Successes With Implementation Of Public Health Service Guidelines

The programs attributed their success to the following elements: infrastructure and research funding; counseling emphasis on newborn and maternal health; health care financing; and routine incorporation of counseling into care. These elements are discussed further below.

Infrastructure and Research Funding

Programs repeatedly ascribed their success to the vigorous efforts of specially trained counseling staff (i.e., nurses, counselors, and social workers). These were the professionals responsible for the bulk of HIV counseling to encourage patients to accept testing and treatment. Counselors' work was often time-consuming because they were trained to approach patients, repeatedly if necessary, and not be deterred by the patient's initial refusal of an HIV test. It was not uncommon for some patients to delay for months the decision to accept testing or treatment (see patient profiles). The duration of a typical counseling session was reported to vary greatly, but consumed up to one hour for some high-risk women. A number of programs reported that the effectiveness of their efforts—in terms of patients' acceptance of testing and treatment—depended greatly upon the experience, training, and motivation of individual counselors.

To be effective, prenatal counseling generally includes outreach, because the women who are hardest to reach are considered to be at highest risk for HIV. An illustration of how labor-intensive outreach and counseling can be was provided by the Francois Xavier Bagnoud Center at the University of Medicine and Dentistry of New Jersey. When a pregnant patient misses an appointment, the center's policy is to mount an elaborate outreach effort. First, staff call the patient, then send a letter, followed by a registered letter. If there is still no reply, they send an outreach worker to the patient's home who is instructed to wait until the patient comes home. Their last option is to track the mother through the child, if the child receives medical care at their center, or to pursue the mother through her insurer. A program administrator summed up the program as "going through extraordinary lengths to get these women in."

Obtaining funds to hire counseling staff was a dominant concern of many programs. Federal research funds were deemed to be essential. Since programs had many of their patients actively enrolled in ongoing research, they were able to use counselors hired with funding for research, patient recruitment, and related purposes. At one program, for example, two of the four HIV counselors were hired with research funds. In light of the pivotal role played by counselors and other staff, program administrators were continually concerned that cutbacks in research or program funds would force them to scale back on their staff. One administrator remarked, "We have created a house of cards … as we lose



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