Discussion

During the discussion a participant remarked on the importance of recognizing that pretest counseling recommendations may deter providers from testing. In response, Dr. Kubota pointed out that if the goal is to recommend prenatal testing, then putting HIV on a checklist for routine prenatal tests is probably what physicians want and is likely to be most effective.

Association of Women's Health, Obstetric, and Neonatal Nurses

Maureen Shannon spoke based on her clinical expertise working as a nurse midwife at the Bay Area Perinatal AIDS Center (BAPAC) at San Francisco General Hospital and her participation in the development of guidelines addressing the HIV counseling, testing, and clinical care of women. BAPAC offers "state-of-the-art" services to HIV-infected women and infants by combining access to clinical trials with primary, perinatal, pediatric, and social support services. Services are family-centered, offering integrated maternal/infant/child clinical care, a model that works well for maintaining the health of both mother and child. Since May 1995, only one of sixty-two infants born to HIV-infected women receiving ongoing prenatal care through BAPAC has tested positive. This represents a perinatal transmission rate of less than 2%. Ms. Shannon offered the following observations.

Incorporation of PHS guidelines in California

California statute has incorporated PHS guidelines, requiring every prenatal care clinician to counsel women about HIV and to offer voluntary testing. These activities must be documented in the woman's medical record. The state has also developed and widely disseminated comprehensive clinician education and resource materials (including interactive teaching materials for use with patients) and has made a toll-free clinician help line available. Ms. Shannon noted that the resource materials were of very high quality and recommended that they be evaluated for use in other states, as in the California Perinatal HIV Testing Project described below.

Implementation in California

Clinical implementation of the guidelines is very uneven. In one large HMO (health maintenance organization), there is more than 95% testing in prenatal clinics, but it is not clear how informed these clients are about the test and its implications. In another large medical center in the same area, only about half of the women using a well-known physician-based practice receive testing. Yet in



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