women must know their HIV status to be able to take action, and this requires testing. The more women know their HIV status early in pregnancy, the better able they will be to consider whether to continue a pregnancy as well as the benefits of antiretroviral therapy. After giving birth, HIV-infected women, like all women, should be counseled about contraception and given referrals for follow-up visits that support the woman's contraceptive choice. This is important for all women, but especially for women for whom the consequences of an unintended pregnancy are particularly great.

If such a program proves successful, it would be appropriate to implement comparable programs more broadly, but with clear provisions for women's right to refuse testing.

Increasing Utilization of Prenatal and Preconceptional Care

The purpose of prenatal care is to improve pregnancy outcomes, particularly for women at increased medical or social risk (IOM, 1988). Since the publication of the ACTG 076 results, the prenatal setting offers the additional opportunity for combating perinatal HIV transmission by HIV testing and by initiating effective treatment for women who test positive. Yet roughly 15% of HIV-infected pregnant women, many of whom are drug users, receive no prenatal care (Chapter 6). Therefore, increasing the proportion of women, especially drug users, who receive prenatal care should be a high priority.

The 1988 IOM report Prenatal Care: Reaching Mothers, Reaching Infants recommends activities to (1) remove financial barriers to care; (2) make certain that basic system capacity is adequate for women; (3) improve the policies and practices that shape prenatal services at the delivery site; and (4) increase public information and education about prenatal care. The improvements in prenatal care coverage documented in Chapter 6 show that progress is being made, but it is troubling that prenatal care utilization is especially limited among those women most likely to be infected with HIV.

Some recent policy changes at the federal and state level do not augur well for improving access to prenatal care, although their full impact is not yet known. The 1996 federal welfare reform legislation creates bureaucratic barriers to the receipt of Medicaid for low-income women, both those who receive cash benefits under the new state welfare programs and those who continue to be Medicaid-eligible when they find employment. The legislation also prohibits undocumented immigrants and certain categories of legal immigrants from receiving Medicaid, despite the fact that any child born to them in the United States automatically becomes a U.S. citizen.

With respect to drug abuse and pregnancy, several states have passed legislation mandating drug testing (prenatal or neonatal) and/or drug abuse treatment (see Chapter 2). Such legislation can have a chilling effect on the willingness of pregnant drug users to seek prenatal care, even in states where such laws have not

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