response to AIDS to the fact that it appeared to be a sexually transmitted disease confined to these socially marginal subpopulations. The marginality of these groups has also affected other aspects of the nation's response. Because many of those currently infected are among the poorest in the nation, with limited access to primary health care, clinical trials to assess drug efficacy are enormously complicated. These circumstances, and the basic unpredictability of the disease's future course, make the AIDS epidemic a challenge of unprecedented magnitude and complexity for both NIH and the nation. The committee's concerns about the inability of the health care delivery and financing system to respond adequately to the epidemic, and its effects on NIH's capacity to conduct research, are addressed later in this chapter.
In the midst of such concerns, however, it is wise to remember that some positive notes have been sounded as well. As the disease has become better understood, behavioral changes among some of the groups most at risk have slowed the advance of infection. In addition, new forms of therapy for those affected have begun to alter the course of the disease, making it more of a chronic than an acute condition. Yet these promising changes are making only modest inroads toward changing the epidemic's course. It is clear that initially afflicted groups are still represented among new cases and that the epidemic is spreading into hitherto untouched populations.
In response to the epidemic, NIH has developed an extensive program of AIDS research that involves every institute at the agency and every type of activity traditionally supported by NIH, ranging from basic research to clinical trials to public information campaigns. In fact, the AIDS program constitutes an unprecedented attempt to address a disease with an NIH-wide program rather than through a single institute. If all AIDS research funds at NIH were allocated to a single institute, it would be the third largest in terms of budget and staff.
NIH's role in responding to the emerging epidemic was, and continues to be, only one element of the federal government's AIDS activities. CDC, another PHS agency and the government's lead agency for investigating disease outbreaks, carried out a significant part of the government 's early efforts. In 1981 and 1982, CDC officials investigated case reports of Pneumocystis carinii pneumonia (PCP) and Kaposi's sarcoma, two of the diseases now known to be characteristic of AIDS, and the results of those investigations prompted the initiation of epidemiological studies. In contrast to the CDC focus, NIH launched studies probing the biological basis of the disease, began admitting patients to its clinical center, and began developing requests for grant applications to investigate clinical and scientific aspects of AIDS. Since AIDS was first identified, CDC, like NIH, has greatly expanded its HIV/AIDS program and continues to make significant contributions to controlling the epidemic by its surveillance and education initiatives. The other PHS agencies have also become involved.
ADAMHA, through its three institutes (the National Institute of Mental Health [NIMH], the National Institute on Drug Abuse [NIDA], and the National Institute of Alcohol Abuse and Alcoholism [NIAAA]), supports a substantial amount of research on HIV infection. NIMH supports research on neuroscience, neuropsychiatric, and behavioral aspects of HIV infection and AIDS; NIDA and NIAAA focus on the connection between drug use and HIV infection, development of more effective pharmacologic agents to treat drug addiction (increasingly a risk factor for HIV infection), and development of effective behavioral interventions to prevent or stop drug abuse.