Jane E. Fox

Increasing Access to Oral Health Care for People Living with HIV/AIDS in the U.S.: Baseline Evaluation Results of the Innovations in Oral Health Care Initiative

Objectives. We provide an overview of the Health Resources and Services Administration HIV/AIDS Bureaus Special Projects of National Significance Innovations in Oral Health Care Initiative, describe the models developed by the 15 demonstration sites and associated evaluation center, and present initial descriptive data about the characteristics of the multisite evaluation study sample. Methods. Baseline data were collected from May 2007–August 2009 for 2,469 adults living with HIV/AIDS who had been without dental care, except for emergency care, for 12 months or longer. Variables included sociodemographic characteristics, HIV status, medical care, history of dental care and oral health symptoms, oral health practices, and physical and mental health quality of life. Descriptive statistics of baseline variables were calculated. Results. The study sample included 2,469 adults who had been HIV-positive for a decade; most were engaged in HIV care. The majority (52.4%) of patients had not seen a dentist in more than two years; 48.2% reported an unmet oral health-care need since testing positive for HIV, and 63.2% rated the health of their teeth and gums as “fair” or “poor.” Conclusions. This study is the largest to examine oral health care among people living with HIV/AIDS in more than a decade. The need for access to oral health care among members of this HIV-positive patient sample is greater than in the general population, following previous trends. Findings from our study reinforce the necessity for continued federal and statewide advocacy and support for oral health programs targeting people living with HIV/AIDS; findings can be extended to other vulnerable populations.

Patient perspectives on improving oral health-care practices among people living with HIV/AIDS.

This qualitative study explored the impact on oral health-care knowledge, attitudes, and practices among 39 people living with HIV/AIDS (PLWHA) participating in a national initiative aimed at increasing access to oral health care. Personal values and childhood dental experiences, beliefs about the importance of oral health in relation to HIV health, and concerns for appearance and self-esteem were found to be determinants of oral health knowledge and practice. Program participation resulted in better hygiene practices, improved self-esteem and appearance, relief of pain, and better physical and emotional health. In-depth exploration of the causes for these changes revealed a desire to continue with dental care due to the dental staff and environmental setting, and a desire to maintain overall HIV health, including oral health. Our findings emphasize the importance of addressing both personal values and contextual factors in providing oral health-care services to PLWHA.

Correlates of Unmet Dental Care Need among HIV-Positive People

Objectives. We analyzed the characteristics of people living with HIV/AIDS (PLWHA) who reported unmet oral health needs since testing positive and compared those characteristics with people reporting no unmet health needs. We also identified barriers to accessing oral health care for PLWHA. Methods. We collected data from 2,469 HIV-positive patients who had not received oral health care in the previous 12 months and who had accessed care at Health Resources and Service Administration-funded Special Projects of National Significance Innovations in Oral Health Care Initiative demonstration sites. The outcome of interest was prior unmet oral health needs. We explore barriers to receiving oral health care, including cost, access, logistics, and personal factors. Bivariate tests of significance and generalized estimating equations were used in analyses. Results. Nearly half of the study participants reported unmet dental care needs since their HIV diagnosis. People reporting unmet needs were more likely to be non-Hispanic white, U.S.-born, and HIV-positive for more than one year, and to have ever used crack cocaine or crystal methamphetamine. The top three reported barriers to oral care were cost, access to dental care, and fear of dental care. Additional reported barriers were indifference to dental care and logistical issues. Conclusion. Innovative strategies are needed to increase access to and retention in oral health care for PLWHA. Key areas for action include developing strategies to reduce costs, increase access, and reduce personal barriers to receiving dental care, particularly considering the impact of poor oral health in this population.

Retention of People Living with HIV/AIDS in Oral Health Care

Objective. We identified factors associated with retention in oral health care for people living with HIV/AIDS (PLWHA) and the impact of care retention on oral health-related outcomes. Methods. We collected interview, laboratory value, clinic visit, and service utilization data from 1,237 HIV-positive patients entering dental care from May 2007 to August 2009, with at least an 18-month observation period. Retention in care was defined as two or more dental visits at least 12 months apart. We conducted multivariate regression using generalized estimating equations to explore factors associated with retention in care. Results. In multivariate analysis, patients who received oral health education were 5.91 times as likely (95% confidence interval 3.73, 9.39) as those who did not receive this education to be retained in oral health care. Other factors associated with care retention included older age, taking antiretroviral medications, better physical health status, and having had a dental visit in the past two years. Patients retained in care were more likely to complete their treatment plans and attend a recall visit. Those retained in care experienced fewer oral health symptoms and less pain, and better overall health of teeth and gums. Conclusions. Retention in oral health care was associated with positive oral health outcomes for this sample of PLWHA. The strongest predictor of retention was the receipt of oral health education, suggesting that training in oral health education is an important factor when considering competencies for new dental professionals, and that patient education is central to the development of dental homes, which are designed to engage and retain people in oral health care over the long term.

Dental case manager encounters: the association with retention in dental care and treatment plan completion

Little is known about dental case managers as few programs have been scientifically evaluated. The goal of this study was to explore the impact of dental case manager on retention in dental care and completion of treatment plans, while specifically exploring the number of dental case manager encounters. Fourteen programs enrolled people with HIV/AIDS (PLWHA) in dental care and a longitudinal study between 2007 and 2009. The 758 participants had a total of 2715 encounters with a dental case manager over twelve months: 29% had a single encounter; 21% had two; 27% had 3-4 and; 23% had 5-29 encounters. Adjusting for baseline characteristics, participants receiving more encounters were significantly more likely to complete their Phase 1 treatment plan, be retained in dental care, and experience improvements in overall oral health status. Organizations considering efforts to improve the oral health of vulnerable, hard-to-engage populations should consider these findings when planning interventions.

Lessons Learned from Applying a Modified Learning Collaborative Model to Promote Change in Regional and Statewide HIV Care Systems.

The Health Resources and Services Administration Special Projects of National Significance launched the Systems Linkage and Access to Care for Populations at High Risk of HIV Infection Initiative in 2011. Six state departments of health were funded to utilize a modified Learning Collaborative model to develop and/or adapt HIV testing, linkage to care and retention in care system-level interventions. More than 60 Learning Sessions were held over the course of the Learning Collaborative. A total of 22 unique interventions were tested with 18 interventions selected and scaled up. All interventions were created to impact services at a systems level, with standardized protocols developed to ensure fidelity. Our findings provide key lessons and present considerations for replication for use of a modified Learning Collaborative to achieve state-level systems change.