated with decreased utilization of and adherence to antiretroviral therapy, reduced retention in HIV care, decreased virological suppression, worse disease progression, more opportunistic infections, and death^9-11.

As people living with HIV in the United States is now living longer, multiple comorbidities and polypharmacy may also directly or indirectly affect their mental health as well as oral health. Pharmacological agents to treat mental illnesses or addiction are known to induce xerostomia and increase risk for oral diseases¹². Furthermore, empirical and clinical data indicate that people who use illicit drugs such as opioids and stimulants commonly experience drug-associated symptoms including xerostomia, bruxism, appetite suppression, and craving for sweet foods and poor oral health outcomes such as generalized caries and periodontal disease^13-15. Poor oral health and symptoms of oral diseases could also negatively affect overall health and wellbeing by undermining self-esteem, social relationships, and dietary intake due to pain and discomfort. However, little is known about how oral health is affected by mental illnesses and co-occurring disorders as well as biologic, psychosocial, behavioral conditions or vice versa in the context of people living with HIV.

Gaps and Opportunitites

Over the past 10 years, there has been limited research focused on mental and oral health in people living with HIV. Mental illnesses along with substance use disorders can be a debilitating factor for the oral health of people living with HIV and oral health care continuum outcomes. It is important, therefore, to understand the relationship and its biological, psychosocial, and behavioral mechanisms underlying the relationship. Such an understanding will inform strategies to prevent and manage oral health issues as part of whole-person care for people living with HIV and ongoing vulnerability to emotional, psychosocial, and immunological distress.

This initiative will build upon recent NIDCR’s HIV/AIDS research initiatives as listed below and will foster interest and advancement of understudied HIV/AIDS research. In addition, one of the four overall strategic goals in the FY2021-2025 NIH Strategic Plan for HIV and HIV-Related Research: “Advance rigorous and innovative research to end the HIV pandemic and improve the health of people with, at risk for, or affected by HIV across the lifespan” will be addressed through this initiative. NIDCR’s HIV/AIDS and Oral Health Research Program intends to collaborate with National Institute of Mental Health (NIMH) as a strategy to promote interdisciplinary collaborations in this research area.

Recent NIDCR HIV/AIDS Research Initiative:

• Oral Health in People Living with HIV and Additional Non-Communicable Diseases (FY2020)
• Engaging Dental Professionals to End the HIV Epidemic (FY2021)
• Understanding Oral Human Papillomavirus (HPV) Infection, Acquisition, and Persistence in People Living with HIV (FY2022)

Specific Areas of Interest

Potential areas of research that could address evidence gaps include but not limited to:

• Study people living with HIV longitudinally to understand the independent and interactive effect of mental illness and co-occurring conditions on oral health outcomes and vice-versa.
• Examine the extent to which people living with HIV with and without mental illnesses may be affected by oral health disparities.
• Identify upstream social determinants of health that influence trajectories of mental and oral health outcomes in people living with HIV and or at risk for HIV across the lifespan.
• Elucidate the interplay of biologic, psychosocial, and or behavioral common pathways contributing to oral health and mental health in the context of people living with HIV.
• Investigate the combined impact of antiretroviral therapy and pharmacotherapy for mental and behavioral disorders on oral health and well-being of people living with HIV or the risk of contracting HIV.
• Examine the extent to which HIV-associated stigma and discrimination impact mental illnesses and oral health outcomes.
• Identify modifiable biologic, psychosocial, and behavioral risk factors and facilitators involving pathogenesis and prognosis of mental illnesses, co-occurring disorders, and oral health in the context of HIV and ART.
• Evaluate the impact of interpersonal factors on the behavioral and disease processes and outcomes of mental and oral health.
• Gain an understanding of whether and how mental health and behavioral disorders could be effectively assessed and intervened in dental settings for people living with HIV or the risk of contracting HIV.

References

1. Kisely S, Sawyer E, Siskind D, Lalloo R. The oral health of people with anxiety and depressive disorders—a systematic review and meta-analysis. J Affect Disord. 2016;200:119-32.
2. Kisely S, Baghaie H, Lalloo R, et al. A systematic review and meta-analysis of the association between poor oral health and severe mental illness. Psychosom Med. 2015;77(1):83-92.
3. DaCosta Vieira V, Lins L, Sarmento VA, et al. Oral health and health-related quality of life in HIV patients. BMC Oral Health. 2018;18(1):151.
4. Parish CL, Feaster DJ, Pereyra MR, et al. Oral health-related quality of life and unmet dental needs among women living with HIV. J Am Dent Assoc. 2020;151(7):527-35.
5. Dobalian A, Anderson RM, Stein JA, et al. The impact of HIV on oral health and subsequent use of dental services. J Public Health Dent. 2003;63(2):78-85.
6. Remien RH, Stirratt MJ, Nguyen N, et al. Mental health and HIV/AIDS: the need for an integrated response. AIDS. 2019;15;33(9):1411-20.
7. National Institute of Mental Health. HIV/AIDS and Mental Health.
8. US Department of Health and Human Services. About Ending the HIV Epidemic in the US: Overview.
9. Rooks-Peck CR, Adegbite AH, Wichser ME, et al. Mental health and retention in HIV care: A systematic review and meta-analysis. Health Psychol. 2018;37(6):574-85.
10. Shuster R, Bornovalova M, Hunt E. The influence of depression on the progression of HIV: direct and indirect effect. Behav Modif. 2012;36(2):123-45.
11. Hodder SL, Feinberg J, Strathdee SA, et al. The opioid crisis and HIV in the USA: deadly synergies. Lancet. 2021;397(10279):1139-50.
12. Cockburn N, Pradhan A, Taking MW, et al. Oral health impacts of medications used to treat mental illness. J Affect Disord. 2017;223:184-193.
13. Murphy DA, Harrell L, Fintzy R, et al. Soda consumption among Methamphetamine users in the USA: Impact on Oral Health. Oral Health Prev Dent. 2016;14(3):227-234.
14. D’Amore MM, Cheng DM, Kressin NR, et al. Oral health of substance-dependent individuals: Impact of specific substances. J Subst Abuse Treat. 2011;41(2):179-85.
15. Yazdanian M, Armoon B, Noroozi A, et al. Dental caries and periodontal disease among people who use drugs: a systematic review and meta-analysis. BMC Oral Health. 2020;20(1):44.