Human Immunodeficiency Virus (HIV)

Infection with human immunodeficiency virus (HIV) remains a significant public health concern in the U.S. and worldwide. HIV is the virus responsible for acquired immunodeficiency syndrome (AIDS), a chronic disease that places individuals at higher risk of acquiring opportunistic infections. HIV infection can be transmitted through contact with infected human blood or other potentially infectious body fluids from an HIV-positive individual (e.g., semen, vaginal/rectal secretions, breast milk, or other body fluid that is contaminated with visible blood).^1-4

According to CDC surveillance data, in 2019, over 65 percent of new HIV infection diagnoses among adults and adolescents in the U.S. were attributed to male-to-male sexual contact; of the remaining HIV infection diagnoses that year, 23.5 percent were attributed to heterosexual contact and 6.8 percent to injection drug use.^{5, 6} As of year-end 2019, an estimated 1.2 million adults and adolescents in the U.S were living with HIV infection,⁷ and over 37 million individuals globally were living with HIV. ⁸ An estimated one in seven HIV-infected persons in the United States are unaware of their infection.⁹ This is a critical gap in the ongoing initiative to end the HIV/AIDS epidemic because approximately 80 percent of new HIV infections in the U.S. are transmitted by individuals who are unaware of their infection status or are not receiving regular care.¹⁰

HIV destroys specific cells in the immune system,¹¹ rendering infected people more susceptible to infection with other organisms and infection-related cancers.^{9, 12} HIV can be controlled, although not cured, with medical treatment. Over time, in the absence of effective treatment, HIV can develop into acquired immunodeficiency syndrome (AIDS), which is characterized by a low CD4+ T lymphocyte count (<200 cells/mm³) or one or more opportunistic infections.⁹

HIV infection typically begins with a brief acute retroviral syndrome that transitions to a chronic illness that, over a period of years, progressively depletes CD4 T-lymphocytes, which are critical for maintenance of effective immune function.¹³ If left untreated, the progressive depletion of CD4 T cells can result in symptomatic, life-threatening immunodeficiency.¹⁴ Without treatment, this late stage of HIV infection, known as AIDS, develops over months to years, with an estimated median time of approximately 11 years.¹³

While no cure for HIV currently exists, with effective medical treatment and care, HIV replication can be suppressed and controlled.¹⁵ The medicine used to treat HIV is termed antiretroviral therapy. When initiated early after the infection and taken every day, antiretroviral therapy can dramatically prolong the lives of those with HIV, keep them healthy, and greatly lower their chance of transmitting the virus to others. Today, a person who is diagnosed with HIV, treated before the disease is far advanced, and stays on treatment can live nearly as long as someone who does not have HIV.

Early diagnosis is crucial to extending life expectancy in HIV-infected individuals and reducing costs of care and the likelihood of further infections.^{9, 13} New HIV infections are primarily acquired from sexual contact or intravenous drug use, and approximately four out of every five new HIV infections in the U.S. are transmitted by individuals who do not know that they have HIV infection or are not receiving regular care.¹⁰

Oral lesions are among the earliest and most common clinical signs of HIV, and detection of oral lesions may signal progression of HIV disease or increase in the plasma HIV-1 RNA level.^{16, 17} Still, oral abnormalities alone are not diagnostic of HIV infection.¹⁶ HIV infection can be diagnosed by serologic tests that detect antibodies against HIV-1 and HIV-2 and by virologic tests that detect HIV antigens or ribonucleic acid (RNA).

Testing begins with a sensitive screening test, usually an antigen/antibody combination or antibody immunoassay. The serologic tests currently available are both highly sensitive and specific. Rapid HIV tests enable clinicians to make a preliminary diagnosis of HIV infection within 30 minutes. Since rapid antibody assays are less able to detect HIV in the first three months after HIV-exposure, follow-up testing after a negative result from a rapid antibody assay should be conducted to verify results.^{9, 13} Home testing kits can also be purchased online or at a local pharmacy.⁹

The U.S. Preventive Services Task Force recommends screening for HIV infection in adolescents and adults aged 16 to 65 years,¹⁸ and since 2006, the U.S. Centers for Disease Control and Prevention (CDC) has recommended that all people between age 13 and 64 get tested for HIV at least once as part of routine health care, with more frequent testing (e.g., annually) for higher-risk individuals.¹⁹ Depending on the state, oral health care providers may be permitted to perform such tests.²⁰

HIV is a bloodborne pathogen and avoiding exposure to blood and bodily fluids is the primary way to prevent transmission of HIV in dental care settings.²¹ Blood has the greatest proportion of infectious viral particles but all bodily fluids, secretions, and excretions other than sweat may contain transmissible infectious agents.²² During dental procedures, saliva tends to become contaminated with blood, increasing the risk of HIV transmission from saliva.²³

Standard precautions should be followed with all patients, whether or not they have been diagnosed with HIV. Dental personnel should wear barrier precautions (e.g., gloves, masks, and protective eyewear) whenever there is potential for contact with body fluids, non-intact skin, or mucous membranes. Personal protective equipment must be removed after leaving work areas, and remember that gloves are never to be reused.²² Although the occupational source of greatest risk of HIV transmission is percutaneous injuries, it is good to understand that after a needlestick exposure to HIV-infected blood, the average risk of HIV transmission is approximately 0.3% per exposure.²⁴ Dental health care personnel can reduce their risk of percutaneous injuries by following standard precautions, having engineering controls and work-practice controls for all sharps, and following safe injection practices.²² Any direct contact with potentially infectious material is considered an exposure that requires clinical evaluation.²²

If an exposure incident occurs to material known or suspected to be infected with HIV, the incident should be reported to a supervisor (if applicable) and the exposed individual should consult with a doctor immediately.²² Antiretroviral drugs may be prescribed as post-exposure prophylaxis (PEP) within the first 72 hours of exposure in order to help prevent HIV infection.²¹ The sooner PEP is started, the more effective it is.

While medical histories are important for all patients, this is especially important for those infected with HIV, since they are more likely to be medically complicated. Consultation with the patient’s physician for a complete medical assessment can help establish a safe treatment plan adapted to the medical condition of the patient. Since HIV may be asymptomatic and may go unrecognized, standard precautions for infection control should be observed for all patients.

Oral Manifestations of HIV

Antiretroviral therapies have reduced the overall prevalence of oral manifestations of HIV, but HIV-related oral conditions still occur in 30-80% of HIV-infected individuals.¹⁶ These orofacial conditions are readily detectable by thorough examinations of the oral cavity.

Pediatric Patients

In pediatric HIV-infected cases, 8.8-18.4% have salivary gland swelling in one or both parotid glands with or without xerostomia.¹⁷ Additionally, some antiretroviral agents can reduce salivary output, increasing the risk of dry mouth. In HIV-infected children, the most commonly reported lesion is oral candidiasis, particularly the pseudomembranous, erythematous, and angular cheilitis variants.^{17, 25} HIV-infected children are also more prone to acquiring opportunistic viral infections in the oral mucosa, including herpes simplex, herpes zoster, Epstein-Barr, and human papillomavirus.²⁷ Increased rates of viral infection also lead to higher rates of infection-related precancerous lesions such as oral hairy leukoplakia, oral warts, or oral cancer.

Gingival and periodontal diseases associated with HIV in children are linear gingival erythema, necrotizing stomatitis, and in 2.2-5% of pediatric patients, necrotizing ulcerative gingivitis or periodontitis.²⁶ Additionally, long-term use of highly active antiretroviral therapy may be associated with dysregulation of calcium homeostasis, bone loss, or diabetes mellitus and dyslipidemia, which may predispose patients to periodontal disease.²⁷ Caries prevalence in HIV-infected children is higher compared to non-infected children, though similar to that of other children with chronic illnesses.¹⁷ Increased caries prevalence may be due to traditional risk factors in addition to a reduction in salivary antibodies, absolute lymphocyte count and salivary flow rate, or a diet rich in sucrose or carbohydrates required to prevent or treat caloric deficits.^{17, 27}

Adult Patients

From 30-80% of HIV-infected adults will present with HIV-related oral abnormalities.¹⁶ As in children, xerostomia is common, occurring in up to 40% of HIV-positive patients.²⁸ Most other HIV-associated oral conditions are caused by opportunistic infections. These include candidiasis (particularly angular cheilitis, erythematous candidiasis, and pseudomembranous candidiasis), salivary gland enlargement, cryptococcosis, cryptosporidiosis, and histoplasmosis.^29-31 Opportunistic viral infections may predispose patients to other conditions: human papillomavirus may lead to condylomata, warts, or cancer³²; Epstein-Barr virus can lead to oral hairy leukoplakia³³; human herpesvirus²³ may develop into Kaposi’s sarcoma; cytomegalovirus may lead to cytomegalovirus oral ulcers.²⁸ Herpesvirus infection may also lead necrotizing periodontal conditions to occur more frequently and progress more rapidly.²⁸ Necrotizing ulcerative gingivitis or periodontitis occur in an estimated 2-6% of HIV-positive adults, and conventional periodontitis is found in up to 30% of HIV-positive adults.²⁸ The combination of periodontal disease, reduced salivary flow and antibodies increases the likelihood of caries.

A comprehensive intraoral soft tissue, periodontal and hard tissue examination should be conducted at an HIV-positive patient’s initial assessment.²⁸ Dentists should continuously monitor dental and oral health for disease progression. If any oral manifestations of HIV are present, the first priority is to relieve pain and treat infections.²⁸ To help prevent further disease, dentists can provide counseling about modifiable risk factors, such as use of tobacco, alcohol, or other drugs that may increase risk of oral abnormalities or complications, as well as work with the patient to implement oral hygiene regimens. Prevention is even more important for HIV-positive patients, who are more susceptible to oral disease.

All dental practices should be able to provide routine dental care for adult or pediatric HIV-positive patients. Nearly all patients with HIV are able to tolerate routine dental care and procedures, including oral surgery.³⁴ Still, dental treatment planning must be done on an individual basis, in conjunction with consultations with the patient and their physician as appropriate. HIV and antiretroviral therapies may be associated with abnormal bleeding, glucose intolerance, or hyperlipidemia, which may be identified through consultation with the patient and their physician.²⁸ Other conditions that may require modification of dental treatment are reduced platelet count <60,000 cells/mL, which may affect clotting, or white-blood-cell neutrophil counts <500 cells/mL, which may require antibiotic prophylaxis.²⁸ However, antibiotic use may predispose patients to adverse drug reactions, superinfection and drug-resistant microorganisms, so antibiotics should be used judiciously, not routinely.^{28, 34} In select circumstances, it may be appropriate to consult with the patient’s physician to determine if there are any recent abnormal laboratory findings (e.g., low platelet count) that may require dental treatment modification or the provision of invasive procedures in a hospital setting.³⁵

Indications for dental extractions and other oral surgical procedures are the same for HIV-positive patients as for any other patient. Preoperative scaling may be performed to help reduce the risk of postoperative complications. All procedures must be performed in a manner to minimize bleeding and avoid bringing oral pathogens into the deeper fascial planes and oral spaces.³⁴

1. Royce RA, Seña A, Cates W, Jr., Cohen MS. Sexual transmission of HIV. N Engl J Med 1997;336(15):1072-8.
2. Mindel A, Tenant-Flowers M. ABC of AIDS: Natural history and management of early HIV infection. BMJ 2001;322(7297):1290-3.
3. Kuhar DT, Henderson DK, Struble KA, et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol 2013;34(9):875-92.
4. Smith DK, Grohskopf LA, Black RJ, et al. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the U.S. Department of Health and Human Services. MMWR Recomm Rep 2005;54(Rr-2):1-20.
5. Centers for Disease Control and Prevention. HIV Surveillance Report, 2019; vol.32; Published May 2021.
6. Centers for Disease Control and Prevention. Estimated HIV incidence and prevalence in the United States, 2015–2019. HIV surveillance supplemental report.  2021;26(1).
7. Bosh KA, Hall HI, Eastham L, Daskalakis DC, Mermin JH. Estimated Annual Number of HIV Infections ─ United States, 1981-2019. MMWR Morb Mortal Wkly Rep 2021;70(22):801-06.
8. World Health Organization. HIV/AIDS. https://www.who.int/news-room/fact-sheets/detail/hiv-aids Accessed August 29, 2023.
9. U.S. Department of Health and Human Services. HIV Basics. https://www.aids.gov/hiv-aids-basics/. Accessed August 29, 2023.
10. Li Z, Purcell DW, Sansom SL, Hayes D, Hall HI. Vital Signs: HIV Transmission Along the Continuum of Care - United States, 2016. MMWR Morb Mortal Wkly Rep 2019;68(11):267-72.
11. Cooper A, García M, Petrovas C, et al. HIV-1 causes CD4 cell death through DNA-dependent protein kinase during viral integration. Nature 2013;498(7454):376-9.
12. Shiels MS, Islam JY, Rosenberg PS, et al. Projected Cancer Incidence Rates and Burden of Incident Cancer Cases in HIV-Infected Adults in the United States Through 2030. Ann Intern Med 2018;168(12):866-73.
13. Centers for Disease Control and Prevention. 2021 Sexually Transmitted Diseases Treatment Guidelines: HIV Infection: Detection, Counseling, and Referral. U.S. Department of Health & Human Services. https://www.cdc.gov/std/treatment-guidelines/hiv.htm. Accessed August 29, 2023.
14. Galloway NL, Doitsh G, Monroe KM, et al. Cell-to-Cell Transmission of HIV-1 Is Required to Trigger Pyroptotic Death of Lymphoid-Tissue-Derived CD4 T Cells. Cell Rep 2015;12(10):1555-63.
15. Volberding PA, Deeks SG. Antiretroviral therapy and management of HIV infection. Lancet 2010;376(9734):49-62.
16. Reznik DA. Oral manifestations of HIV disease. Top HIV Med 2005;13(5):143-8.
17. dos Santos Pinheiro R, Franca TT, Ribeiro CM, et al. Oral manifestations in human immunodeficiency virus infected children in highly active antiretroviral therapy era. J Oral Pathol Med 2009;38(8):613-22.
18. Owens DK, Davidson KW, Krist AH, et al. Screening for HIV Infection: US Preventive Services Task Force Recommendation Statement. JAMA 2019;321(23):2326-36.
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