Title: Rapid HIV testing in the dental setting: an acceptability and feasibility study.
Funder: Department of Health and Social Care

Abstract: Title Rapid HIV testing in the dental setting: an acceptability and feasibility study. The Problem In 2014, Public Health England estimated that 103,700 people in the UK were living with HIV. The overall prevalence being 1.9/1000 (Public Health England, 2015). Around 17% of people living with HIV were unaware of their serostatus and around 40% were diagnosed at a late stage when CD4 counts have already dipped below 350. Late diagnosis is particularly problematic in heterosexual groups, older people over the age of 50, and other ethnic minority groups, in particular Black Africans (Centre for Public Health, 2014). If diagnosis is achieved earlier in the course of the condition it can reduce transmission as well as HIV related morbidity and mortality. Rationale Almost 30 million patients attended a dentist in the UK between 2013 and 2015, equivalent to over 55% of the population. NICE (2016) encouraged opportunistic screening in primary and secondary care settings in extremely high HIV prevalence areas (diagnosed adult prevalence of 5/1000); dental settings based in these areas could be ideal locations to implement HIV testing.Existing studies have investigated patient and professional perceptions of the acceptability of HIV testing in dental settings (Greenberg et al, 2012; Blackstock et al, 2010). These studies found that between 55% and 97.6% of participants were willing to undergo HIV testing in a dental setting. Dental professionals were largely accepting of HIV testing in dental settings; willingness to offer the test ranged from 56.7% in the United States to 90% in Vietnam. To date there have been no similar studies focused on HIV testing in the dental setting conducted in the UK.Aim Phase 1 of the study aims to ascertain the acceptability of HIV testing in dental settings from the perspective of dental professionals and service users, especially those from higher risk communities. Phase 2 aims to establish whether point of care HIV testing in dental settings is feasible and acceptable to patients and the wider dental team. Plan The proposed research project is structured into two phases. The initial phase will involve up to 72 participants across seven focus groups to obtain qualitative data on the acceptability of HIV testing in the dental setting as perceived by dentists and service users, particularly those of people from demographics known to be more likely to have undiagnosed HIV or late diagnosis. The second phase of the research project will be the implementation of a non-randomised feasibility study undertaken in urgent care dental clinics and community clinics targeted at marginalised populations including the homeless, vulnerable migrants and people misusing substances. Opt-in HIV testing will be performed using the INSTI capillary blood test. All services users over the age of 16 who can provide consent and do not have a known diagnosis of HIV will be offered testing. Service users with a reactive test result will be immediately linked to a sexual health service for confirmatory testing, counselling and treatment cascade as appropriate. The feasibility study will provide essential information as to whether the key components of HIV testing are operable in the dental setting and will collect data on the proportion of patients offered screening, the proportion of those offered who uptake the test, the acceptability of the testing to dental professionals and the public, number of reactive tests, stage of HIV at diagnosis and reasons that patients declined to undergo testing. All those offered the test will be asked to complete an anonymous questionnaire on the acceptability of HIV testing in the dental setting. Process evaluation will be undertaken with dental staff and patients at months six and twelve.

Lay abstract: Title Rapid HIV testing in the dental setting: an acceptability and feasibility study. The Problem Public Health England estimates that there are around 100,000 people living with HIV in the UK. This number continues to increase. There are about 5000 new cases of HIV every year. Nearly 1 in 5 people living with HIV do not know of their condition. This means that there is a greater risk that they may unintentionally pass HIV on to others. And over one third of the new cases of HIV are diagnosed late, when their white blood cell (CD4) counts are low. This means that the person may already be unwell, or at higher risk of becoming seriously ill. If someone is diagnosed early when their CD4 count is higher, they will have a much better chance of successful treatment, and can live long and healthy lives. Early diagnosis and treatment for HIV are important for both the individual and society. Some groups are more at risk of late diagnosis than others including: white heterosexuals, people of African origin, people over 50 and other ethnic minority groups. Over half of the population in the UK attended a dentist in the past two years. Dentists no longer require patients to be registered to attend for appointments and emergency dental services can treat those who do not have a regular dentist. Dental practices based in areas where there are a high number of people living with HIV could be an ideal setting for HIV testing. Aims The aim of this research project is to understand whether HIV testing in dental practice is acceptable to both dentists and members of the public from groups of people more likely to have a late diagnosis of HIV. The second part of the research will try and establish whether testing for HIV using finger prick blood samples is both feasible and acceptable in a dental setting.Project Plan Firstly, existing studies on HIV testing in dental settings will be systematically reviewed to understand what research has been done before, and how dentists and patients have felt about testing in a dental setting. The study will happen in two parts. The first part will gather the views of dentists and members of the public about HIV testing in the dental setting, particularly those of people from demographics known to be more likely to have undiagnosed HIV or late diagnosis. Seven focus groups of up to twelve people will discuss the positives and negatives of HIV testing in dental settings and any concerns about the process. This information will help to shape the second part of the study. In the second part of the study, rapid HIV testing that gives an almost immediate result will be offered in three dental clinics. The dental clinics will include urgent care services that may see a lot of patients who otherwise don't have a dentist and community dental clinics specifically for people who are homeless, misusing substances and vulnerable migrants. The clinics are based in areas known to have an extremely high number of people living with HIV. All dentists who carry out the test will have been trained on the referral process and how to counsel those people who get a positive test result. The project will run for one year during which time the staff at the dental clinics will be asked to offer HIV testing to all patients over the age of 16 who aren't known to have HIV and can agree to have the test. Any patients who have a reactive test will be referred to a specialist sexual health service for counselling, treatment planning and local peer support. All dental patients offered the test will be asked to fill out an anonymous questionnaire about whether they felt the HIV test offer was acceptable in the dental setting. The study will record how many people are offered the tests, the number that agreed to the test, and also how patients and dentists felt about the experience. Additionally, information will be collected on: number of positive tests, stage of condition at diagnosis, and ongoing care with the specialist team. Monthly meetings will be held with the lead researcher during to discuss the study and ways in which it could be improved and with the wider dental team and patients at months six and twelve. After the project is finished, results will be shared with patients, dental professionals and policy decision-makers, through scientific posters, articles, presentations at conferences and via relevant websites.

Research activity codes: 4.3 INFLUENCES AND IMPACT
Health categories: INFECTION