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Several lessons have been learned from evaluation of the 1995 PHS guidelines. Many women, especially those who used illicit drugs, were not tested for HIV during pregnancy because of lack of prenatal care (8). In addition, many women refused testing because their health-care providers did not strongly recommend it. Some women declined testing because of perceived low risk, and some providers failed to offer testing because of perceived low risk, perceived difficulties and complexity of required counseling, and misunderstanding of counseling requirements. The logistics of testing, if too complex, also were considered a potential barrier to testing.

Providing mothers and their infants with ongoing HIV-related care can maximize the benefits of prevention interventions. The medical care of HIV-infected women is a complicated task requiring use of potent combinations of antiretroviral drugs, monitoring of viral load and drug resistance, treatment and prophylaxis of opportunistic infections, and monitoring of immune status. In addition to conditions (e.g., Pneumocystis carinii pneumonia [PCP]) for which all immunocompromised HIV-infected persons are at risk, women experience specific manifestations of HIV disease (e.g., aggressive pelvic inflammatory disease and persistent and difficult-to-treat vaginal yeast infections requiring frequent screening and treatment) (61,62). HIV-infected women are also at increased risk for cervical dysplasia, which can result in cancer (63). With early detection and appropriate treatment, many of these complications can be prevented and treated. Improved health outcomes resulting from advances in HIV management and treatment depend not only on access to medical care but also on access to prevention and psychosocial support services. In the United States, most mothers and children with HIV/AIDS live in areas where poverty, illicit drug use, poor housing, and limited access to and use of medical care and social services add to the challenges of HIV disease (4,9). Women with HIV infection often have difficulty gaining access to health care and frequently are responsible for caring for children and other family members who might also be HIV-infected (64). They often lack social support and face other challenges that could interfere with their ability to gain access to and adhere to complicated treatment regimens. The complex medical and social problems of families affected by HIV are best managed by multidisciplinary case-management teams that integrate specialty medical care with prevention, psychosocial, and other HIV-related services (see Revised Guidelines for HIV Counseling, Testing, and Referral).

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