national education programs that would otherwise be difficult, discouraging infected individuals from hiding themselves and thus not benefiting from care, and discouraging a "blame-the-victim" mentality.

The committee prefers universal HIV testing, with patient notification, as a routine component of prenatal care testing to policies that require providers to counsel or offer HIV tests to all women in prenatal care. As noted in Chapter 2 for screening programs in general, and in Chapter 6 for prenatal HIV testing, there is no evidence that making a program "mandatory," in and of itself, leads to more testing. Routine testing with patient notification thus is likely to be at least as or more effective in meeting public health goals, and less onerous.

Incorporating Universal, Routine HIV Testing Into Prenatal Care

As documented in Chapter 6, prenatal care providers are generally aware of and agree with PHS and other recommendations for universal testing. Yet there is great variation among providers in the proportion of women actually tested. Provider and patient surveys (see Chapter 6), the committee's workshops and field visits, and the committee members' own experience have indicated the need for a number of changes in health systems and public policy focused on health care provider behavior. In this light, the committee makes the following general recommendations, although precise actions should vary across states and clinical practices, and according to current practices, the nature of the epidemic, and available resources.

The first condition for these recommendations to be successful, is strong leadership in the public health and medical community, especially at the local level. The committee is aware of the extensive efforts that have been made at the national and state level to develop guidelines, recommendations, laws, and regulations to implement the ACTG 076 findings. The committee's site visits, on the other hand, have revealed a number of instances in which local public health officials and leaders of the medical community have missed opportunities to educate themselves about and encourage prenatal HIV testing, monitor progress, or enforce existing laws or regulations (Appendixes E, F, and G). It is also important, the committee believes, that these approaches be evaluated carefully, and that successful models be disseminated widely in the professional community.

Education of Prenatal Care Providers

Although most prenatal providers are aware of and agree with the need for offering HIV tests to pregnant women, their awareness and attitudes do not always translate into action. In addition to the demands of pre-test counseling, lack of knowledge about HIV therapies and the lack of a referral network, for instance, may deter physicians in private practice from offering HIV tests. One



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