The committee recommends that professional organizations update their clinical practice guidelines to facilitate universal HIV testing, with patient notification, as a routine component of prenatal care.

In addition to their direct influence on clinical practices, guidelines of this sort issued by professional organizations have an important role to play in determining the standard of care used by the courts. The committee's recommendation for universal HIV testing with patient notification in the context of prenatal care is different from most existing practice guidelines, so professional organizations should consider rewriting their guidelines to be consistent with the committee's approach. Relevant state laws and regulations should also be reconsidered.

The development of clinical policies represents another approach to promoting prenatal HIV testing and appropriate care. Clinical policies are usually developed within a clinical department, practice, or health plan, and can be based on national standards. Clinical practice guidelines to implement the committee's recommendation for universal, routine testing with notification might, for example, include an HIV test on the checklist of clinical tests for which blood is drawn at the first prenatal visit, standing orders, and procedures to ensure that positive test results are delivered in a timely and appropriate way. Practice guidelines might also include clear identification of the essential components of post-test counseling for patients who test positive. Thus,

The committee recommends that all health care plans and providers develop, adopt, and evaluate clinical policies to facilitate universal prenatal HIV testing.

Institutional changes can lead to rapid increases in HIV test use. Kaiser Permanente of Northern California, for example, was able to increase test use throughout its service area from 50% to 63% in one year (from 1994 to 1995) by improving providers' ability to provide counseling and testing—for example, by ensuring access to educational materials and laboratory testing (Limata et al., 1997). In Southern California, prenatal HIV testing among pregnant Kaiser members rose from 55% to 85% between 1994 and 1997 (Pettiti, 1998). A provider survey conducted in Massachusetts found the adoption of an HIV clinical practice policy to be the single most important predictor of the occurrence of HIV prenatal testing (Allen et al., unpublished).

The availability of patient educational materials can also help to improve prenatal HIV testing rates, according to the committee's site visits and workshops. The need for clear and readily accessible patient educational materials is even greater under the committee's recommendation for routine prenatal testing with notification. As a result of its support for minimal pre-test counseling to reduce provider burden, the committee foresees greater emphasis on educational materials to inform patients about the test and its implications for the health of the

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