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Antiretroviral Therapies: Old Attitudes and New Perspectives in Dentistry

Carlo Lajolo1*
  • 1 Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Head and Neck Department, Italy

Since the beginning of HIV epidemy in the early eighties, approximately 77 million people have become infected with HIV and 35 million people have died from AIDS-related illnesses (UNAIDS.org, 2018). Considering the history of HIV epidemy, in 1981, Dr. M. Gottlieb described an unusual case of Pneumocystis carinii pneumonia, in a young immunodeficient man and, in the same year, U.S. Centers for Disease Control and Prevention (CDC) published, in a Morbidity and Mortality Weekly Report (MMWR), a case series of serious immune deficiency in adults, characterized by Pneumocystis carinii pneumonia, Kaposi’s Sarcoma, in homosexuals or intravenous drug users (IDU), mainly in big cities (i.e., San Francisco, Los Angeles, New York). By the end of the year, 270 cases of severe immune deficiency among homosexual men were described and some researchers called this syndrome “Gay-Related Immune Deficiency” (GRID), immediately addressing the syndrome as a stigma (CDC.gov, 2018; AIDS.gov, 2018). In 1982, first cases of AIDS were reported in Italy and, at the end of 2012, about 120.000 individuals aged 15 or more were estimated to be living with HIV in Italy (Camoni et al., 2014). In 1983, Professor Luc Montagnier (Pasteur Institute - France) and then Professor Robert Gallo (National Cancer Institute - USA) reported the discovery of a retrovirus that could be the cause of AIDS. In 1984, the term H.I.V. (Human Immunodeficiency Virus) was introduced and, in 1986, the term was officially confirmed by the International Committee on the Taxonomy of Viruses. Only in 1987, the first antiretroviral drug was approved by Food and Drug Administration (FDA): the zidovudine (AZT); nevertheless in 1992, AIDS became the first cause of death for U.S.A. men ages 25 to 44: due to the severe prognosis of the infection and to the spread of the infection among some group of subjects (homosexual and IDU) the stigma of HIV positivity raised and brought to the onset of discrimination behaviors. In 1996, FDA approved the first non-nucleoside reverse transcriptase inhibitor (NNRTI) drug, nevirapine, which, in association with classic drugs, became a very effective therapeutic regimen (Highly Active Anti-Retroviral Therapy - HAART), thus the naturally history of the disease dramatically changed, switching from an acute lethal infection to a chronic curable one (AIDS.gov, 2018). Considering nowadays epidemiology (2017), UNAIDS epidemiology center reports that approximately 37 million people globally are living with HIV, 22 million people are accessing antiretroviral therapy, 1.8 million people become newly infected with HIV in the last year and 940.000 people die from AIDS-related illnesses, with a continuous growing number of adult and children subjects living with HIV. Furthermore, some changes in HIV transmission epidemiology were highlighted by UNAIDS, especially in Europe, with a relative increase in the heterosexual compared with homosexual (UNAIDS, 2018). Considering the clinical presentation of AIDS in the oral cavity, oral lesions develop as immunosuppression progresses and were, historically, indicators of change in immune status. Some lesions, in the pre-HAART era, were so common to be considered as an AIDS defining condition (i.e., oral candidiasis) and had an overall average prevalence of 30 - 50% up to 90% in late AIDS stages. Oral manifestations of HIV were classically classified as strongly HIV-associated oral lesion (i.e., oral candidiasis, hairy leukoplakia, kaposi’s sarcoma, periodontal disease) and less commonly HIV-associated oral lesion (i.e., herpes simplex virus, HPV-related lesions, recurrent aphthous stomatitis) (1993). The HART introduction dramatically changed the pattern of oral lesions: in a recent systematic review on oral manifestations during HIV infection, the prevalence of oral candidiasis, oral hairy leukoplakia and of kaposi’ sarcoma was lower in patients on HAART compared with individuals not on treatment, whereas periodontitis and gingivitis seemed to have an higher prevalence in groups on HAART compared with those who were not (El Howati and Tappuni, 2018). In 2008, a study on oral lesions in patients living with HIV in HAART era was conducted at the Catholic University on 200 HIV positive subjects, which were consecutively enrolled and divided into two groups (Group 1 - 130 HIV positive subjects and Group 2 - 70 HIV–HCV co-infected subjects). Fifty-two subjects (26%) presented oral lesions: oral candidiasis, recurrent aphthous stomatitis and HPV lesions were mainly detected. HIV–HCV co-infection (OR = 2.32; 95% CI = 1.01–5.33; P < 0.05), the use of drugs for the treatment of systemic diseases not associated with HIV (OR = 4.34; 95% CI = 1.78–5.33; P = 0.005) were associated with the presence of oral lesions (Giuliani et al., 2008). Since the beginning of the HIV epidemy and the claim of AIDS stigma, cases of discrimination and violation of human rights happen among health care workers against HIV positive subjects, some of them even in dental setting. For this reason, in the last 15 years, a series of studies were performed, by our research group, to better understand the relationship between HIV positive subjects and dental care workers: 1) on people living with HIV seeking dental treatment (IV national project on HIV social problems – Istituto Superiore di Sanità - 2000, grant no. 60b/4,04); 2) on attitudes and practices of dentists treating people living with HIV in the HAART era (V national project on HIV social problems – Istituto Superiore di Sanità - 2005, grant number 60f/05); 3) on attitudes and practices of hygienists treating people living with HIV in the HAART era (VI national project on HIV social problems – Istituto Superiore di Sanità - 2006, grant no 60g/06); 4) on attitudes and practices of students of dentistry treating people living with HIV in the HAART era (ongoing). In the first project (on people living with HIV seeking dental treatment), a multicenter observational study, using a completely anonymous questionnaire, was performed on 1500 HIV infected individuals in 6 public day hospitals in Italy (Bergamo, Florence, Rome, Chieti, Sassari and Lecce): 630 subjects went to a dentist after HIV diagnosis and, of these, 209 (33.2%) had not disclosed their seropositivity. Of the 421 participants who disclosed their seropositivity to the dentist, 56 (13.3%) were refused treatment. The most common reason for avoiding disclosure was not the fear of discrimination, but the concern over other people discovering that the individual was infected. Although some dentists discriminate refusing to treat HIV-positive persons, this cannot guarantee to avoid exposure to the virus due to the non-disclosure, or even knowledge, of sero-status of many HIV positive subjects, thus adopting universal safety precautions is absolutely mandatory (Giuliani et al., 2005). To this regard, recently, the results of the People Living with HIV STIGMA-Survey UK 2015 were published: the study investigated 1528 Subjects (mean age 44 years) and about half (53%) of participants reported that their dental practice was aware of their HIV status; 39.9% of participants had worried about being treated differently to other patients in dental practices and 14.6% reported that they had actually been treated differently (Okala et al., 2018). In the second project (on attitudes and practices of dentists treating people living with HIV in the HAART era), 8230 questionnaires were delivered to Italian dentists; 2112 (25.7%) were filled and sent back; 93 dentists (4.5%) admitted to refused to treat HIV infected individuals (Giuliani et al., 2009). To this regard, recently a study assessing the knowledge, attitude, and practice towards HIV patients among the dentists of Trichur district (Kerala, India) was published. A cross-sectional survey was conducted among 206 dentists: 39.3% were unwilling to treat HIV patients; staff fears and increased personal risk were the most frequently reported concerns in treating HIV patients (Dhanya et al., 2017): existence of episodes of discrimination by dentists against HIV-positive persons still happen. In the third project (on attitudes and practices of hygienists treating people living with HIV in the HAART era), 1247 questionnaires were delivered to dental Italian hygienists, 287 (23%) were completed and returned: a total of 287 hygienists answered the question ‘Did you ever deny treatment to an HIV-infected person? 5.9% replied ‘Yes”; 1,8% charged a different fee to HIV-infected persons; 2.8% replied that it is correct to refuse to treat HIV-infected persons; 60,4% replied that is more stressed when treating HIV-infected persons (Giuliani et al., 2009). To this regard, in a study published on Thai dental practitioners, out of 1,200 questionnaires sent, 446 questionnaires were returned; 30.5% (n=136) of the participants were dental hygienists: 19.9% of dental hygienists said they would deny treatment for patients with HIV if possible (Rungsiyanont et al., 2013), thus discriminating behavior still happens among dental hygienists. In the fourth project (ongoing on attitudes, knowledge and practices of dentistry students treating people living with HIV in the HAART era), a completely anonymous questionnaire was given to the 6th year course students investigating demographic data, attitudes towards HIV positive patients, knowledge of HIV infection and precautions routinely used to prevent cross-infections. Considering future perspectives on HIV and dentistry, a greater effort should be done to diminish discriminating behaviors, which still influence the routine dental practice of some dental care workers; furthermore, these non-ethical behaviors could contribute to erroneous failing of routine procedures for preventing blood-borne cross infections.

References

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Keywords: Antiretroviral (ARV) therapy, HIV, HAART (highly active antiretroviral therapy), Dentistry, oral disease

Conference: 5th National and 1st International Symposium of Italian Society of Oral Pathology and Medicine., Ancona, Italy, 19 Oct - 20 Oct, 2018.

Presentation Type: oral presentation

Topic: Oral Diseases

Citation: Lajolo C (2019). Antiretroviral Therapies: Old Attitudes and New Perspectives in Dentistry. Front. Physiol. Conference Abstract: 5th National and 1st International Symposium of Italian Society of Oral Pathology and Medicine.. doi: 10.3389/conf.fphys.2019.27.00081

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Received: 28 Nov 2018; Published Online: 09 Dec 2019.

* Correspondence: Dr. Carlo Lajolo, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Head and Neck Department, Rome, Lazio, 00168, Italy, marcomascitti86@hotmail.it