and benefits of testing and followed by counseling that would explain the test's significance. However, there were a number of carefully defined, although always contested, exceptions to voluntary, individualized testing. The Defense Department initiated screening of all new recruits and students at service academies and in the college Reserve Officers' Training Corps (ROTC) program: people who test HIV positive are not eligible for military service. The State Department, Peace Corps, and Job Corps also routinely screen employees. These screening programs have withstood court challenges (Gostin, 1990). In addition, many clinicians and hospitals undertook surreptitious testing of patients, justifying their actions by the belief that the protection of health care workers and sound diagnostic work required such screening. In a survey of HIV testing policies in 561 nonfederal, acute care hospitals (Lewis and Montgomery (1990:2767) found:
[T]he current state of policy adoption related to HIV testing provides no guarantee that [patients] rights will be protected. For example, one of four hospitals surveyed does not require patients' informed consent prior to testing, and one in three does not require pretesting counseling. Moreover, one in four hospitals surveyed does not require a patient to be notified if a test result is positive.
With the announcement in mid-1989 that clinical trials had revealed the efficacy of early therapeutic intervention in slowing the course of illness in asymptomatic but infected persons and in preventing the occurrence of Pneumocystis carinii pneumonia, the political debate about testing underwent a fundamental change. Gay groups such as Project Inform in San Francisco and the Gay Men's Health Crisis in New York (Lambert, 1989) began to encourage people whom they had formerly warned against testing to determine whether they were infected. Physicians pressed more vigorously for the return of AIDS to the medical mainstream so that testing might be routinely done under conditions of informed consent (Rhame and Maki, 1989). And state and federal public health officials launched more aggressive testing campaigns.
Physicians and public health officials have typically avoided the language of compulsion, stressing instead routine HIV testing, testing that would be initiated by doctors caring for people they believed to be at risk. Thus, in the fall of 1990, the House of Delegates of the American Medical Association voted to declare AIDS a sexually transmitted disease, a designation that would give physicians much greater latitude to determine the conditions under which HIV testing should be undertaken.
Nowhere has the shifting perspective on testing been clearer than in the emergence of a powerful movement, supported by obstetricians and pediatricians, for the routine screening of pregnant women, who can transmit HIV infection to their offspring, and the mandatory screening of infants at high risk for infection. For pregnant women, the public health practice of