service delivery and financing for both the mother and the child. Some pregnant patients, however, especially those in rural areas, must access HIV care in the primary care setting. In such cases, the primary care provider must be knowledgeable about HIV testing and treatment and in communication with HIV specialty care. Whatever the arrangement, patients must have a smooth transition from primary to specialty care.
Some of the highly coordinated programs visited by the committee not only furnish specialty care, but also ensure on-site access to medications, to clinical trials, and support services such as transportation and psychosocial services and assistance with applications for public programs that pay for their care, including medications (Appendixes E, F, and G). Ensuring continuity of funding for care for both women and children is also important, especially given the fragmentary nature of federal and state systems documented in Chapter 5.
While lack of prenatal care and not being offered a test are the primary reasons why women are not being tested for HIV, some proportion of women refuse testing when offered. To enhance acceptance of routine HIV prenatal testing, therefore, providers should understand the constellation of reasons why some pregnant women refuse HIV testing. According to the committee's workshops and site visits, pregnant women reject testing because they deny risk; fear disclosure of test results will lead to abandonment, discrimination, and domestic violence; lack trust in the provider; and face religious, cultural, and linguistic barriers (see section on special populations, below). Thus,
The committee encourages the development of outreach and education programs to address pregnant women's concerns about HIV testing and treatment.
Public and private organizations can contribute to these programs, which could include making information available in prenatal care providers' offices and in the popular press.
Providers need to be sensitized to these attitudes to help them devise strategies or interventions designed to heighten acceptance of HIV testing. When a woman refuses to be tested, providers must continue to understand the reasons behind her refusal, and encourage testing while avoiding coercion. Providers' ability to persuade women to be tested is enhanced within a climate of trust in the prenatal care relationship and assurances of confidentiality. If testing becomes truly routine and integrated into prenatal care, some women's concerns may dissipate over time.
Once they agree to be tested, the overwhelming majority of patients who test positive accepts and complies with the ACTG 076 regimen. But this is not universally