The New York State Dental Foundation in conjunction with the NY/NJ AIDS Education and Training Center is pleased to offer this online continuing education opportunity for free to all dental professionals in New York State. This course seeks to provide an overview of rapid HIV testing in the dental setting.
The course consists of two components; the first, requires that you read an article by David Nassry, DMD, of the NYS AIDS Institute. After completing the article, you may continue to step 2, which is an exam corresponding to the material in the article. Once you complete the exam, you will receive your certificate of completion 3-5 business days after successful completion (65% or higher).
Begin by reading the article "Rapid HIV Testing in the Dental Setting" by David Nassry, DMD:
RAPID HIV TESTING IN THE DENTAL SETTING
David Nassry, DMD
In September of 2006, the Centers for Disease Control revised their recommendations for HIV testing in health-care settings. The objectives of these recommendations are to encourage “all health-care providers” to increase HIV screening of patients; foster earlier detection of HIV infection; identify and counsel persons with unrecognized HIV infection and link them to clinical and prevention services; and, therefore, reduce transmission of HIV in the United States. (1)
Human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) remain leading causes of illness and death in the United States. By the end of 2006, an estimated 436,693 persons in the USA were living with HIV/AIDS. In 2007, an estimated 33.2 million people lived with the disease worldwide, and it killed an estimated 2.1 million people, including 330,000 children. Since 1994, the annual number of cases among blacks, members of other racial/ethnic groups and persons exposed through heterosexual contact has increased. (2, 18, 19)
By 2002, an estimated 38%-44% of all adults in the United States had been tested for HIV; 16-22 million persons aged 18-64 years are tested annually for HIV. However, at the end of 2003, of the approximately 1.0-1.2 million persons estimated to be living with HIV in the United States, an estimated one quarter (252,000-312,000 persons) were unaware of their infection and were, therefore, unable to benefit from clinical care to reduce morbidity and mortality.(3) It has been established that persons who are HIV infected and who are unaware of their status are more likely to engage in high-risk behaviors and transmit HIV unknowingly.(4,5) Since the advent of HAART therapy in 1995, survival rates of HIV-infected persons has increased dramatically.(6) Although great strides have been made in the treatment of HIV disease, progress in effecting earlier diagnosis has been insufficient.
In 2001, CDC recommendations for HIV testing in health-care settings were extended to include multiple additional clinical venues in both private and public health-care sectors, encouraging providers to make HIV counseling and testing more accessible and acknowledging their need for flexibility. The CDC recommended that HIV testing be offered routinely to all patients in high HIV-prevalence health-care settings. (7) It is known that routine HIV testing reduces the stigma associated with testing that requires assessment of “risk behaviors.” A substantial number of people do not perceive that they themselves are at risk for HIV or do not disclose their risks. (8, 10, 11) According to the CDC, more patients accept recommended HIV testing when it is offered routinely to everyone; and not just to those perceived to be at high risk. (9, 10)
When HIV disease is screened for in all health care facilities, including dental settings, it can be detected early. Once an early diagnosis is made, patients can be linked to clinical care; they can have improved health outcomes; and they have a slower clinical progression and, thus, a reduced mortality rate. (12) Reduction of viral load through timely initiation of HAART should reduce transmission. (4, 13, 14) Estimated transmission is 3.5-times higher among persons who are unaware of their infection than among persons who are aware of their infection. This contributes disproportionately to the number of new HIV infections each year in the United States. According to the CDC, new sexually transmitted HIV infections could be reduced >30% per year if all infected persons knew their HIV status. (15)
The editorials of Dr. Michael Glick and Dr. Daniel Malamud in JADA, March 2006, have made all oral health-care providers aware that the time to bring oral diagnostics to the dental setting is upon us (16, 17). Conducting rapid testing and counseling individuals in the dental setting not only provides our patients with a much-needed service, it also introduces oral healthcare providers to the emerging role “sialology” (16) plays in the dental practice.
Oral fluid tests requiring only a painless swab of the gingiva can reveal in 20 minutes if a person has HIV antibodies. Almost three years after the CDC recommendations, very few dental offices are offering this test to their patients
OraQuick Advance Test Procedures for Screening
The OraQuick Advance Test is an oral fluid collection screening device that can detect HIV antibodies in the oral fluid in 20 minutes. The test kit contains a testing swab and a vial that contains a predetermined amount of testing solution. The testing procedure requires a painless swab of the gingival tissues with the testing device. The testing device is then placed into a vial containing the testing solution. In 20 minutes, the testing device will indicate if HIV-1 and/or HIV-2 antibodies are present in the solution by displaying reddish-purple lines in a small window on the device. A negative result will show only one line in the device window. If the test result reads “preliminary positive,” the testing device will show two lines in the device window. A “preliminary positive” result will require a secondary confirmatory western blot test be conducted by venipuncture. This test will confirm the presence of viral antibodies in the bloodstream. “Preliminary positive” test results require proper referrals and linkages to care; therefore, proper protocols should be in place.
Sensitivity levels for the OraQuick Advance Test exceed 99%, with specificity rates of up to 100%. False positive results are possible, however, and may be associated with the presence of antibodies to viral infections such as Epstein-Barr, or hepatitis A or B. Negative results are considered definitive.
The OraQuick Advance Test is a CLIA-waived test, which means there is no need for federal requirements for personnel, quality assessment, or proficiency testing.
New York State
New York State mandates a specific informed consent process (http://www.health.state.ny.us/diseases/aids/forms/index.htm) for HIV testing. It must be stressed that any dental office wishing to implement a rapid screening program should have an in-depth protocol for testing and proper referral in place. New York State recommends that all testers have specific training in the counseling and testing procedure.
The consent and pretest counseling process includes a review of testing options and an assessment of a patient’s readiness for rapid test results. Once the rapid test is conducted and the results are delivered to the patient, post-test counseling is recommended. If the rapid test is negative, the provider is expected to review the HIV “window period” and, depending on protocols set at the testing site, assess the risk of HIV exposure in the last 90 days and create a harm reduction plan. If the patient has been at risk for HIV infection within last 90 days, a retesting appointment is recommended. (http://www.health.state.ny.us/diseases/aids/training/index.htm)
If the HIV test is preliminary positive, proper referrals should be made immediately for confirmatory testing, where an in-depth client risk assessment should be conducted. The importance of confirmatory testing and return visit to the provider should also be stressed. Follow-up contact information should be collected and a prevention strategy for decreasing transmission to others implemented.
Conducting routine rapid testing and counseling of individuals in the dental setting provides a much-needed service to subjects who, for various reasons, are unwilling or unable to go to standard medical clinics to receive HIV testing. As oral health-care providers, we do not often cross into the realm of the delivery of a life-changing and possibly fatal diagnosis. If, however, we are going to take a more proactive approach in the testing of saliva, then our embracing of rapid tests, such as those used for HIV, must become as much a part of our treatment as any other screening tools we already use.
Oral health-care providers wishing to establish this service in their practice can contact the NY/NJ AIDS Education & Training Center Oral Health Regional Resource Center at 315-477-8479 for technical assistance.
Click here to complete the exam for this course.
References:
1. MMWR. Recommendations and Reports. September 22, 2006. 55(RR14); 1-17.
2. CDC. HIV/AIDS Surveillance Report, 2004. Vol. 16. Atlanta: Us Department of Health and Human Services, CDC: 2005: 1-46.
3. CDC. Number of persons tested for HIV---United States, 2002. MMWR 2004; 53:1110--3.
4. Marks G, Crepaz N, Senterfitt JW, Janssen RS. Meta-analysis of high-risk sexual behavior in persons aware and unaware they are infected with HIV in the United States: implications for HIV prevention programs. J Acquir Immune Defic Syndr 2005; 39:446--53.
5. Weinhardt LS, Carey MP, Johnson BT, Bickham NL. Effects of HIV counseling and testing on sexual risk behavior: a meta-analytic review of published research, 1985--1997. Am J Public Health 1999; 89: 1397--405.
6. Palella FS, Deloria-Knoll M, Chmiel SS, et al. Survival benefit of initiating antiretroviral therapy in HIV-infected persons in different CD4+ cell strata. Ann Intern Med 2003; 138:620-6.
7. CDC. Revised guidelines for HIV counseling, testing, and referral. MMWR 2001; 50(No. RR-19):1--62.
8. CDC. Voluntary HIV testing as part of routine medical care---Massachusetts, 2002. MMWR 2004; 53:523—6.
9. Fincher-Mergi M, Cartone KJ, Mischler J, Pasieka P, Lerner EB, Billittier AJ IV. Assessment of emergency department healthcare professionals' behaviors regarding HIV testing and referral for patients with STDs. AIDS Patient Care STDs 2002; 16:549--53.
10. CDC. HIV prevalence, unrecognized infection, and HIV testing among men who have sex with men---five U.S. cities, June 2004--April 2005. MMWR 2005; 54: 597-601.
11. CDC. Anonymous or confidential HIV counseling and voluntary testing in federally funded testing sites---United States, 1995--1997. MMWR 1999; 48:509- 513.
12. US Preventive Services Task Force. Screening for HIV: recommendation statement. Ann Intern Med 2005; 143:32--7.
13. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Engl J Med 2000; 342:921--9.
14. Sanders GD, Bayoumi AM, Sundaram V, et al. Cost-effectiveness of screening for HIV in the era of highly active antiretroviral therapy. N Engl J Med 2005; 352:570--85.
15. Marks G, Crepaz N, Janssen RS. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS 2006; 20:1447--50.
16. Glick M. Sialology, who owns saliva anyway? JADA 2006; 137: 282-283.
17. Malamud D. Salivary diagnostics: the future is now. JADA 2006; 137:284-283.
18. UNAIDS, WHO “2007 AIDS Epidemic Update” December 2007.
19. CDC, HIV/AIDS Surveillance Report, 2006, Vol. 18, Atlanta: US Department of Health and Human Services, CDC; 2007 ; 1-55.
Do you have questions for the instructor?
E-mail the instructor with any questions you may have regarding this course.
The New York State Dental Foundation is an ADA-CERP approved provider of continuing education.
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