1 December 2024, is World AIDS Day. Founded in 1988 by United Nations AIDS (UNAIDS), World AIDS Day was the first ever international day for global health [1]. On this day, people around the world unite to show support for people living with HIV and to remember those who have died from AIDS-related illnesses.
Dental and oral health professionals play a critical role in providing holistic care for all patients, including those living with human immunodeficiency virus (HIV). HIV is a retrovirus which causes immunosuppression due to quantitative and functional defects in CD4 T-cells [2, 3]. If left undetected or untreated this immunosuppression leads to acquired immunodeficiency syndrome (AIDS). The intersection of HIV and oral health is particularly important, as the oral manifestations of HIV can be early indicators of disease progression, and maintaining oral health is key to improving overall health outcomes in these patients.
Australian Context
Australia has made significant strides in the fight against HIV, with the nation adopting a “Towards Zero” target by 2030 as part of its National HIV Strategy [4]. This ambitious goal aims to eliminate new HIV transmissions, reduce AIDS-related deaths, and improve the quality of life for people living with HIV. This target is underpinned by advancements in treatment, prevention strategies like pre-exposure prophylaxis (PrEP), and community education efforts.
In Australia, overall HIV diagnoses have reduced by 33% over the last decade, with significant reductions among Australian-born gay and bisexual men, where diagnoses have reduced by 64%. Despite overall declines in HIV diagnoses, there has been a slight increase over the past 10 years among the small number of people living with HIV acquired through heterosexual sex and among people born overseas [5].
HIV Treatment
Advances in the treatment and care of patients with HIV infection have led to dramatic reductions in the morbidity and mortality associated with this disease [6]. The advent of combination antiretroviral therapy (cART) has led HIV to become a manageable chronic disease. In Australia, 95% of people with HIV are on treatment, and 98% have an undetectable viral load [7]. An undetectable viral load means the virus is unable to be transmitted, commonly referred to as U=U (undetectable = untransmissible). Like any medication, antiretroviral medication is not without adverse effects. In the short term, this is commonly gastrointestinal toxicity such as nausea, vomiting, and diarrhoea, rash, and hypersensitivity reactions. In the long-term, hepatotoxicity, renal dysfunction, and lipodystrophy can occur [8]. Dry mouth is also a common side effect [9].
HIV and Oral Health
Prior to cART, HIV infection was associated with many oral health issues. Oral candidiasis, linear gingival erythema, oral hairy leukoplakia, herpes simplex virus infection, necrotising ulcerative gingivitis/periodontitis, and Kaposi’s sarcoma were all commonly found in patients with HIV [10, 11]. It was thought many of these pathologies were associated systemic progression of HIV, progressing towards AIDS [11].
In the era of cART, a marked decline in destructive periodontal diseases and oral pathologies has been observed [10, 11]. In fact, studies have shown no difference in the incidence or severity of periodontal disease between HIV and non-HIV infected patients [12, 13]. However, knowing the oral pathology and disease associated with HIV and AIDS is important as it may lead to earlier diagnosis and treatment.
The management of oral health for patients with HIV should be similar to management of people with other chronic diseases such as type 2 diabetes mellitus. Routine examination with a focus on periodontal treatment and maintenance, and caries management, is most important. Discussion of HIV management is another important aspect – dental and oral health professionals should record the patient’s regular GP or specialist, medications, and blood results. Viral load is seen as a marker of treatment success, <50 copies/ml counted as undetectable, and should be checked at each appointment [14]. CD4 count is also measured regularly but recently has been seen as adding little value as a marker of disease progression [15].
Stigma
One of the most critical aspects of care for dental professionals is addressing the stigma surrounding HIV. Stigma, both within healthcare settings and society at large, continues to affect the lives of people with HIV, often leading to discrimination, fear, and reluctance to seek care. Dental and oral health professionals must commit to fostering an environment of inclusivity and respect, where patients with HIV feel safe and supported.
In the dental setting, this means providing the same standard of care to patients with HIV as to any other patient. Infection control protocols should be consistently applied for all patients, as standard precautions are sufficient to prevent the transmission of HIV and other infections. Any additional protocols for HIV patients are unnecessary and may be seen as discriminatory. By treating patients with HIV with dignity and respect, dental oral health professionals can significantly contribute to reducing the stigma surrounding the virus.
Conclusion
As dental and oral health professionals, we treat more than just the mouth. We treat people. Behind every HIV diagnosis is a person and a story. With timely diagnosis, the right treatment, care and peer connection people with HIV expect a long and productive life. We have a responsibility to treat every patient who walks through our door equally. Modern treatment has resulted in 98% of patients with HIV unable to transmit the virus and has significantly reduced HIV-related oral diseases. Recognising the importance of global efforts like World AIDS Day, understanding the context of HIV in Australia, and embracing equality in treatment are all essential components of providing comprehensive care in dental practice.
References
1. UNAIDS 2024 [Internet]. https://www.unaids.org/en/World_AIDS_Day
2. Haseltine, W.A., 1991. Molecular biology of the human immunodeficiency virus type 1. The FASEB journal, 5(10), pp.2349-2360.
3. Pantaleo, G., Graziosi, C. and Fauci, A.S., 1993. The immunopathogenesis of human immunodeficiency virus infection. New England Journal of Medicine, 328(5), pp.327-335.
4. Department of Health (2018) Eighth National HIV Strategy. https://www.health.gov.au/resources/publications/eighth-national-hiv-strategy-2018-2022?language=en
5. HIV diagnoses trending down in Australia despite 2023 increase [Internet]. https://www.kirby.unsw.edu.au/news/hiv-diagnoses-trending-down-australia-despite-2023-increase
6. Cohen, M.S., Chen, Y.Q., McCauley, M., Gamble, T., Hosseinipour, M.C., Kumarasamy, N., Hakim, J.G., Kumwenda, J., Grinsztejn, B., Pilotto, J.H. and Godbole, S.V., 2016. Antiretroviral therapy for the prevention of HIV-1 transmission. New England Journal of Medicine, 375(9), pp.830-839.
7. HIV in Australia [Internet] https://www.healthequitymatters.org.au/about-hiv/hiv-in-australia
8. Hawkins, T., 2010. Understanding and managing the adverse effects of antiretroviral therapy. Antiviral research, 85(1), pp.201-209.
9. Diz Dios, P. and Scully, C., 2014. Antiretroviral therapy: effects on orofacial health and health care. Oral diseases, 20(2), pp.136-145.
10. Gondivkar, S., Sarode, S.C., Gadbail, A.R., Yuwanati, M., Sarode, G.S., Gondivkar, R.S., Sengupta, N., Patil, S. and Awan, K.H., 2021. Oro-facial opportunistic infections and related pathologies in HIV patients: A comprehensive review. Disease-a-Month, 67(9), p.101170.
11. Ryder, M.I., Shiboski, C., Yao, T.J. and Moscicki, A.B., 2020. Current trends and new developments in HIV research and periodontal diseases. Periodontology 2000, 82(1), pp.65-77.
12. Fricke, U., Geurtsen, W., Staufenbiel, I. et al. Periodontal status of HIV-infected patients undergoing antiretroviral therapy compared to HIV-therapy naive patients: a case control study. Eur J Med Res 17, 2 (2012)
13. Alves, M., Mulligan, R., Passaro, D., Gawell, S., Navazesh, M., Phelan, J., Greenspan, D. and Greenspan, J.S. (2006), Longitudinal Evaluation of Loss of Attachment in HIV-Infected Women Compared to HIV-Uninfected Women. Journal of Periodontology, 77: 773-779
14. Hoffman, J., Van Griensven, J., Colebunders, R. and McKellar, M., 2010. Role of the CD4 count in HIV management. HIV therapy, 4(1), pp.27-39.
