Greater Baltimore HIV Heath Services TO EVALUATE THE LOW UTILIZATION OF ORAL HEALTH SERVICES BY BENEFICIARIES OF RYAN WHITE PART-A PROGRAM 2019 Capstone Project, Gurpreet Kaur, DDS MPH Epidemioloy University of Maryland Greater Baltimore HIV Heath Services Planning Council Patrick Chaulk, MD, MPH

Consequences of poor dental health Gum disease Tooth decay Tooth erosion Mouth sores Tooth sensitivity, aches and emergencies Oral cancer Cosmetic needs Bad breath Negative impact on healthy diet Dental and mouth problems related to HIV can be painful, which can cause trouble chewing or swallowing. This may prevent you from taking your HIV medication. It can also result in malnutrition, as you may have trouble eating and absorbing enough essential nutrients. A compromised digestive system may affect the absorption of your HIV drug treatment. Reference: https://www.mouthhealthy.org/en/az-topics/h/hiv-aids-and-dental-health

Consequences of HIV and oral health Increased susceptibility to dental infections Mouth: first body part to be affected by HIV infection People with HIV may experience: Dry mouth Thrush/Candidiasis Oral hairy leukoplakia Red band gingivitis Kaposi’s sarcoma HSV-1 infections Mouth ulcers (Pakfetrat et. al., 2015) Dental and mouth problems related to HIV can be painful, which can cause trouble chewing or swallowing. This may prevent you from taking your HIV medication. It can also result in malnutrition, as you may have trouble eating and absorbing enough essential nutrients. A compromised digestive system may affect the absorption of your HIV drug treatment. Reference: https://www.mouthhealthy.org/en/az-topics/h/hiv-aids-and-dental-health

Data collection CAREWare, 2017 data Nature of data collected Administrative Clinical Support service data Tabular reports completed annually by Ryan White grantees and their subcontractors

Sample size Total= 12,462 Duplicates= 10 Sample Size= 12,452 Inclusion criteria: patients receiving medical, non-medical or support services under Ryan White Part-A program

Oral health care services utilization Outcome variable Oral health care services utilization Had an oral health visit Did not have an oral health visit

Age AGE (in years) 02-24 13-24 25-45 46-65 >65 N (%) 31 (0.25) 471 (3.78) 4193 (33.67) 6886 (55.30) 871 (7.00) Baseline sociodemographic characteristics of the study sample can be found in Table 1. Participants ranged in age from 03 to 91 years with a mean age of 48.03 years (48.03土13.25). The majority of the sample was male (61.8%). Participants who identified themselves as black comprised of 77.14% of the sample, followed by those who identified as white (14%). About 41% of the study participants were covered under Medicaid for their health insurance followed by Medicare (20.1%) and 20% of the study population had private insurance. Approximately 7% of the sample had no insurance. The majority of the population reported an annual household income in the range of $0 to $20,000 (71.9%). Majority of the participants reported having a stable housing status (72.4%). The study sample that was virally suppressed was 89.4% (having a viral load of less than 200 HIV virus copies). Additionally, majority of the population was also retained in care (63.9%).

Gender GENDER Male Female Transgender Unknown N (%) 7693(61.78) 4562 (36.63) 154 (1.24) 43 (0.35) Baseline sociodemographic characteristics of the study sample can be found in Table 1. Participants ranged in age from 03 to 91 years with a mean age of 48.03 years (48.03土13.25). The majority of the sample was male (61.8%). Participants who identified themselves as black comprised of 77.14% of the sample, followed by those who identified as white (14%). About 41% of the study participants were covered under Medicaid for their health insurance followed by Medicare (20.1%) and 20% of the study population had private insurance. Approximately 7% of the sample had no insurance. The majority of the population reported an annual household income in the range of $0 to $20,000 (71.9%). Majority of the participants reported having a stable housing status (72.4%). The study sample that was virally suppressed was 89.4% (having a viral load of less than 200 HIV virus copies). Additionally, majority of the population was also retained in care (63.9%).

Race & Ethnicity RACE & ETHNICITY White African-American Hispanic Other Not Specified N (%) 1739 (13.96) 9605 (77.14) 401 (3.22) 466 (3.74) 241 (1.94)

Insurance Status Medicaid Medicare Private Other Unknown No Insurance 5123 (41.14) 2501 (20.08) 2490 (20.00) 170 (1.37) 1310 (10.52) 858 (6.89)

Income Status INCOME $0 - $20,000 $21,000 - $40,000 $41,000 - $60,000 >= $61,000 Missing Value N (%) 8879 (71.87) 1250 (10.12) 498 (4.03) 1727 (13.98) 98 (0.007)

Oral health visits ORAL HEALTH VISITS Did not have a visit Had a visit N (%) 10332 (82.97) 2120 (17.03)

Population Characteristics Based on Access to Oral Health Visits STUDY VARIABLES TOTAL N=12452 DID NOT HAVE ORAL HEALTH VISIT N=10332 HAD ORAL HEALTH VISIT N=2120 P-VALUE Age (in years) 02-12 13-24 25-45 46-65 >65 31 (0.25) 471 (3.78) 4193 (33.67) 6886 (55.30) 871 (6.99) 30 (96.77) 449 (95.33) 3633 (86.64) 5514 (80.08) 706 (81.06) 1 (3.23) 22 (4.67) 560 (13.36) 1372 (19.92) 165 (18.94) <0.0001 Race & Ethnicity White African-American Hispanic Not Specified Other 1739 (13.97) 9605 (77.14) 401 (3.22) 241 (1.94) 466 (3.74) 1464 (84.19) 7965 (82.93) 334 (83.29) 180 (74.69) 389 (83.48) 275 (15.81) 1640 (17.07) 67 (16.71) 61 (25.31) 77 (16.52) 0.0085 Gender Female Male Transgender Unknown 4572 (36.64) 7693 (61.78) 154 (1.24) 43 (0.35) 3788 (83.03) 6366 (82.75) 140 (90.91) 38 (88.37) 774 (16.97) 1327 (17.25) 14 (9.09) 5 (11.63) 0.0453

Population Characteristics Based on Access to Oral Health Visits STUDY VARIABLES TOTAL N=12452 DID NOT HAVE ORAL HEALTH VISIT N=10332 HAD ORAL HEALTH VISIT N=2120 P-VALUE Insurance Medicaid Medicare Private Other Unknown No Insurance 5123 (41.14) 2501 (20.09) 2490 (20.00) 170 (1.37) 1310 (10.52) 858 (6.89) 4262 (83.19) 1947 (77.85) 2147 (86.22) 152 (89.41) 1261 (96.26) 563 (65.62) 861 (16.81) 554 (22.15) 343 (13.78) 18 (10.59) 49 (3.74) 295 (34.38) <0.0001 Housing Stable Unstable 9009 (73.35) 704 (5.65) 2739 (22.00) 7504 (72.63) 608 (86.36) 2220 (81.05) 1505 (16.71) 96 (13.64) 519 (18.95) 0.0011 Income $0.00-$20,000 $21,000-$40,000 $41,000-$60,000 >=$61,000 8879 (71.87) 1250 (10.12) 498 (4.03) 1727 (13.98) 7490 (84.36) 1068 (85.44) 400 (80.32) 1292 (74.81) 1389 (15.64) 182 (14.56) 98 (19.68) 435 (25.19)

Findings Oral health utilization is low Barriers: Income Insurance Viral loads Not retained in care Protective factors Age Public insurance: Medicaid, Medicare, Ryan White Of the total 12,452 participants only 2120 individuals had an oral health visit, 10332 individuals did not avail any of the oral health services provided under RWHAP Lower income groups were almost twice likely to not utilize oral health services compared to people with higher incomes The participants in the unknown category were almost 5 times more likely to not utilize oral health care services People who we

Next Steps Utilization is low, but why? Is there a provider capacity issue? MSA versus jurisdictions Best practices local and national Focus group and key informant interviews and/or surveys Clients Providers Develop effective education campaign: clients and providers Identify potential partners: State pilot program for dual eligibles University of Maryland Dental School Maryland Dental Association