are six weeks postpartum and no longer Medicaid-eligible. Interviewees stressed that federal Ryan White funds had been essential to building and maintaining current services and to meeting future need.
On the issue of general barriers to care, particularly among poor, rural African Americans, the following observations were offered. There is not a culture of accessing primary care in general and maternity services in particular. Rather, birthing is something that ''mama and grandmama" used to assist with; family members' attitudes continue to have substantial influence over whether or not a woman seeks prenatal care. In addition, for many, educational levels are very low, so health education must be tailored to make sure patients can understand and follow through with care.
At several points during the site visit, participants were asked their opinions regarding possible changes in the PHS guidelines. Most providers felt that mandated testing is not desirable. One participant said, "I don't think we have to resort to that." Others noted that mandatory testing could exacerbate the problem of women being tested without their knowledge, which in turn could seriously undermine patient–provider trust.
It was pointed out that the real focus should not be on mandatory testing, but rather on how the term "voluntary" is defined and implemented. Most participants preferred maintaining a voluntary approach through routine testing (as part of a standard prenatal test panel), with a patient opt-out provision. The Emory University protocol calls for universal counseling and routine testing, with an exclusion consent. One participant expressed concern that if offered a list of tests from which they could opt out, some patients would refuse syphilis testing. In rural Alabama, people refuse some testing because of the Tuskegee history. Others refuse prenatal genetic testing because they will not terminate the pregnancy regardless of the test outcome. Finally, one participant suggested that financial incentives or disincentives might prod providers to routinely include HIV testing.
Throughout the site visit, participants provided examples of how innovative programs are successfully addressing perinatal HIV transmission. Among the highlights are the following: