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for all who are found to have the condition, as well as agreement as to who will treat them.
As the committee's workshops and site visits have shown, providers' and patients' lack of knowledge of available resources have been barriers to HIV testing itself. If providers and patients do not know that resources are available for treatment, they will not believe that testing is valuable, nor will women who are tested benefit fully from it.
Second, optimal care for HIV-infected pregnant women and their babies is complex, and must be coordinated throughout the prenatal, intrapartum, and postnatal periods. Primary and prenatal care providers cannot all be experts on this care, especially in low-prevalence areas. They should, however, be able to refer patients for appropriate care in any area. A later section of this chapter discusses the resources and comprehensive infrastructure, including federal funding and a regional approach, needed to provide optimal care.
From the moment she is informed of her HIV-positive status, a pregnant woman must know that care is available, on a confidential basis, for herself and her unborn child. Information about, and referral to, care should be incorporated into post-test counseling. It also should be incorporated into pre-test counseling for women who initially refuse to be tested. Some women reject HIV testing out of misplaced fears that a positive result is a "death sentence." These women would be more inclined to accept testing with the knowledge that perinatal transmission often can be prevented and that HIV infection no longer signals an imminent death. Immediate linkage to care is also important for patients who are in a state of fear, shock, depression, or denial after the diagnosis. Some contemplate suicide or delay for months the decision to seek or accept treatment, according to the committee's site visits and workshops. This was especially true of adolescents and immigrants, as discussed below.
In many states, Medicaid will pay extra for an HIV test performed in a sexually transmitted disease (STD) clinic, but not for the same test performed as part of prenatal care because prenatal care is typically reimbursed as a package. During its site visits, the committee learned that some public prenatal clinics were taking advantage of this differential by requiring women in prenatal care to go to an STD clinic for HIV testing. Although in some cases the second clinic was "across the hall," it often required another visit, and more importantly, some women were reluctant to be seen in an STD clinic because of stigma. Systems issues such as this can have a major impact on use of testing, and must be addressed.
The ACTG 076 regimen requires initiation of ZDV therapy early in the prenatal period and continuing through the intrapartum and postpartum periods. As discussed in Chapter 4, optimal care increasingly involves complex antiretroviral therapy for most women as well as special obstetrical procedures. State-of-the-art specialty care for HIV-infected pregnant women is preferable to care provided by non-specialists. For these reasons, a coordinated system of