While Medicaid provides crucial financing of prenatal care, labor delivery, and postpartum care for HIV-infected women, many states end coverage for all but the poorest women at six weeks postpartum. For an HIV-infected woman, the loss of Medicaid can have devastating effects on her own health and her ability to care for her infant. Providers in Birmingham noted that while specialty clinics thus far have been able to piece together financing for women's medication and treatment for women who are no longer eligible for Medicaid, it is not clear that clinics will be able to continue coverage in the future. A second Medicaid-related issue was raised at the San Antonio site visit, where the move to Medicaid managed care has left both providers and patients confused about care options for HIV-infected women. At issue is whether or not patients can switch to the high-risk HIV care center as a primary provider of maternity services.
The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides health education and supplemental foods for pregnant women and their infants. Like Medicaid, it is an important source of care for HIV-infected women and their babies. Denison, however, reports that WIC programs, which promote breast-feeding as the best alternative for infant nutrition, in some instances are not sufficiently sensitive to the needs of HIV-infected mothers.3
Inadequate prenatal care among women at high risk for HIV, health care providers' lack of adherence to PHS guidelines, and women's rejection of HIV testing and ZDV use all limit the ability to further reduce perinatal HIV transmission. This section of the report provides estimates of each potential barrier to HIV transmission reduction, and presents a simple model for assessing the implications of different intervention strategies.
If a hypothetical population of 7,000 HIV-infected pregnant women all obtained early prenatal care; if their providers were in complete compliance with PHS recommendations regarding counseling, testing, and ZDV treatment; and if the women all accepted HIV tests and ZDV treatment and all pregnancies resulted in a live birth, the committee estimates that 350 HIV-infected babies would be born (that is, the risk of transmission under optimal care is 5%). If, however,