The number of children born with HIV, however, continues to be far above what is potentially achievable, so much more remains to be done. There is substantial variability from state to state in the way that the PHS guidelines have been implemented, but no evidence to suggest that any particular approach is more successful than others in preventing perinatal HIV.

Recommendations

Universal HIV Testing, with Patient Notification, as a Routine Component of Prenatal Care

To meet the goal that all pregnant women be tested for HIV as early in pregnancy as possible, and those who are positive remain in care so that they can receive optimal treatment for themselves and their children, the committee's central recommendation is for the adoption of a national policy of universal HIV testing, with patient notification, as a routine component of prenatal care.

There are two key elements to the committee's recommendation. The first is that HIV screening should be routine with notification. This means that the test for HIV would be integrated into the standard battery of prenatal tests and women would be informed that the HIV test is being conducted and of their right to refuse it. This element addresses the doctor–patient relationship, and can reduce barriers to patient acceptance of HIV testing. Most importantly, this approach preserves the right of the woman to refuse the test. If it is followed, women would not have to deal with the burden of disclosing personal risks or potential stereotyping; the test would simply be a part of prenatal care that is the same for everyone. Routine testing will also reduce burdens on providers such as the need for costly extensive pretest counseling and having discussions about personal risks that many providers think are embarrassing. A policy of routine testing might also help to reduce physicians' risk of liability to women and children, where providers incorrectly guess that a woman is not at risk for HIV infection.

The second key element to the recommendation is that screening should be universal, meaning that it applies to all pregnant women, regardless of their risk factors and of prevalence rates where they live. The benefit of universal screening is that it ameliorates the stigma associated with being "singled out" for testing, and it overcomes the problem that many HIV-infected women are missed when a risk-based or prevalence-based testing strategy is employed (Barbacci et al., 1991).

Making prenatal HIV testing universal also has broad social implications. First, if incorporated into standard prenatal testing procedures, the costs of universal HIV screening are low, and the benefits are high. Assuming that the marginal cost of adding an ELISA test to the current prenatal panel is $3 per



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