Engaging Dental Health Professionals to “End the HIV Epidemic”

Behavioral and Social Science Research Branch

HIV/AIDS and Oral Health Research Program, Center for Clinical Research

Division of Extramural Research

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The purpose of this initiative is to support research on how to optimally engage the dental workforce in meeting the unique needs of individuals living with or at risk of contracting HIV. The contributions of these and other health providers will be essential for reaching the ambitious new goals set by the U.S. Department of Health and Human Services (HHS): reducing new HIV infections by 75% in 5 years and 90% in ten years.1

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There are 1.1M people living with HIV in the U.S., 14% of whom are unaware of their infection. Among the 40,000 newly diagnosed HIV infections in 2017,2 21% occurred in young people, 13-24 years old. Men who have sex with men (MSM) bear the greatest burden of HIV, with the majority of new infections occurring among Black/African American and Hispanic/Latino MSM.2 There are also notable disparities in the geographic distribution of HIV infection. Of the 3,007 counties in the United States, over 50% of new HIV infections in 2016-2017 occurred in only 48 counties along with Washington, DC and San Juan, Puerto Rico. These densely populated areas of concentrated HIV infection are paralleled by notable disparities in rural areas, especially 7 states in the Southeast with a high burden of HIV.3

Fortunately, powerful medications already exist to treat and prevent HIV infection. Current treatment strategies for HIV include many FDA-approved, Anti-Retroviral Therapies (ART)4 that increase the life expectancy of newly diagnosed subjects by an average of 53 years.5 Beyond their capacity for extending life, when treatment regimens are adequately adhered to, ARTs can suppress viral load to such an extent that risk of transmission to others is essentially eliminated. It has been established that treated HIV-positive men do not transmit the disease to their partners,6 and many additional studies consistently demonstrated that there is no transmission of the virus over many years of follow up,7 inspiring the message that “undetectable equals untransmissible” (U=U).8 Individuals who are not HIV positive but are at risk may be candidates for pre-exposure prophylaxis (PrEP) regimens that are more than 95% effective in preventing HIV infection if taken daily.8

Despite these and other recent advances in the prevention and treatment of HIV infection, persistent barriers impede progress toward reducing the burden of HIV and reinforce health disparities. Among those receiving HIV treatment, achieving and maintaining suppressed viral load typically requires strict adherence to dosing regimens that may be thwarted by a diverse array of complications, including aversive side effects, limited access to medication supplies, fear of being identified as a member of a stigmatized group, or simply forgetting. Many of these challenges also apply to individuals who could benefit from the protective effects of PrEP, though initiating PrEP use is further complicated by the relative scarcity of informed providers who are willing to prescribe PrEP, often in geographic areas of greatest need.9 These challenges to the uptake and maintenance of effective preventive and therapeutic regimens ultimately enable the continued transmission of HIV infection, and overcoming them will require the coordinated contributions of diverse healthcare professionals and stakeholders.

Better interfacing with established sources of HIV care represents an important opportunity to integrate dental and oral health within overall health. Supporting research in this area could have structural impact by efficiently linking dental healthcare providers with colleagues who have conventionally been more involved in the treatment of HIV. Research supported by this initiative could likewise have public health impact by curbing new HIV infections and ultimately reducing the overall disease burden.

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Gaps and Opportunities

Although ongoing research aims to further advance the biomedical landscape for detecting and treating HIV, there is an immense need for structural, social, and behavioral approaches that maximize the uptake and effectiveness of the best tests, treatments, and prophylactics that are currently available. The HHS “Plan for America” proposes a four-part approach targeting areas of greatest need to eliminate new HIV infections:

  • Diagnose all people with HIV as early as possible after infection
  • Treat the infection rapidly and effectively to achieve sustained viral suppression
  • Protect people at risk for HIV using potent and proven prevention strategies, including PrEP
  • Respond rapidly to detect growing HIV clusters and prevent new HIV infections

The proposed initiative would align with recent activities by NIDCR Program Staff representing DOC interests across NIH as well as the newly announced HHS plan for “Ending the HIV Epidemic.” Notably, oral health has been incorporated into the solicitation language for an upcoming supplement opportunity for Center for AIDS Research (CFAR) investigators on “Gaps in the HIV Care Continuum in Rural Communities.” It would also run parallel to a related initiative on “Increasing uptake of evidence-based screening in diverse adult populations” (PA-18-932) in which the NIDCR participates. This initiative also encourages the application of implementation science principles from NIDCR’s 2018 FOA (RFA-DE-18-001) to the HIV epidemic.

The proposed initiative would expand the NIDCR portfolio at the intersection of HIV/AIDS and Oral Health and Behavioral and Social Sciences Research. In addition to individual grants, the NIDCR co-funds several major relevant programs, including:

  • The Pediatric HIV/AIDS Cohort Study, which was developed in 2005 to determine the long-term effects of fetal and infant exposure to ART as well as the effects of perinatally acquired HIV infection in adolescents.
  • The Centers for AIDS Research, a group of US institutions that aim to support multidisciplinary research to reduce the burden of HIV in the US and around the world.
  • The Multicenter AIDS Cohort Study and Women’s Interagency HIV Study Combined Cohort Study, a decades-long combined effort to understand the biological and behavioral trajectories of HIV infection.
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Scientific Areas of Interest

Stakeholders in the dental health community have long recognized potential roles for dental care providers in reducing the burden of HIV/AIDS, though research and clinical practice have been slow to realize that vision. For example, several studies suggest that many dental providers consider HIV testing and referral within their scope of work but also acknowledge significant barriers to the broad implementation of HIV testing in dental clinics, including inadequate training for discussing HIV risk and status with patients and lack of reimbursement protocols for HIV testing and referral to treatment.10,11 Each component of the HHS plan for Ending the HIV Epidemic poses distinct opportunities for contributions from the dental community that are ripe for scientific inquiry, including:

  • When and how may dental clinics best offer HIV testing to patients?
  • What are the best communication strategies that dental care providers may adopt in discussing HIV risk/prevention or engagement/retention in care with patients?
  • How can dental care providers most effectively coordinate with colleagues in primary or specialty care to help patients successfully adhere to prophylactic or therapeutic regimens?
  • What kinds of billing/reimbursement procedures are necessary for HIV-related care (e.g., rapid testing) to be sustainable in dental clinics?
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  1. Ending the HIV Epidemic a Plan for America
  2. CDC HIV surveillance report 2017 vol 29,11/2018.
  3. AIDSinfo.nih.gov, February 2019.
  4. J Acquir Immune Defic Syndr. 2016 Sep 1;73(1):39-46. Narrowing the Gap in Life Expectancy Between HIV-Infected and HIV-Uninfected Individuals With Access to Care. Marcus JL, Chao CR, Leyden WA, Xu L, Quesenberry CP Jr, Klein DB, Towner WJ, Horberg MA, Silverberg MJ.
  5. N Engl J Med. 2011 Aug 11;365(6):493-505. Prevention of HIV-1 infection with early antiretroviral therapy. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, Hakim JG, Kumwenda J, Grinsztejn B, Pilotto JH, Godbole SV, Mehendale S, Chariyalertsak S, Santos BR, Mayer KH, Hoffman IF, Eshleman SH, Piwowar-Manning E, Wang L, Makhema J, Mills LA, de Bruyn G, Sanne I, Eron J, Gallant J, Havlir D, Swindells S, Ribaudo H, Elharrar V, Burns D, Taha TE, Nielsen-Saines K, Celentano D, Essex M, Fleming TR; HPTN 052 Study Team.
  6. Lancet HIV. 2018 Aug;5(8):e438-e447. Viral suppression and HIV transmission in serodiscordant male couples: an international, prospective, observational, cohort study. Bavinton BR, Pinto AN, Phanuphak N, Grinsztejn B, Prestage GP, Zablotska-Manos IB, Jin F, Fairley CK, Moore R, Roth N, Bloch M, Pell C, McNulty AM, Baker D, Hoy J, Tee BK, Templeton DJ, Cooper DA, Emery S, Kelleher A, Grulich AE; Opposites Attract Study Group.
  7. JAMA. 2019 Feb 5;321(5):451-452. HIV Viral Load and Transmissibility of HIV Infection: Undetectable Equals Untransmittable. Eisinger RW, Dieffenbach CW, Fauci AS.
  8. Lancet Infect Dis. 2014 Sep;14(9):820-9. Uptake of pre-exposure prophylaxis, sexual practices, and HIV incidence in men and transgender women who have sex with men: a cohort study. Grant RM, Anderson PL, McMahan V, Liu A, Amico KR, Mehrotra M, Hosek S, Mosquera C, Casapia M, Montoya O, Buchbinder S, Veloso VG, Mayer K, Chariyalertsak S, Bekker LG, Kallas EG, Schechter M, Guanira J, Bushman L, Burns DN, Rooney JF, Glidden DV; iPrEx study team.
  9. CDC map 2018 “US Areas with the highest burden of HIV diagnosis”
  10. J Am Dent Hyg Assoc. 2017;91(6):41-48. Patients' Willingness to Participate in Rapid HIV Testing: A pilot study in three New York City dental hygiene clinics. Davide SH, Santella AJ, Furnari W, Leuwaisee P, Cortell M, Krishnamachari B.
  11. AIDS Care. 2018;30(3):347-352. HIV testing in the dental setting: Perspectives and practices of experienced dental professionals. Parish CL, Siegel K, Liguori T, Abel SN, Pollack HA, Pereyra MR, Metsch LR.
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Last Reviewed
September 2019