Update on HIV/AIDS

The human immunodeficiency virus (HIV) remains a significant health problem around the world. However, notable advancements have been made in its prevention and treatment. Individuals living with HIV/acquired immuno­deficiency syndrome (AIDS) in the United States are living longer and healthier lives, but HIV remains a pandemic across the world.^1,2 There remains a need for an adequate continuum of care, improved access to health and dental care, reduction of stigma, and increased funding for prevention, diagnosis, and treatment of individuals with HIV/AIDS in the US and abroad.^1,2 Oral health professionals should keep abreast of advancements in HIV/AIDS and review prevention and education, including common opportunistic infections and oral manifestations, stages of HIV, modes of transmission, and infection control and management protocols.

The World Health Organization estimates that 36.7 million people around the globe have been infected by HIV/AIDS.³ Globally, approximately 2.1 million new HIV infections are diagnosed annually.³ About two-thirds of individuals with HIV/AIDS live in Sub-Saharan Africa.³ Approximately 1.2 million people in the US have HIV.⁴ One in seven individuals in the US has HIV/AIDS but remains undiagnosed.⁴ In the US, gay and bisexual men of color are the most likely to experience new HIV/AIDS diagnoses, followed by white gay and bisexual men.⁴ Other populations at increased risk of new HIV infections are sex workers, intravenous drug users, and transgender women.^1,4

HIV is composed of two strains: HIV-1 and HIV-2.⁵ The most commonly found strain in North America is HIV-1, whereas HIV-2 is found primarily in West Africa.⁵ HIV-1 and HIV-2 have molecular differences, with the HIV-2 presenting with significantly smaller molecules, which inhibits its pathogenicity.⁵ This article focuses on the infection, transmission, and management of HIV-1.

HIV targets the immune system, specifically the CD4 lymphocyte cells or T-cells, which protect the body from infections.⁶ When T-cells are compromised, the risk of infection and infection-related cancers increases.⁶ If HIV is not prevented from replicating, the virus further destroys the T-cells, severely compromising the immune system. The normal range of T-cells is 500 to 1,600 per cubic millimeter.⁶ If the T-cells fall below 200 cells per cubic millimeter of blood, the patient has AIDS.⁶The diagnosis of more than one opportunistic infection is another indicator of AIDS and does not require the measurable indicator of cells per cubic millimeter of blood.^6–8

In 2014, the World Health Organization updated treatment and prevention recommendations for all individuals with HIV.^1,2 These recommendations state that antiretroviral therapy (ART) should be given indefinitely to all seropositive individuals regardless of age, population, or CD4 lymphocyte count.^1,2 ART hinders HIV replication, prolongs life, and reduces transmission of infected cells in seronegative individuals.^1,2,9 Routine diagnostic blood testing determines the viral load of HIV and the amount of virus in the blood.¹⁰ART’s ability to control the replication of HIV can lead to the virus becoming virtually undetectable, shifting the disease to a manageable chronic condition.^9,10

HIV is transmitted by blood, anal and vaginal fluid, semen, preseminal fluid, and breastmilk.¹¹ HIV is not transmitted via air; water; insects; pets; sharing toilets, food, or drinks; saliva; sweat; tears; or closed-mouth kissing.¹¹ HIV requires a human host and cannot survive outside of the body for an extended time.¹¹ The risk of HIV infection after an occupational exposure is very low (0.3%).¹² Per US Centers for Disease Control and Prevention (CDC) data collected from 1985 to 2013, there are no known documented cases of occupationally acquired HIV infection in a dental setting.¹³

In 2014, the CDC updated the HIV stages to include undetectable viral loads after a diagnosis.¹⁴ HIV can begin replicating into an acute viral syndrome within 4 days to 11 days of exposure.⁵ Clinical symptoms begin to appear in 2 weeks to 6 weeks.⁵ The most common symptoms are fever, rash, headache, lymphandenopathy, and pharyngitis.^5,14 Once infected and the CD4 T-Cells are reduced, opportunistic infections may occur in the oral cavity.¹⁴

Dental hygienists are well positioned to notice the first clinical signs of HIV/AIDS infection, which may include bartonellosis, candidiasis, condyloma acuminatum, cryptococcosis, hairy leukoplakia, histoplasmosis, Kaposi’s sarcoma, linear gingival erythema, lymphoma, necrotizing periodontal disease, aphthous ulcers, herpes simplex, and cytomeglavirus oral ulceration. An immunocompromised system can make the patient susceptible to oral manifestations of HIV/AIDS. Oral conditions can be used to identify the stage of HIV and predict the patient’s progression to AIDS.⁵ They can also be used to evaluate the effectiveness of ART.⁵Visit the online version of this article to view a description of common oral conditions among individuals living with HIV/AIDS.

INFECTION CONTROL

Clinicians should use standard precautions for all patients, as the infection control procedures for treating patients with HIV/AIDS are the same as for treating uninfected individuals.¹⁵ Standard precautions include the use of personal protective equipment, proper hand washing, effective sterilization technique, maintenance of dental unit waterlines, and successful surface disinfection, to name a few.¹² No modifications are needed to provide dental hygiene preventive services to patients with HIV/AIDS.¹⁵ Modifications should be considered for restorative or surgical procedures when a patient’s platelet count is reduced to <60,000 cells/mL, which affects clotting time, or when the patient’s neutrophil (white blood cells) count is <500 cells/mL, which would necessitate antibiotic prophylaxis.¹⁵ Oral health professionals are encouraged to obtain a thorough medical history and obtain recent bloodwork for all patients with HIV/AIDS.¹⁵

ADVANCES IN PREVENTION

The 2020 national HIV/AIDS strategy includes reducing new HIV infections, increasing access to care, improving health outcomes, decreasing HIV-related health disparities and inequities, and creating a more coordinated national response.¹⁶ Providing test results quickly in convenient locations can aid in the reduction of new HIV infections.¹⁶ The US Food and Drug Administration has approved a rapid test for both HIV-1 and HIV-2.¹⁷ A clinician collects oral fluid via a swab and the results are produced after 20 minutes with 99.9% accuracy.¹⁷ A positive rapid result needs to be confirmed by a blood test.¹⁷ The specificity and sensitivity of these oral tests are comparable to antibody blood tests.¹⁷

The future provides great opportunity for oral health professionals to help reduce new HIV infection via salivary DNA testing. The CDC has expanded the number of sites that provide HIV testing.¹⁶ By testing for HIV in the dental setting, populations that are not routinely seen by medical professionals can learn their HIV status.

In 2012, five dental schools in New York City provided screening for HIV, and positive results were referred to the New York State Health Department.¹⁷ The Jacques Initiative at the Institute of Human Virology at the University of Maryland School of Medicine in Baltimore created the Preparing the Future program.¹⁸ In alignment with the National Strategies for HIV/AIDS, the program provides a six-step process of educational and hands-on training to provide routine testing for HIV and hepatitis C.¹⁷ The program reduces stigma and inspires future professionals in law, medicine, dentistry, physical therapy, dental/dental hygiene, and nursing to improve the continuum of care for patients with HIV/AIDS.

The use of pre-exposure prophylaxis (PrEP) to prevent HIV infection is undergoing development. It involves taking a pill containing tenofovir and emtricitabine (medicines used to treat HIV) on a daily basis, and research has shown this therapy is effective in preventing HIV infection among at-risk, seronegative individuals. Compliance is key for PrEP to be effective in HIV prevention.^1,19Additional research is needed to determine the effectiveness of PrEP in high-risk populations and among those engaging in vaginal intercourse, as well as alternative delivery methods such as injection or a vaginal ring.^1,19,20 The potential for an HIV vaccine is also under investigation; however, no vaccine or cure for HIV/AIDS exists today.⁹ The HIV Vaccine Trials Network study is currently conducting a study to test the efficacy rates of a vaccine used in a clinical trial in Thailand.¹ These findings will support the development of a vaccine that may be able to significantly decrease the rate of HIV infection worldwide.

CONCLUSION

The future of HIV/AIDS research is promising. Oral health professionals value interprofessional collaboration and should be prepared to incorporate global and national strategies to reduce HIV infection. They need to be familiar with basic information, current trends, and resources available for this vulnerable population. The best way to prevent HIV/AIDS is through education and treatment.¹

REFERENCES

1. Steinbrook R. HIV/AIDS in 2016 and beyond. JAMA. 2016;316:1139–1140.
2. Friedrick M. WHO updates HIV treatment and prevention guideline. JAMA. 2015;314:2014.
3.  US Department of Health and Human Services. The Global HIV/AIDS Epidemic. Available at: aids.gov/hiv-aids-basics/hiv-aids-101/global-statistics/. Accessed May 19, 2017.
4. US Departmet of Health and Human Services. HIV/AIDS 101: US Statistics. Available at: aids.gov/hiv-aids-basics/hiv-aids-101/statistics/index.html. Accessed May 19, 2017.
5. Mosca NG, Rose Harthom A. HIV-positive patients: Dental management considerations. Dent Clin North Am. 2006;50:635–657.
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13. Joyce MP, Kuhar D, Brooks JT. Notes from the field: occupationally acquired HIV infection among health care workers -—United States, 1985-2013. MMWR Morb Mortal Wkly Rep. 2015;63:245–246.
14. Centers for Disease Control and Prevention. Surveillance of Occupationally Acquired HIV/AIDS in Healthcare Personnel as of December 2010. Available at: cdc.gov/hai/organisms/hiv/surveillance-occupationally-acquired-hiv-aids.html. Accessed May 19, 2017.
15. Centers for Disease Control. Human immunodeficiency virus (HIV) in health care settings. Available at: cdc.gov/hai/organisms/hiv/hiv.html. Accessed May 19, 2017.
16. White House Office of National AIDS Policy. National HIV/AIDS Strategy: Updated to 2020. Available at:whitehouse.gov/sites/whitehouse.gov/files/images/nhas-2016-progress-report.pdf. Accessed May 19, 2017.
17. Crostjens PLAM, Abrams WR, Malamud D. Detecting virus by using salivary diagnostics. J Am Dent Assoc. 2012; 143(10 Suppl):12S–18S.
18. Unversity of Maryland School of Medicine. Preparing the Future. Available at: jacques.ihv.org/Community/Preparing-the-Future. Accessed May 19, 2017.
19. Spinner CD, Boesecke C, Zink A, et al. HIV pre-exposure prophylaxis (PrEP): a review of current knowledge of oral systemic HIV PrEP in humans. Infection. 2016;44:151.
20. Slomski A. PrEP reduces incidence of HIV in clinical settings. JAMA. 2015;314:1684.
21. Centers for Disease Control and Prevention. HIV Surveillance Report, 2015. Available at: http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html. Accessed May 19, 2017.

From Dimensions of Dental Hygiene. June 2017;15(6):22, 24, 26