not receiving ZDV, lack of prenatal care is the major cause, with illicit drug use being the greatest contributor to the lack of prenatal care. The next biggest reason for not receiving ZDV is that not all women are being offered testing (women in certain high-risk categories are more likely to be offered). This points to the need for education and training to improve provider knowledge, attitudes, and beliefs. While the relative contribution is smaller, some women do refuse to be tested, and some of their reasons—such as fears about potential discrimination or not perceiving themselves at risk—could be addressed. Once women are identified as HIV-positive, there does not appear to be a major problem with providers offering therapy or with women accepting it. Finally, while there is not much data yet on adherence to the ZDV regimen, this is a major concern, especially since there is a move to more complicated regimens.

The CDC is currently pursuing two systemic interventions that it hopes will improve the success of prevention efforts: (1) providing states with model Medicaid managed care contract language on prenatal HIV counseling and testing and (2) adding prenatal testing as a HEDIS quality assurance measure for managed care entities.

To achieve greater success in preventing perinatal HIV transmission, CDC presenters recommended that efforts be undertaken to (1) improve prenatal care access and utilization, especially for substance-using women; (2) improve provider knowledge, attitudes, and practices, especially in private care and managed care settings; (3) improve client perception of risk and need for testing, and address fears about testing; and (4) develop interventions to improve adherence to medications.

Discussion

Among the issues raised in the participant discussion was the need to test all women, regardless of their apparent risk, particularly given the increasing numbers of women who become infected through heterosexual relations. This, in fact, is what CDC is working toward. One participant noted that even if the woman herself does not engage in risky behavior, her partner might. Another participant noted the need for a greater focus on factors such as drug use, other addictive behaviors, and multiple partners, all of which can affect infection rates.

A participant pointed out the need to go beyond a focus on the individual woman's behavior to address broad policy issues that might affect the ability of women who use drugs to access prenatal care; for example, state laws that call for jailing pregnant drug users or that take the baby away if the mother screens positive for drugs. In response, Dr. Rogers suggested a multitiered approach to perinatal AIDS issues, which would address (1) political/social/legal factors; (2) health delivery system factors; and (3) client behavioral factors. There was a discussion of the need to review policies outside the public health system that could affect the availability of and access to prenatal care—especially for illicit



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