Despite the efforts of government and professional organizations, however, prenatal testing remains far from universal, and many HIV-infected women continue to be inadequately treated for their disease because they do not seek prenatal care, because they are not tested for HIV, or because their treatment does not reflect current standards of care. Although there have been substantial improvements in prenatal care coverage in recent years for most women, some 15% of HIV-infected women, especially those who use drugs, receive late or no prenatal care. Prenatal care providers are generally aware of the need for HIV testing, but there are still significant variations across the country in the application of recommended practices. Even in areas where the overwhelming majority of providers agree in principle that HIV testing should be offered to all pregnant women, only 50% to 75% actually offer the test to all women in their practices. Citing a lack of time, resources, legal requirement for pretest counseling, and perceived risk, actual testing practice is often based on providers' assessments of maternal HIV risk, which are not very accurate. On the positive side, the available evidence suggests that when offered, 90% or more of women will accept an HIV test, and acceptance can be enhanced if providers strongly recommend the test and incorporate it into routine practice.

For women who are found to be infected, Ryan White Title IV centers provide excellent maternal and child HIV treatment and care for those who have access to them. Despite the complexity of the ACTG 076 regimen and other difficulties, most HIV-infected women do accept and comply with ZDV treatment. Yet testimony to the committee and its own site visits all point to the conclusion that testing does not necessarily lead to care, and even when it does, women are not necessarily receiving the quality treatment and services they need.

Given these results, the committee must make a qualified response to its congressional charge to assess "the extent to which state efforts have been effective in reducing the perinatal transmission of HIV." The committee interprets this charge to include the efforts of national as well as state and local health agencies, and professional organizations at both levels. The data reviewed indicate that, on the whole,

  1. there have been substantial public and private efforts to implement the PHS recommendations;
  2. prenatal care providers are more likely now than in the past to counsel their patients about HIV and the benefits of ZDV and to offer and recommend HIV tests;
  3. women are more likely to accept HIV testing and ZDV if indicated; and
  4. there has been a large reduction in perinatally transmitted cases of AIDS.
  5. The number of children born with AIDS, however, continues to be far above what is potentially achievable. Much more remains to be done. There is substantial



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