Agenda

1. SPNS IHIP Oral Health Webinar Series: Healthy Mouth, Healthy Body……………….Presented by CDR MahyarMofidi, DMD, PhD and Jane Fox, MPHDecember 13, 2013

2. Agenda • Introduction to SPNS Integrating HIV Innovative Practices (IHIP) project • Sarah Cook-Raymond, Managing Director of • Impact Marketing + Communications • Presentations from: • Dr. MahyarMofidi; Branch Chief of the Division of Community HIV/AIDS Programs and Chief Dental Officer, HRSA HIV/AIDS Bureau • Jane Fox, MPH; Project Director of SPNS Oral Health Initiative Evaluation Center for HIV and Oral Health (ECHO), Boston University School of Public Health • Q & A

3. IHIP Resources onTARGET Center Websitewww.careacttarget.org/ihip

4. IHIP Oral Health Resources • Training Manual • Curriculum • Pocket Guide • Webinar Series • Healthy Mouth, Healthy Body • Dental Case Management • Clinical Aspects of Oral Health Care for PLWHA • Recording and slides for all Webinars will be uploaded to TARGET Center Web site following the live event: www.careacttarget.org/ihip

5. Other IHIP Resources • Buprenorphine Therapy • Training Manual, Curriculum, Monograph,and Webinars on implementing buprenorphine in primary care settings • Engaging Hard-to-Reach Populations • Training Manual, Curriculum, and Webinars on engaging hard-to-reach populations • Jail Linkages • Training Manual, Curriculum, Pocket Guide, and Webinars on enhancing linkages to HIV care in jails settings • UPCOMING: Hepatitis C Treatment Expansion • In Spring/Summer 2014, look for training materials on increasing access to and completion of Hepatitis C treatment for PLWHA on the TARGET Center Web site.

6. Healthy Mouth, Healthy Body: Oral Health Care's Vital Role in Overall Well Being for People Living with HIV/AIDS CDR Mahyar Mofidi, DMD, PhD Branch Chief Chief Dental Officer HRSA, HIV/AIDS Bureau December 13, 2013

7. 12+ years ago • You cannot be healthy without oral health. • Oral health is essential to overall health and quality of life, and all families need access to high-quality dental care.

8. Oral Health for PLWHA • “While good oral health is important to the well being of all population groups, it is especially critical for people living with HIV/AIDS (PLWHA). Inadequate oral health care can undermine HIV treatment and diminish quality of life, yet many individuals living with HIV are not receiving the necessary oral health care that would optimize their treatment.” -U.S. Public Health Service Surgeon General Regina M. Benjamin, MD, MBA

9. Why does good oral health matter in HIV care?

10. Oral Disease in HIV Infection • Oral infections and neoplasms occur with immunosuppression • (bacterial, fungal, viral, neoplastic, lymphoma, ulcers) • High prevalence of dental caries and periodontal disease 32-46%of PLWHA have at least one oral disease condition related to HIV Some HIV medications have side effects (xerostomia or dry mouth) which can lead to tooth decay and periodontal disease

11. Prevalence of Dental Caries and Periodontal Disease in a Ryan White HIV/AIDS Program-Funded Dental Clinic • Dental caries were present in 66% of patients • 54% had gingivitis and 28% had periodontal disease • Infectious Disease Society of America (IDSA) 47th Annual Meeting – November 2009 – Poster #1063

12. Oral Manifestations of HIV/AIDS For those with unknown HIV status, oral manifestations may suggest HIV infection, although they are not diagnostic. Reznik DA. Perspective - Oral Manifestations of HIV Disease. International AIDS Society–USA Topics in HIV Medicine. Volume 13 Issue 5 December 2005/January 2006

13. Oral Manifestations of HIV/AIDS For persons living with HIV disease not yet on therapy, the presence of certain oral manifestations may signal progression of disease. Reznik DA. Perspective - Oral Manifestations of HIV Disease. International AIDS Society–USA Topics in HIV Medicine. Volume 13 Issue 5 December 2005/January 2006

14. Oral Manifestations of HIV/AIDS For persons living with HIV disease on antiretroviral therapy, the presence of certain oral manifestations may signal a failure in therapy. Hodgson TA, Greenspan D, Greenspan JS. Oral lesions of HIV disease and HAART in industrialized countries. Adv Dent Res. 2006 Apr 1;19(1):57-62

15. Oral Disease is Rarely Self-Limiting Oral health diseases are linked to systemic diseases: diabetes, heart disease, pregnancy issues Untreated oral disease may lead to systemic infections, weight loss, malnutrition Oral diseases impact quality of life: psycho-social problems, limited career opportunities

16. How can dental providers make a difference?

17. Role of Dental Providers • Eliminate infection, pain, and discomfort • Restore oral health functions • Early detection of HIV and referral: Oral lesions can be the first overt clinical feature of HIV infection. Early detection can improve prognosis and reduce transmission/ • A visit to the dentist may be a health care milestone for PLWHA. The dental professional can address oral health concerns and play a role in helping engage or re-introduce patients into the health care system and coordinate their care with other primary care providers.

18. What are the Benefits of Early Linkage to Oral Health Care After HIV Diagnosis? • 196 HIV-positive individuals: • 63 newly diagnosed cases (out of oral care and within 12 months of their HIV diagnoses) • Previously diagnosed controls (66 out of oral care and diagnosed with HIV between 1985-2007) • Historical controls (67 receiving regular oral care and diagnosed with HIV between 1985-2007) IADR – March 2011- Jennifer Webster-Cyriaque DDS, PhD – UNC School of Dentistry.

19. Findings • Persons who were newly diagnosed had significantly more teeth at baseline compared to the previously diagnosed and historical groups. • Newly diagnosed individuals had less periodontal disease (attachment loss and less bleeding on probing). • Previously diagnosed individuals had poorer gingival health and more broken teeth. • The previously diagnosed group had the most dental decay. • Service usage varied considerably: • Newly diagnosed: more preventive and maintenance services • Previously diagnosed: more costly prosthodontic services IADR – March 2011- Jennifer Webster-Cyriaque DDS, PhD – UNC School of Dentistry.

20. Findings • The higher levels of dental disease in the previously diagnosed group resulted in higher treatment costs. • “Early dental intervention in the newly diagnosed HIV-positive individuals results in significant functional maintenance, more optimal oral health, and considerable financial savings.” IADR – March 2011- Jennifer Webster-Cyriaque DDS, PhD – UNC School of Dentistry.

21. What oral health needs/barriers do PLWHA face?

22. Unmet Oral Health Needs • Oral health is one of the top unmet needs for PLWHA who obtain services through the Ryan White HIV/AIDS Program nationwide. • PLWHA have more unmet oral health care needs than the general population and have more unmet oral health care needs than medical needs. • PLWHA most likely to report unmet need for dental care are African American, uninsured, Medicaid recipients, and within 100% of federal poverty limits.

23. Barriers to Oral Health Care • Lack of dental insurance • Limited financial resources • Shortage of dentists • Too many appointments, other aspects of illness seen as being more important • Fear, no positive role models, stigma, shame • Negative patient-provider experiences • Shrinking adult dental Medicaid benefits

24. State Adult Dental Coverage in Medicaid, 2013 Number of states 18 14 10 9 Source: ADULT DENTAL BENEFITS IN MEDICAID, ADA

25. Oral Health Care is Expensive

26. What are we doing about oral health?

27. Oral Health: HRSA Strategic Priority Expand oral health and integrate it in primary care settings

28. Ryan White HIV/AIDS Programand Oral Health Services

29. SPNS OHI • Special Projects of National Significance Innovations in Oral Health Care Initiative • 15 sites across country • Grantees implemented innovative models of comprehensive oral health care services to expand dental access

30. Other HIV/AIDS Bureau Oral Health Investments • Oral health capacity assessment during site visits • All Grantee Meeting • Oral health performance measures • Oral health a funding priority under Part C Capacity Development Funding Opportunities • Program evaluations • Publications

31. Impact of Ryan White HIV/AIDS Programs on Oral Health Care • FY 2011: 135,004 clients received dental services • FY 2011: 8,480 dental providers (mostly dental students and residents) provided direct oral health care as part of CBDPP and DRP • FY 2011: 8,461 health care professionals (3,451 dental, 5,010 non dental) received oral health care education through AETCs

32. Impact on Our Clients “People treat you as if they have known you their whole life.” “They take care of my fear.” “They are like a big family…they gave me my smile back.” “I feel free, secure and welcomed by the staff.” “I feel comfortable…not treated as a HIV patient but a person who needs dental care.” “We’re all so fortunate to get what we need.” “It’s affordable. It’s a one stop shop.” “This is the only game in town.” “Quality of care here is 110%.”

33. Acknowledgment • Dr. David Reznik

34. Contact Info CDR Mahyar Mofidi, DMD, PhD HRSA/HAB Chief Dental Officer mmofidi@hrsa.gov 301-443-2075

35. Evaluating the HRSA SPNS Oral Health Initiative Jane Fox, MPH Boston University

36. HRSA Oral Health SPNS Initiative

37. SPNS Sites

38. SPNS Models - Typology • Three types of host agencies • ASO/CBO (5), CHC (4), and hospital/University-based programs (6) • Three basic models: • Fixed site • Expansion of prior dental program/services • Implementation of new dental program • Mobile dental units

39. Evaluation Study Questions • Do the demonstration programs increase access to oral health care for the target population? • What are the main similarities and differences in strategies and program models to increase access to oral health care across programs? • Are the oral health services performed in accordance with professional practice guidelines? • Do clients experience improvements in health outcomes over time?

40. Evaluation Study Questions • Are clients’ oral health care needs met? • Do clients experience improvements in oral health related quality of life after enrollment in oral health care? • What strategies are most effective in furthering successful program implementation: barriers, facilitators, key lessons learned? • What strategies to address the structural, policy and financing issues can be replicated in other settings?

41. Evaluation Study Design • Study criteria • HIV+, 18+ years of age, and no oral health care* for the past 12 months or more • Quantitative survey at baselineand follow-up • Demographics, past access, insurance, HIV status, past oral health symptoms, SF-8, OH QOL, and presenting problem • Utilization and ancillary data • CDT codes of EVERY procedure done, evidence of tx plan completion and recall

42. Evaluation Study Design • Qualitative interviews • In-depth interviews of 60 patients at 6 sites • OH experiences and values, OH self care knowledge and behaviors, patient education, and impact of HIV on OH • Dental case manager focus group • June 2008 with 12 participants

43. Patient Demographics • 75% male • 40.6% Black, 21.2% Latino • 33.4 % high school education, 43.0% beyond high school • 30.6% working, 55.7% monthly income < $850 • Age = 43.6 (18 – 81), • Yrs positive = 10.07

44. Baseline Dental Access

45. Baseline HIV Status

46. Significant Changes in Outcomes at 12 Months, N=1391

47. Significant Changes in Oral Health Symptoms at 12 Months, N=1391

48. Significant Changes in Habits at 12 Months, N=1391

49. Patient Perspectives - Habits • Improvements in oral health care practices • Better brushing & flossing techniques & frequency • “ Now I buy lots of toothbrushes and use them for a short time and replace them.” • “I brush everyday instead of 3 times/week...I floss a lot more” • “I brush longer” • Reduce or stop smoking/tobacco use • “ I still use snuff but I cut back a little and don’t leave it in my mouth as long...” • “I cut down from 3 cigarettes/day from 1 pack...” • Dietary changes • “I still drink soda but only once in awhile...I try not to buy it”

50. Standards of Care • We established a set for the multi-site evaluation: • The presence of a comprehensive exam • The presence of anyxrays • The presence of any cleaning or periodontal work • Completion of Phase I treatment plan • Patient placed on recall