Ensuring the oral health of patients with HIV

T he HIV Cost and Services Utilization Study (HCSUS), conducted by a consortium of private and government institutions centered at the RAND Corp., is a rich source of information regarding access to care for HIV-infected people. It was the first comprehensive U.S. survey of health care use among a nationally representative sample of HIV-positive people who were receiving care for their HIV infections. The HCSUS has generated more than 70 articles on a variety of HIV health care–related subjects. Previously published results of the study pertaining to dentistry include da significant portion of patients who receive regular medical care do not receive the dental care they need; dmany of the patients who report unmet needs for dental care lack dental insurance; dHIV–infected patients who get their medical care at HIV clinics that provide dental care are more likely to get the dental care they need. Both the article by Marcus and colleagues, “National Estimates of Out-of-Pocket Dental Costs for HIV-Infected Users of Medical Care,”and the article by Freed and colleagues entitled “Oral Health Findings for HIVInfected Adult Medicaid Patients From the HIV Cost and Services Utilization Study” use data that were collected between December 1996 and July 1997. These data, although almost eight years old, still are valuable not only because there are no other more current comparable data available, but also because they are a baseline for future investigations of this kind. HCSUS data have been used to assess expenditures on medical care services. A paper delivered in 2003 compared medical expenditures in 1996 with data obtained in 2000. The authors found that while the HCSUS estimated 1996 adjusted outpatient medical costs for patients in care of $201 per month, only $91 per month was spent in 2000. One explanation for this unpredicted result is that outpatient medical expenditures declined with the advent of effective therapies, including highly active antiretroviral therapy, which are able to maintain immunological health in HIV-infected patients. These therapies have transformed HIV infection into a chronic disease. The data presented here can be used in much the same way in future investigations assessing dental expenditures for HIV patients, in the post–effective therapy era. The concept of out-of-pocket expenditures (OPE) for dental services is an important one to appreciate. While OPE have declined since the expansion of private dental insurance in the 1970s, OPE have been approximately 45 to 50 percent of all dental expenditures for the last 15 years and have not changed appreciably since the data were collected for these articles. Brown and colleagues found that OPE by the general public varied according to income. They reported that in 1996, people living below the federal poverty line (FPL) spent $157 out of pocket (36.3 percent of total expenditures), whereas those with incomes greater than 400 percent of the FPL spent $229 out of pocket (46.9 percent). The differences in OPE analyzed by income are even more dramatic among the HIV-infected: $279 for those with incomes greater than $25,000 versus $70 for those with incomes less than $10,000. Moreover, the presence or absence of dental insurance dramatically affects OPE—$246, $84 and $47 for those with no insurance, those covered by adult Medicaid and those with no dental Medicaid coverage, respectively. This speaks to the need to increase the availability of comprehensive adult dental coverage under Medicaid in an era of shrinking adult Medicaid programs. Additionally, according to the U.S. surgeon general’s report on oral health, published in 2000, 95.8 percent of the national general public dental expenditures were made from private funds and only 4.2 percent were funded by government program; in the study by Marcus and colleagues, 52 percent reported using a private