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Update on Managing HIV-Positive Patients in the Dental Setting

Authors: Marci Levine, DMD, MD and Analia Veitz-Keenan, DDS
Introduction HIV Diagnosis Laboratory Studies
Unlike years ago, most patients with man- HIV is often contracted through sexual con- There are three types of tests that are cur-
aged human immunodeficiency virus (HIV) tact or the sharing of drug-related equip- rently available and they include: 1) nucleic
are healthier and living longer in spite of ment (such as needles and syringes). It can acid tests (NAT), 2) antigen/antibody tests,
their diagnosis. New therapeutics have been be passed through infected bodily fluids and 3) antibody tests. NATs measure viral
developed to prophylactically reduce the in- including blood, semen, rectal fluids, vagi- load and are not screening tests. Antigen/
cidence of transmission of the disease and nal fluids, and breast milk. It is not passed antibody tests are more commonly used and
manage many of the ailments from which through saliva, tears, sweat, insects, kissing, the results can be obtained quickly, making
infected patients used to suffer. Today’s touching, or in the air. a rapid variety test available. Antibody tests
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dentists need to know about these new are the only approved tests for in-home use.
drugs and be aware of how to best manage An elevated viral load, the presence of other
patients with HIV, especially if they require sexually transmitted diseases, as well as alco- The accuracy of most rapid tests is quite
invasive dental procedures. The purpose hol and/or drug use can also increase the risk high (>99 percent sensitivity and specifici-
of this article is to inform the reader of the of contracting HIV. A history of substance ty) for patients with chronic infection. How-
modern therapeutics that are now available abuse has been shown to lead to faster rates of ever, testing on oral fluids appears to be less
in an effort to help them best manage their disease progression and to reduced compli- sensitive than testing on finger stick blood
patients as safely as possible. 1 ance with therapeutics in managing the infec- samples.
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tion. Patients with HIV-1 are also more sus-
What is HIV? What is AIDS? ceptible to contracting other strains of HIV HIV Medical Management: Antiretrovi-
As defined by the Centers for Disease Con- virus leading to the potential for super-infec- ral Therapy (ART) 8
trol and Prevention (CDC), HIV is a viral tious states. According to both the WHO and HIV-positive patients are often initially
infection that chronically affects the indi- CDC, people who are at an increased risk of managed with ART which includes a dai-
vidual’s immune system. If left untreated, contracting HIV should be tested more often ly combination of three agents from two
HIV can progress to AIDS (acquired im- than those at a lower risk and they should also different classes. Drug classes for HIV in-
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mune deficiency syndrome). This progres- seek comprehensive and effective HIV pre- clude nucleoside reverse transcriptase in-
sion can often take eight to ten years. At the vention and treatment services early. hibitors (NRTIs), non-nucleoside reverse
time of this publication, there is currently transcriptase inhibitors (NNRTIs), protease
no effective treatment or cure for HIV or New technology, including the develop- inhibitors (PIs), fusion inhibitors, CCR5 re-
AIDS. Most secondary sequelae from HIV ment of more discrete in-home self-tests, ceptor antagonists, integrase strand transfer
infection can be managed medically and the can lead to early diagnosis. Much like oth- inhibitors (INSTIs), attachment inhibitors,
life span of patients who are well-managed er infectious diseases, testing services for post-attachment inhibitors, and pharmaco-
medically is nearly the same as those with- HIV must follow the 5Cs of 1) consent, 2) kinetic enhancers.
out HIV. Without proper medical manage- confidentiality, 3) counseling, 4) correct re-
ment of HIV, it typically progresses through sults, and 5) connection with treatment and HIV-positive patients appear to have a high-
three stages: 1) acute infection, 2) chronic other services. The US Food and Drug Ad- er risk of having certain medical conditions,
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infection and 3) AIDS. ministration (FDA) approved the first HIV including metabolic complications and
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diagnostic test in 1985. Since then, multi- some malignancies, when compared with
Prevalence and Incidence Nationwide ple generations of antibody tests have been the general population. These medical co-
and Worldwide developed and each is an improvement over morbidities may be associated with HIV in-
The primary source for monitoring trends of prior generations with earlier detection and fection itself, risk factors commonly found
infection in the United States is the CDC’s a shorter window period. The window peri- in patients with HIV, or the use of ART.
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National HIV Surveillance System. Accord- od is the time from infection until the first
ing to the latest data from the CDC, between reactive result in any given test. The length For patients on ART, frequent monitoring is
2010 and 2019, the estimated incidence of the period depends on the particular tar- required especially when therapy is initiated
(number of new cases) of HIV in people get being detected by a given assay. The due to the potential for toxicity secondary
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older than 13 years of age was increasing. In diagnosis of acute (or early) HIV infection to the medications used in ART. As a pre-
2019, approximately 1,189,700 people over is made with the detection of HIV viremia cautionary measure, patients are routinely
the age of 13 currently live with the virus in a particular HIV testing pattern (such monitored with blood work, including a
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in the United States. The World Health Or- as a negative screening immunoassay or a complete blood count with differential and
ganization (WHO) estimated that in 2020, positive combination antibody/antigen im- CD4 cell count levels, every three to six
37.7 million people worldwide were living munoassay with a negative antibody-only months and and more often if symptomatic 9
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with HIV and that approximately 1.5 mil- immunoassay). Approximately 10-60% of CD4 cells, also known as T-cells, are white
lion previously uninfected people would people with early HIV infection are asymp- blood cells that play an important role in
acquire HIV in 2020. The WHO African tomatic. In patients with acutely symptom- the immune system. A CD4 count is used to
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region remains the most severely affected atic infection, the usual time from exposure check the health of the immune system in
with nearly 1 in every 25 adults (or 3.6%) to HIV to the development of symptoms is people infected with HIV.
living with HIV, and this accounts for more approximately two to four weeks, although
than two-thirds of people who are living incubation periods up to ten months have
with HIV worldwide. 3 also been observed. 7 C
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