state actions, the authors concluded that policy makers should consider ongoing evaluation data from the states before changing existing state efforts.

Response to State Survey

One overarching sentiment expressed by participants was the need to monitor and evaluate states' implementation of their laws, regulations, and policies. State surveillance efforts were seen as crucial in examining the full impact of policies in reducing transmission rates. In addition, monitoring of individual service sites, especially those under Medicaid managed care, was deemed to be important. Given the dynamic financing environment, participants expressed concerns about testing without consent, undertreatment, or denial of treatment to patients in managed care. A Health Care Financing Administration (HCFA) representative observed that implementation of the PHS guidelines to reduce perinatal transmission requires coordination at many levels and between providers and payers. State laws that require providers to offer HIV counseling and testing to pregnant women may be more effective if there are laws or requirements to report on compliance. A state's Medicaid agency can require Medicaid-contracting managed care organizations (MCOs) to report on rates of HIV counseling and testing of pregnant women. Quality assurance measures related not only to counseling and testing, but to actual delivery of all components of treatment to reduce perinatal transmission (antepartum, intrapartum, postpartum), can be developed and tracked. National Committee for Quality Assurance (NCQA), Joint Commission for Accreditation of Healthcare Organizations (JCAHO), and other organizations may be able to help in developing measures. AIDS Education and Training Centers (AETCs) can train providers. These organizations are in a position to offer incentives to encourage counseling, testing, treatment, and record keeping. They also can sanction organizations that fail to do so. Some participants suggested the utility of a program-by-program scorecard of performance, indicating the percentage of pregnant women who are offered counseling and pursue testing, and the percentage who fill ZDV prescriptions (as recorded by the pharmacy) for themselves and their children. One participant commented that the provider infrastructure is in place, but the incentives are not.

Some of the participants were disappointed by states' disproportionate emphasis on counseling and testing, rather than on treating. They saw treatment of the mother as essential for her health, as well as for her ability to care for, and administer treatment to, the newborn. An HIV-infected woman at the workshop criticized the inequity of state and federal policies that seemed to focus so much attention on the mother and seemingly insufficient attention on the father, who, in her case, had infected seven other women besides herself. She expressed her frustration that policies not only failed to protect these women, but also made them feel solely responsible for the plight of their infants.

After the workshop, it was reported that all states have certified, as required



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