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Abstract Human immunocleficiency virus (HIV), the cause of acquired immune cleficiencysyncirome (AIDS), now infects more then a million people in the Unitecl States and millions more in other countries. The cases of AIDS reported thus far are only the beginning of the expected toll, because the damage the virus inflicts on the immune system and the resulting inability of the victim to fight off infections and cancers- may not be apparent until years after initial infection. The epidemic is growing every clay, partly because persons who may not know they are infected are spreading the virus. HIV is spread in only a few ways: transmission by anal or vaginal intercourse, by intravenous (IV) cirug use, and from mother to fetus or newborn infant now preclominate. Infection occurs mostly in young aclults, usually the healthiest segment of the population. A sizable proportion of those now infected will, in a few years, progress to severe disease and cleath. If the spread of the virus is not checked, the present epidemic could] become a catastrophe. The Institute of Medicine- National Academy of Sciences Committee on a National Strategy for AIDS therefore proposes perhaps the most wide-ranging and intensive efforts ever made against an infectious disease. The situation demancis both immediate action to stem the spread of infection and a long-term national commitment to produce a vaccine and therapeutic drugs. A massive, continuing campaign should begin immediately to increase awareness of ways in which persons can protect themselves against infection, such as using concloms, avoiding anal intercourse, and not sharing cirug injection equipment. The campaign should employ all the skills and 1

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2 ABSTRACT tactics of education and media persuasion, and its message should be directed in language understandable to specific target groups, including homosexual men, intravenous drug users, sexually active heterosexuals (especially those who have had a number of partners), and adolescents. The committee estimates that by the end of the decade approximately $1 billion annually, much of it from federal sources, will be needed for education and other public health measures that it recommends, such as blood screening, voluntary confidential testing for infection, and increased efforts in the treatment and prevention of intravenous drug use. The other arm of the attack on the epidemic is research. The committee believes that a vaccine is not likely to be developed for at least five years and probably longer. One drug has recently shown benefits in the treatment of AIDS, but agents that are acceptably safe for possible long-term treatment and that effectively halt or cure the disease may also not be available for at least five years. The committee calls for extensive basic and applied biomedical investigations to better understand the disease and increase the likelihood of producing a safe and effective drug or vaccine as soon as possible. This program must involve both private industry and the public sector working together. Within the overall research effort there is a need for extensive epidemiologic investigations to assess the spread of infection and the efforts to control it. Finally, there is a need for considerable research on sexual behavior and drug use and factors that influence them. The committee believes that such a program of research will require at least $1 billion in public funds annually by 1990 and a continuing commitment over many years. These funds must be newly appropriated, not money taken from other research, because the nation's general health efforts as well as those directed against HIV need continuing progress in basic biomedical science on a broad front. The increasing need for care of patients with AIDS and other HIV- associated conditions, including those with AlDS-related complex and HlV-re~ated dementia, poses new and often difficult problems. These problems will spread widely in the next few years from the populations now . , , ~ ' ^~ I ..I. I -. ~ l r~ 1:~ i~ ebb affected. The $2- billion yearly expenditure proposed for responding to Ant epidemic is a small fraction of the billions of dollars for care that the ~nirl~mir is sine to cost. esoeciallv if it is not rapidly curbed. The optimal ~ ret , __,___ , organization of care has only begun to be studied in a few cities with the heaviest case loads, but some evidence is emerging to support community- oriented care and minimal hospitalization. The provision of such care should be designed to guarantee equity of access, and the mechanisms for more appropriately financing this care need further evaluation immediately in light of various problems now apparent. There are scientific and medical lessons to be learned about AIDS and HIV infection elsewhere in the world and compelling reasons for U.S.

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ABSTRACT 3 involvement in efforts to control the disease woriclwicle. The committee believes that the Unitecl States should be a full participant in international efforts on the problem, both through the Woricl Health Organization ancl through bilateral efforts. Fecleral agencies, notably the Centers for Disease Control, the National Institutes of Health, and the Foot] ancl Drug Administration, have contrib- uted enormously to the rapid acquisition of knowledge about AIDS ancl HIV or to techniques to help in its control. They should continue their efforts, but greater involvement of the academic ant] private sectors should be encour- agecl. Continuing evaluation of many matters will be neecled, including the spreac] of HIV, directions for research and development, the effectiveness of various efforts to promote risk-reducing behavior, ancl the appropriate level of national effort. There is also a need to mobilize existing resources ancl encourage interaction of the public and private sectors. To fill these needs- and also for informing the American public, Congress, ancl the executive branch the committee proposes a National Commission on AIDS, created either as a presidential or joint presidential ancl congressional entity. The commission should act in an acivisory capacity, because the need for integration of the nation's efforts is not presently such as to require central control that supplants the existing administrative structures. These ancl other of the committee's major recommendations are summa- rizecl at the conclusion of Chapter 1, with detailecl recommendations appearing at the encis of major sections within later chapters.

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