liability to women and children when providers incorrectly guess that a woman is not at risk for HIV infection.

The second key element of the recommendation is that screening should be universal, meaning that it applies to all pregnant women, regardless of their risk factors and of prevalence rates where they live. The benefit of universal screening is that it ameliorates the stigma associated with being ''singled out" for testing, and it alleviates the problem of many HIV-infected women being missed when a risk-based or prevalence-based testing strategy is employed (Barbacci et al., 1991). The PHS guidelines (CDC, 1995b), many state laws and regulations, and professional society recommendations all already call for universal testing.

Making prenatal HIV testing universal also has broad social implications. First, if incorporated into standard prenatal testing procedures, the costs of universal HIV screening are low, and the benefits are high. Assuming that the marginal cost of adding an ELISA test to the current prenatal panel is $3 per woman and the prevalence of HIV in pregnant women is 2 per 10,000, the committee's calculations show that the cost of routine prenatal testing is $15,600 per HIV-positive woman found.1 Even if the cost of the test is $5 and the prevalence 1 per 10,000, the cost per case found is $51,100. Taken in the context of the cost of caring for an HIV-infected child,2 even though not all women found to be HIV-positive will benefit, these figures indicate the clear benefits of routine prenatal HIV testing.

Second, universal screening is the only way to deal with possible geographic shifts in the epidemiology of perinatal transmission. Although perinatal AIDS cases are currently concentrated in eastern states, particularly New York, New Jersey, and Florida, there have been shifts in the prevalence of HIV in pregnant women, including an increase in the South in the early 1990s. Changes in the regional demographics of drug use can also lead to changes in the distribution of HIV infection in pregnant women. Given the uncertainty of these trends, the committee considers universal testing the most prudent method to reduce perinatal transmission despite possible regional fluctuations.

Third, it would help to reduce stigmatization of groups by calling attention to a communicable disease that does not have inherent geographic barriers or a genetic predisposition. Focusing on the communicable disease aspect may allow

1  

In other words, if 10,000 women were tested to identify two positive cases, the aggregate cost of the screening program would be $31,200, or $15,600 per HIV-infected woman found. This calculation includes the cost of confirmatory tests when necessary, but does not account for the unknown proportion of women whose HIV status was known before pregnancy or would have been detected through other means.

2  

The lifetime costs of treating perinatally acquired HIV infection have been estimated at $65,000 to $200,000 (Ecker, 1996; Gorsky et al., 1996; Myers et al., 1998). In addition, there may be reduced costs associated with early detection of HIV infection in the mother.



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