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This sub-study provides a comprehensive perspective on the interrelation between HIV, patient-reported outcomes, prosthodontics, oral and general health. There has not been a study in the literature to date which comprehensively assesses the impact of prosthodontic treatment using validated instruments within an HIV cohort. Secondary to the introduction of highly active antiretroviral therapy, HIV has now become a chronic disease. As such, the number of HIV positive people with these prosthetic needs will continue to increase. In the context of HIV, where feelings of stigma and shame are common117_{, patient-reported measures serve as a critical} component to understanding to totality of the impact of care provision. It is clear that quality of life metrics can be poorer for PLWH, in fact HIV-infected women averaged 10% poorer OHRQOL than HIV-uninfected women (Mulligan, 2008). Overall, in this sub-study, there was a higher burden of oral disease detected at baseline in patients requiring prosthodontic rehabilitation. We have shown that prosthodontic intervention leads to qualitative improvement in general health and wellness (SF-8, p=0.02) but we also observed improvements in select item responses related to OHRQoL and social avoidance and anxiety. In the setting of HIV, prosthodontic care was associated with improved self-perception of overall wellness; patients were less self-conscious and embarrassed. Similar to the general population, there was greater improvement in QoL in patients restored with complete dentures compared to partial dentures.

The motivation for oral prosthetic use such as partials or dentures seems to have a life altering social meaning. Mental health promotion is linked to self-esteem and this is an area where oral health rehabilitation can have the largest impact. The permeating fear and perception associated with having the HIV virus still lingers today. HIV-positive individuals experience personalized stigma, disclosure concerns, negative self-image and concern with public attitudes

toward people with HIV.115 _{The fear of being judged often prevents people from doing many} things in life including things related to self-care and overall quality of life. This study reinforces the fact that we can make real, tangible impacts and alter these patients lives for the good.

We understand that people with HIV may be more likely to seek preventive dental care if financial barriers are removed, they are actively taking ART medications, and are satisfied with their overall oral health.116_{These findings may impact policy making which is vital to the}

planning of oral healthcare programs. Our group is in the process of modifying state and national HIV guidelines to include oral healthcare. Prosthetic intervention in an HIV positive population allows qualitative improvement in QoL as determined by SF8, and OHIP trending toward that of an HIV negative nationally representative sample.

Overall, the S-F 8 instrument served as the most impactful in this study reinforcing the fact that not just oral but general health related quality of life assessments hold an insightful place in the dental research field. It is well understood that missing tooth location is a major factor in patient-reported outcomes pertaining to oral care provided. All complete denture patients were missing anterior teeth which was not necessarily true for the RPD patients, illustrating a much larger impact for CD patients.Although the impact on participants who received CDs was more evident, the impact of oral rehabilitation with RPDs was satisfactory which is consistent with the literature. This study presents with some limitations. The small size of our prosthodontic cohort sample inherently influences the strength of our overall outcomes. Outcome assessment is further complicated by the overall comprehensiveness of the study. Another limitation is that we did not perform a direct HIV negative control comparison. Within the prosthodontic groups, some patients had a single prosthesis while others had two which may have influenced our findings.

Future directions of this study may include stratifying outcomes based on ART status, CD4 count, HIV viral load and diagnosis. Also, the utilization of a more prosthetically focused instruments such as the Burdens in Prosthetic Dentistry questionnaire (BiPD-Q)118 _{or the} Prosthetic Esthetic Index (PEI)119_{might be more useful.}

There is no existing research in understanding how these types of prosthodontic treatments impact the oral microbial status within the context of oral health and disease in this immune-compromised cohort which may be a future area of interest. The inclusion of other prosthodontic treatment types such as fixed restorations and those supported or retained by implants would be beneficial.

We have shown that improvements in oral health translate to improvements in self perceived systemic health. The growing number of people living with HIV much longer requires more effort to increase and strengthen integrated oral health promotion and disease prevention. These changes observed in the HIV positive cohort are similar to findings in the general population. In addition to those living with HIV, other groups such as the elderly, the

developmentally disabled, homeless people, uninsured and institutionalized individuals, as well as members of certain ethnic minorities, remain most vulnerable to oral diseases. These findings may have implications for public health intervention, hopefully supporting the need for a change in the HIV guidelines to include oral health care. Studies like these and others are vital to the planning of oral healthcare programs which can hopefully be extended to other vulnerable groups.

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