mother and child. Educational efforts oriented to the public at large also should be undertaken to underscore the importance of HIV prenatal testing. The New Jersey Department of Health and Senior Services, for example, has developed a public education campaign that includes the use of posters, postcards, videos, and public service announcements (Appendix F). To encourage HIV prenatal testing among adolescents and immigrants, who are among the hard-to-reach populations (see below), educational materials and public service announcements should be tailored to individuals of different ages, cultures, and languages.

Outreach and counseling conducted by nurses, counselors, and other staff would increase the proportion of women tested by minimizing the burden of HIV counseling on physicians. Physicians at many of the sites visited by the Institute of Medicine (IOM) committee believed that counselors and nurses were more successful at counseling patients than they themselves. The Group Health Cooperative of Puget Sound, a large Kaiser-affiliated HMO (health maintenance organization) based in Seattle, Washington, recently took steps to improve HIV testing of pregnant women by (1) communicating with providers about the PHS recommendations, (2) integrating HIV education and counseling into prenatal classes usually given by registered nurses, (3) having test results available for review and discussion at the first visit with a prenatal care provider (midwife, obstetrician/gynecologist, or family practice physician), (4) making written support material for counseling and testing available to medical and nursing care providers, and (5) clearly defining appropriate steps for care of HIV-positive pregnant women (BlueSpruce, 1998).

Performance Measures and Contract Language

Health care plans and providers increasingly are held accountable for the services they provide through performance indicators such as measures of cost, quality of care, and patient satisfaction (IOM, 1996a). Performance measures for preventive services such as childhood immunizations and mammography screening are common. Another way to integrate public health goals and clinical practice is to develop contract language for managed care plans, especially those serving Medicaid populations. To take advantage of this approach.

The committee recommends that health care plans and providers adopt performance measures for a policy of universal HIV testing, with patient notification, as a routine component of prenatal care.

Performance measures are established by health care plans as a result of requirements for accreditation, participation in Medicaid or Medicare, and market demand. In the market-driven approach, health care plans voluntarily supply information relating to performance measures to enable purchasers to compare plans. If providers do not meet performance goals within the plan, the plan faces



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