A study protocol for Project I-Test: a cluster randomized controlled trial of a practice coaching intervention to increase HIV testing in substance use treatment programs.

BACKGROUND: People with substance use disorders are vulnerable to acquiring HIV. Testing is fundamental to diagnosis, treatment, and prevention; however, in the past decade, there has been a decline in the number of substance use disorder (SUD) treatment programs offering on-site HIV testing. Fewer than half of SUDs in the USA offer on-site HIV testing. In addition, nearly a quarter of newly diagnosed cases have AIDS at the time of diagnosis. Lack of testing is one of the main reasons that annual HIV incidences have remained constant over time. Integration of HIV testing with testing for HCV, an infection prevalent among persons vulnerable to HIV infection, and in settings where they receive health services, including opioid treatment programs (OTPs), is of great public health importance. METHODS/DESIGN: In this 3-arm cluster-RCT of opioid use disorders treatment programs, we test the effect of two evidence-based "practice coaching" (PC) interventions on the provision and sustained implementation of on-site HIV testing, on-site HIV/HCV testing, and linkage to care. Using the National Survey of Substance Abuse Treatment Services data available from SAMHSA, 51 sites are randomly assigned to one of the three conditions: practice coach facilitated structured conversations around implementing change, with provision of resources and documents to support the implementation of (1) HIV testing only, or (2) HIV/HCV testing, and (3) a control condition that provides a package with information only. We collect quantitative (e.g., HIV and HCV testing at 6-month-long intervals) and qualitative site data near the time of randomization, and again approximately 7-12 months after randomization. DISCUSSION: Innovative and comprehensive approaches that facilitate and promote the adoption and sustainability of HIV and HCV testing in opioid treatment programs are important for addressing and reducing HIV and HCV infection rates. This study is one of the first to test organizational approaches (practice coaching) to increase HIV and HIV/HCV testing and linkage to care among individuals receiving treatment for opioid use disorder. The study may provide valuable insight and knowledge on the multiple levels of intervention that, if integrated, may better position OTPs to improve and sustain testing practices and improve population health. TRIAL REGISTRATION: ClinicalTrials.gov NCT03135886. Registered on 2 May 2017.

Patient acceptance of HIV rapid testing in the dental care setting.

Dental settings are untapped venues to identify patients with undiagnosed HIV who may otherwise lack testing opportunities. Perceived lack of patient acceptance has been a significant barrier limiting dentists' willingness to offer HIV testing. This study implemented rapid HIV testing in dental settings located in an HIV prevalent region to evaluate patient acceptance. Two South Florida community health centers implemented routine oral rapid HIV testing as part of clinical practice, followed by exit interviews with patients immediately after to determine patient acceptance. The binary primary outcome was patient's acceptance of the rapid HIV test. Multivariable logistic regression assessed associations between patient characteristics and acceptance. Overall acceptance by dental patients (N = 600) was 84.5%. Patients who were more likely to participate in other medical screenings in dental settings were more than twice as likely to accept the test compared to those who were neutral/less likely (OR: 2.373; 95% CI: 1.406-4.004). Study findings highlight the high patient acceptance of HIV testing in dental settings. Widespread implementation of such testing will require an expanded societal view of the traditional role of the dentist that will embrace the potentially valuable role of dentistry in preventive health screenings and population health.

Women's HIV disclosure to the dentist: Does frequent contact matter?

OBJECTIVES: Research has shown inconsistent patterns of patients' HIV serostatus disclosure to their dentists. Common barriers to disclosure have included confidentiality concerns, fear of treatment refusal, and discrimination. This study evaluated the prevalence of HIV serostatus disclosure to the dentist, whether the frequency of dental care utilization is associated with disclosure, and reasons for nondisclosure among women living with HIV. METHODS: We administered a cross-sectional oral health survey to 1,526 women living with HIV in the Women's Interagency HIV Study including questions regarding HIV serostatus disclosure to dentists. Logistic regression models were used to analyze the association between dental care utilization (at least annually versus less than annually) and HIV serostatus disclosure to dentists. RESULTS: Overall, 83 percent of women reported that they disclosed their HIV serostatus to their dentist. The most common reasons for nondisclosure were: a) the dentist did not ask, b) believing that the dentist did not need to know, and c) not having a consistent dentist. In the multivariable logistic regression model, at least annual dental care utilization, compared to less than annual, led to a 59 percent reduction in the odds of HIV nondisclosure to the dentist. DISCUSSION: Study findings highlight that dentists who see their patients infrequently should consider methods for overcoming barriers to HIV nondisclosure and the possibility that their patient's HIV serostatus is undisclosed. Educating women living with HIV about how disclosure to dentists is a critical component of their dental assessment and treatment, and how preventive dental treatment can improve overall health outcomes, is important.

Oral health-related quality of life and unmet dental needs among women living with HIV.

BACKGROUND: Oral health-related quality of life (OHRQoL) is a multidimensional, perception-based measure of how oral health affects social and physical functioning and self-image. OHRQoL is important for assessing women living with HIV (WLWH) who may have unmet dental needs and experience disparities that impact dental care accessibility. METHODS: In 2016, the authors conducted an assessment of OHRQoL among a national sample of 1,526 WLWH in the Women's Interagency HIV Study using the Oral Health Impact Profile instrument, which assesses the frequency of 14 oral health impact items. OHRQoL was measured using multivariable linear regression with a negative binomial distribution to assess the association between report of a recent unmet dental need and OHRQoL. RESULTS: "Fair or poor" oral health condition was reported by 37.8% (n = 576) of WLWH. Multivariable linear regression showed that unmet dental needs had the strongest positive association with poor OHRQoL (difference in Oral Health Impact Profile mean, 2.675; P < .001) compared with not having unmet needs. The frequency of dental care utilization was not associated with higher OHRQoL. Older age, fair or poor dental condition, smoking, symptoms of anxiety and loneliness, and poor OHRQoL were also associated with worse OHRQoL. CONCLUSION: Self-perceived impact of oral health on social and physical function and self-image, as measured by OHRQoL, may be an easily assessable but underrecognized aspect of OHRQoL, particularly among women aging with HIV. PRACTICAL IMPLICATIONS: Dentists should implement OHRQoL assessments in their management of the care of patients with HIV to identify those who do have significant oral health impacts.

Multisite Study of Women Living With HIV's Perceived Barriers to, and Interest in, Long-Acting Injectable Antiretroviral Therapy.

BACKGROUND: Adherence to antiretroviral therapy (ART) is imperative for viral suppression and reducing HIV transmission, but many people living with HIV report difficultly sustaining long-term adherence. Long-acting injectable (LAI) ART has the potential to transform HIV treatment and prevention. However, little LAI ART-related behavioral research has occurred among women, particularly outside of clinical trials. SETTING: Six Women's Interagency HIV Study sites: New York, Chicago, Washington DC, Atlanta, Chapel Hill, and San Francisco. METHODS: We conducted 59 in-depth interviews with women living with HIV across 6 Women's Interagency HIV Study sites (10 per site; 9 at Washington DC). We interviewed women who were not included in LAI ART clinical trials but who receive care at university settings that will administer LAI ART once it is approved. Interviews were recorded, transcribed, and analyzed using thematic content analysis. RESULTS: Most women enthusiastically endorsed monthly LAI ART and would prefer it over pills. The following 3 reasons emerged for this preference: (1) convenience and confidentiality, (2) avoiding daily reminders about living with HIV, and (3) believing that shots are more effective than pills. Challenges remain, however, specifically around (1) medical mistrust, (2) concerns about safety and effectiveness, (3) pill burden for HIV and other conditions, and (4) barriers to additional medical visits. CONCLUSIONS: Most women preferred LAI ART over daily pills given its benefits, including convenience, privacy, and perceived effectiveness. Future research should incorporate more women into LAI ART trials to better understand and align development with user concerns and preferences to enhance uptake.

A Qualitative Study of Rapid HIV Testing and Lesbian, Gay, Bisexual, Transgender, and Queer Competency in the Oral Health Setting: Practices and Attitudes of New York State Dental Directors.

PURPOSE: Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) cultural competency and awareness in healthcare settings have been recognized for minimizing health disparities, yet their integration within the oral health community has been minimal. Furthermore, despite evidence showing the compatibility of rapid HIV testing (RHT) in the oral health setting, actual uptake by dentists has been limited. The purpose of this qualitative study was to document New York State dental directors' perspectives and attitudes regarding issues relevant to the LGBTQ patient care and RHT. MATERIALS AND METHODS: Semi-structured interviews (N=10) were conducted with New York State dental directors practicing in areas of high HIV prevalence. A deductive and inductive qualitative approach was used to develop an interview guide, in accordance with the Theory of Planned Behavior, that elicited their perspectives, attitudes, and perspectives on RHT and LGBTQ issues. RESULTS: Thematic analysis of the interviews revealed that many dentists cited limited, if any, training and experience in RHT and LGBTQ patient care. Additionally, there was also an evident dichotomy between dentists who were offering RHT and dentists who were knowledgeable and well-versed in LGBTQ issues. Barriers to implementation included time constraints and minimal training and knowledge. CONCLUSIONS: While potential facilitators such as test kit reimbursement and patient referral sources could enable LGBTQ and RHT training and uptake, actual implementation in the oral health setting will likely require additional trainings, more involved collaboration with primary care providers, and an overall cultural change amongst the dental profession.

Intimate partner violence screening in the dental setting: Results of a nationally representative survey.

BACKGROUND: The dental setting is a potential venue for identifying patients experiencing intimate partner violence (IPV). The study objective was to assess dentists' current practices and attitudes about IPV screening. METHODS: A nationally representative survey of US general dentists assessed dentists' use of health history forms that queried about IPV and their acceptance of IPV screening as part of their professional roles. Parsimonious Poisson regression models were used in multivariable analysis to estimate risk ratios for the 2 dependent variables. RESULTS: Almost all dentists did not include a question to screen for IPV on their patient history forms. More than one-half of dentists also did not know of a referral place for patients experiencing IPV and did not believe that IPV screening should be part of their professional roles. CONCLUSIONS: Uptake of IPV screening and favorable attitudes toward screening were low among dentists studied. However, prior IPV training and clinical knowledge plus awareness of IPV referral mechanisms were positively associated with greater screening uptake and attitudes. PRACTICAL IMPLICATIONS: The inclusion of brief, focused IPV interventions in dental education and the establishment of collaborations between dentists and IPV agencies for referral mechanisms, in conjunction with an overall shift in dentists' attitudes about their professional responsibilities, may facilitate IPV screening uptake in the dental setting.

HIV testing in the dental setting: perspectives and practices of experienced dental professionals.

The dental setting is a largely untapped venue to identify patients with undiagnosed HIV infection. Yet, uptake of rapid HIV testing within the dental community remains low. This study sought to better understand the experiences of dental professionals who have administered the test and how these experiences might inform efforts to promote greater uptake of rapid HIV testing in dental settings. Qualitative interviews were conducted with United States dentists (N = 37) and hygienists (N = 5) who offered rapid HIV testing in their practices. The data revealed both the impeding and facilitating factors they experienced in implementing testing in their setting, as well as the reactions of their staff, colleagues, and patients. Overall, participants viewed rapid HIV testing favorably, regarding it as a valuable public health service that is simple to administer, generally well accepted by patients and staff, and easily integrated into clinical practice. Many had experience with a reactive test result. Participants described facilitating factors, such as supportive follow-up resources. However, they also cited persistent barriers that limit acceptance by their dental colleagues, including insufficient reimbursement and perceived incompatibility with scope of practice. The widespread adoption of routine HIV testing amongst dental professionals will likely require an expanded notion of the proper scope of their professional role in overall patient health, along with greater support from national dental organizations, dental education, and dental insurance companies, especially in the form of sufficient reimbursement.

Substance use and STI acquisition: Secondary analysis from the AWARE study.

OBJECTIVES: Sexually transmitted infections (STIs) are significant public health and financial burdens in the United States. This manuscript examines the relationship between substance use and prevalent and incident STIs in HIV-negative adult patients at STI clinics. METHODS: A secondary analysis of Project AWARE was performed based on 5012 patients from 9 STI clinics. STIs were assessed by laboratory assay and substance use by self-report. Patterns of substance use were assessed using latent class analysis. The relationship of latent class to STI rates was investigated using Poisson regression by population groups at high risk for STIs defined by participant's and partner's gender. RESULTS: Drug use patterns differed by risk group and substance use was related to STI rates with the relationships varying by risk behavior group. Substance use treatment participation was associated with increased STI rates. CONCLUSIONS: Substance use focused interventions may be useful in STI clinics to reduce morbidity associated with substance use. Conversely, gender-specific sexual health interventions may be useful in substance use treatment.

Screening for substance misuse in the dental care setting: findings from a nationally representative survey of dentists.

AIMS: The dental setting is a potentially valuable venue for screening for substance misuse. Therefore, we assessed dentists' inquiry of substance misuse through their patient medical history forms and their agreement with the compatibility of screening as part of the dentists' professional role. DESIGN: A nationally representative survey of general dentists using a sampling frame obtained from the American Dental Association Survey Center (November 2010-November 2011). SETTING: United States of America. PARTICIPANTS: A total of 1802 general dentists. MEASUREMENTS: A 38-item survey instrument assessing the relationship between dentists' practice, knowledge, behaviors and attitudes with their query about substance misuse and their belief that such screening is part of their professional role. FINDINGS: Dentists who accepted substance misuse screening as part of their professional role were more likely to query about misuse with their patients (85.8%) compared with those who did not accept such screening as part of their role (68.2%) (P < 0.001). Prior experience and knowledge about substance misuse were the strongest predictors of dentists' inquiry about patient substance use/misuse and acceptance of screening as part of their role in their clinical practice (P < 0.05). CONCLUSION: While more than three-quarters of US dentists report that they ask their patients about substance misuse, two-thirds do not agree that such screening is compatible with their professional role.

Addressing the oral healthcare needs of special needs children: pediatric nurses' self-perceived effectiveness.

OBJECTIVES: To examine the oral health knowledge and practices of pediatric nurses who coordinate healthcare services for special needs children and to identify those factors that influenced their perceived effectiveness in managing their patients' oral health needs. METHODS: Self-reported data were collected from 376 nurses employed at Children's Medical Services who responded to an online survey. Likert scale scores were used to specifically assess the nurses' perceived effectiveness in addressing the oral health needs of special needs children. RESULTS: Characteristics significantly associated with special needs pediatric nurses who described themselves as "effective or very effective" included: the self-perception of being very knowledgeable about basic oral health, receiving four or more hours of continuing education training, and securing dental appointments for the majority of their pediatric special needs patients with minimal waiting times. CONCLUSION: Findings reveal that oral health knowledge significantly influenced nurses' perceived effectiveness in addressing the oral health needs of special needs children, as well as their ability to secure timely dental appointments. These results support the need to incorporate oral health education into nursing curricula and expand upon the dental workforce available and willing to treat disabled patients.

Insurer views on reimbursement of preventive services in the dental setting: results from a qualitative study.

OBJECTIVES: We explored insurers' perceptions regarding barriers to reimbursement for oral rapid HIV testing and other preventive screenings during dental care. METHODS: We conducted semistructured interviews between April and October 2010 with a targeted sample of 13 dental insurance company executives and consultants, whose firms' cumulative market share exceeded 50% of US employer-based dental insurance markets. Participants represented viewpoints from a significant share of the dental insurance industry. RESULTS: Some preventive screenings, such as for oral cancer, received widespread insurer support and reimbursement. Others, such as population-based HIV screening, appeared to face many barriers to insurance reimbursement. The principal barriers were minimal employer demand, limited evidence of effectiveness and return on investment specific to dental settings, implementation and organizational constraints, lack of provider training, and perceived lack of patient acceptance. CONCLUSIONS: The dental setting is a promising venue for preventive screenings, and addressing barriers to insurance reimbursement for such services is a key challenge for public health policy.

Dentists' willingness to provide expanded HIV screening in oral health care settings: results from a nationally representative survey.

OBJECTIVES: Using a nationally representative survey, we determined dentists' willingness to provide oral rapid HIV screening in the oral health care setting. METHODS: From November 2010 through November 2011, a nationally representative survey of general dentists (sampling frame obtained from American Dental Association Survey Center) examined barriers and facilitators to offering oral HIV rapid testing (n = 1802; 70.7% response). Multiple logistic regression analysis examined dentists' willingness to conduct this screening and perceived compatibility with their professional role. RESULTS: Agreement with the importance of annual testing for high-risk persons and familiarity with the Centers for Disease Control and Prevention's recommendations regarding routine HIV testing were positively associated with willingness to conduct such screening. Respondents' agreement with patients' acceptance of HIV testing and colleagues' improved perception of them were also positively associated with willingness. CONCLUSIONS: Oral HIV rapid testing is potentially well suited to the dental setting. Although our analysis identified many predictors of dentists' willingness to offer screening, there are many barriers, including dentists' perceptions of patients' acceptance, that must be addressed before such screening is likely to be widely implemented.

HIV medical providers' perceptions of the use of antiretroviral therapy as nonoccupational postexposure prophylaxis in 2 major metropolitan areas.

INTRODUCTION: In 2005, the Centers for Disease Control and Prevention expanded its recommendation of postexposure prophylaxis (PEP) use in the workplace to include nonoccupational exposures (nPEP). The availability and extensive use of nPEP have not achieved widespread acceptance among health-care providers of high-risk populations, and public health and primary care agencies have been sparse in their implementation of nPEP promotion, protocols, and practices. METHODS: We conducted a survey of HIV providers (n = 142, response rate = 61%) in Miami-Dade County (Florida) and the District of Columbia that focused on their knowledge, attitudes, beliefs, and practices related to the delivery of nPEP. We then analyzed differences in survey responses by site and by history of prescribing nPEP using bivariate and multivariate logistic regression. RESULTS: More District of Columbia providers (59.7%) reported ever prescribing nPEP than in Miami (39.5%, P < 0.048). The majority of practices in both cities did not have a written nPEP protocol and rarely or never had patients request nPEP. Multivariable analysis for history of prescribing nPEP was dominated by having patients request nPEP [odds ratio (OR) = 21.53] and the belief that nPEP would lead to antiretroviral resistance (OR = 0.14) and having a written nPEP protocol (OR = 7.49). DISCUSSION: Our findings are consistent with earlier studies showing the underuse of nPEP as a prevention strategy. The significance of having a written nPEP protocol and of patient requests for nPEP speaks to the importance of using targeted strategies to promote widespread awareness of the use of HIV antiretroviral medications as a prevention intervention.