pregnant women have been implemented in Alabama. More specifically, participants reported on (1) incorporation of PHS guidelines into other guidelines or protocols; (2) provider implementation of counseling and testing guidelines; (3) the proportion of pregnant women tested at different sites and reasons for variations; (4) acceptance of treatment and reasons for refusal; and (5) reactions to possible variations in guidelines.

Incorporation of Guidelines

Participants noted that Alabama Department of Public Health (ADPH), the Jefferson Country Department of Health (JCDH), and West Alabama Health Services (WAHS) (a private, non-profit community health provider), have all incorporated the PHS guidelines into their own guidelines or protocols. The ADPH has undertaken several measures. First, shortly after the AIDS Clinical Trials Group protocol number 76 (ACTG 076) was published, the state health officer and the state perinatal advisory committee sent out a joint letter to all health care providers in Alabama recommending that they follow the PHS recommended protocol. The ADPH has also incorporated PHS guidelines into guidelines for public health clinics throughout the state. (Local public health clinics throughout the state are actually operated by the ADPH. Only Mobile and Jefferson counties have relatively autonomous local health departments.) The ADPH guidelines, Comprehensive Health Record Instruction Manual (CHR), require HIV counseling and the offering of HIV testing within the first two prenatal visits. Additional HIV testing will be offered in later visits if clinically indicated. During the postpartum visit, offering of HIV test and counseling are required. Finally, the ADPH supported legislation being considered by the Alabama legislature at the time of the IOM site visit. The legislation, which did not come up for a vote during the recent legislative session, would have given the state board of health the authority to require routine testing for specified notifiable diseases. If the law had passed, then the board of health would likely have required routine HIV testing of all pregnant women, with the patients having the right to refuse testing.

The JCDH has incorporated the PHS recommendations into its clinical management protocols for care of its maternity patients. The JCDH protocol currently in use was developed in June 1995 and includes the following components: (1) a risk assessment at the initial visit for all maternity patients, with risk status recorded in the county's automated record system maintained by the JCDH and the University of Alabama at Birmingham Department of Obstetrics and Gynecology; (2) a strong recommendation that all prenatal patients receive HIV serology testing; (3) routinely obtained written informed consent for confidential HIV serology testing on admission; (4) clear notification to patients that any HIV information obtained will be shared with the hospital responsible for delivery and with the high-risk obstetrics clinic; (5) required pre-test counseling, with components

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