AIDS and Behavior An Integrated Approach (1994) / Chapter Skim
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6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH
6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH
Pages 186-239
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From page 186... ...
. In addition, the committee reviewed a range of documents and plans produced by the institutes that describe their AIDS programs and .
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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.
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From page 188... ...
Since FY 1989, PHS agencies have used the following set of categories, called "Mason" categories {named after then Assistant Secretary for Health, fames O MasonJ: 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; an
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From page 189... ...
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.
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From page 190... ...
At NIDA, about one-third of all grants were multi-coded from 1987 through 1992. Many of these multicoded 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)
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From page 191... ...
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.
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From page 192... ...
NIDA's extramural program has employed the widest variety of mechanisms, particularly by committing resources to research demonstration projects {R18sJ. Although the committee attempted to obtain comprehensive, comparable information on all relevant funding mechanisms {i.e., extramural research project grants, contracts, intramural projectsJ from all three institutes, it was only able to do so for extramural grants.
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1 7J. Investigator-initiated research includes traditional ROls, whereas directed research efforts are usually funded using contracts, cooperative agreements, research demonstrations, and, to a large degree, research centers.
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From page 198... ...
grew from $83.4 million in FY 1987 to $171.5 million in FY 1992 a 106 percent increase. NIAAA's AIDS program supports research exploring the role of alcohol as a potential biological and psychosocial factor in the transmission of HIV infection and its progression to AIDS.
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Overall, the NIAAA AIDS program is small relative to those at NIDA and NIMH, and it has not yet inclucled significant program initiatives on the order of those at NIDA and NIMH. Because its AIDS program is small, NIAAA has never establishect an Office of AIDS and has never employed any full-time AIDS staff.
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From page 200... ...
Use of contracts has been fairly minimal, as has NIAAA's commitment to AIDS training. As with its nonAIDS program, intramural research has constituted a significant portion of AIDS funding accounting for 21 percent of the AIDS budget in FY 1987 and staying near 20 percent through FY 1993.
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/Biobehaviora] Research Since it first initiated its AIDS program, NIAAA has devoted much of its extramural and intramural research efforts to biomedical issues.
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The NIAAA intramural research program primarily has focuses!
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From page 203... ...
prospective cohort studies to examine relationships among alcohol and drug use, high-risk behavior, and HIV seropositivity among various risk groups, including alcohol-dependent abuts and adolescents; a supplement to expand an ongoing prospective survey to include information on sexual practices, drug use, AIDS knowledge, and perceived risk in investigating racial/ethnic and gender differences in the relationship between alcohol consumption and AIDS-risk behaviors; and a supplement to a National Alcohol Research Center grant to develop estimates of the incidence and prevalence of sexual risk taking and drinking and an examination of beliefs, attitudes, anal perceptions of AIDS risk. Psychosocial Research In June 1991 NIAAA issued an announcement for Research on relationships between alcohol use and sexual behaviors associated with HIV transmission.
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From page 204... ...
Another study is collecting information on how social norms, personal beliefs, and the context of drinking influence HIV risk behaviors among African American adolescents. GRANTS As mentioned above, NIAAA's AIDS research program is quite small, especially relative to NIDA and NIMH.
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From page 205... ...
Over time, while NIDA's total budget increased by more than 500 percent, its AIDS budget rose by more than 40,000 percent from $314,000 in FY 1983 to $125.3 million in FY 1992 {Figure 6.10~. NIDA's AIDS research portfolio includes a broad range of initiatives related to HIV/AIDS transmission and disease progression associated with drug abuse.
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50 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993* FIGURE 6.10 NIDA AIDS Expenditures, 1983-1993.
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Centers comprised 9 percent of AIDS funding in FY 1987, dropped to 4 percent in FY 1990, and then rose again to 12 percent in 1992. Treatment Research Demonstrations {shown as part of "other research")
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Intramural research clecreasec! slightly, from 5 percent of the NIDA AIDS budget in FY 1987 to 4 percent in FY 1992.
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PROGRAMS AND PRIORITIES Biomedica7/Biobehaviora7 Research NIDA supports biomedical research to investigate the interrelationships among HIV infection and effects of drugs of abuse on the immune, neuroendocrine, and central nervous systems. Preclinical research predominantly conducted in animal models anti isolated tissues includes research on the effects of stress on the immune system and endocrine function; the effects of various drugs on stress factors; the effects of various drugs on cellular toxins, lymphokines, receptors and other cellular functions affected by HIV/ AIDS; the hypothalamic and immunologic control of drug-moclifiecl HIV neurologic changes; and the physiological, biochemical,
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From page 210... ...
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 stud
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Initiated in 1987, this effort has allowed NIDA to systematically assess the prevalence of HIV infection among injection drug users in treatment programs in seven cities. Although data from this system suggest that levels of HIV infection among injection drug users newly admitted to methadone treatment have been fairly stable, levels of HIV risk behaviors remain high.
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From page 212... ...
And most strikingly, 25 percent of the injection drug users who had never before been in drug abuse treatment entered a treatment program during the follow-up period (Brown and Beschner, 1993~. Cooperative Agreement for Al DS Community-Based Outreach/lntervention Research The NADR program spawned a second generation of communitybased outreach initiatives at NIDA, collectively known as the Cooperative Agreement for AIDS Community-Based Outreach/lntervention Research.
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All of the cooperative agreement projects use randomized controlled trial designs, with interventions based on theoretical models and scientific sampling strategies. Although none of these projects was completed at the time this report was written, baseline data indicate that 36 percent of the injection drug users recruited had never been in drug abuse treatment, 33 percent had not received an HIV antibody test prior to participating in the study, 43 percent were borrowing needles and/or syringes from other injectors, and 11 percent of those tested for HIV antibodies were found to be seropositive.
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NADR evaluated interventions to reduce high-risk injection drug use and sexual behaviors. The second generation of programs the Cooperative Agreement for AIDS Community-Based Outreach/Intervention Research uses randomized controlled trials of interventions to reduce HIV risk behaviors among drug users and their sex part ners.
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Drug Abuse Treatment Research One of NIDA's main priorities for AIDS extramural and intramural research is to develop strategies for increasing the effectiveness of drug abuse treatment. Although treatment research historically has been a priority for NIDA, the AIDS epidemic has heightened its importance {Box 6.3J.
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From page 216... ...
to obtain evidence of use by HlV-infected injection drug users (Heimer, Myers, Cadman, et al., 1992; Myers et al., 1993~. Demographic and behavioral data were obtained from program clients at program enrollment, making it possible to relate data from the STT to individual client characteristics such as age, injection frequency, duration of drug injection and self-reported frequency of needle sharing.
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Most TRUs also include HIV testing, counseling, and education to reduce HIV-related risk behaviors. Experimental therapeutics research projects have also been funded to perform clinical trials of pharmacological and psychotherapy interventions for drug abuse.
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By 1988, 28 percent of AIDS cases were among injection drug users, who with their sex partners constituted a rapidly growing risk group. Although increased support of drug abuse treatment to combat the growing epidemics of cocaine use and AIDS was a clear need, misunderstanding and misinformation concerning the nature of drug abuse and the effectiveness of treatment were widespread.
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Faced with epidemics that threatened to overwhelm an already weakened treatment system, NIDA developed a program of research demonstrations to improve and expand treatment. The initiative was conceived in 1988 as part of a larger AIDS prevention effort under the premise that more effective drug abuse treatment would reduce many of the risk behaviors that were spreading HIV infection.
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From page 220... ...
All of these projects are behavioral interventions aimed at reducing high-risk drug-using and sexual behaviors, and all employ the randomized controlled trial methodology, which has had the effect of eliminating the social-structural component that was present in some of the earlier, NADR projects. Approximately two-thirds of these projects also include the development of a surveillance system to monitor behaviors of out-oftreatment injection drug users (and their sex partners in some projects)
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NIMH NIMH has supported research on the neuroscience, neuropsychiatric, and psychosocial aspects of HIV infection and AIDS since 1983. Research has focused on the identification of determinants of highrisk behaviors and strategies to change those behaviors, as well as the mental health and neurological consequences of HIV infection.
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100 90 80 70 60 50 ._ In ~ 40 = o 30 20 10 o 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993* FIGURE 6.15 NIMH AIDS Expenditures, 1983-1993.
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Unlike NIDA and NIAAA, the AIDS research program at NIMH has for some time been managed by a central AIDS office, which develops the AIDS plan j with input from outside consultants and various divisions and offices within NIMH) , develops the annual AIDS budget, and directs the AIDS extramural program.
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Source: NIMH Budget Office. TABLE 6.4 NIMH AIDS Staffing {FTEs)
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In collaboration with investigators at the Walter Reed Army Medical Center, intramural researchers have also been studying the consequences of HIV infection on neuropsychological and neurological function in early stages of HIV infection. To shape its extramural neuro-AIDS program, NIMH, together with the National Institute on Child Health and Human Development iNICHDJ and the National Institute on Neurological Disorders and Stroke {NINDSJ, first issued several program announcements in September 1988 to stimulate basic neuroimmunological research on the etiology and pathology of HIV infection of the brain and to investigate the neurological and psychiatric sequelae.
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From page 226... ...
Its potential application to AIDS is supported by the hypothesis that behavioral states may modulate immune defenses against HIV anct thereby alter the response to HIV exposure anct the rate of progression to AIDS in those infected. EpidemioJogica7 Research Through its AIDS research centers and investigator-initiated research grants, NIMH has supported behavioral epidemiology research to identify specific populations at risk for HIV/AIDS and to understand the specific high-risk behaviors of various populations, including homosexual and bisexual men, heterosexual women and men, adolescents, injection drug users and their partners, people with severe mental illness, and the homeless.
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From page 227... ...
Nevertheless, NIMH was able to support a vigorous research program in this area, providing for basic psychosocial research and applied research to test the effectiveness of intervention strategies in preventing transmission of HIV infection. Basic psychosocial research at NIMH includes theory development and testing of behavior change models, development and testing of assessments, and research on the determinants of behaviors.
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Basic biomedical/psychosocial grants inclucle: natural history en c! descriptive studies examining the neuropsychological and neurobehavioral sequelae of HIV infection Studies that simultaneously gather information on biological parameters and psychosocial factors)
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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.
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NIDA initiated an AIDS training program in 1986 for counselors and administrators at drug abuse treatment programs. iThis program was transferred to SAMHSA as a result of the ADAMHA reorganization.)
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NIMH are located at NIH, they are part of the funding and programmatic agenda of NIH. An understanding of the overall AIDS budget ant!
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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 l9XOs with the growing concern over pediatric AIDS, the number and ranking of the major players has remained fairly constant.
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The coordinator should be provi~led 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.
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Much of this is ~lirecte`1 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, an
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From page 237... ...
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.
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From page 238... ...
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.
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RESEARCH FUNDING, PROGRAMS, AND PRIORATES / 239 NIMH and NINDS} by collaborating in the program ~levelopment, 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.
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