community to community, but is undergoing rapid change and is financially vulnerable. The ability of public programs and private sector programs using public funds to provide care has been significantly challenged, not only by the growing number of uninsured and the reduction in public funding of health care services, but by the rapid growth of managed care arrangements.

The complex patterns of sources of medical care, financing mechanisms, program authorities, and organizations that influence care make it difficult to institute policies for reducing perinatal HIV transmission. Local, state, and federal agencies have made many efforts to inform providers and the public, and to promote counseling and testing of pregnant women wherever services are offered, especially in states and communities with a high incidence of HIV infection. But more needs to be done to maximize opportunities for prevention of perinatal transmission. The fact that our health care system is itself undergoing dramatic changes in structure, funding, and service delivery presents both challenges and opportunities.

The chain leading to perinatal transmission of HIV infection described in Chapter 1 (Figure 1.1) can be broken in a number of ways, including encouraging pregnant women to seek prenatal care, informing them about HIV testing and urging them to be tested, having all pregnant women tested, and providing treatment to those who test positive. The complexity of the U.S. health care system is often an impediment to the achievement of these goals. Among the many possible obstacles inherent in the current health care system are: financial and access barriers that may discourage women from seeking prenatal care; time constraints imposed by managed care that may discourage physicians from counseling pregnant patients about the importance of testing; prenatal care sites that may not have the staff to overcome the language and cultural barriers that may cause women to refuse testing; financial and logistical problems that may make testing difficult; and financial barriers to treatment of the HIV-positive woman. In addition, the multiple lines of funding responsibility and accountability have made it extremely difficult to educate providers and to convince them of the necessity of testing all pregnant women.