AIDS and Behavior An Integrated Approach (1994) / Chapter Skim
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EXECUTIVE SUMMARY
EXECUTIVE SUMMARY
Pages 1-38
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From page 1... ...
The number of people afflicted by the illness has increased markedly, anal the range of communities affected has expantle(l. In the United States, while AIDS was first considered a disease of gay men, the reach of the epidemic now has expanded to injection drug users and their sexual partners, heterosexual partners of non-drug-using HIV-infected persons, infants born to mothers infected with HIV, and hemophiliacs and others exposed to blood products or blood transfusion.
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The absence of information about the actual sexual behaviors in which people are engaging has hampered AIDS prevention efforts during this period. Now, although the current climate is more supportive of such research, basic behavioral and social science research is having to catch up.
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The most salient elements of that context are: {1J the recent reorganization of the Alcohol, Drug Abuse, and Mental Health Aclministration {ADAMHAJ; {2J the new budget and program authority of the Office of AIDS Research {OARJ at the National Institutes of Health {NIHJ; {3J the budget process; and {4J the grant review process. Chapter 6 contains the committee's assessment of the content and management of the institutes' AIDS programs themselves, focusing on balance among scientific approaches, the use of various funding mechanisms to support research, anti the overall funding picture.
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From page 4... ...
In particular, the prevalence and spread of those behaviors within certain communities is unknown. SEX, DRUG USE, AND HIV TRANSMISSION As with any sexually transmitted disease, the transmission of HIV is highly dependent on the number of partners one has and the specific types of sexual practices in which one engages.
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In order to understand the potential course of the epidemic, behavioral epidemiologists have focused on determining the likelihood that infected individuals in one group will have contact with uninfected individuals in another; identifying the contexts that influence risk taking; investigating whether people in highand low-risk groups are adopting recommended preventive behaviors; and examining how the spread of HIV infection will be altered by changing patterns in concurrent epidemics of drug use ant! infectious diseases.
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In the absence of this basic information, the very existence of a biology of high-risk sexual behaviors a central missing element in basic biomedical and neurobiological AIDS research-cannot be approachecl. Some outstanding issues include: identifying the neurochemical molecular substrates, if any, associated with sexual risk taking; determining how insights from the studies of the neurobiology of sexuality would relate to high-risk sexual behavior and to sexually transmitted diseases, including AIDS; and determining how society might best integrate the stubbly of the biology of sexu
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PSYCHOSOCIAL DETERMINANTS OF RISK BEHAVIOR Theoretical models, primarily from psychology, have been used either to predict risk behavior or to predict behavior change and, less freauentIv. maintenance of positive behavior change.
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However, social influence does not begin and end with a partner. The scope and character of one's broader social network-the array of individuals upon whom one relies for support, who serve as reference groups, and who establish group standards of conduct (social normsJ and sanction behavior are central to understanding the behavior that puts one at risk for HIV infection {KlovclahI, 1985; Klov~ah!
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Even though many intervention studies have demonstrated behavior change, they may be limited in a few ways: {1J most rely solely on self-reported data; {2J for the most part they have not yet demonstrated long-term behavior change {beyond 6 monthsJ; {3J it is not yet known whether they work with populations outside of their target groups; t4) many interventions may not be cost-effective to implement on a larger scale; and {5J with few exceptions, they Lo not measure HIV transmission and do not necessarily indicate that HIV infection has been averted.
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From page 10... ...
sexual systems that mediate sexual behaviors, the CNS neural systems underlying sexual behavior, anti the molecular genetics of sexual behaviors. 3.2 The committee recommends that NIAAA, NIDA, and NIMH expand research on the biology of substance abuse to provide additional knowledge for approaching high-risk behaviors.
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3.9 The committee recommends that NIAAA, NIDA, and NIMH support research that estimates the number of HIV infections averted by current prevention efforts and that inclutles cost estimates for these efforts. DISEASE PROGRESSION AND INTERVENTION Although every effort must be made to prevent new transmission of HIV, it is equally important to diagnose, treat, and care adequately for people who already are infected.
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are common and result in considerable morbidity and mortality. Some conditions are secondary complications of HIV infection, resulting from opportunistic infections or systemic organ dysfunction that follows from immune deficiency induced by HIV infection.
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Research on ADC and CNS HIV infection has biological importance not only for understanding the nature and course of HIV infection, but also more generally for suggesting mechanisms involved in other infectious, immunological, and neuroclegenerative diseases. The early penetration of the blood-brain barrier by HIV, the local immune response detected in the spinal fluid, and the subsequent active replication of HIV in the brain late in infection hold clues regarding the CNS ecology of HIV.
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use and HIV/AIDS remains to be elucidated. Treatment of drug users who are at risk for or already infected with HIV is complicated by many factors: the fact that the clinical course of HIV infection may have special characteristics among drug injectors, the existence of complex meclical and psychosocial comorbidities, and the often tenuous relationship between drug users and the health care system.
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While not directly related to HIV infection per se, there are both diagnostic and therapeutic implications in the management of HIV infection. The bidirectional relationship between psychosocial factors and HIV infection may influence disease progression and the ability to effectively treat related symptoms.
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Stress and other nervous system perturbations may alter immune function in both animal models and humans. The complex interactions among HIV infection, immune function, and mental states have been a major theme of AIDS-related research, particularly at NIMH.
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After reviewing the literature on disease progression and intervention in Chapter 4, the committee makes a number of recommendations: 4.1 The committee recommends that NIMH continue re search on the pathogenesis of HIV infection of the brain, including the factors controlling virus replication such as local immune defenses and changes in the viral genome determining neuropathogenicity. 4.2 The committee recommends that NIGH continue re search on the pathobiology of nervous system injury underlying the AIDS dementia complex, including the morphological, biochemical, and molecular basis of neuronal dysfunction related to viral and cellular gene expression.
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4.5 The committee recommends that NIAAA, NIDA, and NIMH expand research on the natural history of HIV infection among various populations, including injection drug users, other substance abusers, and the seriously mentally ill. 4.6 The committee recommends that NIAAA, NIDA, and NIMH support research on the relationship between the medical consequences of substance abuse and related behaviors and the clinical expression of HIV among the drug-using population.
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4.12 The committee recommends that NIAAA, NIDA, and NIMH support research on the relationship between adherence to HIV/AIDS medical treatment and disease progression among individuals from diverse gender, racial/ethnic, and cultural groups. 4.13 The committee recommends that NIAAA, NIDA, and NIMH support research that integrates substance abuse and mental health treatment; in particular, demonstration projects for integrated multidisciplinary treatment systems that include mental health.
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This office was headed by a part-time acting coordinator, who also directed the NIMH AIDS office. Each institute at ADAMHA devised its own way to manage its AIDS program: NIAAA had only one or two staff acting as AIDS coordinators on a part-time basis; NIDA had an official AIDS coordinator located within one of its regular divisions; and NIMH had a formal Office on AIDS Programs with a full-time director.
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budget request. NIAAA, NIDA, and NIMH joined in the FY 1994 NIH budget process after the major internal HHS decisions already had been made about the NIH AIDS budget, although they still were affected by those decisions.
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Although the ADAMHA Reorganization Act mandated that the review processes {both at the first and second levels) be maintained through 1996, it is not yet clear how AIDS research applications at the three institutes will be reviewed when this period ends.
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5.2 The committee recommends that the NIH task force charged with streamlining peer review consider alternative scoring schemes that would favor cross-disciplinary and innovative research proposals. RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH The specific AIDS programs and priorities of NIAAA, NIDA, and NIMH are analyzed in Chapter 6.
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"Psychosocial" research includes efforts to understand psychological determinants of behavior anclbehavior change end to develop end 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.
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The level of directed research in the AIDS programs as evidenced by program announcements {PAs) , requests for applications {RFAs)
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grew from $43 million to $176 million in the same period {Figure S.1~. Since NIAAA initiated its AIDS program, it has ~levote~1 much of its extramural and intramural research efforts to biomedical issues.
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of NIDA's budget, making it the third largest AIDS budget among the NIH institutes {Figure S.2J. NIDA's AIDS portfolio has included a significant proportion of research demonstration projects (R 1 SsJ and cooperative agreements {U0 1 sJ, in a |
From page 28... ...
Epidemiological research supported by NIDA monitors HIV infection and risk behaviors among injection drug users through surveillance efforts that are an integral part of various program initiatives, including natural history studies, community-based outreach studies, and research on the sex-for-crack phenomenon. NIDA supports basic psychosocial research on the determinants of AIDS risk behaviors {including sexual and drug-using behaviors)
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From page 29... ...
The AIDS budget increased from $200,000 to $76.2 million in the same period, making it the fourth largest AIDS budget among the NIH institutes. AIDS accounted for less than 1 percent of the total NIMH budget from FY 1983 through FY 1985 and rose to 14 percent by FY 1990 {Figure S.3~.
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Basic biomedical/ psychosocial grants include: natural history and descriptive studies examining the neuropsychological and neurobehavioral sequelae of HIV infection and research examining the relationship between psychosocial factors and the immune system generally and/or with HIV disease progression specifically {in humans and nonhuman primatesJ. NIMH's few grants with a social-structural component are all basic research and focus on unclerstanding the role of social relationships and social networks in shaping an individual's HIV riskrelated behavior.
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From page 31... ...
Seven NIH institutes {including NIDA en cl NIMHJ together received the vast majority of AIDS funding during this period: 90 percent of the total AIDS budget for FY 1992 and over 90 percent of the cumulative total since 1983 {Figure S.4J. While NIAAA, NIDA, and NIMH represent a significant portion of the NIH AIDS budget, their funds are distributed quite differently from most of the other institutes.
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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.
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From page 34... ...
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.
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COLLABORATIONS BETWEEN RESEARCH AND SERVICES A major concern about the ADAMHA Reorganization Act of 1992 tsee Chapter 5) was how it would effect the relationship
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Those concerned about the splitting of the research and services programs of ADAMHA expressed fears that such separation could disrupt the linkages that existed within a single agency and make the process of "technology transfer" more difficult. Those favoring the reorganization argued that separating the programs might well enhance relationships and thus improve linkages.
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From page 37... ...
This situation is experienced at the federal level among agencies charged respectively with supporting research and services programs and is evidence by the relatively limited collaborations between the AIDS research programs at NIAAA, NIDA, anti NIMH and the AIDS services programs of SAMHSA, Centers for Disease Control and Prevention (CDCJ, and the Health Resources and Services Administration {HRSAJ, and the broader service-providing community. Even information exchange is limited.
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From page 38... ...
Having reviewed in Chapter 7 the scope of collaborations and exchanges between the AIDS research programs of NIAAA, NIDA, and NIMH and the services programs of SAMHSA and other PHS entities, the committee makes the following recommendations: 7.1 The committee recommends that NIAAA, NIDA, and NIMH ensure adequate follow-up time and money in their AIDS intervention research grants to accelerate information dissemination activities, including technical assistance. 7.2 The committee recommends that formal mechanisms be developed within the NIH institutes and other PHS agencies to foster linkages between AIDS research and services.
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