true. If they are to improve their acceptance and compliance, providers must understand the reasons that some women resist drug therapy. According to the committee's workshops and site visits, the major reasons for patients' resistance to antiretroviral therapy were concerns that it was a ''poison" and might have long-term effects on the child; the side effects; the demanding regimen of administration, especially for babies; and fear that frequent drug administration would make it impossible to conceal their HIV status, in cases where disclosure is feared. Patients sometimes resort to removing prescription labels to evade disclosure.
When integrated into prenatal care, universal, routine HIV testing, with notification, is not costly, and could easily be covered by private insurance, Medicaid, and other prenatal care financing arrangements. Infected individuals are rare, so treatment costs are low when averaged over all women in a practice or health care plan. Indeed, analyses have shown that prenatal HIV testing and subsequent treatment of infected women and infants can be very cost-effective (Ecker, 1996; Gorsky et al., 1996; Mauskopf et al., 1996; Myers et al., 1998; see also Appendix K). In and of themselves, development and dissemination of policy goals will not achieve universal testing and optimal treatment. As the discussions in this chapter illustrate, a comprehensive infrastructure is needed. Maintaining this infrastructure requires federal funding, a regional approach, and ongoing surveillance program.
The committee learned of many successful efforts to build the infrastructure in the New York metropolitan area, Alabama, and South Texas. Other similar examples were brought to the committee's attention at its workshops and in correspondence. The directors of these programs consistently said that federal funding for research and services was essential to maintain the necessary infrastructure, and, hence, the programs' success. The efforts called for in the earlier recommendations in this chapter will require similar or higher levels of investment. Beyond this, HIV does not respect state borders, so although the perinatal AIDS epidemic is concentrated in a few states, it is truly a national problem. Thus,
The committee recommends that federal funding for state and local efforts to prevent perinatal transmission, including both prenatal testing and care of HIV-infected women, be maintained.
The Administration and Congress should examine current budgets thoroughly for adequacy, particularly in light of the expanded programs recommended by the committee. Maintaining current program levels is the minimum requirement. The