Our programme

HIVDOP is a comprehensive oral healthcare access programme for people with HIV/AIDS in Massachusetts and Southern New Hampshire. The programme removes or reduces barriers to oral health services by providing education, advocacy, referrals and reimbursement for care. The programme aims to promote sound oral health by facilitating access to care from knowledgeable and sympathetic dentists in community-based, nondiscriminatory settings. It goes without saying that oral health care will enhance the overall health and well-being of persons living with HIV.

In this, the 25th year of the epidemic, as measured by the first case reports by the United States Centers for Disease Control and Prevention (CDC) in the summer of 1981, dentistry and the delivery of oral health care and those who deliver that care still face unique challenges; some are historical in nature and others have evolved more recently. Historically, stigma and fear have been pervasive in this epidemic. So pervasive that in 1990 a report issued by the American Civil Liberties Union, “Epidemic of fear”, cited dentists and nursing homes as the most frequent discriminators against persons with HIV. Early in the epidemic, prior to scientific-based evidence on the transmission, risk, and abatement measures, and before the era of highly active antiretroviral therapy (HAART), dentists were reluctant to provide oral health care services to people with HIV, actual or perceived. The extent of this discrimination is shameful and much of it was only reversed through state/federal laws and court cases that extended civil rights protections to persons with HIV, including dentists as well as patients. Civil rights advocacy on issues relevant to oral health extends to consumers of care and providers of that care, whether HIV (+) or (-).

The consensus in the scientific community is that “the risk of transmission [of HIV] is very low from a patient to a provider, between patients, and from a provider to a patient”. In 1991, the CDC published their first comprehensive guidelines relative to healthcare workers infected with HIV/HBV, “Recommendations for Preventing Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Patients During Exposure Prone Procedures”1. Prior to this, recommendations were not specific and focused more on HCWs knowing their status to protect their own health. These guidelines were based upon the following principles:

Infected HCWs who adhere to universal precautions and who do not perform invasive procedures pose no risk for transmitting HIV or HBV.

• Infected HCWs who adhere to universal precautions and who perform certain exposure-prone procedures pose a small risk for transmitting HBV to patients.
• HIV is transmitted much less readily than HBV.
• Mandatory testing of HCWs for HIV or HBV is not recommended.

The primary emphasis was on the manner in which a procedure was performed and the protective nature of universal precautions in preventing cross-contamination and less upon the bloodborne pathogen status of a HCW. It was significant that the guidelines rejected mandatory testing, refraining from practice, or disclosure of status. A matter of consensus was the creation of expert review panels for case-by-case evaluation, but this recommendation was on a voluntary, not mandatory basis. However, individual state law or Board of Registration requirements may differ.

Paradoxically, in 1990 the CDC reported on the “possible” transmission of HIV from an infected dentist to a patient2. Subsequent reports noted the “probable” transmission to six patients even though the exact route of transmission remained unknown3. The ensuing public outrage resulted in congressional action – a political response to a scientific issue. The result is that the management of infected HCWs remains inconsistent; based upon state policies (which differ between states), and probably based more on emotion than science. Nevertheless, in look-back studies of HCWs and medical and dental students known to be infected with HIV, no other cases of transmission were exposed and there is no currently available data to support restricting the practice of an infected HCW. To date, no other cases of HIV transmission in a dental setting have been reported.

Since 1990, there have been significant improvements in infection control and significant decreases in the number of reported injuries among dentists in the United States, a threefold decrease from approximate12 injuries per year to two to three per year. There have been no reported cases of HCV transmission by dentists or surgeons in the United States and no reports of HBV transmission from dentists since 1987. Furthermore, in the 2003 dental infection control guidelines from the CDC, HIV infection is not listed as a disease for which work restrictions are recommended. All this validates the protective nature of our policies and practices on infection control andunderscores the importance of adherence to standard precautions, work practice controls, and engineering controls to minimize the risk of exposure incidents.

The CDC cites three conditions necessary for HCWs to be at risk of transmitting a bloodborne pathogen to patients, these are that:

• The health care provider must be infected and have infectious virus circulating in the bloodstream.
• The health care provider must be injured or have a condition that provides direct exposure to infected blood or body fluids.
• The injury mechanism or condition must present an opportunity for the provider’s blood or body fluids to directly contact a patient’s mucous membranes, wound, or traumatised tissue (recontact)4.

Observational studies of injuries among dentists in the United States, when they have occurred, describe them as occurring on hands or fingers and most frequently outside the mouth. Therefore the potential for recontact is minimal at best. From the evidence gathered following improved infection control, there has been a significant reduction of numbers and types of injuries; supporting the notion that infected dental health care workers pose little risk of transmitting a bloodborne disease to their patients. Therefore, restriction of practice or removal from the workforce simply because of HIV disease is no longer a prudent policy.

• Policies relative to infected providers should be evidence-based and not based in emotion or public perception.
• Due diligence in implementing recommended guidelines to prevent the transmission of disease in dental settings is indicated and protective.

Dental providers who are HIV (+) have legal rights under federal antidiscrimination law and state civil rights laws, much like the laws that protect individuals with HIV from discrimination by members of the dental team. The American Dental Association acknowledges the unique challenges a dentist infected with a bloodborne disease may encounter; however, they do not advocate for removal from practice based solely on HIV infection. The ADA has a resource manual that includes information to support infected providers. Excerpting from the ADA policy on HIV-infected Dentists from 1991, “Currently, there is no scientific evidence to indicate that HIV-infected health care providers pose an identifiable risk of HIV transmission to their patients. The ADA strongly affirms that universal precautions are an effective and adequate means of preventing the transmission of HIV from dental health care workers to patient and patient to dental health care worker”.

Twenty-five years into the epidemic and 16 since the Acer case report, it is reasonable to assume that an HIVinfected DHCW presents minimal harm, at most.

1. Centers for Disease Control and Prevention. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure prone invasive procedures. MMWR 1991; 40(RR- 8): 1-9.
2. CDC. Possible transmission of human immunodeficiency virus to a patient during an invasive dental procedure. MMWR 1990; 39: 489-493.
3. CDC. Update: Transmission of HIV infection during invasive dental procedures – Florida. MMWR 1991; 40: 21-27, 33.
4. Chiarello LA, Cardo DM, Panlilio A et al. Risks and prevention of bloodborne virus transmission from infected healthcare providers. Semin Infect Control 2001; 1(1):61-72.