Both the article by Marcus and colleagues,² "National Estimates of Out-of-Pocket Dental Costs for HIV-Infected Users of Medical Care,"and the article by Freed and colleagues³ entitled "Oral Health Findings for HIV-Infected 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 2000.² 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 2000.⁴ 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 colleagues⁵ 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.⁵ Additionally, according to the U.S. surgeon general’s report on oral health,⁶ 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 program⁶; in the study by Marcus and colleagues,³ 52 percent reported using a private dentist and more than 32 percent reported using public clinics or other nonprivate locations for dental services. Additionally, OPE varied dramatically when care was provided by private dentists versus dentists in AIDS clinics ($232 versus $7). As stated in the article by Freed and colleagues,³ 40 percent of those in the Medicaid program live in states without adult dental benefits beyond those covering treatment of pain and infection. A clear public policy imperative to increase access to dental care for those with HIV is to prevent the erosion of adult dental benefits where there is coverage, and to work to include adult dental benefits in states without such coverage. These efforts can occur at the state level or at the national level by seeking to mandate dental coverage within the Medicaid program. Both the Marcus and Freed articles, along with countless others, speak effectively of the need to maintain and increase adult dental Medicaid coverage and the oral health safety net.

Two examples of the oral health care safety net for HIV-infected patients (beyond a comprehensive adult dental Medicaid program), are community health centers (CHCs) with dental clinics and the HIV/AIDS Dental Reimbursement Program (DRP) of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act.

– CHCs, also known as federally qualified health centers, are local nonprofit community-oriented health care providers serving low-income and medically underserved communities. They are intended to improve access to care regardless of ability to pay. CHCs remove barriers to care and as such have been recognized for reducing health gaps for racial and ethnic minorities⁷—gaps that also were found among the HIV-infected patients investigated in these articles. Since 1993, there has been a growth in the number of CHCs with dental clinics. Whereas, in 1993, 45 percent of CHCs had a dental clinic, in 2003, there were more than 4.4 million dental visits serving more than one million dental users. Sixty-six percent of CHCs had oral health programs on site in 2004 (561 of 890). One hundred seventy-nine of the CHCs also received Ryan White CARE Act Title II and III funds in 2004 to help serve the needs of HIV-infected patients.⁸ Future growth of dental programs in CHCs is anticipated, as one of the Healthy People 2010 objectives is for 75 percent of all CHCs to have dental clinics.⁹

– The Ryan White DRP, first funded in 1991 under the Ryan White CARE Act, assists institutions with accredited dental or dental hygiene education programs by defraying their nonreimbursed costs associated with providing oral health care to people with HIV. Important program components include assisting dental education institutions providing care to people with HIV, broadening access to oral health care for people with HIV and providing dental and dental hygiene students and dental residents with current training in the management of oral health care for people with HIV. In fiscal year 2003, the DRP provided $9.7 million to 64 institutions, which provided care to approximately 28,000 people infected with HIV, 43 percent were African-American, 40 percent were white, 30 percent were Hispanic (B. Waterman, unpublished data, 2005). Marcus and colleagues² found that the presence of Ryan White funds markedly effected the OPE of HIV-infected patients ($169 versus $53) and Freed and colleagues cite the importance of the DRP "in providing access to care as well as training students."

Lastly, Marcus and colleagues found that patients with a higher score on an oral health–related quality-of-life measure had lower OPEs. While this may be interpreted in many ways, the implication is that those in better oral health had lower OPEs than those in poor oral health. But for the underserved, in poor oral health and poor oral health care access, this also can mean that HIV-infected patients seek care only when they are in dire need of services, when they already are in pain and have poor physical and psychosocial functioning. Freed and colleagues support this supposition, by expressing concern that more than one-third of patients did not have a usual source of dental care. Having a usual source of care or a "dental home" is an important predictor of use of dental services.¹⁰

Three of the five "Framework for Action" steps from the surgeon general’s report on oral health⁴ relate well to the results of these articles. The steps called for

– changing our perception regarding health and disease so that oral health becomes an accepted component of general health;

– building an effective health infrastructure that meets the oral health needs of all Americans and integrates oral health effectively into overall health;

– removing barriers between people and oral health services.

The results of the articles in this issue of JADA imply that for HIV-infected patients, the time for action is now.