approach enabling teenagers to receive counseling, testing, treatment, and medications for HIV at the same site—both during and after pregnancy (although obstetrical services are available through referral); and understanding the special needs and fears of adolescents.

Immigrants

Although they do not have higher HIV infection rates, many immigrant women face multiple barriers to the prevention of perinatal HIV transmission (Appendixes E, G, and H). The most formidable are cultural, financial, and legal, including potential loss of U.S. residency rights or citizenship. Many immigrants, particularly those who are undocumented, are reluctant to seek prenatal care because they distrust the health care system and fear being reported to the Immigration and Naturalization Service, which may lead to deportation. The foreignness of the language and the institutional atmosphere also lead to avoidance. Some minority groups equate hospitals with death. The cost of prenatal care is another obstacle. Many providers and programs provide free care or care at reduced cost, but federal law explicitly prohibits undocumented immigrants from receiving Medicaid.

Finally, the cost of treatment is yet another barrier. Few immigrants have private insurance or Medicaid, so the only avenues for uninsured women to pay for care is through programs such as health department clinics and community health centers that serve low-income, Medicaid-ineligible people. Children born to undocumented immigrants, however, are covered under Medicaid by virtue of being born in the United States, which confers U.S. citizenship. Nevertheless, in South Texas, undocumented mothers of children born in the United States do not seek care for their children because their use of Medicaid would interfere with other family members' residency or citizenship petitions in the future (Appendix G).

Even with the new program of federally funded state child health insurance programs (CHIPs, described in Chapter 5), a substantial fraction of low-income women and children will remain uninsured and HIV-infected children will be born ineligible for Medicaid. Continued support for public health clinics and neighborhood health centers and innovative insurance programs can help to provide prenatal and HIV testing care for these populations. The committee has seen examples of perinatal HIV centers that have been able to provide care for uninsured women, using combinations of private and governmental resources.

Conclusions

If the promise of the ACTG 076 findings—that perinatal transmission of HIV can largely be prevented—is to be fulfilled, the United States needs to adopt a goal that all pregnant women be tested for HIV, and those who are positive remain in care so that they can receive optimal treatment for themselves and their



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