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Aids and Behavior: An Integrated Approach 6 Research Funding, Programs, and Priorities at NIAAA, NIDA, and NIMH The committee was asked to assess the adequacy of the response of NIAAA, NIDA, and NIMH to the AIDS epidemic by evaluating the scope and content of their AIDS research program activities and the balance between biomedical and behavioral research. To adequately address these two issues, the committee conducted a grant-by-grant analysis of all AIDS research projects funded by NIAAA, NIDA, and NIMH from FY 1983 (the first year of AIDS funding) through FY 1992 (the most recent year for which complete data were available). In addition, the committee reviewed a range of documents and plans produced by the institutes that describe their AIDS programs and priorities. This approach provided the committee with comprehensive budgetary and programmatic information about the institutes' research programs that was not available in one form from any source—the institutes, ADAMHA, SAMHSA, NIH, or any other PHS office. The committee's analysis was able to link specific grants to broad institute initiatives and to actual dollars committed to these various initiatives, bringing together disparate pieces of information to guide the assessment of the institutes' AIDS programs for each fiscal year and over time. This chapter presents an overview and analysis of the institutes' AIDS research funding, programs, and priorities, as well as the grants funded between FY 1983 and FY 1992, including a summary
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Aids and Behavior: An Integrated Approach of the committee's main findings with respect to program activities and balance among scientific disciplines. The discussion is organized by institute, and the grant-based information is presented according to categories developed by the committee. Further information about how the grant-based analysis was conducted—including its limitations—may be found in Appendix A; the results from the research supported are included in the general discussions in Part I. FUNDING AIDS ACTIVITIES The committee was asked to assess the "adequacy" of funding of AIDS programs at NIAAA, NIDA, and NIMH with respect to balance in the scientific portfolios and the relationship between AIDS and non-AIDS research. "Adequacy" is a subjective term, especially since some would argue that until completely effective prevention and treatment interventions are discovered for HIV, no amount of money spent on AIDS research is adequate. The committee did not wish to engage in this discussion, nor did it wish to assess the merits of funding AIDS research relative to funding other disease-related research. Rather, the committee chose to focus on the overall situation of AIDS funding at the former ADAMHA institutes and offices, from the beginning of the epidemic to the present, and to identify areas where serious inadequacies are evident. The historical review of AIDS funding presented here is based on the most recent comparable budget information provided by NIH, NIAAA, NIDA, NIMH, and SAMHSA. Therefore, expenditures are displayed and discussed using the current organizational structure of the institutes and agencies being reviewed. For example, information about SAMHSA and NIH funding reflects the current organizational splits between research and services (designated by the 1992 ADAMHA reorganization). Information about total NIH funding includes the former ADAMHA research institutes. Despite the best efforts of various budget offices, some sets of numbers may not always be completely consistent with other sets since data were derived from a multiplicity of sources and were tabulated for a variety of purposes. In addition, other problems associated with retabulating entire budgets (to make them comparable) after the reorganization arose, such as changes in what was defined as AIDS research from year to year within an institute (i.e., coding anomalies) and differences in rounding.
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Aids and Behavior: An Integrated Approach CATEGORIZING AIDS RESEARCH As mentioned earlier, the committee was charged with assessing the balance between biomedical and behavioral AIDS research at NIAAA, NIDA, and NIMH. Early in the study, however, the committee determined that these categories were too limiting for two reasons: because there were no clear definitions of "biomedical" and "behavioral," and because counterpoising these two categories masked the true level of cross-disciplinary research supported by the institutes. As the committee began to review the research portfolios grant by grant, it became apparent that labeling a project as either biomedical or behavioral was misleading, because significant portions of many projects included elements from both realms. One option the committee faced was to find an alternative way of categorizing AIDS research, by looking at other schema employed by the Public Health Service. Since FY 1989, PHS agencies have used the following set of categories, called "Mason" categories (named after then Assistant Secretary for Health, James O. Mason): Basic Science Research, which includes biomedical research, neuroscience and neuropsychiatric research, behavioral research, therapeutic agents, vaccines, and research training and extramural construction; Risk Assessment and Prevention, which includes surveillance, population-based research, information and education/prevention services; and Clinical Health Services Research and Delivery, which includes health services grants. However, although the Mason categories are more comprehensive than the simple "biomedical-behavioral" distinction, the committee felt—as had an earlier IOM committee (IOM, 1991a)—that they were not sufficient to scientifically characterize the research programs of the institutes. In particular, it was not clear under which category(ies) psychosocial and social science research best fit. Also, prior to FY 1993, individual grants funded by the institutes could not be traced to specific Mason categories. As a result of these problems, and in order to determine the balance of science among AIDS research grants, the committee developed its own simple matrix using four domains of science: biomedical/biobehavioral, epidemiological, psychosocial, social-structural, and two types of research: basic and applied. Figure 6.1 presents the committee's matrix. "Biomedical/biobehavioral" research focuses on improving knowledge about basic biological mechanisms and processes, disease pathogenesis, and clinical issues related to progression and treatment of HIV/AIDS. "Epidemiological" research focuses on
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Aids and Behavior: An Integrated Approach FIGURE 6.1 Committee Codes. of HIV and the natural history of infection and disease progression. This category also includes biostatistical research to develop and refine mathematical modeling techniques for improved forecasting of HIV seroprevalence. "Psychosocial" research includes efforts to understand psychological determinants of behavior and behavior change and to develop and evaluate preventive interventions, the effect of psychosocial variables on disease progression, and the impact of HIV/AIDS on behavior and psychological functioning. "Social-structural" research examines the social context in which HIV/AIDS is transmitted and experienced, by focusing on relationships, families, communities, institutions, and cultures rather than on individuals. Social-structural research includes research on health services, evaluation, and operations. "Basic" research studies the basic mechanisms underlying biological, neurological, behavioral, and social processes and outcomes, and includes theoretical work. ''Applied" research encompasses projects that test interventions. The committee constructed an electronic database from abstracts of funded, extramural grants at NIAAA, NIDA, and NIMH from FY 1983 to FY 1992. Each AIDS grant was either single-coded with one of the four science categories or, where appropriate, multi-coded with two or more of the science categories. Generally, the committee considered the multi-coded grants to be cross-disciplinary research. In addition, each grant was coded as either basic or applied. (See Appendix A for more information about the committee's methodology.) The committee found that a significant proportion of AIDS research at NIAAA, NIDA, and NIMH is cross-disciplinary, according to the committee's coding scheme (Figure 6.2). For example, in 1992, approximately one-third of all research project grants and research demonstrations (R18s) at NIAAA, NIDA, and NIMH were
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Aids and Behavior: An Integrated Approach FIGURE 6.2 Proportion of Multi-coded AIDS Research Grants at NIAAA, NIDA, and NIMH, 1987-1992. Note: Includes RPGs and R18s. Source: NIH CRISP system, and IOM committee database. multi-coded. Since 1987, the proportion of multi-coded grants at NIAAA rose significant. At NIDA, about one-third of all grants were multi-coded from 1987 through 1992. Many of these multi-coded grants were for NIDA-sponsored drug abuse treatment research, which utilizes a wide variety of approaches for improving drug abuse treatment and reducing HIV risk behaviors (sexual and drug using), including pharmacologic and behavioral interventions as well as enhancements for improving access and retention in treatment programs. The proportion of multi-coded grants at NIMH has actually fallen from 55 percent in 1987 to 28 percent in 1992. In 1987, NIMH's AIDS portfolio was much smaller and had a high proportion of psychoneuroimmunology grants, most of which were multi-coded. Because NIMH's AIDS program grew to include research efforts targeted to the development of behavioral interventions and basic knowledge in neuro-AIDS, multi-coded grants eventually represented a smaller proportion of the total. Using the committee's coding for basic and applied AIDS research, the analysis also discovered that most extramural AIDS research grants funded by NIAAA, NIDA, and NIMH are basic research. As demonstrated in Figure 6.3, the majority of NIAAA grants were basic research, falling from 100 percent in 1987 to 87
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Aids and Behavior: An Integrated Approach FIGURE 6.3 Proportion of Basic AIDS Research Grants at NIAAA, NIDA, and NIMH, 1987-1992. Note: Includes RPGs and R18s. Source: NIH CRISP system, and IOM committee database. percent in 1992. Representation of basic research in NIMH's AIDS research portfolio also decreased from 85 percent in 1987 to 75 percent of the total in 1992. The proportion of basic research at NIDA has fluctuated, from as low as 44 percent in 1989 to 65 percent in 1992. This is largely due to the NADR program and the Treatment Research program, both of which were categorized as applied research. MECHANISMS OF SUPPORT NIAAA, NIDA, and NIMH, like all federal research institutes, employ a range of mechanisms for supporting AIDS research. The two major categories are intramural, which is research conducted by the institute staff itself, usually in laboratories on or near the institute, and extramural, which is research conducted by nonfederal scientists at universities, health centers, and other settings around the country and the world.
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Aids and Behavior: An Integrated Approach Extramural research mechanisms include research project grants (RPGs), centers, contracts, and other research. RPGs include: traditional investigator-initiated grants (R01s); research program projects (P01s); cooperative agreements (U01s), which support investigators at different sites working from a common research protocol with some variation in study population or mode of intervention; Small Business Innovation Research grants (SBIR-R43/44); and other research grants (including new investigator awards, first independent research support and transition [FIRST] awards, and methods to extend research in time [MERIT] awards). The vast majority of RPGs funded by NIAAA, NIDA, and NIMH are R01s. Research centers include specialized centers (P50s) and core grants (P30s), both of which support groups of researchers at a single institution working on a common theme. Other research includes research demonstrations (R18s), which typically test the efficacy of theory-driven pilot programs in an applied setting, cooperative clinical research (R10/U10), and research career program awards (K-series). There are two types of contract awards (N-series): research and development, and resource and support. Training includes individual awards (F-series) and institutional awards (T-series). Together, all of these mechanisms make up the extramural research program of an institute. NIAAA, NIDA, and NIMH have utilized all mechanisms for supporting extramural AIDS research, but in different proportions. For example, the majority of NIAAA's extramural research grants and dollars have been committed to R01s. NIMH AIDS extramural funding has been largely committed to R01s and research centers (P50s). NIDA's extramural program has employed the widest variety of mechanisms, particularly by committing resources to research demonstration projects (R18s). Although the committee attempted to obtain comprehensive, comparable information on all relevant funding mechanisms (i.e., extramural research project grants, contracts, intramural projects) from all three institutes, it was only able to do so for extramural grants. (Only NIMH provided complete information on its intramural program; and the contract data obtained were not comparable to the grant information.) Consequently, the analysis of grants presented below is limited to extramural research grants only. Discussions about contracts and intramural research reflect information gathered from sources other than the database. Moreover, because of the limitations of the available data (described in Appendix A)—most notably the fact that the institutes did not systematically nor consistently code grants as AIDS-related before
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Aids and Behavior: An Integrated Approach FY 1987—the specific analysis of the grants focuses primarily on the research portfolios beginning in FY 1987. In the discussions of the grants in this chapter, the figures display the total proportion of research project grants, demonstration projects, and cooperative agreements (R01s, R18s, U01s, U10s, U18s) that were coded by the committee for each scientific domain. Percentages represent an institute's total level of commitment in a given scientific domain. Multi-coded grants appear in all relevant domains; for example, a grant that has both a bio-medical and a psychosocial component is included in both the "biomedical/biobehavioral" and the "psychosocial" categories in the figures (as a way of illustrating how many grants include at least a component of a given scientific domain). Center grants (P50) are not included in this analysis because of their unique structure; however, they represent a significant proportion of AIDS grants (especially at NIMH) and involve cross-disciplinary research. They are, therefore, discussed elsewhere in this chapter. Details of the differential use of mechanisms embedded in the discussions of the institutes' AIDS programs below indicate that in general, when compared to non-AIDS research, a greater proportion of AIDS research at NIAAA, NIDA, and NIMH has been directed in some way by the institutes (see Figures 6.6, 6.7, 6.11, 6.12, 6.16, and 6.17). Investigator-initiated research includes traditional R01s, whereas directed research efforts are usually funded using contracts, cooperative agreements, research demonstrations, and, to a large degree, research centers. The institutes can also help guide the field by issuing a general Program Announcement (PA) or a Request for Applications (RFA). PAs and RFAs reflect the institutes' research priorities. A program announcement is broader than an RFA, and it usually contains suggested research areas. There is no money specifically set aside to fund grants submitted in response to a PA; such grants are funded out of the institute's general funds. An RFA, on the other hand, does have specific funds set aside for grants submitted in response to its release. RFAs usually are more specific than PAs and they specify certain selection criteria. Also, RFAs have one receipt date, whereas PAs remain active for longer periods of time. Table 6.1 lists AIDS-specific and AIDS-related PAs and RFAs issued by NIAAA, NIDA, and NIMH since the beginning of their respective AIDS programs. It does not include general program announcements for FIRST awards, small grants, and fellowships. The level of directed research in the AIDS programs—as evidenced by PAs, RFAs, and the funding of core and center grants—
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Aids and Behavior: An Integrated Approach TABLE 6.1 AIDS-Specific and AIDS-Related Program Announcements (PAs) and Requests for Applications (RFAs): NIAAA, NIDA, and NIMH Date PA/PFA # Title (funds availablea) Mechanisms Institute(s) 1/94 PA-94-023 HIV Therapeutics in Drug Abuse R01-R29-R03 NIDA 11/93 PA-94-010 Research on Needle Hygiene and Needle Exchange Programs R01 NIDA 11/93 DA-94-02 Behavioral Therapies Development Program ($3 million for first year) b R01-R03-R29-IRPG NIDA 10/93 AA-94-03 Alcohol and Minorities: Biomedical and Behavioral Research ($2 million for FY 94)c R01-R29 NIAAA 10/93 AA-94-01 Biomedical and Behavioral Research on Alcohol and Womend R01-R29 NIAAA 10/93 AA-94-02 Biomedical and Behavioral Research on Alcohol and Youthc R01-R29 NIAAA 10/93 AA-94-05 Health Services Research on Alcohol-Related Problemsc R01-R29-T32 NIAAA 10/93 AA-94-04 Underdeveloped Areas of Alcohol Abuse Prevention Researchc R01-R29 NIAAA 9/93 PA-93-111 Partner Notification to HIV-infected Drug Users R01 NIDA 9/93 PA-93-110 Health Care Services for Persons with HIV Infection R01 AHCPR-NIAAA-NIDA-NIMH 9/93 PA-93-106 Drug Abuse Treatment for Women of Childbearing Age and Their Children ($5 million for FY 94)b R01 NIDA 8/93 PA-93-100 Research Program to Improve Drug Abuse Treatment ($10 million for FY 94)b R01 NIDA 7/93 PA-93-098 Drug Abuse Aspects of AIDS (Revised) R01-R03-R29 NIDA 6/93 AI-93-14 Center for AIDS Research/Core Support Grant (NIMH set aside $1.5 million) P30 NIAID-NIMH 5/93 PA-93-087 National Research Service Awards (NRSA) Institutional Training Grants for AIDS T32 NIAID-NIMH 4/93 PA-93-080 Determinants of Effective HIV Counseling R01-R03-R29 NIDA-NIMH 2/93 PA-93-47 Preventing Alcohol-Related Problems Among Ethnic Minoritiesc R01-R03-R29 NIAAA 1/93 PA-93-44 The Spread of Tuberculosis Among Drug Users ($3 million for FY 93) d R01-R03-R29 NIDA
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Aids and Behavior: An Integrated Approach 12/92 PA-93-28 Research to Improve Drug Abuse Treatment, Entry, Retention, Compliance, and Effectivenessb R01-R03-R29 NIDA 12/92 PA-93-27 Psychotherapy, Behavior Therapy, and Counseling in Drug Treatment b R01-R03-R29 NIDA 11/92 PA-93-21 Drug Abuse Treatment of Criminal Justice-Involved Populationsb R01 NIDA 10/92 PA-92-110 Development of Theoretically Based Psychosocial Therapies for Drug Dependenceb R01-R03-R29 NIDA 10/92 PA-93-009 Neural, Endocrine, Immune, and Viral Interactions, Behavior and Mental Healthd R01-R03-R29-P01-T32-K series-F series NIMH-NINDS 7/92 PA-92-95 Neuro-AIDS: HIV-1 Infection and the Nervous System R01-R29-P01 NIMH-NINDS 5/92 AA-92-03 Alcohol Research Center Grants ($1.7 million)d P50 NIAAA 5/92 MH-92-11 The Role of the Family in Preventing and Adapting to HIV Infection and AIDS ($1.8 million for FY 93) R01 NIAAA-NIDA-NIMH 3/92 PA-92-46 Research on the Prevention of Alcohol Abuse Among Youthc R01-R03-R29 NIAAA 3/92 PA-92-58 Clinical Research on Human Development and Drug Abuse ($10 million for FY 93)d R01-R03-R13-R29-F31-F32-T32-K20-K21 NIDA 10/91 PA-92-12 Research Grants on Alcohol and Immunology Including AIDS ($2 million for FY 92) (Revised) R01-R03-R29 NIAAA 6/91 PA-91-75 Research on Relationships between Alcohol Use and Sexual Behaviors Associated with HIV Transmission R01-R03-R29 NIAAA 12/90 PA-90-31 Drug Abuse Researchd (No longer used) R01-R03-R13-R29-R43-R44-P01-R18 NIDA 6/90 PA-90-15 Children with HIV Infection and AIDS R01-R29 NCNR-NICHD-NIDA-NIMH-NINDS 1/90 DA-90-05 Research Demonstration Program to Enhance Drug Abuse Treatment ($10 million for FY 90)b R18 NIDA 1/90 DA-90-02 A Cooperative Agreement for AIDS Community-Based Outreach/Intervention Research ($3 million for FY 90) U01 NIDA
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Aids and Behavior: An Integrated Approach Date PA/PFA # Title (funds availablea) Mechanisms Institute(s) 1/90 DA-90-10 Demonstration Research on Service Delivery in Non-Traditional Settings R18 NIDA 1/90 PA Drug Abuse Aspects of AIDS ($15 million for FY 90) (Revised in 1/93) R01-R03-R29-P01 NIDA 10/89 PA National Research Service Awards for Institutional Training Grants in HIV Infection and AIDS T series NIAAA-NIDA-NIMH 10/89 PA National Research Service Awards for Individual Fellows in HIV Infection and AIDS T series NIAAA-NIDA-NIMH 11/88 DA-89-01 Research Demonstration Program to Reduce the Spread of AIDS by Improving Treatment for Drug Abuse ($10 million for FY 89) R18 NIDA 9/88 PA Research Grants on Alcohol and Immunology Including AIDS (Revised in 10/91) R01-R29-P01 NIAAA 9/88 PA Research on Severely Mentally Ill Persons at Risk of or with HIV Infection R01-R29 NIMH 9/88 PA Research on Behavior Change and Prevention Strategies to Reduce Transmission of HIV R01-R03-R29-P01-K series CDC-NCNR NHLBI-NIA-NIAAA NICHD-NIDA-NIMH 9/88 PA Measurement, Course, and Treatment of HIV-Related Mental Disorders R01-R03-R29-P01-P50-K series NIMH 9/88 PA Brain, Immune System, and Behavioral and Neurological Aspects of HIV R01-R03-R29-P01-P50-K series NICHD-NIMH-NINCDS 9/88 PA Central Nervous System Effects of HIV Infection: Neurobiological, Neurovirological, and Neurobehavioral Studies R01-R03-R29-P01-P50-K series NICHD-NIMH-NINCDS 9/88 MH-86-16 AIDS Research Centers P50 NIDA-NIMH
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Aids and Behavior: An Integrated Approach behavioral interventions for HIV prevention. Single-coded applied psychosocial grants use behavioral outcome measures only. Many NIMH research grants are multi-coded for biomedical and psychosocial research components. Applied biomedical/psychosocial grants include: behavioral interventions for HIV prevention that incorporate outcome measures such as HIV seropositivity rates and/or STD rates in addition to behavioral outcome measures, and treatments and interventions for AIDS-related depression and emotional distress. Basic biomedical/psychosocial grants include: natural history and descriptive studies examining the neuropsychological and neurobehavioral sequelae of HIV infection (studies that simultaneously gather information on biological parameters and psychosocial factors); research examining the relationship between psychosocial factors (including social stress, dominance ranking in social groups, social isolation, and social companionship) and the immune system generally with HIV disease progression specifically (in humans and non-human primates). Most single-coded biomedical grants are basic research and include: psychoneuroimmunology and neuroimmunology research grants that focus on biological processes and mechanisms (mostly in animals, some in humans); research on neural-immune-endocrine interactions; research on neural cell functions; research on CNS pathology; and research on AIDS dementia complex. NIMH has funded several applied biomedical grants, that are therapeutic interventions. NIMH's few grants with a social-structural component are all basic research and focus on understanding the role of social relationships and social networks in shaping an individual's behavior. Although research centers account for a significant proportion of AIDS research funding at NIMH, they are not included in the table above. Because the centers have received funding from other institutes as well as NIMH, they are among the collaborative projects described below. COLLABORATIVE PROJECTS NIAAA, NIDA, and NIMH have collaborated on a number of AIDS research activities. For example, the three institutes issued joint program announcements in September 1988 for Research on behavior change and prevention strategies to reduce transmission of HIV (with four other NIH institutes and CDC) and for the Role of family in preventing and adapting to HIV infection and
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Aids and Behavior: An Integrated Approach AIDS. The institutes also have jointly sponsored multidisciplinary extramural AIDS research centers at institutions around the country. AIDS RESEARCH CENTERS AIDS research centers were first initiated in 1986 to provide support for coordinated, multidisciplinary research programs on the mental health and drug abuse aspects of HIV/AIDS. Since 1986, NIMH has supported five AIDS research centers. NIDA contributed some funding to three of these centers from 1986 through 1991. The Center for Biopsychosocial Study of AIDS at the University of Miami was initially funded in 1986 to focus on biopsychosocial aspects of AIDS. At the intersection of biomedical and psychosocial research, the Miami center has investigated the relationship between lifestyle changes and disease progression as measured by neurocognitive and immune status. Researchers at the UCSF Center for AIDS Prevention Studies (CAPS), also established in 1986, have conducted basic and applied research on sex and drug-related risk behaviors among a range of populations varying by sexual orientation, gender, race/ethnicity, and age. These projects include the National AIDS Behavioral Surveys (NABS), the AIDS in Multiethnic Neighborhoods (AMEN) study, studies of Latino and Latina Americans, and studies focused on improving sexual behavior research methods. The HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University was established in 1987. This center has been committed to research on the behavioral manifestations of HIV infection and disease progression. More recently, it refined its research goals to the investigation of the determinants of sexual risk behavior for HIV and behavior change among heterosexual women and men and among the homeless mentally ill, developmental principles of sexual risk behavior during childhood and adolescence, the involvement of CNS in advanced stages of HIV disease, and improved methodological techniques. Beginning in 1987, NIMH supported AIDS Research Centers to address key neurobiological and behavioral issues through inter-disciplinary research on the CNS effects of HIV, ADC, neuropsychiatric aspects of HIV infection, brain-immune interaction, and behavior change and prevention. The HIV Neurobehavioral Research Center at the University of California, San Diego was established in 1989 to investigate neurobehavioral functioning and to identify
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Aids and Behavior: An Integrated Approach specifically the effect of HIV on the CNS. Using neuropsychological, neuropsychiatric, and neuroimaging techniques, this center is investigating etiology, pathogenesis, and natural history of neuro-behavioral disturbances associated with HIV/AIDS. The Research Center on Molecular and Cellular Mechanisms of AIDS Dementia at the Scripps Research Institute in La Jolla, California was established in 1990 to investigate the molecular and cellular mechanisms underlying ADC. Investigators at this center have conducted multidisciplinary research to define the biological actions of persistent virus infections of the brain, the profiles of cell-to-cell signals activated by these infections, and the nature of the effects of these signals on neuron function, by conducting comparative evaluations of brain pathophysiology in AIDS patients with that found in three animal models. Currently, NIMH is still funding four of the AIDS research centers: the Center for AIDS Prevention Studies, the HIV Center for Clinical and Behavioral Studies, the HIV Neurobehavioral Research Center, and the Research Center on Molecular and Cellular Mechanisms of AIDS Dementia. As this report was being written, NIMH announced it had funded under the ''core" mechanism a new Center for AIDS Intervention Research (CAIR) at the Medical College of Wisconsin. This center will focus attention on HIV prevention and HIV mental health service intervention research. TRAINING Training has been an integral part of the AIDS programs at NIAAA, NIDA, and NIMH. NIAAA has funded training for AIDS-related alcohol research and has contributed to collaborative efforts to develop AIDS and substance abuse curricula for health care providers. NIDA initiated an AIDS training program in 1986 for counselors and administrators at drug abuse treatment programs. (This program was transferred to SAMHSA as a result of the ADAMHA reorganization.) NIDA also funds a number of training grants for predoctoral and postdoctoral students on research issues related to drug abuse and AIDS. NIMH training efforts are designed to prepare young scientists for careers in AIDS research. Training grants are awarded to individuals and to institutions committed to HIV-related mental health research, and the NIMH AIDS research centers provide training programs for new investigators. NIMH has trained more than 40,000 health care providers in the neuropsychiatric and psychosocial aspects of HIV/AIDS
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Aids and Behavior: An Integrated Approach through the NIMH AIDS Health Care Provider Training Program initiated in 1986. THE NIH CONTEXT Now that NIAAA, NIDA, and NIMH are located at NIH, they are part of the funding and programmatic agenda of NIH. An understanding of the overall AIDS budget and program context at NIH will provide some insight into how the former ADAMHA institutes will function in the NIH environment. Total NIH funding increased more than 100 percent between 1983 and 1993 (from $4.3 billion to $10.3 billion). While the growth in AIDS research in the same period appears to be explosive, it reflects the requirement to respond rapidly to a new disease with major public health implications (Figure 6.19). Seven NIH institutes and centers (including NIDA and NIMH) received the vast majority of AIDS funding during this period (Figure 6.20). In order of magnitude, based on FY 1992 expenditures, they are: the National Institute of Allergies and Infectious Diseases (NIAID), which received 43 percent; the National Cancer Institute (NCI), which received 16 percent; NIDA, FIGURE 6.19 NIH Expenditures (AIDS/Non-AIDS), 1983–1993. Note: Includes NIAAA, NIDA, and NIMH for all years. *Estimate. Source: NIH Budget Office.
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Aids and Behavior: An Integrated Approach FIGURE 6.20 NIH AIDS Research Funding by Component, 1992. Source: OAR and Division of Financial Management, NIH.
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Aids and Behavior: An Integrated Approach which received 12 percent; NIMH, which received 7 percent; the National Center for Research Resources (NCRR) and the National Heart, Lung, and Blood Institute (NHLBI), which each received 5 percent; and the National Institute of Child Health and Human Development (NICHD), which received 3 percent. These seven institutes together received 90 percent of the total NIH AIDS budget for FY 1992 and over 90 percent of the cumulative total since 1983. With the exception of NICHD, whose funding increased suddenly in the late 1980s with the growing concern over pediatric AIDS, the number and ranking of the major players has remained fairly constant. AIDS constituted a major portion of the budget for each of the seven institutes (Table 6.5). For example, in FY 1992 nearly half of NIAID's budget, nearly one-third of NIDA's budget, and 16 percent of NCRR's budget were devoted to AIDS. Just 2 percent of the cumulative total of the other institutes was for AIDS research. While NIAAA, NIDA, and NIMH together represent a significant portion of the NIH AIDS budget, their funds are distributed quite differently from most of the other institutes. In FY 1992, NIAAA, NIDA, and NIMH together comprised $209.4 million or approximately 20 percent of the total NIH AIDS budget (NIAAA's portion is minor, however). According to estimates for FY 1993, the three institutes continued to account for 11 percent of the total NIH budget and 20 percent of the AIDS budget. Yet they TABLE 6.5 AIDS Funding as Proportion of 1992 Budget, Selected NIH Institutes (Dollars in Millions) Institute AIDS Total % AIDS NCI 165.7 1,947.6 9 NHLBI 46.2 1,190.1 4 NIAID 448.9 960.1 47 NICHD 34.7 518.6 7 NIMH 76.1 560.8 14 NIDA 125.3 399.1 31 NIAAA 8.0 171.5 5 NCRR 50.1 314.2 16 Other 94.6 3,948.4 2 TOTAL 1,049.6 10,010.4 10 Source: Division of Financial Management, NIH.
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Aids and Behavior: An Integrated Approach funded more than 97 percent of NIH's behavioral research (as defined by the Mason categories), 64 percent of surveillance, 54 percent of neuroscience and neuropsychiatric research, and over 30 percent of health services research and research training. On the other hand, NIAAA, NIDA, and NIMH account for less than 1 percent of the funding for therapeutic agents and 12 percent of the funding for biomedical research, two categories that together represent nearly 60 percent of the total NIH AIDS budget. It is clear that NIAAA, NIDA, and NIMH play a critical role in the overall NIH AIDS research agenda and particularly in its biobehavioral and behavioral agenda. However, at the time this report was written, the overall NIH agenda was in the process of being reformulated, reflecting the requirements of the NIH Reauthorization Act that vested new authority for AIDS planning and budgeting within OAR. In addition to new budgetary authority, OAR also was given responsibility for developing and coordinating a five-year strategic plan for AIDS research across the NIH institutes. The general outline of that plan has been developed, and five AIDS-related research categories have been identified: natural history and epidemiology; etiology and pathogenesis; therapeutics; vaccines; and behavioral research. (Social research for the most part will likely be subsumed under the "behavioral" category.) Coordinating committees composed of NIH staff and external experts will formulate strategies regarding research priorities, goals, and objectives within these categories, across institutes. (The plan also discusses training and infrastructure and information dissemination.) Eventually, OAR will attach budget allocations to various institutes based on these strategies. It is not clear yet how these OAR-level activities will be linked with the AIDS program activities of specific institutes. For example, although the ADAMHA Reorganization Act required that NIDA and NIMH create an Office on AIDS, it did not specify how these entities should work with the NIH OAR. Without knowing at the time this report was written how these offices plan to work together, the committee believes that all three institutes should have an AIDS coordinator for whom this job is the primary responsibility. The coordinator should be provided appropriate resources to develop and coordinate the institute's AIDS programs in cooperation with division and branch staff. The coordinator also should be linked to the OAR and the activities of its coordinating committees. It is the committee's understanding that at least in some cases, such as at NIMH, this is already occurring.
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Aids and Behavior: An Integrated Approach CONCLUSION AND RECOMMENDATIONS CONCLUSION The AIDS research programs of NIAAA, NIDA, and NIMH have developed over the past decade in response to growth and change in the HIV/AIDS epidemic itself. Increased recognition of the substance abuse and mental health aspects of AIDS is both a reflection of and encouragement for the institutes' involvement in AIDS research during this period. This is evidenced by the precipitous growth in funding of the institutes' AIDS programs, which has significantly outpaced growth in overall funding. Characterizing and evaluating the content of the institutes' AIDS programs is a difficult task. Coding by any scheme—whether scientific domain or AIDS versus non-AIDS—is an imperfect science. Moreover, assessing the value of the research supported is hampered for applied research by a notable lack of evaluative studies, and for basic research by the recognition that the benefits of any study may not be discovered for some time after it is conducted—and that findings may end up benefitting a different area than that imagined by the investigators. Nevertheless, the effort undertaken by the committee to assess the AIDS research programs of NIAAA, NIDA, and NIMH did reveal some important findings. Chief among these is that a significant amount of cross-disciplinary research is being supported. Much of this is directed research, which indicates a recognition on the part of the institute staff that understanding and intervening in the substance abuse, sexual behavior, and mental health aspects of AIDS requires a complex approach that takes into account the interactions of neurobiological, psychological, and social factors in the lives of individuals. The committee is encouraged by this, and would like to see the appreciation of cross-disciplinary research applied to investigator-initiated grants as well. A related finding is that the overall balance between what could be considered "biomedical" and "behavioral" (primarily psychological) research at the institutes generally has improved over time (there is greater parity in the number and funding of grants in both domains). NIMH has most consistently balanced its portfolio; and NIAAA has moved quickly in the last couple of years to achieve greater balance. NIDA, however, moved away from its earlier balance toward favoring biomedical research, following the transfer of the NADR program out of its portfolio. In all cases, however, the ''behavioral" category is primarily composed of
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Aids and Behavior: An Integrated Approach psychosocial grants; social-structural research is notably undersupported at all three institutes. A second important finding of the committee's analysis is that most AIDS research supported by the institutes is basic science research. This suggests that there is still a need to uncover the basic mechanisms and processes by which HIV is transmitted, experienced, and prevented in different populations. While the epidemic cries out for the quick application of basic research findings to intervention programs, this will prove ineffective in achieving its intended goal—the prevention of new HIV infections—unless basic research is solid. With respect to AIDS, although there have been significant developments in basic research on sexual behavior, drug addiction, and the effect of the HIV on the CNS, much remains to be learned. Advances in AIDS research at NIAAA, NIDA, and NIMH—especially in the neurosciences and social sciences—will have significant implications for other areas of research at these institutes and others. These advances relate to broader phenomena, such as neurobiological drives toward addiction and sexual gratification, mental health and illness, and the role of social structure and culture in influencing individual behavior. RECOMMENDATIONS FOR RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH 6.1 The committee recommends that NIAAA, NIDA, and NIMH each establish a position for a full-time AIDS coordinator. The coordinator should be provided appropriate resources to develop and coordinate the institute's AIDS programs in cooperation with division and branch staff. The coordinator also should be linked to the NIH Office of AIDS Research. 6.2 The committee encourages OAR to serve as a catalyst for cross-institute and cross-PHS agency research collaborations through its funding authority and leadership role. 6.3 The committee recommends that the OAR leadership include competence in biomedical, neuroscience, behavioral, and social science perspectives. 6.4 The committee recommends that NIAAA, NIDA, and NIMH ensure the maintenance of the behavioral and social science research programs of the three institutes within the NIH context. The committee supports the recommendation
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Aids and Behavior: An Integrated Approach of the National Commission on AIDS (1993b) to expand research in the following behavioral and social science research perspectives: behavioral epidemiology; cognitive science; cultural and ethnographic studies; intervention research; mental health research; behavioral aspects of technological interventions; and organizational studies. The committee adds to that list cost-effectiveness research and evaluation research. 6.5 The committee notes that, of all the types of AIDS research at NIAAA, NIDA, and NIMH, social science research is the most underfunded. The committee therefore recommends that the three institutes develop new initiatives to support research on the role of social, cultural, and structural factors in HIV/AIDS transmission, prevention, and intervention. 6.6 The committee recommends that, given the prominent role of drug injection in HIV transmission and given the considerable evidence that has been assembled over the past several years regarding the efficacy of needle exchange, the U.S. government remove current restrictions barring federal funding for needle exchange programs, promote services-oriented research to help implement such programs where warranted, and evaluate these programs with an eye toward maximizing their preventive impact. 6.7 The committee recommends that drug abuse treatment research at NIDA be continued to support the design and evaluation of innovative and cross-disciplinary drug abuse treatment strategies, including collaborative efforts with SAMHSA. These strategies should include those targeted to highrisk populations, such as drug-involved offenders, prisoners, women, and crack-cocaine users. The committee urges NIDA to pay particular attention to developing treatment strategies for crack-cocaine. 6.8 The committee recommends that NIAAA, NIDA, and NIMH restore support for research demonstration projects, using a mechanism similar to the R18 that facilitates cooperation between the NIH research institute and the relevant PHS services agency or agencies. 6.9 The committee recommends that an effort be made to coordinate between institutes that have overlapping AIDS research programs (for example, HIV and CNS function at
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Aids and Behavior: An Integrated Approach NIMH and NINDS) by collaborating in the program development, review, and funding processes. 6.10 Given the disproportionate impact of the epidemic on men, African Americans, and Hispanics/Latinos, it is important to understand the sociocultural-specific factors—including gender, race/ethnicity, and class—that play a role in the behavioral aspects of AIDS. Therefore, the committee recommends that NIAAA, NIDA, and NIMH, with input from appropriate experts, develop a mechanism for collecting and reporting data on the gender, race/ethnicity, and socioeconomic status (class) of study populations in projects supported by the institutes. Such data collection and reporting should be guided by clear articulation of the role of these variables in the epidemic.
Representative terms from entire chapter: