Social interventions in the care of human immunodeficiency virus (HIV)-infected pregnant women

Social Interventions in the Care of Human Immunodeficiency Virus (HIV)-Infected Pregnant Women Carol Levine and Machelle Harris Allen

The incidence of infection with the human immunodeficiency virus (HIV) is increasing among women of childbearing age. Women now account for 18% of the total number of cases of the acquired immunodeficiency syndrome (AIDS), compared with 9% a decade ago. The medical care of pregnant HIV-infected women must take into account the high prevalence of substance abuse, preceded and often accompanied by significant levels of physical, emotional, and sexual trauma, and the concomitant stigmatization of these women in their families and communities. Pregnancy is often a time when women are motivated to make major positive behavioral and life-style changes. To do this, they need ongoing, multidisciplinary counseling and support, with recognition that progress may be intermittent and slow. The Special Prenatal Care Program at Bellevue Hospital is described to show the level of resource commitment that is needed as well as the nearly universal acceptance o f voluntary HIV counseling and testing in these conditions. Trends in permanency planning for the children ot~HIV-infected women are described. Future research needs are outlined, including female-specific drug treatment and more effective contraceptive technology for both men and women. C o p y r i g h t 9 1 9 9 5 by W . B . S a u n d e r s

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regnancy is a time when a woman's past and present meet to influence her own future and her baby's chances for health and well-being. For a woman infected with the h u m a n immunodeficiency virus (HIV), the hopes and dreams that normally accompany pregnancy are mixed with fears about transmission o f the virus to her baby, and about the future care and custody of this baby and her other children as her H I V disease progresses. The clinician caring for her must be concerned not only about the medical management o f her pregnancy and her H I V infection and reducing insofar as possible the risk of H I V transmission to her fetus, but also about the other factors in her life that may influence the course of her pregnancy and her ability to care for her infant. Although HIV-infected women come from all social and economic strata, those with the most need for social interventions are poor, homeless, or living in inadequate housing, and with a history o f substance abuse and domestic violence. Rarely is H I V the only problem, or even the most immediately threatening problem, in their lives. Despite their often overwhelming difficulties, many women see pregnancy as a chance to interrupt destructive cycles o f behavior and to begin anew. I f they are to accomplish this, however,

they require a great deal of support and patience, because the road is often b u m p y and seldom straightforward. This article describes some of the ways in which pregnant HIV-infected women can be assisted through innovative social interventions. Although many o f these interventions are implemented by social workers, attorneys, case managers, and other team members, the role o f t h e p r i m a r y physician is critical in establishing a framework in which the patient's life situation and family problems are addressed as effectively and thoroughly as her medical needs.

E p i d e m i o l o g y o f HIV Infection A m o n g Women H I V infection is spreading steadily among women o f childbearing age. The Centers for Disease Control and Prevention (CDC) reported in February 1995 that women now account for 18.1% From The Orphan Project: Families and Children in the HIV Epidemic, New York, and the Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, New York University Medical Center, New York, NE. Address reprint requests to Carol Levine, The Orphan Project, 121 Avenue of the Americas, 6th Floor, New York, NY 10013. Copyright 9 1995 by W.B. Saunders Company 0146-0005/95/1904-0011505.00/0

Seminars in Perinatology, Vol 19, No 4 (August), 1995: pp 323-329

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o f all reported acquired immune deficiency syndrome (AIDS) cases, which now total over 440,000. This percentage is twice as high as the percentage o f women a m o n g the first 100,000 r e p o r t e d cases o f AIDS (9%). Some o f this increase is caused by the expanded AIDS suiweillance case definition, introduced in 1993, which included severe immunodeficiency, pulmonary tuberculosis, recurrent pneumonia, and invasive cervical cancer, the only female-specific condition added in the expansion. The expanded case definition resulted in a greater increase in reported cases in 1993 a m o n g women (151%) than a m o n g men (105%). The largest increases were in two age-groups: 13 to 19 years (35% female) and 20 to 24 years (29% female). O f the cases in the 13 to 19 age-group, 22% were attributed to heterosexual transmission, as were 18% in the 20- to 24-year-olds. 1 Even before the expanded case definition, the percentage of cases among women in some regions was higher than the national average (27% in New Jersey in 1992 and 25% in New York City currently, for example2). Since 1987, H I V / A I D S has been the leading cause o f death a m o n g A f r i c a n - A m e r i c a n women aged 15 to 44 years in New York State and New Jersey, and it is now the leading cause o f death o f all women in that age g r o u p in New York City. African-American women (53% of the total rep o r t e d cases o f w o m e n with AIDS in New York City) and Hispanic women (22%) are disproportionately affected, s Twenty-five states now mandate reporting o f H I V infection to the CDC. At the end o f 1994 68,171 cases o f H I V infection had been reported a m o n g adults and adolescents and 1,159 cases o f pediatric H I V infection. Approximately 22% o f the adults and adolescents w e r e f e m a l e . 4 Many women with H I V infection are also mothers who are raising their children without another caregiving parent. Therefore, a large n u m b e r o f o r p h a n e d children must be considered in an epidemiologic analysis of women and AIDS. By the year 2000, as many as 125,000 children and adolescents will have lost their mothers to AIDS in the United States. Most of these surviving children will not be themselves HIV-infected, but will be at risk for H I V infection as they become sexually active or if they inject drugs. Approximately 80% of them will be nonwhite. 5 In summary, the H I V epidemic is taking an increasing toll among women o f childbearing age.

Heterosexual sex is moving ahead o f drug use as a risk factor leading to H I V infection, the rates o f infection a m o n g y o u n g women are steadily increasing, and women from ethnic and racial minorities are those most at risk.

The Interplay o f Medical and Social Factors There is no "typical" pregnant woman with H I V infection. Although there may be c o m m o n features based on age and risk behavior, each woman has her own unique life circumstances. The clinician may be presented with a wide range of case scenarios. One woman may live on the edge o f society in the midst o f " u r b a n ecological collapse, ''6 consumed by her addiction to the point that she rejects shelter from homelessness in favor o f " T h e Life" o f crack pipes and sex for drugs under viaducts and bridges. Another woman may be very much integrated into society, educated, employed, and with strong family supports. This article presents some o f the most challenging situations and one approach currently being used by an inner-city municipal hospital to address most effectively these myriad social issues as they surface in the course o f prenatal care. Because o f this focus, it does not present extensive information on many issues more strictly considered clinical care. ~ Concern about H I V perinatal transmission has long been a major issue for clinicians and their patients. One o f the few hopeful, although not conclusive, signs in recent years has been the results o f the National Institutes o f Allergies and Infectious Diseases (NIAID) AIDS Clinical Trial G r o u p (ACTG) protocol No. 076. O p e n e d to accrual in 1991, this prospective, double-blinded, placebo-controlled randomized trial was designed to evaluate the effect of maternal and neonatal zidovudine (ZDV or AZT) administration on the incidence of H I V infection in infants. The women enrolled initiated ZDV treatment between 14 and 34 weeks' gestation, had no other antiretroviral treatment during the current pregnancy, had baseline C D 4 + lymphocyte counts greater than 200 cells/mm 3, and had no clinical indications for maternal antepartum ZDV therapy. ZDV was administered orally in the antepartum period, intravenously in the intrapartum period, and in a syrup to the neonate for the first 6 weeks o f life.

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By D e c e m b e r 1993, 477 w o m e n h a d b e e n enr o l l e d , with c o m p l e t e d a t a available o n 364 infants. B e c a u s e a review o f efficacy s h o w e d such d r a m a t i c results in the t r e a t e d g r o u p , t h e D a t a M o n i t o r i n g a n d Safety B o a r d t e r m i n a t e d t h e study. T h e e s t i m a t e d p r o b a b i l i t i e s o f t r a n s m i s s i o n b a s e d o n t h e K a p l a n - M e i e r analysis w e r e 8.3% f o r z i d o v u d i n e c o m p a r e d with 25.5% f o r p l a c e b o (P = .000056). a B a s e d o n t h e s e d a t a , t h e N e w York State Department of Health AIDS Institute r e c o m m e n d e d t h a t all H I V - i n f e c t e d p r e g n a n t w o m e n b e y o n d t h e first t r i m e s t e r b e o f f e r e d Z D V during the antepartum and intrapartum period unless t h e m o t h e r is Z D V resistant o r i n t o l e r a n t . 9 W i t h this b a c k g r o u n d , c o n s i d e r t h e f o l l o w i n g two case s c e n a r i o s : Case 1 S.M. is a 32-year-old, Para 4124, HIV-infected woman with cytomegalovirus (CMV) retinitis. She presented for prenatal care at 21 weeks' gestational age. Physical examination was notable for loss of vision in her left eye and healed knife wounds on her face and back inflicted by a previous boyfriend. She had a history of crack use but was not in drug treatment. Her substance abuse began with alcohol at the age of 7 after she had been raped by her stepfather. She had been in a relationship, reportedly violent, with her current partner for 3 years. She did not have custody of any of her previous children, who were in foster care. She had not received treatment for her HIV illness or CMV retinitis. Prenatal care was her entry point for health care. She did not take the recommended AZT. H e r baby to date is HIV-negative by polymerase chain reaction (PCR). Case 2 S.W., a 34-year-old woman, Para 5045, presented for prenatal care at 24 weeks' gestational age. Although her medical history was significant for an 8-year history of known HIV infection, she was asymptomatic and had a CD4 count o f 370 cells/mm 3. She was not taking ZDV because of its side effects. She also had chronic hypertension and a seizure disorder and was noncompliant with prescribed medications for both conditions. Although she had a history of crack use, she was drug free at the time of enrollment for prenatal care. She was in the process of reunification with her 13-yearold son. She also wanted surgical sterilization after she delivered and had signed the appropriate consent forms. Throughout her prenatal course she complied with her appointment schedule. Although she attempted to take ZDV to prevent perinatal transmission,

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after 1 month she discontinued it because she found the side effects of nausea and headaches insurmountable. After two hospitalizations for blood pressure control, she became compliant with her antiseizure and antihypertensive medications. She had been in a stable relationship with her current partner for 11 years and had moved out of the shelter system into a private home with the assistance of the New York City Division of AIDS Services. On presentation in labor with the fetus at 36 weeks' gestational age, she developed eclampsia, suffered a grand real seizure, and underwent an emergent cesarean section before reaffirmation of her tubal ligation consent could be obtained. Her baby to date is HIV-negative by PCR. I n i m p l e m e n t i n g the r e c o m m e n d a t i o n s b a s e d o n the findings o f A C T G 076, it b e c o m e s clear that what a p p e a r s to b e a simple task is n o t so simple after all. I n a life in which chaos is the n o r m , h e a l t h issues take a back seat to basic survival. I n the first case the psychological sequelae o f the violent events in S.M.'s life were so p r o f o u n d that even o r d i n a r y conversation was difficult. H e r eyes w o u l d r e m a i n averted, a n d she spoke in a stream o f consciousness. She readily a g r e e d to any r e c o m m e n d a t i o n , b u t f o r g o t it the next minute. W h e n t r a n s p o r t a t i o n was a r r a n g e d f o r h e r clinic a p p o i n t m e n t s , she o f t e n w o u l d n o t m a k e it to h e r f r o n t d o o r . It was clear to all involved in h e r care that h e r n o n c o m p l i a n c e was n o t a m a t t e r o f conscious recalcitrance, b u t r a t h e r a severe inability to e n g a g e in any activity whatsoever. I n t h e s e c o n d case, we e n c o u n t e r a w o m a n r e c o v e r i n g f r o m y e a r s o f a d d i c t i o n , finally o u t o f the s h e l t e r system, a n d in the p r o c e s s o f r e u n i t i n g with h e r a d o l e s c e n t son, w h o was s t r u g g l i n g with his o w n issues o f f e a r a n d r e s e n t m e n t . H e r p r i m a r y c o n c e r n was m a n a g i n g h e r h o u s e h o l d , k e e p i n g h e r son in s c h o o l a n d o u t o f t r o u b l e , as well as c a r i n g f o r h e r t o d d l e r . A l t h o u g h she d i d n o t e n r o l l i n t o p r e n a t a l c a r e u n t i l late in h e r p r e g n a n c y , h e r a t t e m p t s at c o m p l i a n c e w e r e impressive. She w o u l d s p e n d a n h o u r o n p u b l i c t r a n s p o r t a t i o n to c o m e to t h e clinic, w h e r e she w o u l d s p e n d a n o t h e r 2 to 3 h o u r s , o f t e n l o n g e r if she n e e d e d b l o o d p r e s s u r e m o n i t o r i n g o r fetal surveillance. I n spite o f this, she m a n a g e d to k e e p every a p p o i n t m e n t o n c e e n g a g e d in care. H a v i n g h e r in c a r e with m o d e r a t e b l o o d p r e s s u r e c o n t r o l was v i e w e d as a m a j o r a c c o m p l i s h m e n t . T h e fact t h a t she d i d n o t c o n t i n u e t a k i n g h e r p r e s c r i b e d A Z T was c o n s i d e r e d a c c e p t a b l e as l o n g as she was at least in care.

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Addiction and Trauma A growing body o f evidence exists concerning women who are addicted to drugs, especially crack. It is becoming more apparent that physical, emotional, and sexual trauma often antedate drug abuse, and continued physical abuse is often concomitant with continued drug abuse. An association between posttraumatic stress syndrome and substance abuse has been well d o c u m e n t e d in men as well as in women. 1~ Fullilove et al I4 explain that the stigma associated with being a woman, pregnant or not, addicted to crack, and exchanging sex for drugs ("crack-ho"), adds the trauma o f stigma to physical trauma. The cumulative impact o f childhood physical, sexual, or emotional abuse and adult stigmatization results in such p r o f o u n d personal devaluation that drug treatment for women cannot begin to be successful unless it addresses a "trauma spectrum disorder" and issues of self-worth, shame, and grief. This requires a recognition o f the role o f those forces outside the individual's control that influence her behavior. A willingness to recognize addiction as a result of victimization runs contrary to those theories o f d r u g treatment based on the male model. Standard d r u g treatment until now has been confrontational. Most women find this approach humiliating. Emotional vulnerability is heightened during pregnancy. Those drug treatment modalities not effective for women in general may in fact prove to be damaging during pregnancy. For the woman who is chemically dependent and HIV-infected, her medical needs pale in the light o f her psychosocial problems. Yet invariably pregnancy holds the most crucial key for engagement into any service at all. It is the point for connection into drug treatment, as well as primary health care or psychiatric support.

The Bellevue Hospital Special Prenatal Program It is clear that any treatment in this area needs to be multifaceted; no part can be considered without recognition o f its relationship to the whole. A n d multifaceted care necessitates a team approach. The members o f Bellevue Hospital's Special Prenatal P r o g r a m in New York City, a public municipal hospital, include a nurse, a social worker, a domestic violence counselor and

advocate, as well as an H I V counselor and an obstetrician. The services provided by any one person can be and often are duplicated by another. Whereas the social worker is responsible for the case management, the nurse can also provide this service for those patients who are averse to, or for other reasons bypass, the social worker. All members o f the team provide H I V counseling, but one person dedicated to this work can spend more time "educating" the patient about H I V illness and transmission prevention. The H I V counselor is also a phlebotomist. This makes it possible for the woman who consents to H I V testing to have her blood drawn immediately without being sent to another part o f the hospital to wait in yet another line. In addition, presenting positive results can take more time than either the social worker, nurse, or physician have in the course o f a clinic session, especially if it entails dealing with an extreme reaction such as suicidal ideation. O n enrollment in the Special Prenatal Program at Bellevue Hospital, all women receive indepth screening for past or current abuse. It is recognized that such disclosure often does not occur until there is a basis for trusting the person asking the question, or a belief that the question comes with the possibility o f concrete services. Those women with current or previous abusive relationships are followed closely. They have 24h o u r access to the domestic violence counselor. They receive ongoing counseling and support and facilitation of housing needs as well as legal support when appropriate. Active bidirectional referral mechanisms are in place with the adult primary care clinics, adult infectious disease clinic (for women with symptomatic H I V infection), and drug treatment programs (including outpatient day-treatment facilities, short-term detoxification facilities, long-term residential facilities, and methadone maintenance programs). All HIV-infected pregnant women enrolled for prenatal care at Bellevue are visited by a m e m b e r o f the pediatric infectious disease team. After delivery, before discharge, the pediatrician visits these mothers and informs them of the services provided in the pediatric infectious disease clinic, thus facilitating continuity o f care and follow-up. The H I V counselors in the prenatal clinic also attend the pediatric infectious disease clinic and provide a consistent contact for the mothers. The patients have daily access to the prenatal

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nurse for questions regarding the course o f the pregnancy, missed appointments, compliance with medications, etc. Although any given patient may see the doctor once or twice a month, she may see or talk to the nurse several times a week. The nurse is also pivotal in ensuring compliance with those enrolled in on-site d r u g treatment p r o g r a m s and primary health care referrals. T h r o u g h this multidisciplinary team approach, 96% o f HIV-infected children followed in Bellevue's Pediatric Infectious Disease Clinic have already been identified by the time their H I V serostatus was confirmed. That is, their mothers were identified either during the a n t e p a r t u m or p e r i p a r t u m period t h r o u g h a p r o g r a m of universal counseling and voluntary testing in an inf o r m e d population.

Trends in Permanency Planning A p r e g n a n t w o m a n whose life is complicated by a history o f any one or a combination o f factors such as homelessness, d r u g use, violence, or incarceration requires sustained social intervention to ensure the most positive o u t c o m e for h e r s e l f and h e r baby. But H I V infection offers b o t h special problems and opportunities. In the past few years, the realization that the H I V epidemic was creating a new category o f o r p h a n - - c h i l d r e n whose m o t h e r s are dying o f the d i s e a s e - - h a s had at least one positive effect. More social service and legal providers are b e c o m i n g specialists in assisting mothers with the difficult issues a r o u n d disclosing their H I V status to family members, including children; making plans for t e m p o r a r y and eventually p e r m a n e n t custody of their children; and helping to create positive memories for the children. 1~-17 Pregnancy is an o p p o r t u n e time to introduce these sensitive subjects to women, as long as it is done in a careful step-by-step and sensitive way. Although serious symptomatic disease and disability may be years away for an asymptomatic woman, the o p p o r t u n i t y to discuss long-term custody plans with knowledgeable and caring counselors is valuable. O f course, p r e g n a n t w o m e n should not be b a d g e r e d or m a d e to feel that death is inevitable and imminent. Some o f the most difficult discussions concern disclosure o f the patient's H I V status to family m e m b e r s and o t h e r children. This is particularly difficult if H I V seropositivity is discovered during

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pregnancy. Many women feel isolated, even f r o m their closest friends and relatives, and do not share this information. In doing so, they believe they are protecting themselves and their other children f r o m rejection and possible harsh consequences, but they are also cutting themselves off f r o m potential avenues of support. The decision to tell, whom to tell, what to tell, and when is ultimately a personal choice. Counselors can assist, role play, advise, and support the woman, but the outcomes are often unpredictable. Some family m e m b e r s are extremely supportive and loving; others, often u n e x p e c t e d ones, do reject and isolate, at least for a time. W h e n other children are involved, the decisions are even m o r e complicated. Many w o m e n believe that the b u r d e n of knowledge is either too heavy for their children or they fear that their children cannot keep the information within the family. It is i m p o r t a n t to reassure w o m e n that they do not have to disclose everything all at once; H I V itself n e e d not be m e n t i o n e d until a child is ready. The fact that a m o t h e r is ill is enough to convey at the outset. Moreover, children do not necessarily ask all the most feared questions (How did you get it? Are you going to die?) all at once. They assimilate the pieces of information they need to u n d e r s t a n d their m o t h e r ' s illness and other changes in behavior. Finally, most children do know something is wrong even if they have not b e e n told explicitly. Their fears, especially their fears that they are somehow to blame, are often worse than the reality. As imp o r t a n t as honest and o p e n communication are, these are not simple goals to achieve. In some cases, accepting the child's level o f understanding and desire to know may be the best solution. In the past few years, several steps have b e e n taken to expand options in permanency planning for children whose mothers have H I V / A I D S . Standby guardian legislation, passed in New York State in 1992, and followed in eight other states so far (Connecticut, California, Florida, New Jersey, N o r t h Carolina, Wyoming, Illinois, and Pennsylvania), offers one new option. Although family law varies by state, the general legal situation before standby guardian legislation was that w o m e n could n a m e a potential guardian in a will or could go to court to have a legal guardian designated before her death. The drawback to naming a person in a will is that the will must be probated, and the family court j u d g e has a great

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deal o f discretion in deciding whether to follow the woman's wishes. Because by definition when the will is probated, its writer is dead, she cannot speak to defend her reasons for naming, for example, a cousin rather than her sister, or her reasons for her unwillingness to have the child's father, if he is alive, involved. Naming a legal guardian, however, removes the parent from considerable decision-making power over the child and perhaps even from physical custody. Most ill women are very reluctant to give up this connection to their children; it is, they often say, the only reason they have to live. Standby guardianship avoids these extremes by allowing a parent with a chronic, progressive, life-threatening illness to name (either with prior court approval or by simply signing a paper) a guardian to take over her children when she dies, becomes incapacitated mentally or physically, or when she requests the guardianship to take effect. In the court approval process, all potential legal challenges or problems are b r o u g h t out at a time when the m o t h e r can express her own reasons for choosing a particular person as standby guardian. The designation process does not carry this full approval, but the designation itself is considered important evidence by the judge. Some attorneys believe that the designation is considered more weighty evidence than a statement in a will. When the parent dies, the standby guardian only has to apply for final (or in the case o f designation, full) approval by the court and becomes a legal guardian. The one drawback to this process that mothers and potential guardians should understand is that a person w h o b e c o m e s a legal guardian is not eligible for kinship or regular foster care subsidies. One o f the many i r o n i e s - one might say irrationalities--of the current child welfare system is that the path that leads to stability and continuity for the child is strewn with financial disincentives for the new guardian, who in the case o f H I V / A I D S is often p o o r and burdened with many other responsibilities. In most cities with large numbers o f HIV-infected women, specialized legal and social services are developing expertise in assisting women with disclosure and custody planning. There is also a growing literature on the subject. 18 For the pregnant HIV-infected women who is asymptomatic, discussions on this subject will be just the beginning. It is important that she be

referred to other agencies who can help her with the process as time goes on. A n o t h e r area in which counselors can assist pregnant HIV-infected women is to encourage them to begin to create " m e m o r y stores" for their new baby and other children. Drawing family trees to save for the baby not only helps the mother think through possible resources for help later on but creates a tangible record for her child o f the people who mattered. Records o f pregnancy such as photos, sonograms, cards, balloons, or descriptions o f baby showers or presents can all enhance the importance of the event to the m o t h e r in a way that can be passed on to her child. It also starts a process that can be continued and enlarged for the child's benefit.

Future Research Needs Much more research is needed to illuminate the complex clinical and social needs of HIV-infected pregnant women. Studies are needed that focus on specific aspects o f care and that broaden our understanding o f the ways in which a woman's current and past social environment affects the course o f her pregnancy. Here are a few examples of research needs. 1. Drug treatment. More specific information is needed on drug treatment that is effective with women in general and pregnant women in particular. Much advocacy a r o u n d access to d r u g treatment for women has focused on making slots in treatment centers available to pregnant women without firm understanding o f their differing responses. 2. Sexual behavior. There is some anecdotal evidence that women who successfully stop drug use, and who extricate themselves from abusive relationships, turn to celibacy as a reaction to their past abuse. The extent o f this p h e n o m e n o n and its psychological implications should be explored. 3. Contraceptive technology. There is an urgent need for research on many aspects o f contraception, including women-controlled methods and new forms o f male contraception. The lack exists because o f society's failure to invest in contraceptive research and technology. As a result, methods to prevent pregnancy and methods to prevent sexually transmitted diseases are seen as the same, whereas in reality the problems are distinct.

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4. Preventing perinatal H I V transmission. As more is learned about the many individual factors that seem to influence perinatal H I V transmission, 18 studies are needed to address the best way in which to create a unique profile o f the risks of H I V transmission for each infected woman so that she can be apprised o f her individual risks o f transmission. It will be important to learn whether such individualized risk assessments will make a difference in w o m e n ' s reproductive choices. 5. Permanency planning. More work is needed to determine how best to involve as early as possible HIV-infected women in permanency planning for their children while not giving them an unduly pessimistic view of their H I V status.

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Conclusion Against the current b a c k g r o u n d o f medical specialization and social fragmentation, clinical care o f HIV-infected pregnant women must move toward integration o f services and an approach that takes into account the whole o f a woman's life. Given the pernicious influences that have b r o u g h t the woman to the point in her life when she faces the birth o f a child not just with the normal apprehensions but with the host o f fears s u r r o u n d i n g her life circumstances and the potential of H I V transmission, this is a daunting task. Yet it can and must be done. At a time when the philosophy o f "less is m o r e " appears to govern health policy and in turn clinical decisionmaking, the case for " m o r e is m o r e " must be made for HIV-infected pregnant women, their families, and their expected babies. Social interventions are essential complements to the highest quality o f clinical care.

References 1. Centers for Disease Control: Update: Impact of the expanded AIDS surveillance case definition for adolescents and adults on case reporting--United States. MMWR 43:160-161, 167-170, 1994 2. Hamburg M (New York City Health Commissioner):

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