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Oral Diseases (2016) 22 (Suppl. 1), 193198 doi:10.1111/odi.

2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
All rights reserved


Ethics, research and HIV: lessons learned- a workshop

DA Reznik1,2, D Croser3, TH Kadrianto4, R Lavanya5
Grady Health System, Atlanta, GA, USA; 2Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA;
Dental Protection (part of MPS Ltd), London, UK; 4Oral Medicine Residency Program, Faculty of Dentistry Universitas Indonesia,
Jakarta, Indonesia; 5Department Oral Medicine & Radiology, Panineeya Mahavidyalaya Institute of Dental Science & Research
Centre, Hyderabad, India

Assessing risk for transmission of a blood-borne patho- The organisers of WW7 invited authors from four coun-
gen requires the use of the hazard and risk model. tries with different economies and healthcare systems to
Infection control is a system that uses a number of indi- answer one of the questions posed by Dr. David Croser
vidual processes to eliminate or reduce the probability and Dr. David Reznik:
of a hazard occurring. Strategies employed to reduce
Question 1: Can we use the international experience of
risk should be rehearsed, used routinely, audited,
managing the HIV infected patient to inform future
reviewed, and the results shared. Continuing dental
new infection control risks in the dental setting?
education has improved dental healthcare worker will-
Question 2: Considering the available evidence, what
ingness to treat people living with HIV/AIDS (PLWHA)
success has there been in meeting the educational
and has decreased negative attitudes and staff fears.
needs of the dental team treating patients living with
Providing care for PLWHA during undergraduate
dental school or dental hygiene programme is also
Question 3: What evidence is there to demonstrate the
associated with a greater willingness to treat. Whether
benets of screening for HIV by the dental team in the
by identifying suspect oral lesions or offering rapid
dental setting?
screening tests in the dental setting for HIV, the dental
Question 4: If the interests of the patient should always
team can play an important role in linkage to confirma-
come rst, what is the best model for the dental profes-
tory diagnosis and care with the goal of reducing to
sion as a whole to balance dental/oral health needs
zero the number of undiagnosed cases.
with the fear of treating the patient when a new life-
Oral Diseases (2016) 22, 193198 threatening disease arises?
Keywords: HIV; AIDS Oral Health; dental treatment; risk Each author presented a brief answer to their allocated
control; dental education; PLWHA; HIV screening question, which the participants then debated. This report
synthesises the debate using notes and literature reviews
provided by each author. The disparate nature of the individ-
ual author experiences generated an outcome that was more
Introduction conceptual than practical. But then not every question will
receive a complete answer on rst being asked. If the ques-
Initiatives in the dental setting to screen for HIV highlight tion has value, it should be asked again in a different way.
the benets of an integrated approach between the medical
and dental professions. This effort can lead to earlier diag- Question 1
nosis and better health outcomes while reducing HIV Can we use the international experience of managing
transmission rates. When dealing with the risk of a new the HIV infected patient to inform future new infection
blood-borne pathogen, organised dentistry must quickly control risks in the dental setting?
respond and disseminate information that is timely, Presenter: David Croser (UK)
morally sound and evidence-based. Any assessment of risk also requires us to consider
the concept of hazard (
alarpglance.htm [accessed on November 2014]). By its
nature, a hazard involves something that could potentially
be harmful to a persons life, health, property or the envi-
Correspondence: DA Reznik, Grady Health System, 341 Ponce de Leon ronment. Simply put, a hazard is something that can lead
Avenue Atlanta, Georgia 30308, USA. Tel: 404-616-9770, Fax: 404-616-
0450, E-mail: to adverse effects. For example, water on a staircase is a
Ethics, Research and HIV
DA Reznik et al

hazard because it could make you slip. Any patient in the 1 It offers a means of rapidly sharing accurate informa-
dental surgery poses a potential hazard if you think there tion to establish a credible evidence base to inform a
is a risk of passing infection from that individual to scientic response.
another patient or to a member of the clinical team. In 2 There is now a means of rapidly sharing information
order to assess risk we must evaluate the likelihood that a and updated infection control advice in the light of
hazard will actually produce an adverse effect, despite tak- new disease threats that with time, serve to combat
ing precautions to contain the hazard. The risk is unfounded fears experienced by healthcare workers.
expressed as a probability (MacCollum, 2006). Risk per- A proportional response facilitates a caring attribute
ception is the subjective judgment people make about the to those with disease while ensuring best practice for
severity and/or probability of a risk, and may vary from the healthcare providers.
person to person (Hansson and Zalta, 2014). Question 2
To prevent the hazard of disease transmission we use a Considering the available evidence, what success has
variety of infection control techniques or processes at our there been in meeting the educational needs of the den-
disposal. The strategies need to be rehearsed, used rou- tal team treating patients living with HIV (PLWHA)?
tinely for every patient, audited, and the audits need to be Presenter: Theodorus Hedwin Kadrianto (Indonesia)
reviewed and the results shared, in order to improve or Research has revealed that willingness to provide dental
maintain prevailing standards. Public scrutiny backed by treatment to PLWHA among dentists varies greatly by
legislation can provide additional motivation for dental country. For example, inclination to manage PLWHA
teams to engage with the routine. Vigilance in infection was still very low in several countries, such as 14.7% in
control techniques is important because of the ever-present Iran (2009), 15% in Jordan (2005), 23.3% in Pakistan
potential for a hazard to arise (Reason, 2000). (2011) (El-Maytaah et al, 2005; Khosravanifard et al,
A needle stick is the commonest risk of disease trans- 2012; Khail et al, 2013). This number is relatively higher
mission in the dental setting. Even if it does not lead to in some American and European countries such as 81%
the transmission of disease, the incidence of needle sticks in Canada (1995), 78.7% in Denmark (1993), 74.2% in
among healthcare workers is worryingly frequent (Wilburn Mexico (1998), 63% in England (1996), 56.6% in Croa-
and Eijkemans, 2003). A medical history may alert the tia (2000) and 55% in Brazil (1999) (Scheutz and Lange-
team of a potential risk. However, by instituting standard bk, 1995; Craven et al, 1996; Irigoyen et al, 1998;
infection control with barrier protection, effective sterilisa- McCarthy et al, 1999; Vucicevic-Boras et al, 2001;
tion techniques, and safety devices for needle, the risk is Senna et al, 2005). Research has also revealed the rela-
greatly reduced. In the case of HIV disease transmission tively low number of refusal to treat PLWHA among
in the medical setting, postexposure prophylaxis has pro- dentist in countries such as 16.2% in Thailand (2013),
ven to be another important tool for reducing the risk to 10% in USA (1998) and 4.5% in Italy (2009) (Gershon
the clinician. In the United States since 1999 there has et al, 1998; Giuliani et al, 2009; Rungsiyanont et al,
only been one case of HIV transmission in the medical 2013). Reasons for refusal or unwillingness to treat
eld (a laboratory technician sustaining a needle puncture PLWHA among dentists vary from lack of ethical
while working with a live HIV culture in 2008) (Joyce responsibility, fears related to cross-infection or complica-
et al, 2015) tion of treatment, staff anxiety and reluctance, nancial
In the UK, of 1,001 cases (20022011) involving burden in complying to cross-infection procedures, fear
patient with HIV only 1 sero-conversion of a healthcare of losing HIV-negative patients, lack of knowledge about
worker was recorded (Phlebotomist working with a HIV, to limited resources in developing countries
wide-bore needle) ( (Scheutz and Langebk, 1995; Craven et al, 1996; Iri-
4781/1_Eye_of_the_needle_2012_accessible.pdf). goyen et al, 1998; McCarthy et al, 1999; Vucicevic-
Of the predisposing factors of risk to address, fear is Boras et al, 2001; El-Maytaah et al, 2005; Senna et al,
particularly signicant. Dissemination of standard pre- 2005; Khosravanifard et al, 2012; Khail et al, 2013).
cautions via different education modalities is vital to Nevertheless, most of the previously cited papers mention
reduce the burden of fear. An accurate understanding of the need for educational interventions to improve den-
disease transmission from a needle stick removes the tists willingness to treat HIV-positive patients.
propinquity experienced by uneducated healthcare work- One clear example of educational success in improving
ers. A distorted comprehension of risk inhibits the beha- dentists willingness to treat PLWHA can be seen in
viour modication required to provide access to dental research from McCarthy and Koval in Canada. They
treatment in a safe environment. A paper by Bolton and showed that dentists attendance in a continuing education
others usefully describes the distorting effect (Bolton course on HIV/AIDS in the previous 2 years signicantly
et al, 2011). increased willingness to treat PLWHA and decreased neg-
Through the experience of the last 34 years, the work- ative attitudes about difculties dealing with staff fears.
shop strongly believes that the lessons learned will inform The authors found that more education about occupational
the future management of new infection control risks that transmission of HIV may dispel excessive fears. Dentists,
may arise, while an unemotional response to the accumu- who correctly identied the risk of HIV infection after a
lated evidence base will help to optimise access to care. needle stick injury as <1%, were signicantly more will-
The development of digital communications provides the ing to treat PLWHA. Their conclusion is that all signi-
key to dealing with future disease for two reasons: cant improvements might be partly attributable to the

Oral Diseases
Ethics, Research and HIV
DA Reznik et al

introduction of mandatory continuing education in 1993 tation Center for Behavioral Diseases (CCBD), in the
(McCarthy and Koval, 1996). Department of Infectious Diseases in a local hospital in
Since 1987, the US Ryan White HIV/AIDS Programs Tehran, where individuals with HIV/AIDS receive free con-
AIDS Education and Training Centers (AETCs) were sultation and treatment. The students were divided to three
established to provide primary care professionals (includ- or four students per session. During that period of observa-
ing dental practitioners) with the knowledge and skills tion, every student had the opportunity to be involved in a
necessary to care for HIV-infected patients and to increase discussion with CCBD staff regarding information about
the numbers of trained professionals working with HIV- HIV/AIDS, the patients dental condition, issues the dentist
infected patients. There are several means by which the must be aware, patients challenges, registration and service
AETCs offer training including a programme that takes for the patients, precautions and preventive actions for nee-
three to 5 days where dentists and dental hygienists learn dle stick injuries and responsibility for dentists to provide
to recognise oral manifestations of HIV, to counsel dental treatment. All students also attend a 1-day workshop
regarding risk for exposure, and how to provide continu- about infection control. As the result, the students in the
ous dental care for their patients with HIV while maintain- intervention group showed signicantly higher scores in
ing the highest quality of infection control (http:// knowledge, attitudes and willingness to treat HIV-positive [accessed on 10 patients and to completely follow infection control proce-
June 2015]). The regional AETCs each have a dental dures in the post-test questionnaire, compared to the control
director and the training ranges from one-to-one consulta- group (Jafari et al, 2012)
tions to demonstration clinics where dental healthcare The other critical issue that must be addressed in HIV
workers can observe routine dental care for PLWHA, and education is how to maintain all aspects of condentiality
continuing education via didactic conferences. and to understand the role of stigma plays in the lives of
One success in meeting educational need of dental stu- HIV-positive individuals. Concerns about condentiality
dents can be learned from Loma Linda University School have been shown to be a major barrier in seeking dental
of Dentistrys (LLUSD) Ryan White Community-Based care, while concerns about stigma from health profession-
Partnership Program, which developed an innovative train- als can violate patient trust. Rohn et al (2006) suggested
ing programme for their dental students. This HIV training some strategies to effectively address issues about con-
programme is a required rotation for all students during dentiality and stigma associated with HIV in dental
the fourth year. The programme is conducted entirely at schools, such as conversation with HIV-infected individu-
the local community health clinic, and has both clinical als, role play of appropriate interaction with HIV patients,
and didactic components. The didactic component includes periodic training, policies reinforcement about conden-
lectures, discussion of cases, interaction with staff dentists, tiality, formal evaluation of student competency in main-
interviews with patients, role-playing to illustrate possible taining patient condentiality and evaluation of staff
responses to various clinical situations and a video pro- interaction.
duced specically for this programme. The clinical com- Though HIV education is still a global challenge, evi-
ponent involves students providing dental care to people dence of successful endeavours are encouraging. Educa-
with HIV/AIDS under the supervision of faculty members. tional programmes that provide skills building are
Students were divided to small groups consisting of 5-7 critical in order to increase the number of dentists and
students. The students in each group then spent a total of dental students who are comfortable with and willing to
eight hours during 1-week periods in the HIV training provide quality care for PLWHA. Methods used should
programme at the community clinic so that every student overcome the barriers to learning and address all beha-
could have direct interaction with PLWHA. The result vioural components: knowledge, attitudes and practices.
demonstrated that the students showed signicant While comparing effectivity of different educational
improvement in ve topics which had been tested before methods are difcult due to various background and sit-
and after the programme: uational difference, publications about success in any
method of educational intervention are strongly encour-
1 HIV general knowledge.
aged, as those will help stakeholders to apply the most
2 Attitudes towards PLWHA.
appropriate one in his country. Network, support and
3 Comfort with treating this group.
dissemination of information should be developed
4 Condence in the effectiveness of standard precau-
between experienced educators across countries to make
this vision possible.
5 Postexposure prophylaxis following blood-borne
Field of further research will be aimed to start reporting
exposures (Rogers et al, 2011).
research of measurable educational intervention in coun-
With suitable local modications, this successful model tries with high refusal or unwillingness to treat PLWHA.
of education could be applied to improve the situation in Faculties should conduct further educational research to
other countries where access to dental services for develop more effective curriculum or method for dental
PLWHA has yet to be optimised. students that cover wider aspects of treating PLWHA,
An example of a successful effort can be gleaned from while dental associations should continue to improve the
research in Iran involving a shorter and simpler educational quality of dental treatment towards PLWHA through
intervention. Students in nal year of a dental school in research-based improvement of its training or continuing
Tehran were exposed to a 2 days observation at the Consul- education courses.

Oral Diseases
Ethics, Research and HIV
DA Reznik et al

There is plenty of information available and healthcare a viable option to increase the number of people who
champions such as delegates at WW7 should be empow- would know their HIV status. Once the Kansas City Free
ered to work with local dental teams to overcome any bar- Clinic began to offer HIV screening to their dental
riers to accessing and acting on that information. National patients, six newly diagnosed cases were found in an
Dental Associations are a particularly good way to pro- 18 month period out of 817 individuals tested (Deitz
mote such an initiative. Similarly, PLWHA often organise et al, 2008).
self-help groups which can verbalise their healthcare needs A study of 532 Australian dentists conducted from
and in many developed countries have brought about June-October 2013 revealed that the majority of
change. There is a clear advocacy role for anyone living respondents (65.1%) believed that HIV screening via
in a democracy who becomes aware of a healthcare need rapid testing was needed in dental clinics. Approximately
to which there is also a solution. two-thirds of the respondents indicating that rapid HIV
screening for HIV should begin immediately. The major
Question 3
barrier identied in this paper was informing patients of
What evidence is there to demonstrate the benets of
a preliminary reactive response, indicating there is a need
screening for HIV by the dental team in the dental set-
for training dentists in HIV medicine, test administration
ting? and giving reactive results immediately (Santella et al,
Presenter: David Reznik (USA)
HIV is a systemic infectious disease that dental health-
Harlem Hospital Center, located in New York City,
care professionals can help identify with the goal of
instituted a counsellor-based HIV screening initiative in
improving health outcomes, addressing health disparities
their dental clinic (Blackstok et al, 2010). As patients
and improving quality and quantity of life. Whether by
waited for their dental appointment; a trained counsellor
identifying suspect oral lesions or offering rapid screen-
tested 3,565 individuals, a 97.6% acceptance rate. Fifteen
ing tests in the dental setting for HIV, the dental team
newly diagnosed individuals were linked to care, six of
can play an important role in linkage to conrmatory
whom had a CD4 count of less than 200 cells mm 3 and
diagnosis and care.
therefore by denition had AIDS at the time of their ini-
Early diagnosis of HIV can lead to a healthier and tial diagnosis. It was concluded that a counsellor-based
more productive life, improve the outcomes of early
HIV screening programme with linkage to HIV primary
antiretroviral treatment and is cost-effective over time
care can be successfully implemented in a large urban
(Walensky et al, 2007; Hammer et al, 2008; Long et al, dental clinic (Reznik et al, 2008).
2010). In addition, early diagnosis may reduce HIV
A study conducted at the New York University School
transmission rates as persons who know they are HIV+
of Dentistry, the largest provider of low-cost dental care
signicantly reduce behaviours that would put others at
in New York State, revealed that 74% of those
risk (Marks et al, 2005, 2006). Finally, results from the
approached would accept HIV screening if it were
landmark HIV Prevention Trial Network 052 revealed
offered as a part of their dental visit (VanDevanter et al,
that early initiation of antiretroviral therapy by HIV-
2012). This qualitative study revealed three recurrent
infected individuals resulted in a 96% reduction in HIV
themes in the views of patients asked about rapid oral
transmission to their HIV-uninfected sexual partners
HIV screening in the dental setting: acceptability and per-
(Cohen et al, 2011).
ceived advantages; congruence between HIV screening
Data from the 2005 U.S. National Health Interview and patients view of dental settings and the roles of
Survey revealed that 3.6 million Americans report that
dental healthcare workers; logistical issues related to
they are at signicant HIV risk yet have never been
implementation (VanDevanter et al, 2012). The identied
tested. Three-quarters of these individuals had seen a
logistical concerns included receiving preliminary reactive
dental healthcare worker within the previous 2 years,
(positive) results; the need for professional counselling to
and the authors concluded that these dental visits repre-
address psychological concerns; and the importance of
sent missed opportunities to provide HIV testing for
linkage to conrmatory testing and care (VanDevanter
high-risk individuals (Pollack et al, 2010) Dental ofces
et al, 2012).
represent novel settings to reach millions in the U.S.
The National Association of Community Health Cen-
who visit a dentist during the course of a year, but
ters, in conjunction with the U.S. CDC, has produced a
who do not see a physician, and can serve as additional toolkit for health centres that wish to initiate routine HIV
sites to identify health issues among diverse groups of
screening in the dental setting (
patients (Strauss et al, 2012) Similar opportunities exist
tal%20Tools.cfm [accessed on 08 April 2015]). This effort
in other countries. includes a comprehensive guide on all aspects of imple-
Studies have revealed a high patient acceptance rate
mentation including words that dental healthcare profes-
when offered a free rapid HIV test in the dental setting
sionals should consider using when offering this screening
(Deitz et al, 2008; Santella et al, 2015). In an attitude
test. More recently, the New York State Department of
assessment study piloted by the Kansas City Free Health
Health AIDS Institute released HIV Testing in the Oral
Clinic at their stand-alone dental clinic located in a
Health Care Setting (October 15, 2015). This guideline
neighbourhood with a high HIV prevalence, 73% of the
document states that oral health care settings that can sup-
150 respondents were willing to take a free, oral uid
port an HIV testing programme should offer testing to all
HIV screening test in the dental setting. This study con-
dental patients.
cluded that rapid HIV screening in the dental setting was

Oral Diseases
Ethics, Research and HIV
DA Reznik et al

197 a number of cofactors that contribute to the variation in
10/HIV-Testing_OH-Setting_10-14-15.pdf?utm_source= the quality of the response to the dental needs of PLWHA.
HIV+Testing+in+the+Oral+Health+Care+Setting_10-15-2015& Although limited nancial resources may be a commonly
utm_campaign=HIV+Testing+in+the+Oral+Health+Care+ cited factor in the delay in achieving best practice for this
Setting+Flash+Email&utm_medium=email patient group, we must look harder at the other factors
Future research into this question must include survey- which are delaying access to the management of HIV/
ing public and private dental patients acceptability of AIDS if we are to optimise the quality of life for everyone
HIV testing in the dental setting and ultimately testing the living with this disease wherever in the world that might
feasibility of implementation. Documentation of these be. The role of the dental healthcare worker screening
efforts must include a broad spectrum of countries focus- patients for HIV in the dental setting highlights the bene-
ing on those with the highest burden of HIV disease. ts of an integrated approach by the medical and dental
professions. Such cooperation would undoubtedly have
Question 4
value in responding to healthcare challenges that have yet
If the interests of the patient should always come rst,
to arise, particularly as the ability to establish an evidence
what is the best model for the dental profession as a
base and share information with both patients and health-
whole to balance dental/oral health needs with the fear care providers, has never been so rapid.
of treating the patient when a new life-threatening dis-
ease arises?
Presenter: Lavanya Reddy (India) Author contributions
Balancing the dental health needs of patients against any All authors contributed equally to the design of this manu-
residual personal fear within the dental team must take into script. All authors read and approved the nal manuscript.
account the lessons learned from the AIDS pandemic. Keep-
ing abreast of the latest information to base decision-making
on factual information instead of emotionally based opinion References
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Oral Diseases