|David A. Reznik, DDS
It has been 28 years since the first reports of acquired immunodeficiency
syndrome (AIDS) were reported to the Centers for Disease Control and
Prevention (CDC). The CDC’s 2007 HIV/AIDS Surveillance Report reveals that
more than 1.7 million people have been infected with human immunodeficiency
virus (HIV) since the beginning of the epidemic, including more than 580,000
who have died, and an estimated 1.1 million who are living with HIV in the
United States.1 More than 56,000 new HIV infections are estimated to occur
annually—a 40% increase over previous estimates.2 The CDC also reports that
approximately 25% of HIV-positive individuals remain undiagnosed.3
Approximately 36% of those who do test positive are identified late and
progress to an AIDS diagnosis within 1 year.4 The CDC recommends offering
routine HIV screening in alternative settings, which can include dental
programs, to enable people to learn their HIV status earlier.
Early diagnosis of HIV leads to a healthier and more
productive life, improves the outcomes of therapies, and is cost-effective
over time.5 In addition, more than half of all new infections are
transmitted by people who are unaware of their serostatus.6 In 2006, the CDC
updated its HIV testing recommendations, summarized in Table 1, to include
that all individuals aged 13 to 64 should be screened for HIV at least once
and those at higher risk for infection should be tested annually.4
Why Screen in the Dental Setting?
Screenings for health-related conditions have long been a
part of routine dental care. For instance, dental healthcare workers must be
knowledgeable about hypertension, particularly detection and proper referral
for treatment.7 More than one quarter of the US population has undiagnosed
hypertension and does not show any obvious symptoms.8 The present
recommendation is that blood pressure readings should be taken on all new
patients and at recall appointments at least on an annual basis.7 Screening
for oral cancer is a part of a routine dental examination and the industry
continues to develop tools to help assist in the detection of oncogenic
changes early in the course of the disease.
The dental team has been an important part of HIV primary
care since the early days of the epidemic, when up to 80% of all
HIV-positive patients would present with an oral manifestation related to
disease progression.9 Dental healthcare workers are often the first to
recognize symptoms consistent with HIV and typically refer patients out to
learn their status. However, the referring dental provider could not be
confident that the patient would obtain an HIV test. Considering that
advances in the medical management of HIV transformed this once-certain
death sentence into a chronic condition, it is time for a new dental public
health strategy that incorporates the latest scientific advances, including
rapid oral-fluid–based diagnostics. The advent of rapid HIV-screening
technologies allows individuals to learn their HIV status in approximately
20 minutes, well within the timeframe of a routine dental visit. People are
more than twice as likely to receive their results when rapid HIV-testing
technologies are used.10 The advantages of rapid HIV tests, particularly
with oral-fluid specimens, include increased acceptability of testing among
populations at risk for HIV infection and increased receipt of test
results.11 Proactive dental programs in both the public and private sectors
have partnered with AIDS service organizations, community health centers,
free health clinics, and hospitals to facilitate confirmatory testing and
linkage to primary HIV care and appropriate support services.
Review of HIV Testing Methods
Standard HIV Test: ELISA
ELISA antibody testing looks for antibodies to HIV in the
patient’s blood. After a patient has blood drawn, it is sent to a laboratory
for processing where a laboratory technician places the serum in contact
with particles of HIV in the presence of an indicating substance. If HIV
antibodies are present, they will bind to the HIV particles and cause the
serum to change color. If the ELISA test is positive, the laboratory will
automatically perform a confirmatory test.
Rapid HIV Tests
Rapid tests are similar to the ELISA test in that they
look for antibodies in the patient’s blood, serum and/or oral fluid. They
are called rapid as the results are available within 1 hour or less compared
to several days for ELISA. If a rapid test is positive, it must be followed
up with a confirmatory test. For a complete list of FDA-approved rapid HIV
tests, see Table 2, which appears courtesy of the American Academy of HIV
The sensitivity (the proportion of people with a disease
who are accurately identified by a test) and specificity (the proportion of
people without a disease who are correctly identified by a test) of these
tests ranges from 98.4% to 100%. A patient with a history of recent HIV risk
behaviors should have a repeat rapid HIV test because it may take up to 3 to
6 months for HIV antibodies to be detected after exposure. Testing during
this period may be indeterminate or give a false-negative test result.
Western Blot: This is the most widely used confirmatory
test for HIV infection. Western Blot uses an electrophoretic technique that
separates out specific HIV antigens. The Western Blot confirmatory test will
rarely be indeterminate and this most frequently occurs if the patient was
Immunofluorescence antibody (IFA): Infected HIV cells are
fixed to a microscope slide. Serum is added and allowed to interact with HIV
antigens. If HIV antibodies are present in the serum, a fluorescent label
will light up the slide.
Patient Attitudes Regarding HIV Screening in the Dental
Setting: Before instituting opt-out rapid testing at the Kansas City Free
Health Clinic’s dental program, an attitude assessment survey of dental
patients was performed. This pilot project assessed patients’ willingness to
be screened for HIV with an oral-fluid rapid test in the dental setting.12
Among 175 adult patients who were asked if they would accept a free
oral-fluid–based rapid HIV test in the dental program, 73% (P < .001)
responded that they were willing to be screened.
Screening in Action
Dental programs in community health centers in Casper,
Wyoming, and upstate New York were among the first to have successfully
incorporated HIV screening as a part of routine dental care in the United
States. Other dental programs soon followed in Kansas City, New York City,
Detroit, and Washington, DC. These forward-thinking programs understood that
a significant percentage of the population accesses dental care during the
course of a year that do not access medical care, leading to many missed
opportunities to screen patients for diseases ranging from hypertension to
Before initiating rapid HIV screening, certain steps need
to take place:
Programs must become aware of state HIV testing laws and
incorporate HIV testing into general consent processes or develop consent
tools that will work in their setting. The national HIV/ AIDS Clinicians’
Consultation Center (www.nccc.ucsf.edu) has up-to-date information on
relevant state-specific testing laws, including information on informed
A Clinical Laboratory Improvement Amendment (CLIA)
application must be submitted if the dental program does not have one in
place. Waived tests, such as HIV rapid testing and glucose monitoring, are
not exempt from CLIA. Facilities that perform waived tests, such as dental
offices, must apply for a CLIA Certificate of Waiver. (To receive a
certificate of waiver under CLIA, a facility must only perform tests like
the glucose meter or rapid HIV tests that the FDA and CDC have determined to
be so simple that there is little risk of error. In addition, these tests
are exempted from most CLIA requirements and the programs that perform them
do not receive routine inspection.) If a private dental office decides to
implement rapid HIV screening, a CLIA application would need to be submitted
along with the $150 biennial fee. Further information on the process can be
located on the Centers for Medicare and Medicaid Services (CMS) Web site
located at www.cms.hhs.gov.
Clinicians who will be performing HIV screening must
receive training/certification on how to accurately perform the test. AIDS
Education and Training Centers (AETC) is a good resource to learn about HIV
testing. Further information can be found at the AETC National Resource
Choose which HIV test will be used and how confirmatory
testing and linkage to care will take place. It is very important to follow
the manufacturer’s test instructions to control and maintain the product
appropriately and to read the results within the specified time frame.
Decide which personnel in the dental office will be
involved in performing rapid HIV screening and gain buy-in from all staff
Programs that perform rapid HIV testing must have linkage
to care for confirmatory testing, counseling, and follow-up care in place.
Dental programs providing rapid HIV screening must have knowledge of the
private and public resources available for people living with HIV/AIDS in
As stated in a September 2005 editorial that appeared in
the Journal of the American Dental Association, “It would be wrong to demand
that all dental care providers perform HIV tests in their office. However,
for the provider who will take the time to acquire the skills necessary to
perform such a task, doing so could be a great benefit to society.”13 Dental
programs presently screening for HIV have already made a significant impact
in their communities above and beyond the vital oral health services they
provide. The path has been outlined by trailblazing individuals and
organizations across our nation. The question remains, how many will follow
and take the lead in their community by helping HIV-positive people learn
their status and enter into care?
HIV Dental Alliance receives grant/research support from Orasure
- Centers for Disease Control and Prevention. HIV/AIDS Surveillance
Report. Vol. 19. Atlanta: US Department of Health and Human Services,
Centers for Disease Control and Prevention: 2007.
- Hall HI, Song R, Rhodes P, et al. Estimation of HIV incidence in the
United States. JAMA. 2008;300:520-529.
- Centers for Disease Control and Prevention. HIV Prevalence
Estimates—United States, 2006. MMWR 2008;57(39): 1073-1076. Atlanta: US
Department of Health and Human Services, Centers for Disease Control and
- Centers for Disease Control and Prevention. MMWR, 2006;55:14. Atlanta:
US Department of Health and Human Services, Centers for Disease Control
and Prevention; 2006.
- Walensky RP, Freedberg KA, Weinstein MC, Paltiel AD. Cost
effectiveness of HIV testing and treatment in the United States. Clinical
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- 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(4): 446-453.
- Herman W, Konzleman J, Prissant LM. New national guidelines on
hypertension—a guideline for dentistry. J Am Dent Assoc.
- Cutler JA, Sorlie PD, Wolz M, et al. Trends in hypertension
prevalence, awareness, treatment, and control rates in United States
adults between 1988-1994 and 1999-2004. Hypertension. 2008;52(5): 801-802.
- Reznik DA, Bednarsh H. HIV and the dental team: The role of the dental
professional in managing patients with HIV/AIDS. Dimensions of Dental
Hygiene. 2006;4(6): 14-16.
- Hutchinson AB, Branson BM, Kim A, Farnham PG. A meta-analysis of the
effectiveness of alternative HIV counseling and testing methods to
increase knowledge of HIV status. AIDS. 2006;20(12):1597-1604.
- Roberts KJ, Grusky O, Swanson AN. Outcomes of blood and oral fluid
rapid HIV testing: a literature review, 2000-2006. AIDS Patient Care.
- Dietz CA, Ablah E, Reznik DA, Robbins DK. Patients’ attitudes about
rapid oral HIV screening in an urban, free dental clinic. AIDS Patient
- Glick M. Rapid HIV testing in the dental setting. J Am Dent Assoc.
About the Author
David A. Reznik, DDS
Chief, Dental Service
Grady Health System
HIV Dental Alliance