way to achieve the goal of universal HIV testing in prenatal care is for federal, state, and local health agencies; professional organizations; regional perinatal HIV research and treatment centers; AIDS Health Education Centers (AHECs); and health plans to increase efforts to educate prenatal care providers about the value of testing in pregnancy. They also must ensure that providers are linked to sources of information and referral for women who test positive. In addition, academic and residency training programs in family medicine, pediatrics, obstetrics/gynecology should include the knowledge, skills, and techniques for prevention of perinatal HIV transmission.

In particular,

The committee recommends that health departments, professional organizations, medical specialty boards, regional perinatal HIV centers, and health plans increase their emphasis on education of prenatal care providers about the value of universal HIV testing and about avenues of referral for patients who test positive.

Through its workshops and site visits, the committee found many examples of existing provider education programs initiated by state and local health departments and professional organizations. Nearly all states have sent material about the ACTG 076 results and the PHS counseling and testing guidelines (CDC, 1995b) to prenatal care providers. Provider education programs have been designed to explain the risks of perinatal transmission, the importance of universal prenatal testing, the benefits of interventions, and the availability of referral sites. These efforts should be continued and enhanced.

California and New Jersey developed their education programs as a result of legislation mandating that providers counsel and offer voluntary HIV testing to all pregnant women (see Appendixes D and E). California recently devised and disseminated comprehensive clinician education and resource materials (including interactive teaching materials for use with patients) and made available a toll-free physician help line. Similar educational programs need to be developed and evaluated in other states. It has been difficult, however, to get physicians to participate, because many do not think that HIV is common enough in their practices to warrant the time (see Appendixes E and G).

It is important for provider education programs to overcome physicians' apparent tendency to offer HIV tests only to pregnant women who report, or in whom they suspect, HIV risk behaviors. Risk-based counseling and testing strategies are ineffective because they fail to identify as many as half of HIV-infected women (Barbacci et al., 1991). Belief that they are not at risk is the most common reason for patients' refusal of an HIV test, according to the committee's workshops and site visits. Many who deny risk do so because they are unaware of their partners' risk history.

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