The Compliance Divas Podcast
Our podcast covers current topics such as infection prevention and control, OSHA and HIPAA compliance for dentistry. We discuss the latest regulatory information, answer frequently asked questions and give suggestions for dental practices to make compliance easy and sustainable. The Compliance Divas are a trusted source for consistent, accurate information based upon current guidelines, standards, science, and recommendations.
The Compliance Divas Podcast
#211 HIV Discrimination - Does it Still Exist in Dentistry?
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The Divas take a deep dive into the attitudes, stigmas and facts surrounding the treatment of patients with HIV/AIDS. This compelling discussion includes historical as well as current information about providing oral health care to this very deserving group of patients.
Resources:
- Williams Institute Study on HIV Discrimination in Dental Care https://bit.ly/45nO1UZ
- CDC Stop HIV https://bit.ly/4fEzdom
- CDC - Undetectable = Untransmittable https://bit.ly/3HhTZxx
- NIH - Attitudes and Practices of Dentists Treating HIV+ Patients in the Era of New Antiretroviral Therapy: A 12-year Update https://bit.ly/4lD7dTA
- CDC MMWR Notes from the Field: Occupationally Acquired HIV Infection Among Health Care Workers - United States, 1985-2013 https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6353a4.htm
- HIVDENT https://www.hivdent.org/
- Movie - And the Band Played On: Politics, People, and the AIDS Epidemic Available on most streaming services
Welcome. I'm Leslie Canneman. I'm Mary Gavoni. I'm the party.
SPEAKER_00I'm Olivia Wann, and together we are the Compliance Divas.
SPEAKER_02Welcome to the Compliance Divas Podcast. My name is Leslie Cannum, and I'm your moderator for this podcast today called HIV and Discrimination in Dentistry. Our podcast today is on HIV and discrimination in dentistry. You might not think that there is still discrimination, but occasionally we find that patients feel that they've been discriminated against because they're HIV positive. In 2007, there was a study that was conducted by the Williams Institute in Los Angeles, California, where 612 dental offices were contacted to find out whether there were levels of HIV discrimination among these offices. And the key findings were that 5% of the dental offices had an unlawful blanket policy of refusing dental services to any patient who was living with HIV or AIDS. An additional 5% of the dental offices said that they would treat these patients, but they would be treated differently than other patients and in ways that could potentially violate state and federal anti-discrimination laws. There were many factors in just determining the caller type and the caller's insurance, the geographic area of the dental practice and where the dentist had graduated dental school. 90% of the dental offices that were contacted by these trained researchers responded that they would treat patients that were living with HIV or AIDS. Now, it's interesting to note the kind of research that was done was a telephone call. And the telephone call, the trained researchers were asked to pose as patients, sort of similar to a mystery call from a mystery patient. They asked the dental practice what their hours were and what insurance they took and whether they would have any evening or weekend hours. And once they determined that they had a fit, the researcher had stated that they were a patient who had was HIV positive. And they asked, would you still take me as a patient? And that's where they collected the data of the offices that would and would not see patients who are living with HIV or AIDS. Now, it's also interesting to note that many times the illegal response for the offices that did decline to see the patients or say that they would treat them differently, the common theme seems to be that they weren't trained well on what standard precautions are. We're going to talk a little bit about standard precautions later, but it's important to make sure our team is always on the same page when it comes to answering questions from potential patients regarding our infection control. What I'd like to do is lead off with Mary and talk a little bit to us, Mary, about what is HIV stigma?
SPEAKER_00Thanks, Leslie. HIV stigma is something that all of the divas lived through, starting in the early 1980s, through probably most of the 1990s, before things I would describe as calmed down a little bit. HIV stigma, as defined by the CDC, is negative attitudes and beliefs about people with HIV. And I think some of that still dwells within a lot of people, but thinking back to those early years when we didn't really know how HIV was transmitted and we didn't know if it could be easily transmitted in a dental setting, it was a pretty scary time. And people will perhaps make moral judgments, believing that it's only certain people or population groups that get HIV. One of the things, and I'll put a link in the in the resources, a very powerful movie to watch that really sums up HIV stigma when we first discovered HIV is a movie called And the Band Played On. It will literally bring you to tears to know the stigma and the discrimination that happened in the homosexual male community who had and probably still have some of the big biggest stigma. There are still some people who make moral judgments about folks that say they deserve it because of their lifestyle choices or whatever that may be. So the reality is that we do not have any confirmed cases of transmission of HIV from a patient to a healthcare worker. In the January 9th, 2015 issue of the Morbidity Mortality Weekly report or the MMWR from the CDC, there was a study reported that was done from 1985 to 2013, and it looked at the occupationally acquired HIV infections among healthcare workers. It did say that there were six dental workers who had possible cases of occupationally acquired HIV infection, but the differentiation was that these were not ones that were documented exposures in the dental practices. So the exposure may very well have occurred, but it may not have been reported. And then this person possibly developed some symptoms, and it was suspected perhaps that it was an occupational exposure, but it was not confirmed. That study is in the resources in the show notes. So although the stigma is not front and center like it was 20 years ago or so, it is still there.
SPEAKER_02Well, thank you, Mary. Linda, can you explain to us what HIV discrimination is?
SPEAKER_01Leslie, to play off of what Mary mentioned regarding stigma and how that refers to an attitude or belief, discrimination takes it a step further because now that's the behavior that results from those attitudes or beliefs that someone has, that they're making those moral judgments about a population group or individuals, and people get what they deserve from what their lifestyle choices and those kinds of beliefs that someone may hold. But now discrimination takes it a step further by acting out or treating individuals living with HIV differently than those individuals without HIV. And just for a couple of quick examples, you know, a healthcare professional refusing to provide care or services to a person living with HIV, or refusing casual contact with someone living with HIV, isolating a member of the community because they are HIV positive. So those are some general community examples. And what I've seen over the years in dentistry, Leslie, is that there's a silent discrimination that goes on even today, which is sad. And one of the things that happens is when individuals' HIV are scheduled, perhaps, you know, at the end of the day or the end of the week. So that way the room is cleaned and it's it's over the weekend, and it makes somebody feel better thinking that the room has just been aired out or whatever the rationale might be, that there's really no rationale, Leslie, because you mentioned standard precautions. And that applies to all patients, whether we know they have something, or whether we don't know, or whether they do have any disease process or they don't have any disease process. So it makes a difference in how we treat individuals, and we have to remember everybody deserves the same type of respect in our dental practice. So coming in and treating everybody with the respect and dignity that they deserve is very important. And it's a very keen aspect of a culture of compliance, a culture of safety, and a culture that's teams that's patient-centric in their care. So thanks for asking this question, Leslie. It's very important.
SPEAKER_02Well, thank you for that explanation, Linda. And our Dima Olivia is not with us here today, but she wanted to make sure that we covered a couple of things. One is the effects of HIV stigma and discrimination on our patients. And then also we're going to talk about something called undetectable equals untransmissible. Starting out with the effects of HIV stigma and discrimination, it really does affect the emotional and uh well-being and mental health of people who are living with HIV. And oftentimes they internalize the stigma and they experience what that they experience in settings and they begin to develop a negative self-image. They may fear that they will be discriminated against or judged negatively if their HIV status is revealed. Internalized stigma or self-stigma happens when a person takes the negative ideas and stereotypes about people living with HIV and start to apply them to themselves. HIV internalized stigma can lead to feelings of shame, fear, fear of disclosure, isolation, and despair. And these feelings can actually keep people from getting tested and treated for HIV. So it's important that we have full inclusion with our patients and recognize that standard precautions prevail regardless of our patients' diagnosis. And we're going to talk a little bit more about why standard precautions are important and why our patients may not share with us their status. But I'd like to go to something that may give us a little bit more confidence. And that is a phrase that is undetectable equals untransmissible. And it's an essential strategy for HIV prevention. And it is a community-led global health campaign where CDC is a leader in the global movement to promote you equals you, undetectable equals untransmissible, and ultimately prevent AIDS or HIV transmission. So undetectable means a person with who is living with HIV who is on treatment and maintains an undetectable viral load has zero risk of transmitting HIV to their sexual partners. With sustained antiretroviral treatment, it reduces the amount of HIV in the body to an undetectable level in viral load test. And studies have demonstrated that people living with HIV with an undetectable viral load cannot transmit HIV to sexual partners. This science or treatment as prevention is one of the most effective biomedical tools for preventing HIV transmission. So detectable equals untransmittable is commonly referred to when we talk about exposure incidents. If a patient has an undetectable viral load, they're untransmissible to another person. So this gives us a little bit more confidence of being feeling just a little bit better about the low risk of HIV transmission. But Mary, when we talk about standard precautions, could you tell us uh about patients and maybe their position of even disclosing their status of being HIV positive to us?
SPEAKER_00Absolutely. And Leslie, thank you first of all for choosing this topic for this podcast because I think this is a great review. We've been focused on COVID-19 and so many other things in terms of infectious disease transmission that HIV for some people has kind of been in the background. And I think it's always good to keep it at the front of your mind. Some of our listeners may remember when we called standard precautions universal precautions, and that was changed a number of years ago because the terms universal precautions meant strictly exposure to blood or some other body fluids. And now standard precautions means with any patient, anytime. I call it the take no prisoners rule. But the reason behind this is that we cannot make assumptions. We all know that health histories are not necessarily reliable. Patients may not know that they have HIV or other health conditions. They may decide not to tell us because of some of the stigma and the discrimination that we talked about earlier. And they may have become HIV positive since the last time they updated their health history. So whenever we have contact with patients' blood or saliva in dentistry, we always wear gloves. We always wear eye protection if there's going to be splatter or splash. We wear respiratory protection, which also prevents exposure of splatter and splash to the nose or mouth, which kind of sounds gross. And we wear our protective clothing so that we don't contaminate our clothing and then wear it into our lunchroom or our break room. But just know that we assume everyone is not only infectious to us for HIV, but hepatitis B, hepatitis C, and respiratory symptoms as well. That is what standard precautions is all about.
SPEAKER_02Mary, thank you for that. Take no prisoners. It doesn't matter if someone is 6, 16, or 60. We treat all blood or body fluid the same. And a recap, patients may not tell us that they're HIV positive because they're worried that there may be some discrimination or that team members may treat them differently. They may not know that they have HIV, or they may have acquired HIV since the last time we did a health history with them and were reluctant to share that status with us because they know that we have to practice standard precautions in the care of all patients. An interesting case of some, I guess you could say ignorance when it comes to infection control occurred when we had seen our first case of hepatitis C transmission in dentistry. And you may remember hearing about Tulsa, Oklahoma, and Dr. Scott Harrington. And we had a speaker from who was the public health director, I believe it was Christy Bradley, that came to an OSAP meeting now called ADS, and she spoke to us about the findings of their investigation and the interview with the dental assistants who were working with Dr. Harrington in that case. And the ultimate uh way that the transmission occurred was thought to have been through unsafe injection practices. But there were also many other unsafe infection control protocols that were practiced by the dental assistants. And one was to soak the instruments that were used on HIV-positive patients in undiluted bleach, which of course is very corrosive to instruments. But the idea of doing something differently with your instruments when you know someone has HIV, well, the first thing is that that isn't standard precautions. We treat all instruments the same. All patients, whether they are HIV positive or not, uh all are processed the same way. But the other thing that that brings to mind is it uh it rings true that they would think that their systems are not good enough. If you're having to do something different that than doing your processes of cleaning and sterilizing instruments appropriately, then you're worried that that's not enough. And it needs to be enough. Linda, you wanted to chime in?
SPEAKER_01I would love to, Leslie. What you're discussing with Dr. Harrington and Dr. Ecker in Florida reminds me of when I saw my first known HIV-positive patient decades ago now, but nevertheless, still the same concern that happens when all of a sudden you're faced with seeing a patient yourself. How do you deal with it? And this was during the time period where we didn't know much about HIV. And this young man was in the final disease processes, and my wonderful doctor at the time was so kind to do some work for him to help make it more palatable with his oral condition, you know, as he was progressing with the disease process. And we didn't know how to handle the instruments, just as you said, Leslie. I remember some of the team were floating the idea well, should we sterilize them before we put them in the ultrasonic? Because we didn't know what we didn't know. And I think even then, not just didn't we not know about HIV because it was so new, but I think we weren't as educated on the whole sterilization process and understanding as much as teams do today. And why that now would make no sense to sterilize instruments and harden the debris onto an instrument and then try to put it in ultrasonic solution, we can simply, you know, the ultrasonic solution is designed for that. So things have changed so much, and I'm so glad that we're addressing this topic, just to really remind our listeners that we are doing every, if we're doing everything we should according to the standard precautions that Mary talked about, then we are fine. So challenge ourselves to live up to those standards.
SPEAKER_00Thank you, Linda. And Mary? Linda, thank you for taking us down memory lane about when we didn't really know as much as we know about HIV. I remember that there were practices that would literally drape their walls in their treatment rooms in plastic sheeting and do a lot of really extraordinary things out of fear. And now we don't operate as much from a fear-based protocol, but a science-based protocol. And we know that the transmission possibilities are low in dentistry, but we still can't let our guard down. And there are probably a lot of people who don't even remember the whole story about Dr. Acker in Florida and the CDC investigation and so forth. And I will put a link in the resources for that just because many people find that sort of interesting who don't know what happened back then. And it was a scary time. People were canceling appointments. There were stories. Um, I remember the president of the American Dental Association being interviewed on 60 Minutes, and they made her look not so intelligent as I knew her to be, but we didn't have a lot of information yet that we could disseminate. So it was a tough position for dentistry all around.
SPEAKER_02Thank you, Mary. And you know, there's a resource I want to mention to our listeners that it is a web-based, an internet-based type of website called HIV Dent. And we will include that in the show notes of this podcast in the resources section. This is a great place to stay up to date. We have 28 years of being the internet oral healthcare resource on HIV AIDS, and it has a picture gallery to help you identify things you might see in a patient's mouth and help you to better care for patients who may be HIV positive or living with HIV or AIDS. And with that, I'd like to wrap up our podcast today, reminding everyone that we bring clarity and simplicity to compliance by navigating regulatory compliance to keep you on course. We welcome your questions to support at the compliancedevas.com. And again, the resources will be available in the show notes. You can find our episodes on your favorite podcast channel, or you can simply go to our website, thecompliancedivas.com. Submit your questions to support at the compliancedevas.com, and we look forward to having you download our episodes and podcasting with you in the future.