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

. 1AgendaIntroduction to SPNS Integrating HIV Innovative Practices (IHIP) projectSarah Cook-Raymond, Managing Director of Impact Marketing + CommunicationsPresentations from:Dr. Mahyar Mofidi; Branch Chief of the Division of Community HIV/AIDS Programs and Chief Dental Officer, HRSA HIV/AIDS BureauJane Fox, MPH; Project Director of SPNS Oral Health Initiative Evaluation Center for HIV and Oral Health (ECHO), Boston University School of Public HealthQ & A

*IHIP Resources onTARGET Center Website www.careacttarget.org/ihip IHIP Oral Health ResourcesTraining Manual

Curriculum

Pocket Guide

Webinar SeriesHealthy Mouth, Healthy BodyDental Case ManagementClinical 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

Other IHIP ResourcesBuprenorphine TherapyTraining Manual, Curriculum, Monograph, and Webinars on implementing buprenorphine in primary care settingsEngaging Hard-to-Reach PopulationsTraining Manual, Curriculum, and Webinars on engaging hard-to-reach populationsJail LinkagesTraining Manual, Curriculum, Pocket Guide, and Webinars on enhancing linkages to HIV care in jails settings

UPCOMING: Hepatitis C Treatment ExpansionIn 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.

Healthy Mouth, Healthy Body: Oral Health Care's Vital Role in Overall Well Being for People Living with HIV/AIDSCDR Mahyar Mofidi, DMD, PhD Branch ChiefChief Dental Officer HRSA, HIV/AIDS BureauDecember 13, 2013

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12+ years agoYou 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.

7Oral Health for PLWHAWhile 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

8Why does good oral health matter in HIV care?9Oral Disease in HIV InfectionOral infections and neoplasms occur with immunosuppression (bacterial, fungal, viral, neoplastic, lymphoma, ulcers)High prevalence of dental caries and periodontal disease

1032-46% 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 diseasePrevalence of Dental Caries and Periodontal Disease in a Ryan White HIV/AIDS Program-Funded Dental ClinicDental caries were present in 66% of patients54% had gingivitis and 28% had periodontal diseaseInfectious Disease Society of America (IDSA) 47th Annual Meeting November 2009 Poster #1063

11Oral Manifestations of HIV/AIDSFor 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 SocietyUSA Topics in HIV Medicine. Volume 13 Issue 5 December 2005/January 200612Oral Manifestations of HIV/AIDSFor 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 SocietyUSA Topics in HIV Medicine. Volume 13 Issue 5 December 2005/January 200613Oral Manifestations of HIV/AIDSFor 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):57-6214Oral Disease is Rarely Self-Limiting15Untreated oral disease may lead to systemic infections, weight loss, malnutritionOral health diseases are linked to systemic diseases: diabetes, heart disease, pregnancy issuesOral diseases impact quality of life: psycho-social problems, limited career opportunitiesHow can dental providers make a difference? 16

Role of Dental ProvidersEliminate infection, pain, and discomfortRestore oral health functionsEarly 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.17What 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.18FindingsPersons 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 servicesPreviously diagnosed: more costly prosthodontic services

IADR March 2011- Jennifer Webster-Cyriaque DDS, PhD UNC School of Dentistry.19FindingsThe 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.20What oral health needs/barriers do PLWHA face?21

Unmet Oral Health NeedsOral 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.

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Barriers to Oral Health Care Lack of dental insuranceLimited financial resourcesShortage of dentists Too many appointments, other aspects of illness seen as being more importantFear, no positive role models, stigma, shame Negative patient-provider experiencesShrinking adult dental Medicaid benefits

2323State Adult Dental Coverage in Medicaid, 2013Source: ADULT DENTAL BENEFITS IN MEDICAID, ADANumber of states9

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14

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24Oral Health Care is ExpensiveServiceNational average fees charged by private practitioner Sample reimbursed fees by Medicaid Comprehensive oral evaluation/ examination$66.29$14.89 - $44.61Limited oral evaluation$57.60$14.00 - $36.76Intraoral radiograph (first film)$23.41$3.63 - $14.91Adult cleaning$77.64$22.10 - $58.00Filling (amalgam, one surface)$110.35$15.59 - $64.56Filling (clear, one surface)$131.30$25.62 - $65.90Extraction (simple)$138.21$25.62 - $63.54Extraction (surgical)$224.11 $33.43 - $109.23Endodontic (molar root canal)$868.00$157.93 - $409.90Crown (porcelain)$908.00$580.00Complete denture (upper)$1,333.57$584 - $60025What are we doing about oral health?26Oral Health: HRSA Strategic Priority Expand oral health and integrate it in primary care settings27

Ryan White HIV/AIDS Programand Oral Health ServicesSafety net28SPNS OHISpecial 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 29Other 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

30Impact 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 DRPFY 2011: 8,461 health care professionals (3,451 dental, 5,010 non dental) received oral health care education through AETCs3132Impact 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 familythey gave me my smile back.I feel free, secure and welcomed by the staff.I feel comfortablenot treated as a HIV patient but a person who needs dental care. Were all so fortunate to get what we need. Its affordable. Its a one stop shop. This is the only game in town. Quality of care here is 110%.

Acknowledgment Dr. David Reznik 33Contact InfoCDR Mahyar Mofidi, DMD, PhDHRSA/HAB Chief Dental Officermmofidi@hrsa.gov301-443-207534

Evaluating the HRSA SPNS Oral Health InitiativeJane Fox, MPHBoston University35

HRSA Oral Health SPNS InitiativeSeptember 2006 HRSA funded 15 sites and one evaluation & TA centerFive year funding cycleSites were charged with increasing access to oral health care for PLWHA Eval center at BU Site could design any program to meet this goal.

Evaluation center: Study design includes a quantitative survey with patients baseline, 6 and 12 months (with an optional 18 and 24), collection of all dental utilization data, and a qualitative study with in-depth interviews with 60 patients from 6 sites.36

SPNS Sites

15 sites = 7 urban and 8 rural2 in NYC, 2 in CA and one in USVI. The remainder are scattered.37

SPNS Models - TypologyThree types of host agenciesASO/CBO (5), CHC (4), and hospital/University-based programs (6)Three basic models:Fixed site Expansion of prior dental program/servicesImplementation of new dental programMobile dental units

Since sites were not required to follow a set format in creating their programs, we designed a typology to categorize the programs for descriptive purposes. All of the sites fall into one of these 3 types of host agencies and have adopted one of these 3 basic models. Fixed sites either expanded the kind of services they provided or expanded their service area by opening satellite clinics.

Other commonalities we looked at across the sites were the use of a case manager either dental specific or the HIV case manager and collaboration between the sites and a dental/hygiene school.38

Evaluation Study QuestionsDo 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?

Working with the sites and HRSA we came up with 8 study questions we proposed to answer by the end of the project.39

Evaluation Study QuestionsAre 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?40

Evaluation Study DesignStudy criteriaHIV+, 18+ years of age, and no oral health care* for the past 12 months or moreQuantitative survey at baseline and follow-upDemographics, past access, insurance, HIV status, past oral health symptoms, SF-8, OH QOL, and presenting problemUtilization and ancillary dataCDT codes of EVERY procedure done, evidence of tx plan completion and recall

Quantitative survey at baseline, 6, 12 and optional 18 and 24

Challenges of collecting utilization data Every procedure by code vs billing codes and formal vs informal recall systems

Ancillary data optional and good consistent data from 5 sites41

Evaluation Study DesignQualitative interviewsIn-depth interviews of 60 patients at 6 sitesOH experiences and values, OH self care knowledge and behaviors, patient education, and impact of HIV on OHDental case manager focus groupJune 2008 with 12 participants

Two sets of qualitative interviews have been conducted with this subset of patients 12 -14 months apart.Sites included HIV Alliance, Montefiore, Native American Health Center, Special Health Resources in Texas, St Lukes Hospital and the University of Miami

DCM is a new concept so we hosted a focus group to gather more information about the tasks, training and needs of this type of professional42

Patient Demographics75% male40.6% Black, 21.2% Latino33.4 % high school education, 43.0% beyond high school30.6% working, 55.7% monthly income < $850Age = 43.6 (18 81), Yrs positive = 10.07N=246911.7% patients were diagnosed in the past yearMore than half the patients reports their last dental visit 2 or more years ago.43

Baseline Dental AccessUsual place for dental care: 38.6% none; 31.0% private dentist48.2% reported needing dental care but were not able to get it since testing positiveOf those who did not get dental care, 53.8% stated affordability as the reason.Usual place for dental careNone 37.6Private dentist 30.4Community health center 17.9Dental school 5.4Other 6.7

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Baseline HIV Status 97.5% had a regular place for HIV care and 95.0% had seen their HIV provider in the past 6 months 85.2% had an HIV case manager and 77.9% were taking ARTs57.35 had a CD4 count over 350 and 52.8% had an undectable viral load45Significant Changes in Outcomes at 12 Months, N=1391 OutcomeBaseline12 Mos.Report unmet need for oral health care48%17%Report good/excellent health of teeth and gums38%67%Oral health symptoms: mean (SD)3.35 (2.34)1.78 (1.93)

We found significant changes at 12 months related to a reduction in unmet need for oral health, improvement in the overall health of peoples teeth or gums and the total reduction in symptoms.46Significant Changes in Oral Health Symptoms at 12 Months, N=1391

We also found significant reductions in oral health symptoms over 12 months, as we would hope to find. All of these were significant at p