HIV & Oral Health PDF

BREAKING BARRIERS HIV/AIDS and the Dental Patient THE GAP BETWEEN OUR TEETH H E A LTH I N S U RA N C E - G E N E RA L P O P U L ATI O N Adults 19-64. (ADA Stats) 59.0% have private dental benefits 7.4% Have Dental Benefits through Medicaid 33.6% Do not have dental benefits Nearly 46% of all adults o...

BREAKING BARRIERS HIV/AIDS and the Dental Patient THE GAP BETWEEN OUR TEETH H E A LTH I N S U RA N C E - G E N E RA L P O P U L ATI O N Adults 19-64. (ADA Stats) 59.0% have private dental benefits 7.4% Have Dental Benefits through Medicaid 33.6% Do not have dental benefits Nearly 46% of all adults over 30 years or older show signs of gum disease H EA LTH I N S U RA N C E - P LW H A Presently, 68% of PLWHA have incomes below 100% of the federal poverty level (FPL), yet only 34% qualify for Medicaid. More than half the people with diagnosed HIV in the United States—nearly 562,000 people in 2020—receive services through RWHAP each year. Many PLWHA may not gain Medicaid coverage until their illness progresses to the point that they are determined to be eligible as a result of disability, even though national treatment guidelines recommend access to early treatment. Access to oral health care is constrained, even in states where Medicaid covers adult dental care, because relatively few dentists participate, many people face geographic barriers to care, administrative requirements can be arduous, coverage is often limited, and Medicaid reimbursement is low compared with a dentist's usual fee. OLDER AMERICANS Older Americans have a tooth problem - half lack dental insurance - in 2018 nearly half received no dental care - big changes in dental care and oral health after older adults become eligible for Medicare - covers medical services but not dental care - recent survey (Harvard School of Dental Medicine/Brigham) (Published in Health Affairs)of 97,000 people ages 50-85 *dramatic drop in the percentage who received restorative dental care * five percent increase in the number of people who lost all their teeth after turning 65 * Older adults have lowest rates of dental insurance in the US * traditional Medicare and Medical Advantage beneficiaries experienced immediate and long-term reduction in dental services use after Medicare enrollment * total number of annual dentist visits did not change…but the number of visits for restorative procedures such as filings or crowns decreased by 8.7 percent * increase in complete loss of teeth- higher risk of poor nutrition, lower quality of life BARRIERS FOR PLWHA 1.1 Million people living with HIV Infection in the US Amid all advances in HIV/AIDS care and treatment, access to oral healthcare continues to be frequently cited by state and regional HIV/AIDS patient needs assessments as a primary unmet need. (CDC Public Health Report) 1. Lack of coverage through private insurance 2. Dwindling benefits provided by state Medicare 3. Patients inability to pay for dental services out of pocket 4. Inability to find HIV friendly dentist 5. Fear of going to the dentist 6. Concerns about confidentiality, stigma and discrimination 7. Ryan White refunding (Political Climate) DI S C U S S I O N - W H AT W O U L D YO U DO ? RE A L PATI E N T EXPERIENCES Patient referred to a booked and confirmed emergency dental appointment by care team nurse. Upon arrival patient was told that she didn’t have an appointment even though it was confirmed. Patient was told to go to emergency room not before patient was pestered by questions regarding her HIV status. And not about the emergency issue that she was experiencing. She was asked at front desk in sight and in earshot of waiting room patients “what medications are you on?”, “why are you not on medications”, “do you have a doctor” “are you virally suppressed”? Patient felt that she was being judged, and that many of the questions regarding her HIV care, health, medications and status were invasive and stigmatizing. Patient stated that the way the front office staff spoke to her about her HIV status made her uncomfortable and ashamed and she hasn’t felt that way about her status in a long time. Since patient was not receiving help, she went to the ED and end up having to pay $251.00 out of pocket. RE A L PATI E N T EXPERIENCES Patient arrived at dental clinic with scheduled appointment. Patient was told that she couldn’t be seen because her labs were not up to date. She had labs within the past six months and dental practice had those results, but because it was not recent three months (old protocol) she couldn’t be seen and was told to ”be on top of things” and get her labs re-drawn. Patient also heard and observed staff team discuss her HIV status loudly and openly in the clinic. Patient was made to feel ashamed since they were discussing her HIV status as if she was not present. Patient stated that “I was so hurt”. They were stigmatizing me and it was so unfair. I was treated like I was a disease and not a human. I was so upset when I left that I had forgotten my bag and my sunglasses and had to go back and face the same people who treated me so shamefully. I will never go back. A Common Form of Human Rights Violation is a Dentist refusing to take on a new patient due to their HIV status. SOME OTHER COMMON FORMS OF HUMAN RIGHTS V I O L AT I O N S I N D E N TA L P R A C T I C E S Dentists abandoning the care of long- term patients due to their HIV status Breaches of confidentiality Use of extra protective precautions Duty to Accommodate Not only must dentists not discriminate, they must accommodate the individual needs of people with disabilities They must take reasonable steps to accommodate, up to the point of “undue hardship” Within reason, a dentist may need to educate themselves or consult with other professionals in order to provide adequate treatment to their patient (e.g. call their doctor to discuss possible drug interactions with HIV meds) P R E PA R E A L L Y O U R O F F I C E S TA F F TAKE THE TIME TO BUILD A SAFE AND EMPATHETIC ENVIRONMENT R E Q U I R E M E N T S F O R YO U A N D YO U R D E N TA L S TA F F Hold a staff meeting focused on developing a compassionate and safe environment for people living with HIV to access services: Designate a facilitator to lead the office through a discussion of HIV in the workplace, this facilitator will prepare in advance to carry out the following activities Call a staff meeting, let staff know that at the meeting you will be discussing how your office can better address HIV in your practice Begin the meeting by discussing that HIV is a challenging issue for dental providers, not just technically, but also emotionally. Explain that what you want to do today is to have an open discussion about people’s concerns around HIV/AIDS. This means that people need to feel safe and to feel like they are free to discuss their feelings on this difficult issue. Set the tone for the discussion by setting ground rules. Ask the group what they think the rules for this discussion should be. Include rules like: 1) No judgment- don’t judge the way people feel, 2) Allow others to express themselves without interrupting, 3) Respect each other, etc. Ask people to brainstorm some of their concerns and fears regarding providing dental care to people living with HIV. Write those concerns and fears on the whiteboard/ paper If people are hesitant to talk, the facilitator can get the ball rolling by discussing some of their own fears/ concerns (e.g. concern about getting a needle stick, not being sure about the best sterilization techniques for a specific piece of equipment, not liking to provide dental care to people who don’t take care of their teeth well, not knowing what to talk to them about, not wanting to offend them, being worried about infections or drug interactions, etc.) Try to get some discussion going. If the discussion is too superficial, delve deeper by asking people why they have a certain concern or fear, or by asking people what their experiences providing care to people living with HIV have been so far. After some discussion, look at the responses and summarize them. This could include comments like, “This group seems quite comfortable with serving people living with HIV, but it seems like there are a few things people would like to learn more about”, or, “This group seems to have a lot of concerns about serving this group, so it may be a good idea to create a strategy to help us address these concerns”. Leave the initial brainstorm on the whiteboard or wall, and write two new words the white board/ paper: Overcoming fears, finding solutions Start going though the list of concerns/fears and, for each one, ask the group: “What could we do in our office to overcome this fear or find a solution to address this concern” Write the responses on the whiteboard/ paper. If people are not sure how to address a certain concern, write that down too. In the end, this list may include things like having a staff information session on HIV transmission, having a consultant come in to review the office sterilization system, having a staff in-service on barriers to good dental hygiene and how a provider can help patients work with limited resources to maintain their dental care or inviting a person living with HIV to visit the office and talk to the staff about their experience living with HIV, contacting an HIV doctor to discuss possible infection and drug interaction issues, etc. U N D E R S TA N D I N G L A N G U A G E THE DENVER PRINCIPLES We condemn attempts to label us as “victims” a term which implies defeat, and we are occasionally “patients” a term which implies passivity, helplessness, and dependence upon he care of others. We are “People with AIDS” (1983) NIAID HIV LANGUAGE GUIDE (HPTN.ORG) NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES language has been a central theme in efforts to dismantle stigma around HIV. Many HIV advocacy groups and media outlets embrace slogans such as “language matters” and promote primers on using empowering language Empowering language remains an important focus for all medical/dental and all organizations because language perpetuates stigma, and as studies continue to bear out, stigma helps perpetuate the HIV epidemic KNOWLEDGE IS P O W ER. W H AT CAN YOU DO TO PREVENT STIGMA AND D I S C RI M I N AT I O N PUT PATIENTS’ INTERESTS FIRST AND ACT TO PROTECT THEM. Work to overcome any fears or concerns you may have in order to provide your patients living with HIV with the best care possible If you feel like someone in your office is not being respectful towards a patient, pull them aside to discuss the problem Consider the challenges your patients may be facing, and try to find ways to help them overcome those challenges. For example, many people living with HIV are living on very low incomes, so providing them with an extra toothbrush, floss and toothpaste may help them better maintain their dental hygiene between visits. Similarly, many people living with HIV are on income support programs like AISH or CPP-D that provide limited dental coverage. So, taking the time to discuss which dental options cost the least but offer the best quality could help reduce the financial burden they will need to bare. Take patient complaints seriously and respect their right to make a complaint if they feel that the service they have received is not adequate or respectful. Respond to those complaints appropriately. Understand that many people living with HIV have had negative experiences in the dental office, and may be more sensitive to the way they are treated as a result. RESPECT PATIENTS’ DIGNITY AND CHOICES. Treat all of your patients with dignity and respect Even if you don’t agree with the choices your patient has made (e.g. drug use, smoking etc.), respect their right to make decisions for themselves and do not treat them badly because of their choices. Recognize the right of each individual to make decisions regarding their bodies, their care, and their priorities and discuss any treatment decisions with the individual before proceeding to deliver care. Treat patients equally. Do not discriminate against any person on the basis of physical/ mental disability including HIV status, Hepatitis C status, drug and alcohol addiction, gender including transgendered people, sexual orientation, family status, marital status, source of income race, color, ancestry, place of origin, religious beliefs or age. Create an office space that is welcoming and inclusive of diversity. Decorate with posters and provide reading materials that reflect the diversity of the people you serve, including ethnicity, sexual orientation, gender, socio-economic status and disability. Including a poster or pamphlet to raise awareness about HIV and to reduce stigma will help encourage your patients to feel safe about disclosing their HIV status.(Especially with the initiative to provide HIV testing in dental clinics.) Contact your local AIDS Service Organization to request materials. 1. Protect the confidentiality of patients’ information. 2. Due to the stigma attached to HIV status, many people living with HIV do not even share their HIV status with their friends and family. Any information on HIV status shared with a dental professional must be kept confidential and used only for the purpose for which it was given 3. Within the dental office, extra care should be taken in discussing the individual’s HIV status to ensure that other staff and patients are not able to eavesdrop on confidential conversations in open concept spaces. If it is necessary to discuss information related to the patient’s HIV status, the conversation should take place in a private and confidential location, like a closed office or examination room 4. All patient information collected should be kept in a secure location (e.g. a locked filing cabinet) in order to prevent accidental disclosure or unauthorized access to confidential files 5. If it is necessary to share patient information with a health professional outside of the dental office, the patient should be asked to provide their written consent 6. Ensure that intake forms in dental offices are specify that information collected will be kept confidential and will not be used to screen people as patients, but instead, will be used to ensure superior care tailored to their specific needs, and appropriate referrals when necessary. TEACHING YOUR STUDENTS Focus on professional ethics involving discussion and debate on essential topics of respect, dignity, confidentiality, discrimination and stigma, the application of interpersonal and communication skills in the context of delivering dental care to PWH. Develop a professional identity of a clinician who has insight into one's attitudes; be emotionally prepared for treating people with infectious diseases, be stimulated to build selfconfidence and treat all patients with respect. In some studies dental students perceived a lack of preparedness in delivering dental care to HIV patients. Nearly a quarter of students (24%) did not agree with the statement “The HIV teaching prepared me to provide dental treatment to HIV patients.” It would be enlightening to explore further the reason for this reluctance and to identify whether it is due to students' perception that PWH need specialist complicated clinical management or if it is due to prejudice against this group of people. Bring speakers in for a specialty class to hear experiences and suggestions that PLWHA can bring to the students including, use of language, their experiences, address students concerns, biases and attitudes regarding issues they may be struggling with, especially within marginalized and disenfranchised communities. A didactic and experiential problem-based approach using role-play with simulated patients with feedback, and discussion should be utilized. C U RRE N T RE S E A RC H I N I TI ATI V E S H I V & ORA L H EA LTH SCIENTIFIC WORKING GROUP Providence/Boston CFAR H I V & ORA L H EA LTH S W G Purpose: Advance the scientific understanding of the interplay between HIV and oral diseases through hypothesis-driven clinical, social/behavioral, and basic research by developing new collaborations between HIV, dental, and other oral health researchers to address important scientific questions prioritized by NIH and by fostering the career development of junior researchers. Leadership: Co-Director: Michelle Henshaw, DDS, MPH, Associate Dean, Office of Global and Population Health, BU Goldman School of Dental Medicine Co-Director: Curt Beckwith, MD, Associate Director of the P/B CFAR, Division of Infectious Diseases, Miriam Hospital/Brown University Associate Director: Hisashi Akiyama, PhD, Research Assistant Professor of Microbiology, Boston University School of Medicine Multidisciplinary participation: Clinical, social/behavioral, basic science research across multiple specialties (HIV medicine, dental medicine, infectious diseases, oncology, otolaryngology, addiction medicine), C-CERC, and community providers SPECIFIC AIMS Aim 1: Support and expand clinical research on HIV and oral health including the delivery of HIV testing, prevention, and linkage services in dental clinics that serve high-risk populations. Aim 2: Support and expand social and behavioral science research on HIV and oral health including the impact of HIV-related and intersectional stigmas on access to dental and oral health services Aim 3: Conduct basic science research to investigate the interplay between chronic inflammation in the oral cavity and HIV pathogenesis, HIV and oral mucosal epithelial interactions, and HIV and the oral microbiome Aim 4: Recruit junior and senior investigators to pursue research in HIV and oral health C OMMU NITY PARTNERS CFAR Community Engaged Research Council (C-CERC) QUESTIONS/DISCUSSION