of perinatal AIDS cases (Chapter 3). Drug treatment programs have higher HIV prevalence rates (2.9%) than at other testing sites, such as HIV counseling and testing sites, sexually transmitted disease clinics, and family planning programs (CDC, 1997d). Engaging drug abusers in drug treatment, needle exchange, and related programs is pivotal to primary prevention of HIV. Drug abuse treatment, and HIV prevention education given in the context of drug treatment, have been documented to reduce HIV risk behaviors, for example, drug use, risky injection practices, and number of sexual partners (IOM, 1995b, 1996b). Women found to be drug users in mandatory drug testing (see Chapter 2) need opportunities for treatment, not just identification and threats of removing their children. Similarly, needle exchange programs are effective in preventing HIV transmission (NRC, 1995). Targeted prevention programs also are essential in correctional settings, as discussed below.
As a general proposition, pregnancies that are intended—consciously and clearly desired—at the time of conception are in the best interest of the mother and the child (IOM, 1995b). If a woman is infected with HIV, unintended pregnancy and childbearing clearly have special significance. For these reasons, preconception counseling represents an important opportunity to identify HIV-infected women who are considering pregnancy. Couples are increasingly being urged to plan their pregnancies (AAP and ACOG, 1997), and part of this planning process should be a visit to a health care provider to ensure that the women enters pregnancy in optimal health. Such a preconception visit usually includes advice about nutrition, folic acid, weight, and tests for infectious and chronic diseases. Insofar as women and their partners avail themselves of this opportunity, preconception visits provide an early opportunity to obtain HIV testing for the woman and her partner. For those found to be HIV-positive, it provides a chance to consider avoiding pregnancy, and/or to be counseled about antiretroviral therapy during pregnancy.
Some women who know they are HIV-infected choose to become pregnant, especially now that the ACTG 076 regimen is available, but others become pregnant unintentionally. More women learn their HIV status in the course of their pregnancy. Nevertheless, improved knowledge of the consequences of unintended pregnancy (including HIV transmission) and the ways to avoid it as well as access to contraception can help to ensure that all pregnancies are intended (IOM, 1995b), and this would reduce, to some extent, the number of children born with HIV infection. The committee does not want to restrict reproductive choice (Faden et al., 1991), but notes that interventions for such women who choose to terminate unintended pregnancies can also be beneficial in reducing the number of children born with HIV infection. To be most effective, however,