• for intervening in the prenatal period) the terms of the newborn testing debate remained fixed. Given the advent of rapid testing and the potential value of zidovudine (ZDV) therapy antenatally, medical science is only now beginning to demonstrate any evidence for proactively identifying HIV-antibody-carrying infants at birth. The cornerstones of the political discourse on the testing policy, though, were predicated on emotional and political issues, not scientific ones. Furthermore, as a case finding tool, newborn testing was principally effective only in identifying the mother. When the issue was first raised legislatively in 1993, there was no system of follow-up care or any reliable way to assure that all HIV-positive babies were accurately identified when they seroconverted.
  • Given the players, the program, and the shifting political environment, it is likely that mandatory testing was inevitable in New York State. The mandatory newborn testing policy has also facilitated the successful passage of other HIV legislation in New York, such as mandatory partner notification and named HIV reporting.

The chronology of newborn testing policy unfolded in a shifting context of decision making and debate: from insular public health (the pragmatic era), to the population/clinical split (the era of mounting clinical frustration), to the political arena (marked by polarization, issue framing, and political "processes" of negotiation and pressure), to clinical optimism (retroviral therapy and protease inhibitors), and a return to public health pragmatism (the implementation of a political decision).

There were two points of strong federal state interaction regarding newborn screening, and the nature of each reveals a great deal about the shifting eras. In 1987, the CDC strongly supported New York's surveillance efforts as a complement to its "Family of Surveys" and provided half the ongoing funding for New York's newborn screening program. This was clearly the era of public health pragmatism, particularly in the face of uncertainty about the epidemic's future path. In 1995–1996, there was increasing political momentum at the federal level (evidenced by amendments to the Ryan White Reauthorization Act proposed by Congressmen Tom Coburn and Gary Ackerman) for mandatory newborn testing. With the sweep of Republicans into U.S. Congress, and similar Republican inroads in the New York State legislature (and the change at the executive level from a Democratic to a Republican governor), the Democratic-controlled Assembly faced increasing political pressure to conform to the governor's wishes for a mandatory newborn testing program. In 1996, after quiet negotiations between several key legislative players, the New York State Assembly speaker reversed his three-year opposition to mandatory testing and helped pass the "Baby AIDS" bill.

The framing and marketing of the issue of newborn screening and testing played a significant part in the decisions and actions taken. The early blinded screening program publicized its findings of high seroprevalence rates among



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