prenatal care. With managed care, the responsibility is clear, and plans can be held accountable for the services they provide, although few actually are. Thus the contracts that govern the care provided to patients in managed care systems can be powerful tools, and are especially important for increasing the number of women covered by Medicaid managed care.

Current Medicaid managed care contracts, however, are limited by what the states specify, and in most states, financing rather than public health agencies develop the contracts. Thus no one asks for contract provisions relating to perinatal transmission or other prevention issues (Wehr et al., 1998). Fewer than half the states that have Medicaid managed care contracts require HEDIS data, for instance. Managed care and insurance contracts typically do not mention specific conditions, but in 1996, 18 states mentioned HIV or AIDS in their contracts. Of those, ten are limited to a reference to counseling and testing as a covered service, usually only in the context of family planning services. Only one state, Florida, specifically assures access to the ACTG 076 protocol (Wehr et al., 1998).

A number of things could be specified in Medicaid managed care contracts. At a minimum, managed care organizations could be required to report what they tell their providers about prenatal testing and counseling and ZDV use. Managed care organizations could also be required to report on the proportion of women counseled and tested (or documented refusal), and the proportion of HIV-infected pregnant women who receive ZDV (whether there was a HEDIS question on this or not). Since many women qualify for Medicaid when they become pregnant, offering an HIV test could be a required part of the intake process (Wehr et al., 1998).

Improving Coordination of Care and Access to High-Quality HIV Treatment

Prenatal HIV testing can achieve its full value only if women who are found to be positive receive high-quality prenatal, intrapartum, and postnatal care for themselves and their children. In its workshop and site visits, however, the committee heard many unfortunate instances of inferior-quality HIV treatment and poor linkage to specialty care for women diagnosed with HIV. Thus,

The committee recommends efforts to improve coordination of care and access to high-quality HIV interventions and treatment for HIV-positive pregnant women.

This recommendation has two components. First, HIV testing in pregnancy should be seamlessly linked to specialty care for HIV-infected women identified in the prenatal setting. Without linkage, the committee's recommended policy of universal HIV testing, with patient notification, as a routine component of prenatal care would violate one of the fundamental criteria for public health screening, that is, there should be adequate facilities for diagnosis and resources for treatment



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