摘要：Objectives. Although people with HIV experience significant oral health problems, many consistently identify oral health as an unmet health care need. We conducted a randomized controlled trial to evaluate the impact of a dental case management intervention on dental care use. Methods. We evaluated the intervention according to self-reported dental care use at 6-, 12-, and 18-month follow-ups. Multivariable logistic models with generalized estimating equations were used to assess the effects of the intervention over time. Results. The odds of having a dental care visit were about twice as high in the intervention group as in the standard care group at 6 months (adjusted odds ratio [OR] = 2.52; 95% confidence interval [CI] = 1.58, 4.08) and 12 months (adjusted OR = 1.98; 95% CI = 1.17, 3.35), but the odds were comparable in the 2 groups by 18 months (adjusted OR = 1.07; 95% CI = 0.62, 1.86). Factors significantly associated with having a dental care visit included frequent physician visits and dental care referrals. Conclusions. We demonstrated that a dental case management intervention targeting people with HIV was efficacious but not sustainable over time. Barriers not addressed in the intervention must be considered to sustain its use over time. In the era of antiretroviral therapy, people with HIV are living longer and the treatment of associated medical and oral manifestations of the disease has shifted to a chronic disease model. 1 Previous studies have shown that a person living with HIV/AIDS is more likely than a person without the disease to experience oral health problems. 2–5 Furthermore, the oral health problems of individuals with HIV can be more severe and difficult to treat than those of the general population and may also contribute to the onset of opportunistic infections. 5 The oral health complications associated with HIV are well documented, 2–6 and oral manifestations are increasingly being recognized as markers for monitoring treatment efficacy and predicting treatment failure. 7 Oral manifestations, including Kaposi’s sarcoma, necrotizing ulcerative periodontitis, oral hairy leukoplakia, and candidiasis, may be present in up to 50% of people with HIV and 80% of people diagnosed with AIDS, 5,6 and may predict low CD4 counts. 8 In addition, individuals living with HIV/AIDS may experience difficulty in maintaining adequate salivary flow, which affects chewing, swallowing, and the ability to take medication. 4 Chronic use of highly active antiretroviral therapy can also contribute to diminished salivary flow as well as an increased risk of oral candidiasis and oral hairy leukoplakia. 9 Throughout the 1990s, a series of study findings highlighted the unmet needs for dental care among people with HIV infection. 10–14 This gap in oral health care services was corroborated by findings from the oral health component of the HIV Cost and Services Utilization Study, 15 which demonstrated that unmet dental needs were twice as common as unmet medical needs among HIV-positive adults 16,17 and led to a national call to action to improve access to oral health care. 18 That study also showed that approximately half of people living with HIV had dental insurance, and those without dental insurance had greater unmet needs for dental services. 17,19,20 Recently published findings suggest that an unmet need still persists. One example is an initiative, funded by the Health Resources and Services Administration, that included 2469 people living with HIV who had not received dental care during the preceding year. Nearly half of these individuals (48%) reported an unmet dental need since their HIV diagnosis, 52% had not seen a dentist in more than 2 years, and 63% rated the health of their teeth and gums as fair or poor. 21,22 An earlier investigation involving baseline data from the study presented here showed that oral health problems and symptoms were very prevalent among our study population, with 63% of participants having experienced an oral health impact very often or fairly often in the preceding 4 weeks. 23 Barriers to dental care use among individuals living with HIV include fear of dental care, HIV-specific stigma, fear of disclosing their HIV status to health care providers, perceived cost barriers, and poor adherence to medical guidance. 20,22,24–31 Compounding patient access barriers, dental care providers may be reluctant to treat patients with HIV owing to fears of HIV transmission and associated stigma. 32–36 Previous research conducted in Florida revealed that more than one third of people with HIV do not discuss oral health with their primary care providers. 37 Although clinical guidelines recommend that HIV care providers examine the oral cavity during initial and interim physical examinations of people living with HIV, this still may not be a regular clinical practice. 37 To address underuse of oral health care services among individuals with HIV, we evaluated the efficacy of an intervention that linked individuals to dental care. The sample comprised a population of HIV-positive individuals in south Florida who had received HIV primary care but had not received oral health services in the preceding 12 months.
