According to recent CDC and state-sponsored studies, more than 80% of HIV-exposed infants whose mothers' HIV infection was identified before birth are receiving at least some ZDV treatment (Table 6.3 shows summaries of studies of ZDV use). In a CDC-sponsored study involving 29 states that conduct surveillance of perinatally HIV-exposed children, by 1996 more than 80% of perinatally exposed children whose mothers were diagnosed HIV-infected before or at birth were treated with ZDV, during either the prenatal, the intrapartum, or the neonatal period. Roughly 70% of HIV-exposed infants had prenatal ZDV treatment (Appendix D). Analyses of blood specimens collected as part of the Survey of Childbearing Women (SCBW) showed increases in ZDV use from 1994 to 1995 and on average that, more than half of HIV-infected women giving birth in eight states in 1995 had received perinatal treatment with ZDV.

Evidence from three states suggests variations in success with providing ZDV treatment. As of 1997, 62% of HIV-infected women in New York State received ZDV treatment during pregnancy and 79% of HIV-exposed newborns received at least some ZDV treatment (prenatal, intrapartum, or neonatal) (Birkhead, 1998). In Michigan, as many as 93% of HIV-infected women used ZDV prenatally in 1996, and 90% of HIV-exposed babies were treated with ZDV (Michigan Department of Community Health, 1998). In New Jersey, prenatal ZDV use among women known to be HIV-infected increased from 8% to 47% between 1993 and 1996, and neonatal ZDV use increased from less than 1% to 64% between 1993 and 1996, according to heel-stick blood sample studies (Paul et al., 1998b). In 1995, HIV-infected women under age 30 were more likely than older women to have used ZDV, but race/ethnicity and volume of HIV-positive births in hospitals were not correlated to ZDV use (Appendix D).

Most women who are offered ZDV treatment initiate therapy. Side effects of treatment and the intense treatment regimen, however, contribute to treatment non-compliance. In a CDC-sponsored review of the medical charts of HIV-infected women and their babies in four states (New Jersey, South Carolina, Louisiana, and Michigan) in 1994–1995, very few (5%) women had chart-documented evidence of refusal of ZDV when offered. Relatively few (6%) women discontinued using ZDV during pregnancy, but this is likely an underestimate because non-compliance may not have been documented in the medical chart. Some have suggested that intensive nurse case management increases adherence to the ACTG 076 regimen and reduces perinatal transmission (Havens et al., 1997).

Barriers to use of ZDV among HIV-infected pregnant women include not having information about maternal HIV status, late onset of prenatal care, insufficient time to administer ZDV (e.g., short labor), and discontinuity in care (e.g., delivery at hospital not associated with prenatal care providers). Some evidence suggests that there are negative attitudes toward ZDV use among some HIV-infected women. In a series of face-to-face interviews with 71 HIV-infected women in New York City, many women viewed the drug as highly toxic with distressing and dangerous side effects, prescribed indiscriminately by providers



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