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January 2005, Vol 95, No. 1 | American Journal of Public Health 73-75
© 2005 American Public Health Association
DOI: 10.2105/AJPH.2003.025403

RESEARCH AND PRACTICE

A Longitudinal Analysis of Unmet Need for Oral Treatment in a National Sample of Medical HIV Patients

Marvin Marcus, DDS, MPH, Carl A. Maida, PhD, Ian D. Coulter, PhD, James R. Freed, DDS, MPH, Claudia Der-Martirosian, PhD, Honghu Liu, PhD, Benjamin A. Freed, BS, Norma Guzmán-Becerra, MS and Ronald M. Andersen, PhD

At the time of this study, Marvin Marcus, Carl A. Maida, Ian D. Coulter, James R. Freed, Claudia Der-Martirosian, Benjamin A. Freed, and Norma Guzmán-Becerra were with the School of Dentistry, Division of Public Health and Community Dentistry, University of California, Los Angeles. Honghu Liu is with the Department of Medicine, General Internal Medicine/Health Services Research, and Ronald M. Andersen is with the School of Public Health, Division of Health Services, University of California, Los Angeles.

Correspondence: Requests for reprints should be sent to Marvin Marcus, DDS, MPH, UCLA School of Dentistry, Box 951668, Los Angeles, CA 90095-1668 (e-mail: mamarcus{at}ucla.edu).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 

This longitudinal study examines perceived unmet dental need in a nationally representative probability sample of HIV-infected persons in medical care. A logistic regression analysis modeled the relationship between unmet need and explanatory variables. We estimate that 40% of HIV/AIDS patients report an unmet need associated with being male, being unemployed, injecting drugs, being heterosexual, lacking dental insurance, and having less education. Disparities in unmet need are related to socioeconomic status rather than to disease stage or ethnicity.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 References
 
Perceived unmet need for oral health care is a useful measure of potential demand in that it represents whether people feel their "wants" for dental services are being fulfilled. In the general adult population, 16.7 million people (11%) reported needing oral health care but not receiving it. African Americans reported higher rates of unmet need for oral health care than other groups.1 Reports of perceived unmet need for oral health care among persons living with HIV/AIDS range from 5% to 52%.2–6 These studies occurred prior to the wide use of highly active antiretroviral therapy (HAART).

The current study expands on previous work in 2 ways. We use longitudinal, rather than cross-sectional, data from the first national probability sample of patients receiving care for HIV in the United States.7 Second, this study reports the prevalence of perceived unmet need for oral health care from 1996 through 1998, the period during which HAART was introduced and became the standard of treatment. These medications alter the course of the disease and appear to reduce the frequency and severity of oral opportunistic lesions.8–12


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 References
 
The HIV Costs and Services Utilization Study (HCSUS) created a representative sample of HIV-infected adults in medical care in the contiguous United States. The 2864 initial study participants in HCSUS represent approximately 231400 people with HIV disease in the United States. The interviews were conducted in 3 waves from January 1996 through January 1998. Full details of the design are available elsewhere.13,14 Data analysis is based on a weighted HCSUS patient cohort that completed all 3 interviews (2109 subjects). Reported unmet oral health need was measured by a binary outcome variable (1=yes, 0=no). Respondents were asked if there was a time when they needed dental treatment but could not get it. The analysis consists of bivariate comparisons between unmet need and each of the covariates and multivariate modeling using a generalized estimating equations (GEE) approach. The GEE method enables us to account for the dependence of repeated observations from the same subject over time with a binary outcome.15,16


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 References
 
We estimate that 88 000 (40%) of HIV-infected medical patients reported unmet need for oral health care during at least 1 of the 3 HCSUS interviews. In the multivariate analyses presented in Table 1Go, among demographic variables, gender and education showed significant differences. Over the course of the study, women were 25% less likely to have perceived an unmet oral health need than men. Compared with college graduates, persons with some college reported a 44% increase in perceived unmet need, high school graduates a 45% increase, and persons with some high school education an almost twofold increase.


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  		TABLE 1—— Multivariate Longitudinal Analysis Predicting Unmet Need for Oral Health Care Among HIV Patients
 
Compared with males who had sex with males, all other subgroups were more likely to report unmet oral health need during the course of the HCSUS study. The reported rate of unmet need was 56% higher among intravenous drug users, 75% higher among heterosexuals, and 65% higher among those exposed through hemophilia or blood transfusion (or not defined). Respondents without any dental insurance were twice as likely to report a perceived unmet need for oral health care as those with private dental insurance. Those enrolled in a Medicaid program that did not have a dental benefit were 2.5 times more likely to report a perceived unmet oral health need. Another consistent finding was that those who were employed were less likely to have a perceived unmet need. None of the disease stage or clinical measures showed any significant differences.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
References
 
This report expands our previous research and models by examining perceived unmet oral health needs during the course of the entire HCSUS study using data from all 3 interviews. Neither CD4 count levels, nor being diagnosed with AIDS, nor taking HAART were significant determinants even though we had expected that more severe effects of HIV might lead to more unmet dental need. Not being employed, which in this population might be a proxy for not only income but also the effects of HIV, was the only measure suggesting that disease severity might have an effect on unmet dental need. One might also argue that employment status can be an indirect measure of well-being or disease stage.

Although the rate of unmet need decreased as the population increased their use of HAART, comparisons between those not taking HAART and those taking HAART were explained by other factors in the multivariate analysis, namely, that the most economically vulnerable persons were less likely to have access to this treatment. Factors associated with lower socioeconomic status (e.g., education, employment, and availability of dental insurance) were more important than ethnic minority status. Perceived unmet need for oral health care for this population is considerably higher than the general US population.

More than medical care, dental care presents greater social and economic barriers for working poor and indigent individuals living with a chronic disease. Our findings, therefore, have implications for the organization and delivery of dental care for the most economically vulnerable patients with HIV, particularly in states that do not include dental care in their public insurance programs. Injecting drug users and ethnic minorities, the groups among which the epidemic is spreading most rapidly, are also the most likely to be uninsured or inadequately insured. Providing dental coverage to those on Medicaid would probably reduce unmet need for dental care for these more vulnerable groups. Such coverage is becoming even more critical when states are seeking to eliminate adult dental benefits from Medicaid as a cost-saving measure in their current budgetary crisis. Besides greater generosity with respect to state-sponsored dental Medicaid coverage, there is also need for a more coordinated system linking the medical and dental care—perhaps at the same site—of patients with HIV. This comprehensive approach would require concerted efforts by clinicians, health care administrators, and public health practitioners to increase access to oral health care through coordinated case management and patient referral strategies.


   Acknowledgments
 
This analysis was supported by National Institute of Dental and Craniofacial Research grant R01 DE13729-01A1. The HIV Cost and Services Utilization Study is being conducted under cooperative agreement HS08578 (M.F. Shapiro, principal investigator; S.A. Bozzette, co-principal investigator) between Rand Corp and the Agency for Healthcare Research and Quality and the National Institutes of Health Office of Research on Minority Health. Additional support was provided by the UCLA International Center for Dental Health Policy.

Human Participant Protection
This study was approved by the institutional review board of the University of California, Los Angeles.


   Footnotes
 
Contributors
M. Marcus and C.A. Maida were principally responsible for the conception and design of the study, its analytical framework, and interpretation of its findings, and they supervised all aspects of its implementation. I.D. Coulter, J.R. Freed, C. Der-Martirosian, and H. Liu made substantial contributions to the design and interpretation of the data. B.A. Freed and N. Guzmán-Becerra were principally responsible for the analysis. All authors contributed to the conception and design of the study, the analysis and interpretation of the data, and writing and editing.

Peer Reviewed

Accepted for publication February 17, 2004.


   References
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 References
 
1. Oral Health in America: A Report of the Surgeon General. Rockville, Md: National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000:83.

2. Marx R, Katz MH, Park MS, Gurley RJ. Meeting the service needs of HIV-infected persons: is the Ryan White CARE Act succeeding? J Acquir Immune Defic Syndr Hum Retrovirol. 1997;14(1):44–55.[ISI][Medline]

3. Capilouto EI, Piette J, White BA, Fleishman J. Perceived need of dental care among persons living with acquired immunodeficiency syndrome. Med Care. 1991;29(8):745–54.[Medline]

4. Fleishman JA, Schneider DA, Garcia I, Hardwick K. Dental service use among adults with human immunodeficiency virus infection. Med Care. 1997;35(1):77–85.[CrossRef][Medline]

5. Shiboski CH, Palacio H, Neuhaus JM, Greenblatt RM. Dental care access and use among HIV-infected women. Am J Public Health. 1999;89(6):834–839.[Abstract/Free Full Text]

6. Marcus M, Freed JR, Coulter ID, et al. Perceived unmet need for oral treatment among a national population of HIV-positive medical patients: social and clinical correlates. Am J Public Health. 2000;90(7):1059–1063.[Abstract/Free Full Text]

7. Bozzette SA, Berry SH, Duan N, et al. The care of HIV-infected adults in the United States. HIV Cost and Services Utilization Study Consortium. N Engl J Med. 1998;339(26):1897–1904.[Abstract/Free Full Text]

8. Eyeson JD, Warnakulasuriya K, Johnson NW. Prevalence and incidence of oral lesions—the changing scene. Oral Dis. 2000;6:367–273.

9. Patton LL, McKaig R, Strauss R, Rogers D, Eron JJ Jr. Changing prevalence of oral manifestations of human immunodeficiency virus in the era of protease inhibitor therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;89(3):299–304.[ISI][Medline]

10. King MD, Reznik DA, O’Daniels CM, Larsen NM, Osterholt D, Blumberg HM. Human papillomavirus-associated oral warts among human immunodeficiency virus-seropositive patients in the era of highly active antiretroviral therapy: an emerging infection. Clin Infect Dis. 2002;34(5):641–648.[CrossRef][ISI][Medline]

11. Selik RM, Starcher ET, Curran JW. Opportunistic diseases reported in AIDS patients: frequencies, associations and trends. AIDS. 1987;1:175–182.[ISI][Medline]

12. Phelan JA, Saltzman BR, Friedland GH, Klein RS. Oral findings in patients with acquired immunodeficiency syndrome. Oral Surg Oral Med Oral Pathol. 1987;64(1):50–56.[Medline]

13. Shapiro MF, Berk ML, Berry SH, et al. National probability samples in studies of low-prevalence diseases, I: perspectives and lessons learned from the HIV Costs and Services Utilization Study. Health Serv Res. 1999;34(5 Pt 1):951–968.

14. Frankel MR, Shapiro MF, Duan N, et al. National probability samples in studies of low-prevalence diseases, II: designing and implementing the HIV Costs and Services Utilization Study. Health Serv Res. 1999; 34(5 Pt 2):969–992.

15. Laird NM, Ware JH. Random-effects models for longitudinal data. Biometrics. 1982;38:963–974.[CrossRef][ISI][Medline]

16. Diggle PJ, Liang KY, Zeger SL. The Analysis of Longitudinal Data. Oxford, England: Oxford University Press; 1994.




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J. R. FREED, M. MARCUS, B. A. FREED, C. DER-MARTIROSIAN, C. A. MAIDA, F. S. YOUNAI, J. M. YAMAMOTO, I. D. COULTER, and M. F. SHAPIRO
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