The development of the Public Health Service (PHS) counseling and HIV testing guidelines for pregnant women (CDC, 1995b), released on July 7, 1995, was triggered by the ACTG 076 results a year earlier. The guidelines called for universal counseling and voluntary testing of pregnant women, in lieu of a more targeted approach to either high-risk women or high-incidence states (the guidelines are reproduced in Appendix N). The rationale for universal counseling was that many HIV-infected pregnant women and newborns in low-risk groups and low-prevalence areas were not being tested and treated. The universal approach was seen by the PHS as a means of stimulating the development of a testing and treatment infrastructure in low-prevalence states and regions (Appendix C).
The adoption of voluntary, as opposed to mandatory, testing was recommended for a number of reasons: widespread support for the policy, particularly from patients for whom adherence to a demanding drug regimen is essential for prevention of transmission; a concern that mandatory testing might have served as a potential deterrent to prenatal care; the risks of testing positive (e.g., discrimination and domestic violence) might outweigh the benefits in some cases; and experience indicating that greater than 90% of women accept testing when offered (Appendix C).
Based on a survey of state activities, Gostin and colleagues (in press) concluded that states have moved rapidly to implement the PHS counseling and testing guidelines (CDC, 1995b), mostly without mandatory or coercive actions. As of June 20, 1998, almost all states had taken steps to implement the PHS guidelines in law, regulation, or policy (see Box 6.1). Only three states (Idaho, Kansas, Vermont) have neither laws nor policies on counseling and testing of pregnant women. Most states have policies, recommendations, or guidelines to prevent perinatal transmission; 45 states have policies on counseling/testing of pregnant women; 38 have policies on treatment of pregnant women; and 22 have policies on testing, monitoring, or treatment of newborns. Only 19 states have adopted laws or regulations on HIV counseling and testing of pregnant women.
Four states (Michigan, Mississippi, Tennessee, Texas) have routine "opt-out" procedures, in which a woman will be tested unless she specifically objects.