Over the next decade, the policy climate changed dramatically with medical and scientific advances in early treatment of HIV and prevention of perinatal transmission. In 1994, the PHS formally inaugurated policy development to revise its earlier guidelines. After seeking broad input, especially from HIV-positive women and their advocates, the PHS proposed new guidelines in the Federal Register. The guidelines were revised in accordance with comments received during a 45-day comment period and were issued in final form on July 7, 1995. The guidelines proposed universal counseling and voluntary testing, in lieu of a more targeted approach to either high-risk women or high-prevalence states. The rationale for universal counseling was that many HIV-infected pregnant women and newborns in low-risk groups and low-prevalence states still were not being tested and treated. The universal approach was seen by the PHS, according to Dr. Rogers, as a means of stimulating the development of a counseling, testing, and treatment infrastructure in low-prevalence states and regions.

The PHS adoption of voluntary, as opposed to mandatory, testing was recommended for the following reasons: the policy had widespread support, particularly from patients for whom adherence to a demanding drug regimen is essential for prevention of transmission; mandatory testing was thought to be a deterrent to prenatal care; the risks of testing positive (e.g., discrimination and domestic violence) would outweigh the benefits in some cases; and experience had indicated that a high rate of acceptance was achievable since more than 90% of women accept testing when offered in several reported studies. Although the guidelines did not explicitly specify how patient consent to testing was to occur, Dr. Rogers pointed out that two types of patient consent are consistent with the intent of the PHS guidelines: the "right of refusal" (in which women are tested routinely unless they expressly refuse) and the "recommended with consent" (in which testing is recommended by the health care provider but performed only after explicit consent).

Four professional organizations shared with the IOM committee their respective positions on HIV counseling and testing of pregnant women. The American Medical Association was the only one of the four to endorse mandatory testing of pregnant women and newborns. The other three organizations were in accord with the PHS in supporting universal counseling and voluntary testing of pregnant women. None of the organizations is actively monitoring the impact of its policies on member attitudes and practices.

The American Medical Association (AMA) support mandatory testing of all pregnant women and newborns. This policy, according to Dr. John Henning of