violence from jealousy. Alternatively, if males are HIV-positive, they may become violent toward the woman they blame for infecting them—again, whether or not this is true. For women who are striving to conceal their HIV status, the fear of family desertion or domestic violence affects far more than their decision to be tested. It extends through the treatment period and affects their ability to comply with a demanding medication regimen, as discussed below.

Resistance to Antiretroviral Therapy

While programs described pregnant patients' overwhelming acceptance of antiretroviral therapy, this was not universally true. Some patients needed persistent encouragement by motivated counseling staff. These patients were often in such shock or denial after the diagnosis that it sometimes took them months to confront the need for and accept the medication. This was especially true of adolescents (see later section).

Among the reasons given for patients' reluctance to accept, or comply with, antiretroviral therapy were concerns that it was a ''poison" and might have long-term effects on the child; the side effects; the demanding regimen of administration, especially for babies; and fear of disclosing their HIV status to family members by virtue of the frequent administration of medications for themselves or their newborn. Patients sometimes resorted to removing prescription labels. One patient, a former injection drug user, admitted to the IOM visitors her fears that the medication was addictive and actually caused AIDS, although she realized in retrospect that her fears were unjustified (see patient profiles).

Managed Care

The advent of managed care, in both public and private health insurance programs, was considered to be detrimental to the prevention of perinatal transmission of HIV. While program administrators acknowledged that managed care is receptive to prevention in general, the reality was more ominous because of competing priorities. Their major concern was with managed care's emphasis on shorter hospital stays. The labor and delivery process has become so compressed that program administrators complained of the difficulty of finding the appropriate time to counsel and test women who never received prenatal care. Even if the program had succeeded in motivating the mother to be tested, test results would not be back in sufficient time before patient discharge. Outreach efforts seemed futile because in many cases, patients were not reachable, having provided a false address.

Another problem is encountered in the prenatal setting, where there are strong pressures to increase patient load by reducing the time spent with each patient. This is seen as leaving insufficient time or financial incentives for HIV counseling by physicians who receive flat fees per patient or are on salary. Many

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