Awareness of Dental Surgeons on Indications for STI/HIV referral in Dental patients and their current practice of STI/HIV referrals

Kaluarachchi D.V.V1, Silva S.P.I2, Kulathilake K.A.D.T3, de Alwis W.M.M.S4

National STD/AIDS Control Program1

Dental Institute, Maharagama2

Chest Clinic, Colombo3

National Institute of Health Sciences, Kalutara4

INTRODUCTION

Sexually Transmitted Infections and Human Immunodeficiency Virus (STI/HIV) show rising statistics both globally as well as in Sri Lanka even though Sri Lanka remains as a low prevalence country for HIV.

These infections have their manifestations in the genitalia as well as in the extra genital sites such as oral manifestations of STI/HIV.

As of end of year 2013, 1845 HIV cases were detected with 301 AIDS related deaths and 71 cases of mother to child transmissions

Getting more and more patients with high risk behavior for screening has to be done with the collaboration of other subspecialties.

JUSTIFICATION

Sexually transmitted diseases frequently affect the mucous membranes producing characteristic and potentially diagnostic lesions on the oral mucosa which can be a valuable marker to identify them early.

Dental Surgeons who are well educated on different aspects of oral presentations are an important source of referral to be made on the aspect of sexually transmitted infections including HIV

Venereology is a medical specialty which needs multisectorial collaboration in providing quality service to patients in need

Proper identification and referral system to National STD/AIDS Control Program is mandatory since all the patients are not voluntarily attending STI services

The new National HIV strategic plan in Sri Lanka for year 2013 – 2017 states five health directions to achieve the goal of preventing new infections along with provision of comprehensive care and treatment for people living with HIV

Strengthening health systems towards STI/HIV is the fourth direction to achieve which includes building capacity of existing health infrastructure

Dental Intuitions in Colombo and Maharagama and the Dental Hospital in Peradeniya are all tertiary care centers in dentistry where all the problematic clinical dentistry cases are aggregated and referred for further management. So these become ideal study settings for this study as well.

OBJECTIVES

General Objective

To assess the awareness among Dental Surgeons on indications for an STI/HIV referral and to assess the current practice on STI/HIV referral on Dental patients.

Specific Objectives

• To assess the awareness among Dental Surgeons on the indications for an STI/HIV referral on Dental patients

• To assess the current practice among Dental Surgeons on STI/HIV referral on Dental patients

METHODOLOGY

Study DesignA Descriptive Cross Sectional Study

Study SettingDental Institute, Colombo/ Dental Institute, Maharagama/ Dental Hospital, Peradeniya

Study PopulationAll Dental Surgeons currently attached in service to the above service stations.

Sample SizeThe study sample included 130 dental surgeons ; 48 from Maharagama, 47 from Colombo and 35 from Peradeniya.

Inclusion Criteria

• The Dental Surgeons qualified as Bachelor in Dentistry with or without post graduate qualifications attended for duty at Dental Institutes Colombo and Maharagama on the day of data collection in Colombo

• The Dental Surgeons qualified as Bachelor in Dentistry with or without post graduate qualifications attended for duty at Dental Hospital, Peradeniya on the day of data collection in Peradeniya, Kandy.

Exclusion Criteria• The Dental Surgeons who were on leave on the date of the data collection at

the above study settings.• The Dental Surgeons entitled to field or outreach services on the date of data

collection at the above study settings.• All the Dental Surgeons attached to the above study settings as post graduate

trainees in Dentistry. • Any Dental Surgeon who refused to participate in the study.

Study InstrumentSelf Administered Questionnaire with Information sheet and Consent form

Data Analysis

The statistical Analysis was done using the SPSS version 17.0 The significance of the practice of referring patients vs. demographic factors/ work station was analyzed using Pearson chi square

RESULTS

Socio-demographic Data

Male37%

Female63%

Sex Distribution46.20%

36.20%

17.70%

31 - 40 yrs 41 - 50 yrs 51 - 60 yrs

Age Distribution

Mean Age 42.47 yrs.Age Range 25 - 59

27%

36%

37%

Service StationPeradeniya Colombo Maharagama

50.80%

49.20%

Yes

No

PG Qualifications

43.10%33.80%

16.20%6.90%

0 - 10 yrs 11 - 20 yrs 21 - 30 yrs 31 - 40 yrs

Service Years

Knowledge on referring patients for STI/HIV Services

Yes No NA

Have you ever been taught the oral presentations of STI/HIV in Dental faculty?

115(88.5%)

15(11.5%)

Have you ever been taught the oral presentations of STI/HIV in your post graduate studies?

64(49.2%)

13(10.0%)

53(40.8%)

Have you ever been advised by your seniors to refer a patient for STI/HIV services after identifying oral presentations of STI/HIV?

86(66.2%)

44(33.8%)

Awareness of Dental Surgeons on Indications for STI/HIV Referral

126

7469 71

2445

82

5134 34

18 23

Received Identified

Practice on Referring Patients to STI/HIV Services

Have you ever decided on your own to refer any of your patients to exclude the possibility of STI/HIV ?

Yes37%

No63%

Approximately how many times patients were referred during the last 6 months ?

112

124 2

Not Ref. Only Once Twice >2

Have you ever referred any pregnant mothers in your dental practice to STI/HIV care?

0

20

40

60

80

100

120

140

Referred Not Ref No Mothers

20%

2.30%

13.10%

18.50%

11.50%

34.60%

STD Clinic/ NACP

Medical Faculty

MRI

Others

Don't know

Not sent

Practice on the Station of Referrals

Practice on Referrals on Oral Manifestations of STI/HIV

Oral Candidiasis

OHL NUP Viral Warts

Kaposi'Sarco

maSTU

Received Frequency 126 74 69 71 24 45Reffered Frequency 3900% 19 15 15 3 17

0

20

40

60

80

100

120

140

Obstacles encountered when referring patients for STI/HIV Services

Obstacle encountered Frequency Percentage

1. Unawareness of place of referral 18 13.8%

2. Patients not attended STI/HIV services despitereferral

2 1.5%

3. Difficulties in explaining the need for referral 5 3.8%

4. Patients not consenting for STI/HIV referral 10 7.7%

5. Patient not given consent + not attended STI/HIV services despite referral

4 3.1%

6. No comments 91 70.0%

Association Between Practice of Referrals and Demographic variables/ Working Station

Demographic Variable/Work Station

Pearson Chisquare P Value

Age vs. ever referred 1.5 0.221

Sex vs. ever referred 0.735 0.391

PG Qualifications vs. ever referred

1.742 0.187

Work Station vs. ever referred

9.617 0.008

Conclusions

Conclusions on Knowledge on making Referrals :-

• More than 50% have been taught on oral presentations of STI/HIV• At each oral manifestation majority (> 50%) identified them as indications

to refer.

Conclusions on practice on making referrals :-• The ratio of the sample at making referrals as never ref. : ref was 1.4:1• Only 37% of the referred patients have been directed to NSACP/STD clinic• The percentage referred out of the percentage received were less than 40% at

each oral manifestation

• No significant association found with the Age, Sex and PG qualifications• The working stations had a significant association with the practice of

referrals• Unawareness of the correct station to refer was the obstacle pointed out by

majority of the Dental Surgeons

Recommendations

Action should be taken to motivate Dental Surgeons to identify and refer patients with oral manifestations of STI/HIV for screening

• Lectures /SGD on important oral manifestations, places to refer• Making them aware of the currently available STI/HIV care services• Importance on identifying risky patients early• How to motivate their patients to get screened to reduce missing patients

Acknowledgements

Dr. Jayasundara Bandara, Deputy Director General (Dental Services), Health Ministry for providing permission for data collection in Dental Institutes Colombo, Maharagama and Dental Hospital, Peradeniya.

Directors of Dental Institutes Colombo, Maharagama and Director Dental Hospital, Peradenya for providing permission for data collection at above study settings

The Ethical Committee, National Institute of Health Sciences, Kalutara for granting ethical clearance for the study

Dr. Padma Silva, Consultant Oral and Maxillofacial Surgeon for being the supervisor as well as for providing technical support

THANK YOU !