of HIV risk; (2) acknowledging risk behaviors; (3) confidentiality protections; (4) presenting counseling and testing as "routine" rather than optional; and (5) the provider's belief that counseling and testing will benefit the client. Factors associated with low acceptance rates included prior HIV testing, fears about coping with results, and explicit informed consent.

While the benefits of testing appear clear and relevant to the current situation where effective treatment is available, serious cautions must be acknowledged. According to Quinn (1998), testing could have a paradoxical effect on public health. For example, tremendous fear about AIDS, its existence within stigmatized groups, and the perception that AIDS was a death sentence contributed to discrimination against those with AIDS or even those perceived to be at risk for HIV infection. Being tested per se was viewed as a sign that one was at risk. Additionally, among ethnic and racial minority populations, there were concerns that the benefits of early detection might have resulted in further stigma and discrimination (see below), outweighing the benefits of treatment. Thus, recommendations for broader testing might serve to drive those at highest risk underground.

When HIV testing programs were first instituted, HIV-positive individuals were subject to discrimination, and in some cases, even those known to have been tested for HIV were assumed to be at high risk. Presently, most HIV testing is voluntary and intended to benefit the person being tested, yet there is mandatory testing in certain situations such as the armed forces and prisons. Both the Congress and state legislatures continue to consider legislation mandating HIV testing for other defined populations. Considering these events, the affected communities have lingering concerns about HIV testing. This history explains why HIV testing was, and still is, thought by many to differ from other clinical testing and public health screening programs, part of a phenomenon often labeled "AIDS exceptionalism" (Bayer, 1991).

As this report was being prepared in 1998, an increasing number of states are requiring positive HIV test results to be reported to state health departments with names or other personal identifiers (Gostin et al., in press). The purpose of most of these requirements is to improve surveillance, as people with HIV infection are living longer and AIDS cases per se have become increasingly less informative about the HIV epidemic (Gostin et al., 1997). Legislation enacted in New York in June 1998, however, includes a provision that would require that HIV-positive individuals be asked about their sexual partners so that health department officials could trace contacts. AIDS activists have expressed concern about the potential loss of privacy that would come from linking surveillance and contact tracing activities, and suggested that these provisions would discourage people from being tested and seeking treatment (Perez-Pena, 1998).

Meeting in January 1998, AIDS activists, public health officials, and others considered the important changes that had occurred in recent years in terms of new diagnostic tests, improved treatment opportunities, and progress in behavioral



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