In San Antonio, a case was cited in which a doctor assumed the pharmacy automatically stocked ZDV, which he planned to administer to a pregnant HIV-infected woman during labor. By the time he realized the pharmacy did not have ZDV readily available and ordered it from a specialty HIV clinic, it was too late. The woman delivered without benefit of intrapartum antiretroviral therapy.
In Birmingham and San Antonio, committee members were told that although high-risk centers provide triple or other multiple therapies, many other providers offer only ZDV. In some instances the reliance on monotherapy seems to reflect a resource shortage, and in others it reflects a concern among providers that multiple therapies are still experimental and that their use may be unethical and/or leave the provider subject to malpractice charges. In testimony at the April 1, 1998 Workshop, Denison noted the importance of continuing research protocols and of incorporating new findings into standard care for HIV-infected women (Appendix D).
Even when women receive care from specialty clinics, they and their providers are often faced with difficult decisions about care options. For many basic obstetric procedures, there is no standard of care established for HIV-infected women. There are, for example, no standard recommendations or cost-benefit analyses on cesarean sections, amniocentesis, and fetal scalp monitoring for the HIV-positive mother and her infant.
There are extra barriers for some special populations to obtaining adequate care for HIV-infected pregnant women and their infants. These special populations include undocumented immigrants, some categories of legal immigrants, substance users, and adolescents. Chapter 7 reviews some of the systemic issues related to receipt of HIV-specific and other care for these populations.