No Time To Lose

Getting More from HIV Prevention

Committee on HIV Prevention Strategies in the United States

Monica S. Ruiz, Alicia R. Gable, Edward H. Kaplan, Michael A. Stoto, Harvey V. Fineberg, and James Trussell, Editors

Division of Health Promotion and Disease Prevention

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page R1
No Time to Lose: Getting More from HIV Prevention No Time To Lose Getting More from HIV Prevention Committee on HIV Prevention Strategies in the United States Monica S. Ruiz, Alicia R. Gable, Edward H. Kaplan, Michael A. Stoto, Harvey V. Fineberg, and James Trussell, Editors Division of Health Promotion and Disease Prevention INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C.

OCR for page R1
No Time to Lose: Getting More from HIV Prevention NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, DC 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the Committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This project has been funded entirely with federal funds from the Centers for Disease Control and Prevention, under Contract No. 200-1999-00123. The views presented are those of the Institute of Medicine Committee on HIV Prevention Strategies in the United States and are not necessarily those of the funding organization. Library of Congress Cataloging-in-Publication Data No time to lose : getting more from HIV prevention / Committee on HIV Prevention Strategies in the United States, Division of Health Promotion and Disease Prevention, Institute of Medicine ; Monica S. Ruiz . . . [et al.] editors. p. cm Includes bibliographical references and index. ISBN 0-309-07137-2 1. AIDS (Disease)—United States—Prevention. I. Ruiz, Monica S. II. Institute of Medicine (U.S.). Committee on HIV Prevention Strategies in the United States. RA643.83 .N6 2001 362.1′969792′00973—dc21 00-065369 Additional copies of No Time to Lose: Getting More from HIV Prevention, are available for sale from the National Academy Press, 2101 Constitution Avenue, N.W., Box 285, Washington, DC 20055; call (800) 624-6242, or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP on-line bookstore at www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2001 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Cover photograph: W. Benjamin Incerti, 1951-1993.

OCR for page R1
No Time to Lose: Getting More from HIV Prevention “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE Shaping the Future for Health

OCR for page R1
No Time to Lose: Getting More from HIV Prevention THE NATIONAL ACADEMIES National Academy of Sciences National Academy of Engineering Institute of Medicine National Research Council The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council.

OCR for page R1
No Time to Lose: Getting More from HIV Prevention COMMITTEE ON HIV PREVENTION STRATEGIES IN THE UNITED STATES HARVEY V. FINEBERG, M.D., M.P.P., Ph.D. (Co-Chair), Provost, Harvard University JAMES TRUSSELL, Ph.D. (Co-Chair), Associate Dean and Professor of Economics and Public Affairs, Woodrow Wilson School of Public and International Affairs, Princeton University RAYMOND BAXTER, Ph.D., Executive Vice President, The Lewin Group WILLARD CATES, JR., M.D., M.P.H., President, Family Health International MYRON S. COHEN, M.D., Professor of Medicine, Microbiology and Immunology; Chief, Division of Infectious Diseases; and Director, Center for Infectious Diseases, University of North Carolina at Chapel Hill ANKE A. EHRHARDT, Ph.D., Director, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Professor of Medical Psychology, Columbia University BRIAN FLAY, D.Phil., Professorof Community Health Sciences and Director, Health Research and Policy Centers, School of Public Health, University of Illinois at Chicago LORETTA JEMMOTT, Ph.D., Director, Center for Urban Health Research, Associate Professor of Nursing, University of Pennsylvania EDWARD H. KAPLAN, Ph.D., William N. and Marie A. Beach Professor of Management Sciences; Professor of Public Health, School of Management, Yale University NANCY KASS, Sc.D., Associate Professor and Director of Program in Ethics and Health, Johns Hopkins University School of Public Health MARSHA LILLIE-BLANTON, Dr.P.H., Vice President, Henry J. Kaiser Family Foundation MICHAEL MERSON, M.D., Dean and Chairman of Epidemiology and Public Health, School of Medicine, Yale University EDWARD TRAPIDO, Sc.D., Vice-Chair and Professor, Department of Epidemiology and Public Health, University of Miami STEN H. VERMUND, M.D., Ph.D., Professor and Director, Division of Geographic Medicine, Department of Medicine; Director, Sparkman Center for International Public Health Education, School of Public Health, University of Alabama at Birmingham

OCR for page R1
No Time to Lose: Getting More from HIV Prevention PAUL VOLBERDING, M.D., Professor of Medicine and Director, UCSF Positive Health Program at San Francisco General Hospital; Codirector, Center for AIDS Research, University of California at San Francisco ANDREW ZOLOPA, M.D., Assistant Professor of Medicine, School of Medicine, Stanford University; Director, Stanford Positive Care Program; and Chief, AIDS Medicine Division, Santa Clara Valley Medical Center, San Jose EXPERT CONSULTANTS IVAN JUZANG, M.B.A., President, MEE Productions, Philadelphia MICHAEL A. STOTO, Ph.D., Chair and Professor of Epidemiology, George Washington University LIAISONS FROM THE BOARD ON HEALTH PROMOTION AND DISEASE PREVENTION JOYCE SEIKO KOBAYASHI, M.D., Director, HIV/AIDS Neuropsychiatric Consultation Services, Denver Health Medical Center KATHLEEN E. TOOMEY, M.D., M.P.H., Director, Division of Public Health, Georgia Department of Human Resources STAFF MONICA S. RUIZ, Ph.D., M.P.H., Study Director ALICIA R. GABLE, M.P.H., Research Associate DONNA ALMARIO, Research Assistant ANNA STATON, Project Assistant ROSE MARIE MARTINEZ, Sc.D., Division Director

OCR for page R1
No Time to Lose: Getting More from HIV Prevention LIAISON PANEL Federal Organizations Judith Auerbach, Ph.D., Prevention Science Coordinator and Behavioral and Social Science Coordinator, Office of AIDS Research, National Institutes of Health Kathy Cahill, Associate Director for Policy, Planning, and Evaluation, Office of the Director, Centers for Disease Control and Prevention William B. Calvert, M.S., M.B.A., M.P.H., Chairman, Department of Defense Sexually Transmitted Diseases Prevention Committee and Program Manager, Sexual Health and Responsibility Program, Navy Environmental Health Center, Department of the Navy Robert Fullilove, Ed.D., Associate Dean for Community and Minority Affairs, Columbia University School of Public Health, CDC Advisory Committee on HIV and STD Prevention Randolph Graydon, Director, Division of Advocacy and Special Issues, Center for Medicaid and State Operations, Health Care Financing Administration Kim Hamlett, Ph.D., Associate Director for HIV Prevention, AIDS Service, Department of Veterans Affairs Leslie Hardy, M.H.S., Special Assistant to Assistant Secretary for Planning and Evaluation, Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services King Holmes, M.D., Ph.D., Director, Center for AIDS and STD, University of Washington, CDC Advisory Committee on HIV and STD Prevention Richard Klein, HIV/AIDS Program Director, Food and Drug Administration Mark Magenheim, M.D., M.P.H., Medical Director, Sarasota County Health Department, CDC Advisory Committee on HIV and STD Prevention Dorothy Mann, Southeastern Pennsylvania Family Planning Council, CDC Advisory Committee on HIV and STD Prevention Jean McGuire, Ph.D., AIDS Director, Massachusetts Department of Public Health, AIDS Bureau, CDC Advisory Committee on HIV and STD Prevention M. Valerie Mills, M.S.W., Associate Administrator for HIV/AIDS, Office of Policy and Program Coordination, Substance Abuse and Mental Health Services Administration Matthew Murguia, Associate Director for Policy, White House Office of National AIDS Policy

OCR for page R1
No Time to Lose: Getting More from HIV Prevention John Palenicek, Ph.D., Director, Policy and Program Development Office, HIV/AIDS Bureau, Health Resources Services Administration Ronald Valdiserri, M.D., M.P.H., Deputy Director, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention Deborah Von Zinkernagel, R.N., M.S., Deputy Director, Office of HIV/ AIDS Policy, Office of the Secretary, U.S. Department of Health and Human Services Captain Greg Wood, M.S.N., F.N.P., Director, Centers of Excellence, Associate Director, HIV Center of Excellence, Phoenix Medical Center, Indian Health Service, United States Public Health Service State and Local Organizations Guthrie Birkhead, M.D., M.P.H., Director, AIDS Institute, New York Department of Health, Council of State and Territorial Epidemiologists Joe Cronauer, Co-Director, AIDS Activities Coordinating Office, Philadelphia Department of Public Health, National Association of County and City Health Officials Helen Fox-Fields, Senior Director for Infectious Disease Policy, Association of State and Territorial Health Officers Martin Gonzales-Rojas, CDC Community Planning Group, Chicago, Illinois David Johnson, M.D., M.P.H., Deputy Director for Public Health and Chief Medical Executive, Michigan Department of Community Health, Association of State and Territorial Health Officers Leigh Lipson, Program Associate, National Association of County and City Health Officials John Middaugh, M.D., Alaska State Epidemiologist, Council of State and Territorial Epidemiologists Julie Scofield, Executive Director, National Alliance of State and Territorial AIDS Directors Evelyn Ullah, B.S.N., M.S.W., Director, Office of HIV/AIDS Services, Miami-Dade County Health Department, Miami Crisis Response Team Liaison, Congressional Black Caucus Initiative Nongovernmental Organizations Larry Abrams, Associate Director of Prevention, Gay Men’s Health Crisis Julio Abreu, Associate Director of Government Affairs, AIDS Action Council

OCR for page R1
No Time to Lose: Getting More from HIV Prevention Terje Anderson, Executive Director, National Association of People with AIDS Cornelius Baker, Executive Director, Whitman Walker Clinic Ignatius Bau, J.D., Policy Director, Asian and Pacific Islander American Health Forum Lorraine Cole, Ph.D., Executive Director, National Medical Association Blake Cornish, Federal Legislative Lawyer, National Gay/Lesbian Task Force Lawrence D’Angelo, M.D., M.P.H, Society for Adolescent Medicine Debra Fraser-Howze, Chief Executive Officer, The National Black Leadership Commission on AIDS Leroy Gross, M.D., M.P.H., Aerospace Medicine Regent, American College of Preventive Medicine Christopher La Bonte, Senior Policy Advocate, Human Rights Campaign Miguelina Ileana León, Director of Government Relations and Public Policy, National Minority AIDS Council Barbara Menard, Senior Policy Advocate, Human Rights Campaign Commission on AIDS Wayne J. Mitchell, Ph.D., Executive Director, Association for Drug Abuse Treatment and Prevention Clark Moore, Director for Policy and Communications, AIDS Alliance for Children, Youth, and Families Martin Ornelas-Quintero, Executive Director, The National Latina/ Latino Lesbian, Gay, Bisexual, and Transgender Organization Sally Raphel, M.S., R.N., Director of Nursing Practice, American Nurses Association Elena Rios, President, Hispanic Medical Association Ron Rowell, M.P.H., Executive Director, National Native American AIDS Prevention Center Jane Silver, Director of Public Policy, American Foundation for AIDS Research Shepherd Smith, President, Children’s AIDS Fund Research Institutions Thomas Coates, Ph.D., Director, Center for AIDS Prevention Studies, University of California at San Francisco James Curran, M.D., M.P.H, Dean, Rollins School of Public Health, Director, Center for AIDS Research, Emory University Robert H. Remien, Ph.D., Research Scientist, HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University

OCR for page R1
No Time to Lose: Getting More from HIV Prevention This page intentionally left blank.

OCR for page R1
No Time to Lose: Getting More from HIV Prevention Preface Through 1999, more than 733,000 acquired immune deficiency syndrome (AIDS) cases and 430,000 deaths from human immunodeficiency virus (HIV) infection and AIDS have been reported in the United States. Prevention efforts conducted by federal, state, and local government agencies, nongovernmental organizations, and the private sector have shown considerable success in slowing the rapid growth of the epidemic. However, the demographic face of the epidemic is changing dramatically; this in turn, is changing how the nation must respond. Men who have sex with men remain at high risk in many areas. However, racial and ethnic minorities, women, adolescents, and young adults are increasingly affected by HIV/AIDS. In addition, recent improvements in the treatment of HIV disease have enabled more people to live longer with HIV and AIDS, but have contributed to a growing complacency toward the disease. The promise of a vaccine for HIV remains only a hope, not a reality. Given these challenges, the Centers for Disease Control and Prevention (CDC) requested that the Institute of Medicine convene a committee to conduct a comprehensive review of current HIV prevention efforts in the United States. Specifically, this Committee on HIV Prevention Strategies in the United States was asked to review the HIV prevention efforts of the CDC and other Department of Health and Human Services (DHHS) agencies, as well as the efforts of various other public and private sector

OCR for page R1
No Time to Lose: Getting More from HIV Prevention This page intentionally left blank.

OCR for page R1
No Time to Lose: Getting More from HIV Prevention Acknowledgments This report represents the collaborative efforts of many organizations and individuals, without whom this study would not have been possible. The Committee extends its most sincere gratitude to the organizations and individuals mentioned below. Numerous individuals and organizations generously shared their knowledge and expertise with the Committee through their active participation in Committee workshops that were held on January 23, March 1–2, and April 13, 2000. These sessions were intended to gather information related to current HIV prevention activities in order to help inform the Committee’s vision of future prevention efforts. These individuals are listed in Appendix F. Members of the study’s liaison panel contributed valuable information and suggestions that were helpful in preparing this report. These organizations and their representatives to the liaison panel are listed on pages vii–ix. The directors and staff of the Colorado, Maryland, New York, and Connecticut state health departments hosted individual committee members during site visits. Additionally, the Centers for Disease Control and Prevention hosted the project staff during a site visit to its main offices in Atlanta, GA. The Committee would like to thank all of the individuals at the Community Planning and Leadership Summit in Los Angeles, CA, on March 29–31, 2000, who discussed the current state of HIV prevention and shared

OCR for page R1
No Time to Lose: Getting More from HIV Prevention their experiences in conducting HIV prevention at the state, local, and community level with us. Julie Scofield, Executive Director of the National Association of State and Territorial AIDS Directors, was instrumental in facilitating the Committee’s public hearing and focus groups at this meeting. The Committee is grateful to all of the individuals who shared their experiences via their responses to the Committee’s request for public comment. The Committee would like to thank the numerous staff members of the Institute of Medicine, the National Research Council, and the National Academy Press who contributed to the development, production, and dissemination of this report. The Committee is most grateful to Monica Ruiz who did a remarkable job of directing a very fast-track, complex, and demanding study, and to Alicia Gable, who showed exceptional skill in conducting research and assisting in project management. Donna Almario provided outstanding research support, as well as guidance to the new staff on IOM procedures. Cara Christie provided excellent administrative support through the first three months of the study. Anna Staton was an invaluable project assistant, who skillfully coordinated Committee meetings, organized site visits, and maintained project records and files. Rose Martinez and Susanne Stoiber provided guidance and assistance above and beyond the call of duty. Kathleen Stratton and Donna Duncan provided valuable support and advice regarding project organization. Andrea Cohen and Melissa Goodwin handled the financial accounting of the study. Mike Edington provided editorial assistance. Jennifer Otten, Vanee Vines, Neil Tickner, Jim Jensen, and Sandra McDermin provided assistance with report dissemination. We are especially grateful to Claudia Carl and Clyde Behney for cheerfully and skillfully guiding the staff through the report review process. In addition to IOM staff, we are most grateful to Jennifer Rubin for her assistance in preparing the data needed for the resource allocation scenarios in Chapter 3, to Jeffrey Levi and Andy Schneider for their noteworthy contributions to Chapter 4, and to Tom Burroughs for invaluable assistance in drafting appendices and editing the report. The Centers for Disease Control and Prevention generously provided funding and lent support to this project. Our project liaisons—Ronald Valdiserri, Lydia Ogden, and Eva Margolies Seiler—were extraordinarily helpful in providing data, information, and support throughout the course of the study. Their encouragement and support are gratefully acknowledged.

OCR for page R1
No Time to Lose: Getting More from HIV Prevention REVIEWERS The report was reviewed by individuals chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments to assist the authors and the Institute of Medicine in making the report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and the draft manuscript remain confidential to protect the integrity of the deliberative process. The Committee wishes to thank the following individuals for their participation in the report review process: Karen Basen-Engquist, Ph.D., Department of Behavioral Science, The University of Texas, M.D. Anderson Cancer Center, Houston Ronald Bayer, Ph.D., Columbia University School of Public Health Sophia Chang, M.D., M.P.H., Director, Center for Quality Management in HIV Care, Department of Veterans Affairs, Palo Alto, California Thomas Coates, Ph.D., Director, Center for AIDS Prevention Studies, University of California at San Francisco Gerald Friedland, M.D., Director, Yale AIDS Program, Yale University School of Medicine James O. Kahn, M.D., Positive Health Program, San Franciso General Hospital Harold Pollack, Ph.D., Department of Health Management and Policy, University of Michigan Liza Solomon, Dr.P.H., Director, Maryland State AIDS Administration Darrell P. Wheeler, Ph.D., Assistant Professor, Columbia University School of Social Work Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Kristine M. Gebbie, Dr.P.H., R.N., Associate Professor of Nursing, Columbia University, appointed by the Institute of Medicine and Charles C.J. Carpenter, M.D., Professor of Medicine, The Miriam Hospital, Brown University, appointed by the NRC’s Report Review Committee, who were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

OCR for page R1
No Time to Lose: Getting More from HIV Prevention This page intentionally left blank.

OCR for page R1
No Time to Lose: Getting More from HIV Prevention Contents     EXECUTIVE SUMMARY   1 1   INTRODUCTION: RETHINKING HIV PREVENTION   11 2   TRACKING THE EPIDEMIC   14      National AIDS Surveillance System,   15      Rationale for a National System of HIV Surveillance,   16      HIV Case Reporting,   16      Population-Based HIV Incidence Estimation,   19 3   ALLOCATING RESOURCES   26      Current Allocation of Federal HIV Prevention Funds,   28      Assessing the Cost-Effectiveness of HIV Prevention Interventions,   32      Protecting the Blood Supply,   33      Preventing Perinatal Transmission of HIV,   34      Implementing Needle Exchange Programs,   34      Using Epidemic Impact as a Measure of Success,   35      A Strategic Vision for HIV Prevention Investments,   37      Resource Allocation for HIV Prevention,   38      Allocating Resources at the Community Level,   39      Allocating Resources at the National Level,   39      Support for State and Local Resource Allocation,   46

OCR for page R1
No Time to Lose: Getting More from HIV Prevention 4   USING THE CLINICAL SETTING   50      Clinical Care-Based Prevention,   51      Programs That Provide Clinical Care to HIV-infected Persons,   55      Financing of HIV Care,   56      Changes Needed to Encourage HIV Prevention: Medicaid and Ryan White Care Act Programs,   58      Financing Options for Medicaid Coverage,   58      Encouraging HIV Prevention in CARE Act Programs,   61      DHHS-wide Policies to Encourage Integration of Prevention into Clinical Care,   63 5   TRANSLATING RESEARCH INTO ACTION   68      Current Efforts in Prevention Technology Transfer,   68      Barriers to Effective Technology Transfer at the Community Level,   72      Opportunities for Improving Prevention Technology Transfer,   74 6   SEARCHING FOR NEW TOOLS   80      Promising New Tools,   80      Rapid Testing Methods for Detecting HIV Antibodies,   80      Alternative Barrier Methods,   83      Antiretroviral Therapies,   86      Vaccines,   87      Promising New Collaborations,   89 7   OVERCOMING SOCIAL BARRIERS   97      Social Barriers,   98      Poverty, Racism, and Gender Inequality,   98      The Sexual “Code of Silence,”   100      Stigma of HIV/AIDS,   101      Misperceptions,   103      Lack of Leadership,   104      Unrealized Opportunities,   106      Access to Drug Treatment and Sterile Injection Equipment,   106      Comprehensive Sex Education and Condom Availability in Schools,   116      HIV Prevention in Correctional Settings,   120     APPENDIXES         A The Changing Epidemic   139     B The Prevention Portfolio: Interventions to Prevent HIV Infection   152

OCR for page R1
No Time to Lose: Getting More from HIV Prevention     C Federal Spending on HIV/AIDS   162     D Description and Mathematical Statement of the HIV Prevention Resource Allocation Model   173     E Data Gathering Activities   180     F Agendas for Public Committee Meetings   194     G Biographies   200     INDEX   213

OCR for page R1
No Time to Lose: Getting More from HIV Prevention This page intentionally left blank.

OCR for page R1
No Time to Lose: Getting More from HIV Prevention No Time To Lose Getting More from HIV Prevention

OCR for page R1
No Time to Lose: Getting More from HIV Prevention This page intentionally left blank.