of physicians are demonstrating an interest in helping out. Most of the women treated do not have the resources to pay for care.

Community First Health Plans is the first public HMO in Texas. It was established in 1997 and is a tax-exempt Texas corporation sponsored by the University Health System. The HMO was established in response to the changing marketplace, especially the move to managed care for Medicaid populations. Community First Health Plans tries to identify plan members who are at risk for HIV infection through their claims data. Members with HIV infection are assigned a case manager who facilitates members into infectious disease services and tracks health status. Members with HIV are allowed to choose their infectious disease provider as their primary care physician.

Centro del Barrio is a private non-profit community health center that provides HIV testing and offers free obstetric and gynecologic services. Counselors are registered nurses, educators, certified nurses, and social workers. HIV testing is free, and an on-site laboratory provides results within two or three days. More than 95% of the women who receive prenatal care through the Centro del Barrio are tested. Pregnant women who are in shelters have outreach workers who link them to care. The center also collaborates with the hospital district.

The San Antonio Metropolitan Health District's Family Health Services Bureau sees 4,000 prenatal patients per year out of the 20,000 births in Bexar County. Most of the women are indigent, and since 1996, four women have been diagnosed with HIV.

Barriers To Care

Some of the barriers to implementing the PHS counseling and testing guidelines in South Texas are: counseling and informing patients in a low prevalence area, obtaining and correctly analyzing test results, notifying patients of the test results, the distance some must travel to obtain care, providing care for undocumented residents, and cultural stigma.

The low prevalence of HIV in the South Texas region makes it difficult to educate physicians to counsel and inform their patients of HIV. Patients with HIV make up less than one percent of the typical physician's workload. Because of the low percentage, keeping up to date with the current literature can be considered inefficient, counseling may impede a doctor's workload, and seeing fewer patients may decrease revenues. There are training classes for HIV counseling offered at the AIDS Training Center in Houston, but few physicians attend; instead, social workers and nurses usually attend. One participant recounted an incident that demonstrates providers' lack of training: a medical resident who notified a pregnant patient of her positive result was unable to answer the patient's questions about HIV, the effect of the medication on the baby, or refer her to STAIDS. When the patient asked for a retest, the resident incorrectly answered, "the tests are accurate and there is no need for retest."



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