care, the proportion of women in prenatal care actually tested would be an appropriate performance measure. Health care plans must, however, ensure patient confidentiality and guard against coercive testing when patients refuse to be tested.

Another approach to integrating public health goals and clinical practice is the development of contract language for managed care plans. In particular,

The committee recommends that health care purchasers adopt contract language supporting a policy of universal HIV testing, with patient notification, as a routine component of prenatal care.

If universal HIV testing with patient notification is to become a routine component of prenatal care, contracts should not allow health insurers to deny benefits under "pre-existing conditions" or similar clauses based on the client's HIV status.

Improving Coordination of Care and Access to High-Quality HIV Treatment

Prenatal HIV testing can achieve its full value only if women who are found to be positive receive high-quality prenatal, intrapartum, and postnatal care for themselves and their children. Thus,

The committee recommends efforts to improve coordination of care and access to high-quality HIV interventions and treatment for HIV-positive pregnant women.

Without linkage to specialty care for HIV-positive women, the committee's recommended policy of universal HIV testing, with patient notification, as a routine component of prenatal care would violate one of the fundamental criteria for public health screening programs, that is, there should be adequate facilities for diagnosis and resources for treatment for all who are found to have the condition, as well as agreement as to who will treat them.

Addressing Concerns about HIV Testing and Treatment

To enhance acceptance of HIV prenatal testing as a routine component of prenatal care, providers should understand the constellation of reasons why some pregnant women refuse HIV testing. Thus,

The committee encourages the development of outreach and education programs to address pregnant women's concerns about HIV testing and treatment.

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