Introduction

Update on the HIV Epidemic

Roseann Mulligan, DDS, MS

Copyright 2001 Journal of the California Dental Association.

Nothing is as constant as change itself.

So wrote the Greek philosopher of Ephesus, Heraclitus (535-475 BCE).

This is certainly true of the human immunodeficiency virus or HIV/AIDS epidemic. In reviewing the last Journal of the California Dental Association theme issue devoted to this topic (September 1993), it is clear that many changes have occurred when it comes to this epidemic. The demographic profile of the population most at risk for contracting the disease has been changing, as has our knowledge of the virus itself, its mutability, and its potential for oral transmission; the medical treatments and protocols for medications; the intraoral manifestations being observed; and how we assess and manage our dental patients whether they have already been diagnosed with HIV infection or are demonstrating behaviors that place them at risk for acquiring the disease.

Nor does the epidemic show any signs of waning. Dr. Michael Campsmith’s paper in this issue reports that the cumulative number of California AIDS cases has more than doubled in the seven-year time span since our previous report. He clearly describes the increasingly disproportionate effect this disease is having on African-Americans and Hispanics and the increasing percentage of women contracting the disease through heterosexual exposure. He also indicates that people with HIV are living longer than ever due to new treatment regimens, and the number of people acquiring the disease is remaining constant. The net effect is that more people are living with HIV infection.

Dr. Geeta Gupta’s paper on HIV pathogenesis and treatment details the steps that occur in the life cycle of HIV. The knowledge of these stages has allowed a number of new medications to be developed that specifically target a biological mechanism at that stage. The 1993 Journal issue discussed only three anti-retroviral drugs that were used to diminish HIV replication. Dr. Gupta discusses three categories of anti-retroviral drugs, specifically highlighting combination therapy or HAART (highly active anti-retroviral therapy). She notes that the combination of CD4 count and viral load testing is now used as a prognosticator of HIV disease activity and states that adherence to the medication regimen is particularly important, as mutations that may result in a drug-resistant virus are more likely when dosages are suboptimal. Dr. Gupta addresses cross-resistance sparing strategies, metabolic complications that may develop in people on protease inhibitors, and the risk of co-infections such as tuberculosis, and provides an update on recommendations for drug therapy for pregnant HIV-positive women.

Many of the common intraoral lesions discussed in 1993 are seen with considerably less frequency. Dr. Mahvash Navazesh details these changes, especially those that appear to be related to treatment of HIV infection by newer classes of medications, including HAART therapy. She discusses the relationship between CD4 counts and RNA viral load levels and the more common intraoral lesions in HIV-infected children and adults and reports on other intraoral findings that have been investigated more thoroughly over the intervening years, including salivary gland involvement and salivary flow measurements.

The controversial topic of HIV transmission through the oral route is the subject of Dr. Fariba Younai’s paper. Although transmission through casual salivary exchanges, such as via shared eating utensils, is still considered unlikely due to the antiviral properties of saliva, other oral transmission modes have been examined. Her review of the literature leads her to assert that unprotected orogenital sex may not be as safe as has been previously thought. Dr. Younai also discusses the inefficiency of local inhibitory factors in the saliva of the newborn that may be a contributing factor to the acquisition of HIV infection through breastfeeding.

Since the initial infection with the human immunodeficiency virus results in "flu-like" symptoms that resolve, followed by a 10-year incubation period, an individual may not be aware that he or she has become infected and is harboring the HIV virus. The dentist may notice a suspicious intraoral finding or become aware of the patient’s involvement in behaviors that have been documented to result in HIV transmission. The paper I wrote with Ms. Sue Lemme deals with this issue by presenting a strategy of risk assessment that can be utilized by the dentist to interview the patient. This step-by-step approach in reviewing the patient’s likelihood of contracting the HIV virus, in addition to providing information to the dentist, helps the patient engage in the realization of his or her potential for infection. This is an important first step to the individual’s seeking HIV testing and/or ceasing involvement in hazardous behavior.

Since HIV-infected patients are living longer, many are returning to regimens of receiving routine oral health care that might have been neglected in the past due to depleted personal, financial, and emotional resources. Dr. Ann Lyles wraps up the issue with a discussion of the likely questions that are frequently asked about caring for the oral health needs of HIV-positive patients such as: When do you need to consult with the physician; what should you ask during the consult; when should you prescribe antibiotics; and when should you refer a patient. She discusses those components of the medical history review that should receive the most attention and includes contraindications for certain drugs used in dentistry with medications used to treat HIV.

The dentist may be the first health care practitioner to interact with an undiagnosed HIV-infected person; to learn of an HIV positive patient’s lack of adherence to an ongoing drug regimen; or to realize that an HIV-positive individual has dropped out of the health care system. Staying knowledgeable about the disease, so that the practitioner can reassure patients and introduce them to or induce them into the health care system, is vitally important for patients’ overall well-being, including their oral health. This issue of the Journal will help you to update your knowledge base of HIV topics so that you can be more prepared to treat your HIV-positive or at-risk patients. By no means it is the last word, for the disease is likely to be with us for some time, constantly evolving. We must continue to update our knowledge and skills to assist our patients. We can count on the fact that when it comes to the HIV epidemic in particular, to use another of Heraclitus’ quotes: All is flux, nothing stays still.

Contributing Editor

Roseann Mulligan, DDS, MS, is a professor and associate dean for community health programs at the University of Southern California School of Dentistry. She is also the dental director of the Pacific AIDS Education and Training Center.