survey should be available in June 1998, along with statewide data on the impact of the California law on HIV testing rates.

American College of Nurse Midwives

Jan Kriebs spoke on behalf of the American College of Nurse Midwives (ACNM), which represents approximately 6,500 certified nurse midwives in practice or in school in this country. Nurse midwives practice in every state as well as in the District of Columbia and Puerto Rico. While nurse midwifery is usually thought of as care for low-risk women, two-thirds of U.S. midwives care for women who are at-risk—socioeconomically, demographically, or medically.

Incorporation of PHS Guidelines

The ACNM has incorporated PHS recommendations into its "ACNM Position on HIV/AIDS," which calls for universal counseling and offering of HIV testing, with informed consent. In addition, the statement specifically (1) opposes mandatory testing; (2) calls for non-directive counseling regarding reproductive choices and pregnancy care; (3) advises that all HIV-positive women should be counseled regarding risks of prenatal ZDV and should be offered the medication; and (4) recommends that all HIV-positive women with access to adequate formula supplies should be advised to avoid breast-feeding. The current ACNM statement is likely to be amended to include a discussion of more complex antiretroviral therapies.

Implementation

Nurse midwives have good compliance with counseling programs because they are taught that risk status alone cannot identify all HIV-infected women, which means that every woman needs to hear the basics of counseling. The ACNM also has a program of continuing education for members, which regularly includes topics relating to HIV.

Clinical Experience

Using universal counseling and voluntary testing, two Baltimore area practices with which Ms. Kriebs has been affiliated have achieved a greater than 95% acceptance of testing and 100% acceptance of ZDV use by HIV-positive pregnant women. As a result, transmission has been less than 10% over four years. The success rate has been attributed to a well-coordinated multidisciplinary team effort that provides smooth transitions between counseling, testing, and follow-up care. Within these practices, there is a growing trend for HIV-positive women to plan pregnancy. These women, like other high-risk mothers, want to minimize



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