program administrators expressed concerns that if managed care organizations established HIV counseling requirements, counseling would be done too hastily, or testing might be performed without consent.

Resistance to HIV Counseling by Private Physicians

Through their active outreach efforts and professional contacts, many of the programs were able to shed light on why HIV counseling does not seem to be occurring in private obstetrical practices. Program administrators confirmed the widespread failure on the part of private physicians to offer HIV counseling, even in New Jersey where counseling is mandatory for all patients. The most common explanation was that counseling is seen as too burdensome, particularly when most of their patients are not at risk. One program administrator relayed the experiences of a colleague in private practice who had counseled and tested about 600 pregnant patients without finding one to be HIV-positive. In the judgment of private physicians, HIV counseling consumes too much time in relation to the rarity of infection. While other administrators acknowledged pre-test counseling to be unnecessarily onerous, they thought it presented an important opportunity to educate the patient more generally about HIV rather than perinatal transmission per se.

Physician discomfort was deemed to be another important factor deterring counseling in private offices. Not only did physicians seem to be uncomfortable discussing sexual practices with patients, but they also were uncomfortable with the possibility of implying—however erroneously—to a patient that she might be at risk. One administrator put it starkly, "Doctors don't want to offend private patients. In a competitive health care environment, they're afraid of losing them." Another administrator, however, observed that patients' reactions depend upon the manner in which testing is offered. He noted that patients would not be offended when the testing message is presented as a policy that applies uniformly to all patients. The singling out of at-risk patients was what offended patients, according to this view.

Other reasons offered for private physicians' disinclination to counsel pregnant patients and encourage HIV testing were lack of financial incentives for counseling; lack of physician knowledge about complex HIV therapies and side effects; lack of referral networks; discomfort with counseling in general; and ignorance of the details of their state's counseling, testing, or consent laws and regulations.

Special Populations

This section examines the additional problems in preventing perinatal HIV transmission in adolescents and immigrants. Two of the programs visited by the IOM specialized in counseling and/or caring for these special populations. Other

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