develop a full scale MSAFP program, collaboration with an existing program, at a regional level [Simpson and Nadler, 1987].

MSAFP is thus a non-directive patient choice screening program, with strong incentives to providers to inform women about its availability.

Prenatal and Newborn Screening for Substance Abuse

State policies on prenatal and newborn screening for substance abuse are evolving rapidly in the context of a discussion of changing state policies regarding drug use (Chavkin et al., 1998). Overall, states are moving away from a therapeutic approach focusing on treatment and oversight to criminal prosecution. Between 1992 and 1995, the number of states with mandatory drug or alcohol testing of pregnant women increased from one to six, and the number of states with mandatory drug or alcohol testing of neonates increased from zero to four.3 An increasing number of states have a practice of reporting positive toxicology results. The number of states with such practices for pregnant women increased from 7 to 31, and for neonates from 18 to 33, over the same period. Furthermore, in 1995, 12 states mandated treatment for pregnant women found to be using drugs, and 13 mandated treatment for women with children. No states had mandatory treatment policies in 1992.

Many of these screening programs are being introduced in prenatal care as a result of substance abuse laws and policies, without clear public health goals and without providing treatment to improve health outcomes. In addition, the common intervention, removal of the child from the mother's care, is not acceptable to the affected population. Some of these programs are targeted to minority groups, and thus are stigmatizing. More basically, perinatal substance abuse screening programs illustrate the problems that arise when a screening program is set up to deal with a problem that all agree about (e.g., "crack babies") but the implications are not carefully thought through (Jos et al., 1995).

To date there has been little outcry about prenatal and newborn substance abuse screening programs, perhaps because the interests of the affected women are not well reflected in policy decisions, but the history of other screening programs suggests that this approach may not serve public health goals well.

HIV Testing And Screening In The United States

As described in Chapter 4, the primary HIV/AIDS screening tests used in the United States identify antibodies to the HIV virus, indicating that an individual has been exposed to the virus and has mounted an immune response. As such,


The District of Columbia is counted as a "state" in this paragraph.

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