• pregnant women for evidence of disease progression with the offering of appropriate combination therapy. In addition, as a pediatric ACTG site, BAPAC has been able to offer pregnant women and their infants access to perinatal/neonatal research trials that improve maternal health and further reduce perinatal transmission rates.
  • Mandatory versus universal testing: It is important to define terms. It is Ms. Denison's impression that most women will accept testing and most prefer being asked rather than being forced. She believes testing should still remain voluntary, even though this is an imperfect approach.
  • Standards of care needed: For many basic obstetric procedures, there is no standard of care established for HIV-infected women; for example, there are no standard recommendations or cost-benefit analyses on cesarean sections, amniocentesis, and fetal scalp monitoring for the HIV-positive mother.
  • Testing does not equal care: Ms. Denison cited several examples of known HIV-positive women receiving unacceptable care from poorly informed physicians.
  • ZDV issues: There are many issues around the use of ZDV, including women's fear of long-term side effects. Ms. Denison noted that of all the women she has talked to, none was told about the National Cancer Institute study findings on potential long-term risks to the children whose mothers took ZDV prenatally. She stressed that women need to be told about the study and then be told that the potential benefit outweighs the risk. It is also important to acknowledge that some infants are still becoming infected even though their mothers took ZDV during pregnancy.
  • Violence: Issues around domestic violence need to be taken seriously. Disclosure can lead to a life-or-death situation for some women with violent partners.
  • Prevention gaps/men's role: There are serious gaps in prevention, particularly with regard to the male role. Current efforts put the burden for prevention on the woman, which is unfair. There is also a need for support groups for heterosexual men who are HIV-positive or who have HIV-positive partners.
  • WIC: The WIC program can be a source of infant formula for some HIV-infected mothers; however, it does not pay the full cost of formula. A more significant problem is that WIC programs "push" breast-feeding, but do not adequately screen for or counsel regarding the HIV status of the mother. Ms. Denison noted that this approach is frightening and needs to be addressed.
  • Welfare reform and immigrants: With welfare reform, undocumented immigrants are cut off from publicly assisted prenatal care. Ms. Denison cited an example from California of an HIV-positive pregnant immigrant who was afraid that accessing care would lead to deportation.
  • Trust is essential: Ms. Dension stressed the importance of trust in the provider-patient relationship. Providers can be extremely judgmental in their attitudes toward HIV-positive women. Women need to feel comfortable going to


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