the committee believes that all pregnant women should be tested for HIV as early in pregnancy as possible, and those who are positive should remain in care so that they can receive optimal treatment for themselves and their children. In order to meet this goal, the committee's central recommendation is for the adoption of a national policy of universal HIV testing, with patient notification, as a routine component of prenatal care. Routine with notification means that the test for HIV would be integrated into the standard battery of prenatal tests, and that women would be informed that the HIV test is being conducted and of their right to refuse it. The HIV test can be readily added to the list of tests for which blood already is drawn, such as complete blood count, blood type, and syphilis.

Providers have reported that, in the context of prenatal care, pre-test counseling following standard HIV protocols (CDC, 1994) is too onerous and that, therefore, many of their patients remain untested. Eliminating the requirement for extensive pre-test counseling, while requiring the provision of the basic information to all patients, would likely increase the proportion of women tested for HIV. The committee therefore recommends that pre-test counseling consist primarily of notification that HIV testing is a regular part of prenatal care for everyone, and that women have a right to refuse it. Patients' explicit written consent to be tested should not be necessary, but some professional guidelines say that refusal should be documented in the patient's medical record to protect the provider from liability. This recommendation is not intended to diminish more extensive counseling when providers feel it is warranted.

Under the proposed policy, women found to be HIV-positive would receive extensive counseling and be referred for treatment for themselves and to prevent perinatal transmission. For the small proportion of women who test positive, PHS counseling and testing guidelines suggest that post-test counseling include information about the clinical implications of a positive test result; the benefit of, and ways to obtain, HIV-related medical interventions and treatment; the interaction between pregnancy and HIV infection; the risk for perinatal HIV transmission and ways to reduce this risk; transmission to partners; and the prognosis for infants who become infected (CDC, 1995b).

Refusal of the HIV test at the initial prenatal visit should not necessarily be taken as final, but providers should assess the clinical circumstances and, in some cases, counsel women at later prenatal care visits about the benefits of HIV testing. At its site visits, the committee learned of many cases in which pregnant women, later identified as HIV-positive, initially refused testing, but eventually agreed after repeated discussions with their providers. Patients who continue to refuse testing should never be coerced or denied services, and providers should understand that for some women a positive test may lead to severe consequences, such as discrimination, eviction from housing, and domestic violence. Also, there may be clinical indications for repeating the HIV test later in pregnancy.

The committee's de-emphasis of pre-test HIV counseling also should not be



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