With rapid HIV testing being trialled in some medical clinics in Australia, could the dental surgery be next? By Sarah Hollingworth
Australia’s initial response to the HIV pandemic has been hailed as one of the most successful disease prevention and public health education programs in the world. However, with the rate of new HIV diagnoses on the rise and an estimated 6000 to 10,000 Australians being unaware of their HIV-positive status, new measures for testing and early diagnosis are being put in place.
In December 2012, the Therapeutic Goods Administration (TGA) approved in Australia a new rapid screening test for HIV. The finger prick test, which is performed by medical practitioners, screens for HIV antibodies and gives a preliminary result within approximately 20 minutes.
While a positive result still requires a further blood test for confirmation, specific benefits include more opportunities for testing and the immediate communication of results—as opposed to waiting more than 24 hours.
Rapid HIV testing is currently being trialled in New South Wales, Victoria and Queensland but, compared to other parts of the world, Australia has been slow on the uptake. In the US, the Food and Drug Administration (FDA) approved the finger prick test in 2002 and an even less invasive oral swab test in 2004.
As with the US, it is hoped the approval of the oral swab test in Australia is not far behind. A less invasive method of screening, the oral-fluid collection uses an absorbent pad on a stick to take a swab of the patient’s upper and lower gums. It is then placed in a vial with a developing solution.
There are several benefits to the oral swab test. It is non-invasive, does not require specialist phlebotomy training or equipment, and saliva specimens can be easily collected under difficult conditions.
With dental practices presenting unique opportunities for implementing routine rapid testing, the connection between the oral swab test and the dental profession is an obvious one.
However, in the US—where it is currently being trialled in prisons and some public dental clinics—it has raised debate. While there has been enthusiasm from a public health perspective, it has also raised questions as to whether the dental practice is an appropriate setting or, indeed, whether the dental profession is willing to accept HIV screening as an additional responsibility.
Dr Anthony Santella and Associate Professor Mark Schifter, who are currently conducting a research study assessing Australian dentists’ knowledge and attitudes to HIV and their willingness to conduct rapid HIV tests, believe the broader public health issue is around disease prevention and the significant role dentists can play in the early detection and treatment of HIV.
“I think rapid HIV testing fits really well within the remit of dental practice. I don’t see it as different from screening for oral cancer.” – A/Prof Mark Schifter from the Faculty of Dentistry at The University of Sydney
“This represents an important opportunity for the dental profession to consider its place in the delivery of health services in Australia,” says A/Prof Schifter from the Faculty of Dentistry at The University of Sydney.
“In terms of a broader preventative health initiative—and that is the emphasis—I think it [rapid HIV testing] fits really well within the remit of dental practice. I don’t see it as particularly different from screening for oral cancer.”
In Australia, at the end of 2011 an estimated 24,731 people were living with diagnosed HIV infection; representing an increase of 8.2 per cent from 2010. Until this time, the number of new diagnoses had been relatively stable (around 1000 per year). Dr Santella, a public health scientist and lecturer from Western Sydney Sexual Health Centre, Sydney Medical School, believes this steady rise means Australia needs to take an innovative approach to HIV testing.
“To combat the rise in HIV incidence, you need more novel evidence-based strategies and the rapid test has proven very efficacious in other countries,” he says. “To apply this in a dental setting would provide this opportunity.”
Undeniably, dentists have the strongest professional interest and knowledge of saliva, as well as the oral manifestations of HIV infection. But does this make them the best practitioners to be screening and advising patients about a potentially life-altering and life-threatening disease?
Darlinghurst dentist Dr Wayne Sherson, whose private practice treats many HIV-positive patients, believes not.
“In a medical setting I think the rapid HIV test is a fantastic advance,” he says, “but I do not believe the dental profession in private practice currently have the skills and facilities to test and deliver test results in the patient’s best interests and benefit.” Go back to the basic principles of clinical or medical practice and Dr Sherson says any diagnostic test should be as a result of a sound examination and history.
“If you’re going to apply a diagnostic test to a patient for HIV, you really should have done an extensive sexual health history,” he says. “I don’t know many dentists in Australia who are doing this.”
Under the current National HIV Testing Policy, which sets out a framework for providing quality testing, practitioners implementing HIV tests require a certain diagnostic and treatment knowledge base. In addition to being capable of taking a sexual history, they also need to be trained in pre- and post-test counselling, provide information about support mechanisms and potential treatment options, and be capable of contact tracing and partner notification strategies.
“It’s a big leap to go from ‘is that tooth sensitive?’ to ‘does your partner know about this result and how does that impact on your sexual practices?’,”
says Dr Sherson.
“That very quickly steps outside the bounds of a dental consultation.”
Reflecting these concerns, study results in the US reveal dentists have issues around a lack of counselling skills. In addition, there is also apprehension around their knowledge of HIV/AIDS and HIV testing, time constraints, low patient acceptance, lack of training, financial reimbursement, privacy and confidentiality, and issues related to the scope of practice under state dental practice acts.
While many of these issues are being tested in A/Prof Schifter and Dr Santella’s University of Sydney research study, Australia’s differing approach to minimising the spread of HIV, plus its vastly different healthcare system, could well produce different attitudes in Australian dentists.
“Australia is very concerned with harm minimisation in relation to HIV,” says A/Prof Schifter. “So I think there is a cultural context in which this test sits.”
While dentists’ acceptance of the rapid HIV testing is critical, so too is patients’ acceptance of dentists performing the tests. Successful implementation will require an understanding of patient attitudes, perceptions and willingness to be screened.
Currently, the recommendations for medical history include asking patients questions around being at risk for HIV. However, where and how the question is asked is very much the individual dentist’s prerogative. It could be argued that, if the subject is already being broached, it won’t be a great leap to ask if a patient wants a rapid test. But Dr Sherson maintains there are still patients who raise concern about what dentists do with the information.
“There is a lot of concern about the way dentists will treat patients with an HIV-positive status,” he says. “As it is, I think there is an awful lot of non-disclosure to that question because of the way it is asked.”
According to the Australian Bureau of Statistics’ Patient Experiences in Australia: Summary Findings, 2011-12, 49 per cent of people aged 15 years and over had seen a dental professional at least once in the previous 12 months. By comparison, 81 per cent had visited a GP at least once in the previous 12 months.
While the percentage of people visiting a GP is much higher, dentists are seeing a cohort of patients who either don’t have a regular medical practitioner or who haven’t seen a medical practitioner because they’re not unwell. Dentists, therefore, may be the only provider to see an asymptomatic HIV-infected person in any given year. Dr Sherson can see the public health benefit of rapid testing and, likewise, the access to greater numbers through dental surgeries. However, he firmly believes Australia already has a medical infrastructure that is well placed to maximise the benefits of rapid tests.
“Why don’t we treat it [rapid HIV testing] like we treat other systemic diseases and use it as a referral point for testing; rather than testing it ourselves?” he asks.
A/Prof Schifter counters this argument by saying that rapid HIV testing in a dental setting could be the start of salivary-based diagnostic testing for other community diseases, such as diabetes and hypertension.
“In terms of a community preventative-health approach, I see this as one of a number of point-of-care testings that dentists should be involved in,” he says. “I think it’s really exciting and there are a lot more positives than negatives.”
To participate in the research study, ‘Australian Dentists’ Knowledge and Attitudes to HIV and Willingness to Conduct Rapid HIV Testing 2’, go to: www.surveymonkey.com/s/99K5CLS