associated with STDs, they responded that it may be a barrier and this is a local decision.

In Jefferson County, testing among the county's eight clinic sites has been uneven as well. The percentage of JCDH maternity patients tested increased from 45% in July 1995–June 1996, to 69% in November 1997–March 1998; however, rates vary by site. Recent data from the county's Obstetrical Automated Record (OBAR) system indicate that among the eight clinic sites, the proportion of maternity patients not tested ranges from 2% to 66%. To address variations in testing across sites, in November 1997 the health department held an in-service education program aimed at changing provider behavior.

It is important to note that on an annual basis, clinics provide maternity care to about 5,000 pregnant women in Jefferson County, and to 30,000 women statewide (roughly half of all childbearing women in each jurisdiction). Changes in implementation of counseling and testing practices in the public sector could thus have a profound impact on overall perinatal HIV transmission in Alabama.

With regard to testing at WAHS, the director stated that under its comprehensive counseling/education program, 99% of WAHS maternity patients voluntarily accept testing. Finally, although no data were available on the proportion of private maternity patients in Jefferson County or in the state who received HIV counseling and testing, public health officials noted that private providers clearly are testing, using state labs, and reporting cases to the state.

Acceptance of Therapy

On the issue of acceptance of ZDV and other, complex therapies (combination, protease inhibitor-containing regimens), all those interviewed agreed that once HIV-infected pregnant women receive test results, most accept therapies. Reasons given for non-acceptance include fear of loss of confidentiality for those being in small communities; fear of domestic violence; and fear, denial, and depression about the disease itself. Participants noted the importance of providing a smooth transition from testing to treatment, offering comprehensive primary care to the HIV-infected woman and her infant, establishing a trusting provider–patient relationship, and providing needed mental health and social services.

Participants indicated that both ethical and resource issues impact whether mono- or combination antiretroviral therapy is offered. In Jefferson County, while the HIV high-risk centers are offering complex therapies, the JCDH reimburses only for ZDV, primarily because of resource constraints. Some providers also are concerned that multiple therapies may be considered experimental, and so are reluctant to prescribe them for ethical reasons or fear of liability.

Participants pointed to a growing need for resources to sustain care. They were particularly concerned about insufficient funding to pay for care and medications (especially combination therapies) for HIV-infected mothers once they



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