The programs encountered the following barriers to implementation of the PHS guidelines: lack of prenatal care; lack of perceived risk; lack of rapid HIV test; family ostracism and domestic violence; some resistance to antiretroviral therapy; and resistance to HIV counseling by private physicians. These topics are discussed further below.
The lack of prenatal care was seen as one of the greatest barriers to the prevention of perinatal transmission of HIV. Without prenatal care, there simply is no opportunity to counsel, test, and treat women prior to labor and delivery. For instance, there were four HIV-positive newborns born at Bellevue Hospital Center in 1997, to mothers whose HIV status had not been known until the baby was identified. Three of the four were born to mothers who had not received prenatal care. The fourth was born to a mother who had declined to be tested prenatally. These four infants were part of a cohort of 20 HIV-positive newborns born that year, 16 of whom were born to mothers whose infection was detected during pregnancy.
Programs estimated that about 10% to 15% of women giving birth did not receive prenatal care. Lack of access was not considered to be a major factor, because New York and New Jersey heavily subsidize prenatal care and outreach activities. One administrator described his program's outreach efforts as an "ongoing battle" to bring women into care. Most programs deemed injection drug use as the overriding explanation for women not accessing prenatal care. Injection drug users (IDUs) are considered to be the most difficult to reach group of pregnant women. They are thought to avoid prenatal care out of a mixture of apathy, shame over their drug use, and fear that their children may be removed from their custody. The lack of prenatal care is one of the key factors fueling the demand for a rapid HIV test for use in the labor and delivery setting. Bellevue Hospital Center, for example, has proposed a rapid testing program, with results available within hours (see below). The availability of a rapid test paves the way for intrapartum administration of zidovudine (ZDV) and continued treatment of the mother and infant.
Women who do not perceive themselves to be at risk are believed to account for a large share of those who refuse HIV testing during pregnancy. For instance, at New York's Bellevue Hospital Center, where prenatal HIV counseling is mandatory under the state's health regulations, about 20% of pregnant women refuse HIV testing.