would also help to develop and implement strategies to improve HIV testing in prenatal care, as discussed above.

As discussed above, optimal care for HIV-infected pregnant women and their babies is complex, and must be coordinated throughout the prenatal, intrapartum, and postnatal periods. Obstetric as well as prenatal care is necessary, as is care for the mother's own HIV disease. The committee's workshop and site visits have shown that substantial efforts to improve coordination of care and access to high-quality HIV treatment are still necessary, despite recent successes. To effectively identify HIV-infected women and prevent transmission, moreover, this infrastructure must include the education of prenatal care providers; the development and implementation of practice guidelines; the implementation of clinical policies, the development and adoption of performance measures and Medicaid managed care contract language for prenatal HIV testing; interventions to overcome pregnant women's concerns about HIV testing and treatment; interactions with HIV prevention programs and drug treatment programs; and efforts to increase utilization of prenatal care, as discussed in this chapter.

A Ryan White-funded program in Tampa, Florida, for example, provides nurse case managers for all pregnant women who are HIV-positive, whether they are being cared for by public or private providers. These case managers ease the baby's transition into a Title IV program, and provide supplementary services in conjunction with regular care providers. The program also works to improve compliance with Florida's law, which requires that all women in prenatal care be counseled and offered an HIV test. It is estimated that nearly all women who receive prenatal care in the public sector are tested, compared to 85% to 90% of the women in the private sector. To address this discrepancy, the program works with private sector physicians and group practices by sending nurses who visit offices, do chart audits, and make recommendations on how to improve testing rates. These nurses are viewed as individuals who can help the practices with HIV testing and who can link women and children with specialized HIV care when necessary, as well as "government auditors" (see Appendix H).

Defining the organization, funding, and operations of the recommended regional approach is beyond the scope of this report. Steps are needed, for instance, to ensure that regional centers do not allow private providers to "dump" patients and to not overly burden mothers with long distances to travel. To advance this plan, HRSA's Bureau of HIV/AIDS and its Maternal and Child Health Bureau, which together have authority and funding to deal with prenatal care and HIV treatment, should convene a national working group to implement this regional approach. The members of the working group should include representatives of Centers of Disease Control and Prevention (CDC) for their prevention authority, National Institutes of Health (NIH) because many of the existing centers receive significant research funding, and Health Care Financing Administration (HCFA) because of its oversight of Medicaid. State and local health authorities, representatives



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