drug users, but for others as well. For example, national welfare reform legislation may have added more barriers to the ability of women to receive care. A concern was raised about the impact of a shift to Medicaid managed care, which moves women out of public sector prenatal care clinics (where counseling and testing are more likely) and into the private sector, where women may be less likely to receive counseling or testing. A multivariate analysis of factors associated with the receipt of counseling and testing would be helpful in projecting the impact of managed care.

Noting that from a public health perspective, testing prior to pregnancy would be ideal, a participant asked about CDC surveillance data and efforts to promote pre-pregnancy testing. Dr. Rogers noted that a very large percentage of CDC's prevention program goes to publicly funded counseling and testing centers, which include family planning, prenatal care, sexually transmitted disease (STD) prevention, and drug treatment clinics. Dr. Wortley noted that for the STEP project, 33% to 40% of the women who delivered were tested prior to pregnancy.

Discussion focused next on the impact of state statutes on overall outcomes. Are laws that require prenatal counseling and offering of HIV testing rigorously enforced? Perhaps a more salient question is whether the statutes establish a standard of care to which a physician can be held (i.e., does the statute permit lawsuits against the physician?). One participant noted that the California law has resulted in more testing, probably because providers think testing is mandatory. Another participant noted that as cases are litigated, state law and PHS guidelines are both used to establish a standard of care, so that passing state laws gets a message to private providers. The same participant further noted that in many of the cases in litigation, the issue is really perception of risk.

Turning to the impact of prenatal ZDV use on infants, another participant asked if there is any information indicating whether HIV-infected infants born to women who took ZDV in pregnancy actually progress to AIDS more slowly. Dr. Simonds noted that there was not yet enough data from observational cohort studies to really address whether prenatal ZDV exposure prevents or has an effect on the natural history of those children who do become HIV-infected. Ongoing, long-term follow-up studies will provide some of these answers.

It was noted that there is confusion in the field regarding how the guidelines apply to treatment for HIV-exposed infants who did not receive ZDV in the prenatal or intrapartum periods. Discussion focused on the guidelines and what is known about the efficacy of newborn treatment that only begins after delivery. Dr. Simonds responded that both the older and the newer guidelines allow—and in a sense encourage—beginning treatment as soon as possible after delivery, but the efficacy of this approach is not yet known.

Discussion focused on confidentiality being a deterrent to treatment. It was noted that in some policy discussions there is a sentiment that this is non-issue.



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