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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. As of end of year 2013, 1845 HIV cases were detected with 301 AIDS related deaths and 71 cases of mother to child transmissions These infections have their manifestations in the genitalia as well as in the extra genital sites such as oral manifestations of STI/HIV.

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 Design A Descriptive Cross Sectional Study

Study Setting Dental Institute, Colombo/ Dental Institute, Maharagama/ Dental Hospital, Peradeniya Study Population All Dental Surgeons currently attached in service to the above service stations. Sample Size The 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 Instrument Self 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

Sex Distribution

Age Distribution

46.20%

36.20%

Male 37% Female 63%

17.70%

31 - 40 yrs

Mean Age Age Range

41 - 50 yrs

51 - 60 yrs

42.47 yrs. 25 - 59


Service Station Peradeniya

Colombo

Maharagama 27%

37%

PG Qualifications

36%

No

Yes

Service Years 43.10%

33.80% 16.20%

0 - 10 yrs

11 - 20 yrs

21 - 30 yrs

6.90% 31 - 40 yrs

49.20%

50.80%


Knowledge on referring patients for STI/HIV Services Yes

No

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%)

86 Have you ever been advised by your seniors to refer a patient for (66.2%) STI/HIV services after identifying oral presentations of STI/HIV?

44 (33.8%)

NA

53 (40.8%)


Awareness of Dental Surgeons on Indications for STI/HIV Referral Received Identified 126 82

74 51

69

71 34

34

24

45 18

23


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 ?

Yes 37% No 63%


Approximately how many times patients were referred during the last 6 months ? 112

12

Not Ref.

Only Once

4

2

Twice

>2


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

140 120 100 80 60 40 20 0 Referred

Not Ref

No Mothers


Practice on the Station of Referrals Not sent

34.60%

Don't know

11.50%

Others

18.50%

MRI Medical Faculty STD Clinic/ NACP

13.10% 2.30% 20%


Practice on Referrals on Oral Manifestations of STI/HIV 140 120 100 80 60 40 20 0

Oral Candi diasis

Received Frequency 126 Reffered Frequency 3900%

OHL

NUP

Viral Warts

74 19

69 15

71 15

Kaposi 'Sarco ma

STU

24 3

45 17


Obstacles encountered when referring patients for STI/HIV Services Obstacle encountered

Frequency

Percentag e

1. Unawareness of place of referral

18

13.8%

2. Patients not attended STI/HIV services despite referral

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

!


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