The impact of these changes on access to care and, therefore, primary and secondary prevention opportunities for reducing perinatal transmission is significant and complex. Most women with or at risk for HIV have low-incomes, are uninsured, and/or often rely on government programs to support their access to health care. Women with HIV disease may become impoverished because the disease itself prevents them from working or because of the expenses associated with it. Women's traditional linkage with the Medicaid program often came with their enrollment in AFDC (the former welfare program). With reduced access to welfare due to changes in eligibility and the imposition of time limits and sanctions, women may not be aware of their potential eligibility for Medicaid or how to access the program. Although many states have attempted to ease access to Medicaid for those applying for TANF benefits by creating a single application for TANF and Medicaid, access has been made more complicated for those not eligible or interested in TANF benefits because separate routes to Medicaid have not been effectively established in many jurisdictions. With access to both welfare and health care services restricted to certain categories of legal immigrants and unavailable for the undocumented, opportunities for prevention and treatment are more limited. Many undocumented women are fearful of accessing care because of INS reporting requirements. Women seeking drug treatment may not have the financial support they need because of the prohibition on benefits for those with a prior conviction.
While there are still opportunities for many women to access health services, the PRWORA is new and so sweeping that there is still much confusion on the part of potential recipients and those administering the new law. States are just beginning to develop the capacity and systems needed to appropriately inform and educate staff and reach out to potential recipients with information and mechanisms for linkage to appropriate services.
Some important policy changes affect this program's relationship to HIV prevention and treatment services for women and children. As previously noted, Medicaid plays a critical role in providing health care for low-income people