Prenatal Care: Reaching Mothers, Reaching Infants (IOM, 1988) 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.
Correctional settings—prisons and jails—offer a unique opportunity for prevention activities targeted to hard-to-reach women at risk for, or already infected with, HIV. The prevalence of HIV infection among incarcerated women is far higher than in the community at large: 4% of female state prison inmates nationwide are known to be HIV-positive; in nine states the proportion exceeds 10%. Women are more likely than men to be incarcerated for drug-related offenses, so female inmates are more likely than male inmates to be infected or at risk for HIV infection. Many interventions could be introduced in correctional settings either for primary prevention of HIV transmission or, particularly, for prevention of perinatal transmission among HIV-infected pregnant women. Interventions should focus on HIV testing and treatment, drug testing and treatment, prenatal care, and efforts to ensure continuity of care for HIV-positive patients who leave the correctional setting.
Because reporting of conventional HIV tests takes about one to two weeks, an accurate rapid test, with results available in hours, might have applications in prenatal, labor, and delivery settings to prevent perinatal transmission in some groups of patients. Women and newborns identified with a rapid test late in pregnancy or intrapartum could receive the intrapartum or postpartum component of the ACTG 076 regimen, respectively. In the prenatal setting, a rapid test might be especially valuable for women who are unlikely to return for test results. According to the committee's site visits and workshops, these women are more likely to be adolescents, drug users, undocumented immigrants, and/or homeless. In the labor and delivery setting, a rapid test might be valuable for women who have not been tested previously or have not received prenatal care. The prevalence of HIV infection is elevated in women who have not received prenatal care, and the labor and delivery setting offers the last opportunity to interrupt HIV transmission through administration of intrapartum therapy and advice to avoid breast-feeding. Since this is not an ideal time to obtain consent to testing and to discuss the implications of a positive result, program design and implementation would need to address these issues.