Access to dental care for HIV patients: does it matter and does discrimination exist?

INTRODUCTION

A number of surveys have highlighted a severe shortage of dentists in the UK. ^1,2 According to a poll conducted by Citizens Advice in January 2008, ¹ lack of access has prevented one in six people from seeing a National Health Service dentist for almost two years. They surveyed 1800 people in England and Wales and found 300 had been frustrated in registering with a dentist, suggesting as many as 7.4 million adults could be affected. An earlier Department of Health Dental review conducted in 2004 also reported a serious shortage of UK dentists, with a shortfall of some 1850 dentists in England alone that was set to worsen and potentially double by 2011. ²

Against this backdrop, there is evidence suggesting discrimination against HIV patients, reported both within the dental profession ^3–5 and by service users. ^6,7 An anonymous qualitative survey exploring attitudes among dental practitioners working in the northwest of England found that one-third thought that treating HIV patients would put themselves at risk of infection and one-fifth felt that they had no ethical responsibility for treating HIV patients. ³ A recent survey of 475 HIV patients conducted by an HIV Patient Partner Involvement group sponsored by Ealing Primary Care Trust in west London found that a quarter of patients reported discrimination by dentists. ⁴

HIV patients are particularly affected by oral health problems and these have been shown to adversely impact on quality of life. ⁸ Manifestations such as oral candidiasis, oral hairy leukoplakia, Kaposi's sarcoma, recurrent periodontitis and gingivitis may be important markers of HIV infection. ⁹ Access to dental care provides an important opportunity to maintain good oral health and also to identify previously undiagnosed infection, particularly among at-risk groups.

To assess dental care access and to control for reporting bias, we conducted a cross-sectional survey looking at a sample of HIV outpatients and patients at risk of HIV infection recruited from the routine genitourinary (GU) medicine clinic.

METHODS

A questionnaire was developed, exploring issues relating to access to dental care. This was reviewed and approved by the local HIV Patient Public Engagement forum. Both groups of patients were recruited from the Courtyard Clinic (Department of Genitourinary Medicine) based at St George's Hospital, southwest London between September 2008 and November 2008. The questionnaire was handed out to a random sample of male and female HIV outpatients, with GU clinic outpatients recruited as controls.

RESULTS

A total of 241 outpatients attending the Courtyard Clinic were surveyed, of whom 51 (21%) were HIV patients and 190 were patients attending the walk-in GU clinic (Table 1). Overall, the sample of HIV patients who took part in the survey was predominantly male and older than the GU patients. White (45.1%) and black African ethnicity (41.2%) represented the majority of HIV patients surveyed whereas nearly two-thirds of the GU sample was white (42%) or black Caribbean ethnicity (21%) and black Africans represented only 8% of the sample. The proportion of both groups currently registered with a dentist was similar (HIV 64.7%, GU 71.1%), although significantly more HIV patients reported difficulty registering with a dentist than GU patients (58.8% versus 18.2%, χ² with Yates correction = 8.76, P = 0.0031). However, when the sample of HIV patients was matched for age and gender with GU patients, the proportion of both groups currently registered with a dentist remained similar (HIV 64.1%, GU 71.8%). Significantly more HIV patients than GU patients (54.9% versus 32.1%, χ² with Yates correction = 8.02, P = 0.0046) reported having a current dental problem, the commonest complaints being toothache, broken or missing teeth, bleeding gums and mouth ulceration.

In addition, HIV outpatients were asked whether disclosure of their seropositive status affected the dental care they received (Table 2). Approximately 50% (26/51) of HIV patients said that they had ever disclosed their status. Of those who did, nine (34.6%) said that this had affected their care. Their comments included being treated differently (6/22 responses, 26%), given specific appointments (usually at the end of a list) (18%), having their confidentiality breached or their application for dental treatment turned down (14% each), being denied certain treatments (9%) or being referred elsewhere (9%). Only a small number (3/47, 6.2%) who completed a final section of the questionnaire said that disclosure subsequently resulted in being refused dental treatment. Of note, 26 of 48 (48.3%) HIV patients admitted to avoiding dental care for financial reasons.

Of the remaining patients who did not disclose their HIV status (25/51, 49%), the most common reasons given for non-disclosure included fear of being treated differently (12/46 responses, 26%), that it was unnecessary for the dentist to know (20%), fear of discrimination or that they felt there was a risk of having their confidentiality breached (17% each).

DISCUSSION

This cross-sectional survey of outpatients attending a GU/HIV clinic in southwest London confirms difficulties with access to dental care. HIV patients currently have less access to dental care and appear to have more difficulty finding a dentist. They also have significantly more dental health problems than GU outpatients. Within the HIV group, more white male patients than other gender/ethnicity groups were currently registered with dentists and had been registered for longer, whereas HIV-infected women seemed to find it harder to find a dentist. As women of black African ethnicity represented the vast majority of the HIV women surveyed (17/21, 81%), language, cultural or other issues such as responsibility for childcare may be hindering access. Approximately one-third of HIV patients surveyed said that declaring their status had adversely affected their dental care and 6.2% had been refused care because they were seropositive.

Although our survey was limited by the relatively small sample size of HIV outpatients, the data suggest that discrimination continues to exist in terms of access to care as well as the type and level of dental care provided. As a result, some HIV patients chose not to disclose their status (49% in this survey, compared with 25–48% in literature ^7,9 ). While this may overcome access issues in some instances, it means that dentists may be unaware of the significance of oral pathology that is subsequently identified. Non-disclosure may also pose an occupational risk to the dental team, not just to HIV (and the provision of post-exposure prophylaxis) but to other blood-borne virus infections such as hepatitis B and C from co-infected patients.

The written responses from HIV patients detailed in our survey have offered some insight into the problems they experienced with a minority of dentists. Other comments, however, reflect their experience of high standards of care and professionalism. This becomes apparent when users distinguish dentists as being ‘HIV friendly’ or not; yet the British Dental Association state that it is unethical to refuse dental care to those patients with a potentially infectious disease on the grounds that it could expose the dental clinician to personal risk. ^10,11 While it may be useful for patients to be given a list of ‘HIV-friendly’ dentists to register with, greater effort should be made to raise professional standards and HIV awareness to ensure that all patients are treated equitably.