Marginalized No More

***This story appears in the UCLA School of Dentistry's Spring 2023 Magazine***

In the late 1980s, as a newly-minted dentist working at New York University during the height of the AIDS epidemic, Fariba Younai, D.D.S., found herself at the darkest point of her career.

“We had the names of four gay dentists who announced they were willing to see HIV-positive patients,” recounted Dr. Younai. “Any infected patient who came through our oral medicine clinic where I treated them for oral manifestations of HIV – whether they needed basic dental care or if they had a bombed-out tooth – I was required to refer them out. It really killed me to do that.”

As the years passed and exhaustive AIDS research helped destigmatize the disease, Dr. Younai worked her way up the NYU College of Dentistry faculty ranks. In 1990 she was appointed director of Hospital Dentistry and Special Patient Care. Serving in a leadership role gave Dr. Younai the confidence to advocate for these marginalized patients.

“I had a heart-to-heart with our dean, Edward Kaufman, and told him I think it's time that we started opening our doors to patients with HIV. He agreed, with the condition that they be seen in Special Patient Care,” Dr. Younai said.

For a clinic that historically treated adults with intellectual disabilities and wheelchair-bound patients with neurological issues, absorbing a population with a still-mysterious and often-terminal disease brought a host of challenges. There were questions such as what medications could be prescribed and how patients might physically respond to an extraction. Dr. Younai began networking with fellow healthcare professionals working with New York’s HIV and AIDS-infected population; they exchanged best practices and formalized standards of care. Soon thereafter NYU Dentistry started mainstreaming patients throughout its clinics.

There was also a research component to Dr. Younai's work, leading her to the epidemic's sociological side.

“In 1990 I got a grant from HRSA [Health Resources and Services Administration], studying social factors that put people at risk for HIV and using oral manifestations as a proxy for identifying them,” she explained. “That had me working with homeless women, runaway adolescents, and a lot of patients in substance abuse programs. This study helped put our clinic on the map in New York City.”

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Three-thousand miles west, additional advocacy was taking place. According to HRSA’s A Living History: The Ryan White HIV/AIDS Program, the idea for a Federal program to support dental care for those infected germinated in the late 1980s from conversations between then-UCLA School of Dentistry Dean Henry Cherrick and Dr. Jay Gershen, chair of its Public Health section.

Not only was the School providing substantial unreimbursed care for people living with HIV/AIDS, but as a pathologist, Dr. Cherrick realized that dentists, if properly trained, could be a key first line of defense in AIDS patient care due to the soft-tissue lesions they encountered. In collaboration with American Association of Dental Schools (now the American Dental Education Association) peers and with support from several California congressional members, the UCLA visionaries successfully lobbied the House of Representatives to authorize HRSA’s Dental Reimbursement Program in 1991; funds were first allocated in 1994.

“Early on, policymakers asked us why they should fund fillings for people who were dying, but once we explained the need and the important role dentists could play in diagnosing and treating people with HIV, they came on board,” Dr. Gershen recounted in 2008.
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These two forces of change converged in 1997 when Dr. Younai accepted a faculty position at the UCLA School of Dentistry. She immediately connected with oral medicine professor Dr. Frank Lucatorto, an author of numerous papers on diagnosing and treating oral lesions in HIV/AIDS-infected patients, and who – according to his 2001 obituary – “treated every patient with compassion and dignity.”

Using her experience from NYU administering the Ryan White Care Act (RWCA) federal funds that UCLA administrators had advocated for nearly a decade earlier, Dr. Younai took on the challenge of scaling up the School’s care for those living with HIV and AIDS; at the time averaging less than 100 patients per year.

“The experience I brought to UCLA was that you can expand services, you can provide care to a large population of patients, and you can find ways of identifying streams of funding for the provision of care,” Dr. Younai said. “We developed a way of capturing and reporting the cost of patient care and every year we were able to increase funding from HRSA.”

On top of her faculty responsibilities, in 2002 Dr. Younai was asked to serve as the UCLA Medical School representative on the Los Angeles County Commission on HIV. What she expected to be a two-year term turned into a 14-year commitment. During this time, Dr. Younai not only helped allocate approximately $50 million in annual federal Part A funds, but she also co-chaired the Commission’s Standards of Care Committee, which developed treatment standards in over 30 categories; LA County lacked such checks and balances prior to their introduction in 2006.

While serving as a commissioner, Dr. Younai negotiated an oral health contract between the School and the County. In May 2014, with then-Dean No-Hee Park serving as primary investigator and clinic-side support from Associate Dean Paulo Camargo, the School received its first Los Angeles County Department of Public Health grant of $2.36 million over two years.

Completing her civic tenure in 2016 allowed Dr. Younai to redouble her efforts in directing UCLA’s oral health services to people with HIV and AIDS. After building a program for general dentistry, recruiting patients, and developing administrative systems across the School, in 2018 she secured additional County funding for specialty care. Combined, these grants now total more than $2 million per year, supporting an average of 1,700 patients annually and providing invaluable opportunities for dental students and postgraduate trainees alike.

“Patients come here with tremendous oral health needs, and once they complete treatment, they are happy, they find employment, they have a better quality of life,” Dr. Younai said. “Of course, in the process, we are training the next generation of oral health providers who are comfortable treating patients with HIV and AIDS. As an educator, this is the best thing I can ask for.”

The Patient
“I crushed up my Marlboro Reds and yelled out the window as loud as I could, ‘I'm going to live!’”

That was Murray Mead’s visceral reaction in 1990 upon learning he had ulcerative colitis, a potentially fatal inflammatory bowel disease that Mead’s gastroenterologist said was triggered by years of hard living. It provided the jolt he needed to give up his many vices and commit to a healthy lifestyle. Mead began distance running and rekindled a love affair with pole vaulting, the sport in which he won a Hawaiian high school state title.

In 2019, his physician at Kaiser Permanente suggested he look into a new grant-funded program at the UCLA School of Dentistry. Mead did so immediately, and after completing the application to determine his qualification for RWCA Part A-funded treatment, he was accepted.
Mead underwent two complex implant procedures in the Postgraduate Periodontics and Implant Surgery Clinic involving bone grafts, and he continues as a patient for all his oral health care needs. The School has performed nearly 600 such dental implants since Part A funding was expanded in 2018.

“I find that the residents at UCLA are so meticulous because they’re fresh out of dental school,” Mead said. “Their level of kindness is incredible. I never feel like they're rushing to get to their next patient.”

Mead remains healthy and has transitioned to a once-daily antiretroviral therapy with limited side effects compared to the longstanding HIV “drug cocktail.” Now semi-retired, Mead coaches the next generation of pole vaulters at a local high school. He is grateful to UCLA Dentistry not only for the care received but for how it’s alleviated his financial burden.

“There’s just no anxiety, knowing everything is going to be covered,” Mead said. “I was born a poor child, and I'll die a poor man … but I’m rich in experience!”

The Practitioner
When Masooma Rizvi, D.D.S. ’21, P.D. ’24, moved from Pakistan to enroll in UCLA’s Professional Program for International Dentists, she was surprised that reality didn’t match her preconceptions.

“I went to a lot of community events which exposed me to low-income populations around Los Angeles. This was news to me because, coming from a third-world country, I always thought of LA as being this fancy, luxurious city,” she intimated.

Now in the second of a three-year periodontics residency, Dr. Rizvi’s service work includes seeing patients living with HIV and AIDS. In addition to performing Mead’s recent teeth cleaning, she inspected the health of tissues surrounding his implants.

The scale of UCLA Dentistry’s clinical operation allows it to treat more patients than any other dental provider contracted with the LA County Division of HIV and STD Programs. General restorative services are typically performed by third- and fourth-year D.D.S. candidates – averaging 7,000 patient visits per year – with more complex procedures in the hands of residents like Dr. Rizvi.

The impact of Part A funding and similarly-altruistic School of Dentistry initiatives have helped shape Dr. Rizvi’s post-residency goals.

“I plan on having a community service day twice a month in my private practice where we provide basic exams and cleaning and oral hygiene tips and tricks free of charge in order to make a difference for all populations,” she said.

The Support Staff
The phrase “it takes a village” can often seem cliché, but it is certainly applicable to UCLA Dentistry’s oral health services for people living with HIV and AIDS. One of the first villagers whom patients meet is program coordinator Vanessa Porter.

Hired by Dr. Younai soon after the first County contract was awarded in 2014, Porter oversees much of the RWCA Part A funding administration, including determining patient eligibility. She also collaborates with dental students, residents, faculty, and staff, as well as other medical and dental offices, all working towards one common goal: Helping people.

Having engaged with thousands of individuals in her nine years at UCLA, one success story particularly resonates with Porter.

“I often think about a patient who entered the dental clinic in a low state. He told me you don’t realize how important your teeth are to you until you no longer have them, and how scary it is if you don’t have a way to fix them,” she recounted.

“This was humbling and made me grateful for the grant program we have at UCLA. By the time he finished his dental treatment, he was a completely different person. It was incredible to witness his journey a see him become a person he was no longer ashamed to be.”

Joining Porter on the School’s core RWCA team is program coordinator Aaron Shearer, who oversees fund administration for more complex, specialty-level dental services such as implants, crowns, and root canals. Finally, the program also employs a licensed clinical social worker (although the position is currently vacant), focusing on holistic patient care and addressing some of the personal challenges those living with HIV and AIDS often experience.

The Future
Dr. Younai has worn many hats during her 26 years as a UCLA School of Dentistry faculty member, including her current role as chair of the Division of Diagnostic and Surgical Sciences. However, she remains focused on continuing to enhance the program which has become a personal passion. She says donor funding for those outside LA County who don't meet Part A’s strict qualification criteria, as well as a corporate partner to provide needed supplies would take this initiative to the next level.

As a change agent for four decades, seeing this patient population transition from marginalized to mainstream has been especially gratifying for her.

“Because of the sacrifices that the first generation of HIV-positive patients and practitioners made, money became available that we can continue to use for our patients,” Dr. Younai said. “But the reality is that you have to always be at the table and speak up; I want to see the next generation of dentists care about advocacy, too.”