prevent perinatal transmission of this virus," but concluding that "there should be mandatory HIV testing of all pregnant women and newborns with counseling and recommendations for appropriate treatment" (AMA, 1996). The House of Delegates reaffirmed this position in 1997 (AMA, 1997).

The American College of Nurse Midwives (ACNM) policy is that all women should be counseled on HIV risk behaviors and risk reduction strategies, and following counseling, all women should be offered HIV testing with informed consent. The group opposes mandatory testing as a condition of receiving care, and recommends that women be counseled in a non-directive manner regarding reproductive choices and pregnancy care. ACNM recommends that all HIV-infected women be counseled on the risks and benefits of ZDV therapy during pregnancy, and offered this medication. The college also recommends that all HIV-infected women receive prenatal and perinatal care that minimizes the risk of vertical transmission through utilization of non-invasive techniques, and that HIV-infected women with access to adequate formula supplies should be advised to avoid breast-feeding (ACNM, 1997). The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) also supports voluntary HIV testing with appropriate counseling, maintenance of confidentiality, and freedom from discrimination based on HIV status (AWHONN, 1995).

The Association of Maternal and Child Health Programs (AMCHP), which represents state maternal and child health programs, has incorporated PHS guidelines into its policy on HIV counseling and testing (AMCHP, 1995), which supports early and routine counseling to enable all pregnant women and others of reproductive age to understand the risk of HIV infection and the benefits of early testing, identification, and treatment. In addition, the statement calls for voluntary testing with informed consent as the standard of practice.

The AIDS Policy Center for Children, Youth and Families (APCCYF), an advocacy organization for service providers supported by Title IV of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, recommends that routine HIV counseling and voluntary, confidential HIV testing with informed consent be the standard of care for all pregnant women, and supports policies and procedures in all hospitals, clinics, and doctors' offices related to routine HIV counseling and voluntary, confidential HIV testing with informed consent, and follow-up for linkages to care (APCCYF, 1995).

Implementation Of Counseling And HIV Testing And Quality Care For HIV-Infected Pregnant Women

As indicated in Chapter 1, the committee has organized its analysis in terms of a chain of events needed to prevent perinatal transmission of HIV (Figure 1.1). In the following section, this chain is used to summarize the evidence about the implementation of the PHS counseling and testing guidelines (CDC, 1995b) in clinical practice. In particular, this section covers access to and utilization of



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