"perinatal transmission"? What should be the role of newborn HIV prevalence data in states with mandatory HIV reporting? Because of this imprecision, states would likely choose the most favorable statistic they have available to avoid the loss of federal funds. The law recognizes that in states with few cases of perinatal AIDS (less than ten) an alternative measure is needed because of the inherent statistical variation in rates based on small numbers, but fails to specify such a measure. In 1997, 39 states had fewer than ten perinatally transmitted AIDS cases (Chapter 3).

The second measure is overly precise. The restriction to "women who have received at least two prenatal visits prior to 34 weeks of gestation" seems to be based on the ACTG 076 protocol, but as Chapter 4 illustrates, women who start prenatal care late can also benefit from ZDV use. Since most health plans' data systems do not record prenatal care utilization in this much detail, the only way to compile these statistics would be to review individual medical charts, which is very costly. Birth certificates could be changed to include similar information, but currently only record prenatal care by trimester, and this information would have to be validated.

Other Approaches To Preventing Perinatal HIV Transmission

Although the committee's charge was focused on prenatal HIV testing and appropriate care, other ways to prevent perinatal transmission of HIV should be also considered. A detailed discussion of these interventions would be beyond the scope of this report, yet the committee believes that the following areas offer possibilities for preventing HIV infection in children, and should be included in a prevention package.

Primary Prevention of HIV Infection

Primary prevention of HIV refers to the avoidance of HIV infection in the general population before it occurs. Since perinatal transmission begins with infected mothers and their partners, primary prevention of HIV can contribute markedly to preventing perinatal transmission by lowering the number of HIV-infected women and their male partners. There are many established approaches to primary prevention of HIV: HIV/AIDS education, behavioral interventions, partner notification, treatment and prevention of sexually transmitted diseases, and community programs (IOM, 1994, 1995a, 1996b; NRC, 1989, 1990, 1991, 1995; CDC, 1997b, 1998b; NIH, 1997).

Beyond more general HIV prevention efforts, HIV prevention programs targeting drug users, as well as increasing drug treatment slots for HIV-infected pregnant women, appear to be especially vital. Injection drug use in women or their partners is the primary cause of perinatal AIDS, accounting for about 70%



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