taken to undermine the need for health care professionals to counsel their patients in routine encounters about the risks of sexually transmitted diseases or methods for preventing them (IOM, 1997), or in practices where providers decide routine pre-test counseling is appropriate. Rather, providers should not allow the requirements for pre-test HIV counseling to become a barrier to testing itself.

Clinical policies to implement universal HIV testing, with patient notification, as a routine component of prenatal care, will have to be developed, as discussed below. These policies should be tailored to the needs of the patients served by the practice, and should include the protection of confidentiality.

The committee's recommendation is in concert with recent analyses and policy changes in other countries. In April 1998, for instance, in Intercollegiate Working Party for Enhancing Voluntary Confidential HIV Testing in Pregnancy in the United Kingdom recommended that "testing for HIV infection should be integrated within established antenatal testing such as for hepatitis B, rubella and syphilis." (Intercollegiate Working Party, 1998). A recent clinical trial in Scotland showed an increase in testing from 18% to 90% of pregnant women when the approach was switched from opt-in (non-directive patient choice) to opt-out (routine, with notification) (Simpson et al., 1998). In September 1998, Alberta Health will begin to promote a policy of routine HIV testing, as part of the standard battery of prenatal exams for all pregnant women in Alberta, Canada (Pilon, 1998).

Rationale for the Committee's Recommendation

The discussion of public health screening programs in Chapter 2 sets out a series of policy options ranging from completely mandatory to voluntary, and Chapter 6 shows how current laws and policies implement a wide variety of approaches to prenatal HIV screening. Rather than this patchwork approach, the committee believes that a policy of universal, routine testing with notification reflects an appropriate balance among public health goals, justice, and individual rights. This policy would increase HIV testing, and hence improve outcomes, by striking a balance in the doctor/patient interaction as well as in the broader society.

There are two key elements to the committee's recommendation. The first is that HIV screening should be routine with notification. This element addresses the doctor/patient relationship, and can reduce barriers to patient acceptance of HIV testing. Most importantly, this approach preserves the right of the woman to refuse the test. Women would not have to deal with the burden of disclosing personal risks or potential stereotyping because the test would simply be a part of prenatal care that is the same for everyone. Routine testing will also reduce burdens on providers such as the need for costly extensive pre-test counseling and having discussions about personal risks that many providers think are embarrassing. A policy of routine testing might also help to reduce physicians' risk of



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