for instance, would reduce the number of HIV-infected babies by 33%—about 386 children per year.

This simplified model illustrates the need for multifacted approaches to significantly reduce perinatal HIV transmission. Even with a multifaceted approach, however, it will be difficult to achieve significant further reductions in the number of HIV-infected babies. As shown in Appendix K, even if the gap were reduced by 50% (e.g., prenatal care increases from 85% to 92.5%), there would only be a 29% decline in the number of HIV-infected babies (i.e., from 1,172 to 830). Here it is assumed that 92.5% of HIV-infected pregnant women obtain early prenatal care, 87.5% of women are offered HIV testing, 90% of women accept testing, 95% of HIV-infected women are offered ZDV, and 95% of women accept and comply with ZDV therapy. To achieve a further 50% decline in the number of HIV-infected babies (i.e., from 1,172 to 580 infected babies) and be within reach of the currently achievable state (i.e., 350 infected babies), the gap between observed and achievable rates would have to close by 78% and rates for factors related to transmission would have to be very high (e.g., 96.7% of women receiving prenatal care).

Since the publication of the ACTG 076 findings in 1994, there has been a concerted national effort to bring the benefits of HIV testing and appropriate treatment to as many women and children as possible. In 1995, the PHS published guidelines focusing on universal counseling and voluntary testing of pregnant women (CDC, 1995b). In the ensuing years, professional organizations representing prenatal, obstetrical, and perinatal care providers developed practice recommendations consistent with this approach. Only the American Medical Association chose to adopt a more stringent approach, mandating HIV testing for all pregnant women and newborns. States have also moved rapidly to implement the PHS guidelines. Almost all have taken steps to implement the guidelines in law, regulation, or policy, in most cases without mandatory or coercive actions. Some states have chosen to require counseling about HIV, or the offering of an HIV test, in prenatal care. Texas chose to make HIV testing a routine part of prenatal care, with notification and opportunity for women to refuse.

As a result of these efforts, and in direct response to the ACTG 076 findings themselves, many providers have changed their prenatal care practices. As documented in Chapter 3, perinatal AIDS cases fell by about 43% between 1992 and 1997. This decline was due to a number of factors, including a 17% decline in the number of births to HIV-infected women, increased testing and adherence to the ACTG 076 guidelines, better prenatal and intrapartum care, and (for declines that occurred before the publication of the ACTG 076 findings) use of ZDV for women's own health.