Almost 25 years after the first reports of AIDS in the United States, slowing the spread of the causative virus (HIV) remains an elusive goal. Approximately 40 million people worldwide, including an estimated one million Americans, live with this preventable, treatable but incurable disease.

Although the modes of transmission have been known and are unchanged since the discovery of HIV, 40,000 new infections occur annually in the United States alone. Many of these infections are transmitted from people unaware of their HIV status. It is possible that 250,000 people in the United States do not know they are HIV-infected, yet many continue to engage in behaviors linked to HIV transmission.

A disproportionately high number of newly diagnosed HIV infections in the United States are found among ethnic minorities. Almost one-half of new infections occur among African-Americans, 16 percent among Hispanics and 32 percent among whites.¹ Women account for the fastest growth in the population of people newly diagnosed as positive for HIV.² A recent study published by the Centers for Disease Control and Prevention (CDC) shows little overall epidemiological change in the disease since the mid-to-late 1990s among men who have sex with other men (MSMs).³ Specifically, the incidence and prevalence rates still are high among MSMs, and many black MSMs younger than 30 years are unaware of their HIV infection.³

Unfortunately, people at risk of acquiring HIV infection often do not get tested in a timely fashion. As a result, more than one-third of all those tested for HIV in the United States already are so far along in their HIV status that they develop AIDS within a year of diagnosis. This is particularly disconcerting, as early medical intervention improves prognosis when compared with treatment that starts after a patient’s immune system already is severely compromised.

Knowing one’s HIV status often reduces risky behaviors, resulting in a decrease in HIV transmissions. The most common reasons stated for not getting tested are the fear of finding out, the fear that someone else will find out, the fear of losing jobs and insurance coverage, the fear of rejection and loss of family and friends, and even the fear of needles.

Obviously, the psychological impact of HIV testing differs sharply from that of most other laboratory tests. Consequently, all HIV testing should be accompanied by some type of counseling with an appropriate care provider and, when necessary, referral to a physician.

Unless rapid HIV tests are used, the time that passes between getting tested and being informed of the test results is about 10 to 14 days. Although 27,000 to 30,000 HIV tests that have positive results are performed annually at publicly funded testing sites, almost 10,000 of those who test positive unfortunately do not return for their results.

A 2002 National Health Interview Survey indicated a steady, nonchanging annual pattern of HIV testing among adults of 10 to 12 percent for the last decade.⁴ It is clear—and has been promulgated by public health officials—that to improve prevention and treatment outcomes and also reduce HIV transmissions, testing practices need to be expanded beyond traditional settings.

Today, it is possible to diagnose HIV disease with an oral fluid test. Furthermore, a recent study did conclude that dental offices may serve as an alternative site for HIV testing.⁵ That raises an obvious question: should dentists implement HIV testing in their dental offices?

Available serologic and oral fluid-based rapid HIV tests are very accurate. Sensitivity levels for both types of tests exceed 99 percent, with specificity rates of up to 100 percent. False positive results are possible (one to two per thousand tests) and may be associated with the presence of antibodies to other viral infections, such as Epstein-Barr or hepatitis A or B. Negative results should be considered definitive.

The great advantage of these rapid tests is the possibility of getting chairside results within five to 20 minutes. There is no need for the patient to return at a later date. The U.S. Food and Drug Administration has approved four of these rapid tests, but only one—the OraQuick Advance (OraSure Technologies, Bethlehem, Pa.)—can be used with oral fluids. The OraQuick Advance test provides a result after 20 minutes and can be read directly on the device used to perform the test.

In general, any dental office that performs a rapid HIV test for the purpose of providing a patient with a test result must comply with the Clinical Laboratory Improvement Amendments (CLIA) of 1988. Other restrictions, such as "Subject Information," also apply and are provided in a package insert that comes with the test kit.

The OraQuick Advanced test is a CLIA-waived test, which means that no federal requirements for personnel, quality assessment or proficiency testing are needed. State and local regulations and laws still may apply. However, these CLIA-waived tests can be performed outside a traditional medical office only after the clinician obtains a certificate of waiver from the CLIA program.

Any HIV test needs to be accompanied by patient counseling both before and after the test is conducted. Pretest counseling includes providing information about HIV/AIDS, routes of transmission, sensitivities and specificities of different tests, issues concerning discrimination, partner notification, advice on refraining from any behavior that may result in transmission until a test result has been delivered, a plan for dealing with a positive test result, and today’s understanding of prognosis and treatment of HIV disease.

If the test comes back negative, posttest counseling should include a discussion of the concept of a "window period"—the time between getting infected and when that infection will show up on a test—and the consequences of behavior that may pose a risk of transmission. If the test comes back positive, posttest counseling becomes daunting and complex, and most dental providers will lack the knowledge, experience and training to provide it.

It would be wrong to demand that all dental care providers perform HIV tests in their offices. However, for the provider who will take the time to acquire the skills necessary to perform such a task, doing so could be a great benefit to society.