摘要：Objectives. The 1994 and 1995 US Public Health Service Guidelines regarding HIV testing and treatment for pregnant women and the resulting 1995 California law mandating an HIV test and treatment offer to every pregnant woman aim to reduce perinatal HIV transmission. However, the effectiveness of such policies after implementation is often unclear. We analyzed the association between these policies and offers of HIV tests and treatment to HIV-infected women in California. Methods. Data from active, population-based surveillance of 496 HIV-infected women and their infants, collected from 1987 to 2002, were analyzed to compare rates of offers of HIV tests and treatment before and after 1996. Results. We found significant increases in offers of HIV tests ( P <.001) and offers of treatment ( P <.001) when we compared women who delivered between 1987 and 1995 with those who delivered between 1996 and 2002. Receipt of prenatal care was the major predictor of both test and treatment offer. A significant shift in reported HIV risk factors was also evident between the 2 groups. Conclusions. Our findings of increased offers of HIV tests and treatment to HIV-infected pregnant women suggest that the national guidelines and the 1996 California law improved health care for these women, which may lessen the risk of perinatal HIV transmission. Perinatal HIV transmission accounts for 85% of pediatric HIV cases and more than 90% of pediatric AIDS cases in the United States. 1 , 2 In 1994, the US Public Health Service (USPHS) issued guidelines stipulating that HIV-infected pregnant women and their newborns be offered a 3-part zidovudine regimen, 3 based on the Pediatric AIDS Clinical Trials Group Protocol 076 (hereafter referred to as “076 Protocol”) finding that this regimen reduces perinatal transmission by 67%. 4 Because a barrier to HIV treatment may be unknown HIV status, the USPHS recommended, in 1995, all pregnant women be offered voluntary HIV testing. Since these recommendations were implemented, US perinatal HIV has decreased significantly. 5 , 6 Nonetheless, 390 new perinatal infections were reported from 36 states in 2001. 1 In California, Senate Bill 889 became effective January 1, 1996. The bill mandates that prenatal care providers offer, and document the offer of, an HIV test to every pregnant woman. 7 The law also requires that HIV-infected women be offered treatment for themselves and their newborns. However, 2 California studies performed in or after 1996 found that only 47.3% to 56.2% of populations of pregnant or recently delivered women reported HIV counseling, and 74.3% to 79.9% reported a test offer. 8 , 9 Furthermore, the 1998 California Survey of Child-bearing Women, in which newborn heel-stick blood specimens were tested for HIV antibodies and zidovudine, found that 23.4% of infants with HIV-infected mothers did not have evidence of zidovudine. This suggests that HIV-infected mothers may not have had zidovudine during pregnancy or at labor. 10 These results raise questions about the impact of policies like the 1996 California law and illustrate the importance of evaluating the effectiveness of such policy. In addition, to increase interventions aimed at HIV-infected women and their prenatal care providers, it is crucial to determine whether subpopulations of HIV-infected women are not being tested and treated. In California, active population-based surveillance data on HIV-infected mothers and their infants has been collected since 1989. 11 , 12 We used these data both to evaluate the association of the 1994 and 1995 USPHS guidelines and the 1995 California law with HIV testing and treatment in California and to define characteristics of HIV-infected pregnant women who do not receive appropriate care as defined by the policies. Specifically, we assessed which HIV-infected mothers are not offered HIV testing in prenatal care despite having unknown HIV status or are not offered preventative therapy despite being known to be HIV infected.
