clines can be attributed to advances in antiretroviral therapies (CDC, 1999a) and, in part, to a number of HIV prevention efforts carried out by federal, state, and local government agencies, nonprofit organizations, and the private sector. Most notable were prevention efforts that led to: changes in sexual behavior among men who have sex with men, reduced transmission among injection drug users, increased safety of the nation’s blood supply, and reduced perinatal transmission from infected mothers to their children. Recent data suggest that the declining trends in AIDS incidence and deaths may be stabilizing, however (CDC, 2000b).

Despite the enormous successes in HIV prevention over the past decade, there are additional prevention challenges. The populations that need to be reached by prevention interventions have changed considerably. Women, youth, and racial and ethnic minorities now account for a growing proportion of new AIDS cases, and increasing numbers of cases are emerging in rural and smaller urban areas (CDC, 2000a), whereas many prevention programs have previously focused on gay white men in major metropolitan areas. In addition, an increasing proportion of new AIDS cases are now being linked to heterosexual exposure, while a declining proportion of new cases are being attributed to men who have sex with men. Men who have sex with men still remain the largest exposure group, however (CDC, 2000a). These new at-risk populations are not being reached for prevention as effectively, or on as large a scale, as at-risk populations have been in the past, and prevention programs tailored to specific social contexts of an earlier period in the epidemic are not proving as effective during the current period.

As a result of such challenges, the Centers for Disease Control and Prevention requested that the Institute of Medicine convene a committee to review current HIV prevention efforts in the United States, to develop a visionary framework for a national HIV prevention strategy that could significantly reduce new infections, and to suggest the roles that public and private-sector agencies should have within this framework. The Committee examined the available evidence, and received much useful information and advice from federal, state, and local agencies, as well as from community organizations involved in research on HIV prevention and in implementing HIV prevention programs. The Committee’s review revealed several important findings.

Above all, HIV prevention works: there is a wide range of proven strategies to reduce behaviors that increase the risk of transmitting or acquiring HIV. However, the ways in which prevention efforts are currently being implemented do not allow the nation to fully reap the benefits of these proven strategies. The Committee identified a number of problems.

First, expenditures on HIV prevention activities appear to be allo-



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