The single greatest reason appears to be the lack of perceived risk. Many of the women are undocumented immigrants in what they perceive to be monogamous relationships. They view HIV as affecting only prostitutes and homosexuals, not themselves. Other women who do not view themselves at risk may be in denial about their own risky behavior.

Lack of Rapid HIV Test

An accurate, rapid test, with results available in hours, is considered to be an important HIV prevention tool. While a Food and Drug Administration (FDA) approved rapid test is commercially available, its rate of false positives is regarded as too high for widespread use. Conventional HIV testing, using enzyme-linked immunosorbent assays (ELISA) and confirmatory testing takes about one to two weeks for results. This is a crucial gap for adolescents and other groups of patients who commonly do not return to receive test results in the prenatal setting. It is seen as an even more crucial gap in the labor and delivery setting, which offers the last opportunity to interrupt HIV transmission via administration of intrapartum antiretroviral therapy and advice to avoid breast-feeding.

Bellevue Hospital Center has applied for permission to launch a voluntary, rapid testing demonstration program for all women in labor and delivery who previously have not been tested for HIV. Since women who do not agree to prenatal testing, or who did not obtain prenatal care, are considered to be an "enriched" population with high HIV prevalence, the commercially available rapid test is less likely to be beset by false positives. When the rapid test is positive, antiretroviral therapy is to be offered beginning immediately in the intrapartum period, even though the rapid test must be confirmed by more definitive tests. If such tests later find the mother not to be infected, the protocol permits the interruption of therapy to mother and infant. Program administrators acknowledged that the labor and delivery setting is not an ideal time to obtain informed consent and hoped to counsel patients in as sensitive and thoughtful a manner as possible under the circumstances.

Family Ostracism and Domestic Violence

Many pregnant women fear taking an HIV test for the devastating impact of disclosure of positive results on their sexual partner or families. Many are single women often living at home with a parent(s). One HIV-positive mother admitted that if her family learned of her HIV status, she would be evicted (see patient profile). She would lose more than just shelter, since families often provide emotional, economic, and baby sitting support. Programs also spoke of patients' fears of domestic violence committed by sexual partners. Males who are ignorant of their own HIV status or are unwilling to be tested may blame the woman for having sex with someone else, however true or untrue, and may be prone to



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