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AIDS and Behavior: An Integrated Approach (1994)

Chapter: FRONT MATTER

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

AIDS and Behavior

An Integrated Approach

Judith D. Auerbach, Christina Wypijewska, and H. Keith H. Brodie, Editors

Committee on Substance Abuse and Mental Health Issues in AIDS Research

Division of Biobehavioral Sciences and Mental Disorders

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.
1994

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

National Academy Press
2101 Constitution Avenue, N.W. Washington, D.C. 20418

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance.

This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.

The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.

Support of this project was provided by the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, and the National Institute of Mental Health.

Library of Congress Cataloging-in-Publication Data

Copyright 1994 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America.

The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on relief carving from ancient Greece, now held by the Staalichemuseen in Berlin.

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

COMMITTEE ON SUBSTANCE ABUSE AND MENTAL HEALTH ISSUES IN AIDS RESEARCH

H. Keith H. Brodie,*Chair, President Emeritus and James B. Duke Professor of Psychiatry, and Professor of Law,

Duke University, Durham, North Carolina

Hortensia de los Angeles Amaro, Professor,

Department of Social and Behavioral Sciences, Boston University School of Public Health, Boston, Massachusetts

Ira B. Black, Professor and Chair,

Department of Neuroscience and Cell Biology, University of Medicine and Dentistry of New Jersey, The Robert Wood Johnson Medical School, Piscataway, New Jersey

Colleen Conway-Welch, Professor and Dean,

Vanderbilt University School of Nursing, Nashville, Tennessee

Curtis L. Decker, Executive Director,

National Association of Protection and Advocacy Systems, Inc., Washington, D.C.

Baruch Fischhoff,* Professor of Social and Decision Sciences and of Engineering and Public Policy,

Carnegie Mellon University, Pittsburgh, Pennsylvania

Mindy Thompson Fullilove, Associate Professor of Clinical Psychiatry and Public Health,

Columbia University, and Research Psychiatrist, New York State Psychiatric Institute Community Research Group, New York, New York

Kristine M. Gebbie,* Former Secretary,

State of Washington Department of Health, Olympia, Washington

Margaret A. Hamburg, Health Commissioner,

New York City Department of Health, New York, New York

James G. Haughton,* Senior Health Services Policy Advisor,

Los Angeles County Department of Health Services, Los Angeles, California

James A. Inciardi, Professor and Director,

Center for Drug and Alcohol Studies, University of Delaware, Newark, Delaware

Ernest H. Johnson,± Associate Professor and Director of Behavioral Medicine,

Morehouse School of Medicine, Atlanta, Georgia

*  

IOM Member

  

Resigned August 1, 1993, upon appointment as National AIDS Policy Coordinator, The White House

±  

Served through July 15, 1993

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

Edward H. Kaplan, Professor of Management Sciences,

Yale School of Organization and Management, and

Professor of Medicine,

Yale School of Medicine, New Haven, Connecticut

Richard W. Price, Professor and Head,

Department of Neurology, University of Minnesota, Minneapolis, Minnesota

Alfred Saah, Associate Professor of Epidemiology,

School of Hygiene and Public Health, and

Associate Professor of Medicine,

School of Medicine, Johns Hopkins University, Baltimore, Maryland

Peter Selwyn, Associate Director, AIDS Program, and Associate Professor of Internal Medicine, Epidemiology, and Public Health,

Yale University School of Medicine, New Haven, Connecticut

LIAISON TO THE COMMITTEE

Susan Folkman, Co-Director,

Center for AIDS Prevention Studies, and

Professor of Medicine,

University of California, San Francisco, San Francisco, California

STUDY STAFF

Judith D. Auerbach, Study Director

Christina Wypijewska, Project Officer

Karen Autrey, Project Assistant

Holly Dawkins, Research Assistant

Robert Cook-Deegan, Director,

Division of Biobehavioral Sciences and Mental Disorders

Constance M. Pechura, Associate Director,

Division of Biobehavioral Sciences and Mental Disorders

OTHER IOM STAFF

Michael A. Stoto, Director,

Division of Health Promotion and Disease Prevention

Leslie Hardy, Study Director,

AIDS Activities

Gail Spears, Administrative Assistant,

Division of Biobehavioral Sciences and Mental Disorders

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

Preface

In its FY 1992 appropriations bill for the Departments of Labor, Health and Human Services, and Education (P.L. 102–170), Congress called for an assessment of the AIDS research programs of the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). This action resulted in part from a long-standing concern among members of Congress, the behavioral and social science community, and AIDS advocates that insufficient attention was being paid by federal research agencies to the potential contributions of behavioral and social science research to AIDS prevention efforts.

Congress specifically directed ADAMHA to contract with the Institute of Medicine (IOM) to undertake a study that was to "include, but not be limited to an assessment of the mission, programs, management, and funding levels" of the ADAMHA AIDS research and services programs. The mandate specifically required that the evaluation of ADAMHA's AIDS programs be similar to the previous IOM assessment (1991a) of the AIDS programs of the National Institutes of Health (NIH) and that it (1) assess the balance between biomedical and behavioral research in the AIDS research programs, (2) pay particular attention to behavioral-science-based AIDS prevention efforts at ADAMHA, and (3) assess the links between AIDS research and services programs in ADAMHA (Senate Report 102–104:154).

In order to conduct the study, IOM convened the Committee on Substance Abuse and Mental Health Issues in AIDS Research, which was composed of fourteen members with expertise in clinical

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

medicine, epidemiology, neurology, neuroscience, nursing, operations research, psychiatry, psychology, public advocacy, public health, and sociology. Many committee members also had extensive experience in the areas of AIDS, mental health and illness, and substance abuse.

Once the study was under way, however, two events occurred that had a direct effect on the ability of the committee to conduct the project as mandated. First, after a year of debate and consideration, Congress passed the ADAMHA Reorganization Act of 1992, which, effective October 1, 1992 (the day after the IOM contract began), restructured ADAMHA by separating out its research and services functions. The three research institutes—National Institute on Alcohol Abuse and Alcoholism (NIAAA), National Institute on Drug Abuse (NIDA), and National Institute of Mental Health (NIMH)—were transferred to NIH. The two services offices—Office of Substance Abuse Prevention (OSAP) and Office of Treatment Improvement (OTI)—were renamed Centers (CSAP and CSAT) and, along with a newly created Center for Mental Health Services (CMHS), were reconstituted as the Substance Abuse and Mental Health Services Administration (SAMHSA).

As a result of the reorganization of ADAMHA, the IOM study was refocused to assess the AIDS research portfolios of NIAAA, NIDA, and NIMH with respect to balance between biomedical and behavioral research, attention to behavioral preventive interventions, and the relationship between research at the institutes and AIDS-related mental health and substance abuse services programs at SAMHSA and elsewhere in the Public Health Service (PHS).

The second event of consequence to this study was the passage of the NIH Revitalization Amendments (P.L. 103–43) on July 10, 1993. That bill substantially increased the authority of the NIH Office of AIDS Research (OAR) to determine budgeting and, to some degree, program priorities for AIDS research at all NIH institutes effective FY 1994 (October 1, 1993). Because the former ADAMHA institutes had become part of NIH, the "mission, program management, and funding levels" of their AIDS portfolio were affected by the new OAR authority during the course of this study.

Together, the changes at ADAMHA and NIH produced a set of difficulties not only for the institutes themselves—which were forced to operate for several years in a climate of uncertainty—but also for the study committee, which had to deal with a "moving target" throughout the course of its efforts. Although these

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

legislative changes were not intended to be the focus of the study, the committee decided that their consequences for the AIDS programs of NIAAA, NIDA, and NIMH could not be ignored. Therefore, the implications of this set of circumstances for both the institutes' programs and the committee's work are noted, where relevant, throughout this report.

After revising the contract to reflect these structural changes, the charge to the committee became to assess: (1) the scope and content of each institute's AIDS research program activities; (2) the relationship between their research and the services-oriented programs at SAMHSA, Centers for Disease Control and Prevention (CDC), and Health Resources and Services Administration (HRSA); (3) the balance among various research categories (e.g., biomedical, neuroscientific, neuropsychiatric, and behavioral research) and research mechanisms; (4) the role of behavioral-science-based preventive interventions in the institutes' research programs; (5) the role of the public and field opinion in influencing the direction of AIDS research; (6) the adequacy of the administrative structure to support the institutes' AIDS programs; and (7) the adequacy of interagency coordination of AIDS activities.

In order to address the various elements of the study charge, the committee and the study staff engaged in a range of data collection activities. These included: creating an electronic database of abstracts of all AIDS grants funded by the three institutes between FY 1983 and FY 1992; reviewing strategic planning, conference summary, and other relevant documents related to their AIDS programs; conducting interviews with federal agency staff, external researchers, AIDS advocates, and other interested persons; visiting four institute-funded AIDS research centers; holding a public meeting; and conducting widespread literature searches. These diverse methods yielded a wealth of information and insights into the accomplishments and the shortcomings of the institutes' AIDS programs vis-à-vis the epidemic.

The resulting report is divided into two parts. Part I, "Research Findings and Opportunities," presents an overview of findings from neurobiological, psychological, and social science research related to the substance use, sexual behavior, and mental health aspects of HIV. Much, but not all, of this research has been supported by NIAAA, NIDA, and NIMH. These findings provide a useful backdrop against which to assess the AIDS programs of the institutes, and they help to point out future directions for AIDS research. Moreover, the committee felt it was important to identify the scientific contributions of the former ADAMHA institutes as they

Page viii Cite
Suggested Citation:"FRONT MATTER." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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integrate into the larger context of NIH and its AIDS research agenda. Part II, "Managing the AIDS Research Programs at NIAAA, NIDA, and NIMH," provides information about the context in which the institutes" AIDS programs have been operating and presents the committee's assessment of their actual AIDS programs.

Throughout the report, the committee makes a number of recommendations related to advancing the scientific agenda and improving the management of AIDS research at NIAAA, NIDA, and NIMH. The committee wishes to note here that these recommendations are not prioritized or ranked; rather, they follow the order of the text in each chapter. Furthermore, because the three institutes were reviewed simultaneously, the recommendations reflect both their unique and their overlapping missions.

Although this report contains a number of important findings and recommendations, the committee wishes to stress that many of the scientific fields relevant to this study, such as neuro-AIDS, behavioral epidemiology, and qualitative sociology, are still in the early stages of their development and application. The AIDS epidemic requires better integration of these basic biological, psychological, and social science perspectives in order to achieve the complex understanding that will lead to more appropriate and effective AIDS prevention and intervention efforts.

H. Keith H. Brodie, Chair

Judith D. Auerbach, Study Director

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

Acknowledgments

The committee's efforts were enabled by the extraordinary work of an excellent project staff under the insightful leadership of Judy Auerbach. We are indebted to Christina Wypijewska for her excellent skills in collecting, analyzing, and presenting a range of information and for her oral and written contributions to the structure and substance of the report. Holly Dawkins brought notable research skills to our efforts, including intensive literature searches and the retrieval of numerous documents from the institutes under review and elsewhere. Karen Autrey provided the committee with extraordinary attention to the logistics of our meetings and to the production of the report, including the documentation of all of our references. Constance Pechura, Robert Cook-Deegan, Mike Stoto, and Leslie Hardy, all members of the IOM staff, contributed constructively to our committee's deliberations and provided necessary guidance in informing the committee of our responsibilities in developing a report worthy of publication.

The committee also benefitted from excellent background research provided by Robert Walkington and Beth Kosiak. Additional thanks are owed to Linda Humphrey for carefully editing and improving the structure of many sections of the report, to Mike Edington for coordinating editing and publication, to Claudia Carl for coordinating the review process, to Nina Spruill for guiding the budget, and to Gail Spears for providing a range of administrative assistance.

We are also indebted to the many federal agency and congressional

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

staff, external researchers, AIDS advocates, and representatives of other interested groups who provided input into the committee's deliberations. These individuals are acknowledged by name in Appendix C. One of these people, however, deserves special mention. William A. Bailey, a legislative affairs officer for the American Psychological Association, contributed greatly to this study, by lobbying Congress to mandate the IOM examination of the AIDS programs at the former ADAMHA, by presenting memorable testimony at the committee's public meeting, and by facilitating communication among the committee, the AIDS research and advocacy communities, and the federal government. Bill was a tireless advocate for AIDS prevention, a generous commitment from someone already afflicted with the disease. AIDS claimed Bill's life on April 23, 1994. The committee notes his passing with sadness and remembers his work with thanks.

Finally, the committee wishes to express its deep appreciation for the leadership, insight, and extraordinary diligence of our project director, Judy Auerbach, who instilled in us all a commitment to produce a report of which we could be proud. In addition to writing significant sections herself, she brought out our best efforts and was consistently able to produce the information we required to make this report responsive to our charge and, we hope, helpful to the field.

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×
 
   

Psychosocial Perspectives on Risk Behavior

 

83

   

Psychological Theories of Behavior Change

 

84

   

Social Science Perspectives on Behavior and Behavior Change

 

88

   

Interventions to Change Behavior

 

98

   

Individual-Focused Interventions

 

99

   

Community-Focused Interventions

 

114

   

Maintaining Behavior Change and Preventing Relapse,

 

116

   

Evaluating the Effects of AIDS Interventions

 

119

   

Conclusion and Recommendations

 

121

4

 

DISEASE PROGRESSION AND INTERVENTION

 

124

   

The Relationship Between HIV and the Central Nervous System

 

125

   

Effects of HIV on the Central Nervous System: Defining the Issues

 

125

   

Staging and Cellular Sites of Central Nervous System Infection in AIDS Dementia Complex

 

127

   

Mechanisms for Causing Symptoms

 

128

   

Mechanisms of Central Nervous System Injury

 

129

   

Significance of AIDS Dementia Complex for Other Central Nervous System Disorders

 

133

   

Clinical Significance of AIDS Dementia Complex

 

134

   

Interactions Among HIV, Substance Use, and Mental Illness

 

134

   

Alcohol and the Immune System

 

134

   

Drug Use and HIV/AIDS

 

135

   

Interventions for the Seriously Mentally Ill

 

140

   

The Relationship Between Psychosocial Factors and HIV Infection

 

140

   

Psychoneuroimmunology

 

141

   

Coping with HIV/AIDS

 

142

   

Caregiving for People with HIV/AIDS

 

145

   

Conclusion and Recommendations

 

151

PART II
MANAGING THE AIDS RESEARCH PROGRAMSAT NIAAA, NIDA, AND NIMH:

5

 

THE CONTEXT OF AIDS PROGRAMS AT NIAAA, NIDA, AND NIMH

 

157

   

The Reorganization of ADAMHA

 

158

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Suggested Citation:"FRONT MATTER." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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Suggested Citation:"FRONT MATTER." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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Suggested Citation:"FRONT MATTER." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

List of Boxes, Figures, and Tables

BOXES

2.1

 

HIV Risk among the Seriously Mentally Ill

 

72

3.1

 

The Female Condom

 

112

5.1

 

A Brief History of Research and Services Programs for Mental Health and Substance Abuse

 

159

5.2

 

ADAMHA Programs Transferred to SAMHSA as a Result of Reorganization

 

166

6.1

 

National AIDS Demonstration Research (NADR) Program

 

212

6.2

 

Needle Exchange Research

 

216

6.3

 

Treatment Research

 

218

A.1

 

Sample Form

 

302

FIGURES

S.1

 

NIAAA Expenditures (AIDS/Non-AIDS), 1983–1993

 

26

S.2

 

NIDA Expenditures (AIDS/Non-AIDS), 1983–1993

 

27

S.3

 

NIMH Expenditures (AIDS/Non-AIDS), 1983–1993

 

29

S.4

 

NIH AIDS Research Funding by Component, 1992

 

32

S.5

 

ADAMHA AIDS Budget Authority, 1983–1992

 

36

2.1

 

Death Rates for Leading Causes and HIV Infection for Persons Aged 25–44, 1982–1991

 

68

5.1

 

Organization of the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA)

 

164

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

5.2

 

Organization of the Substance Abuse and Mental Health Services Administration (SAMHSA)

 

165

5.3

 

Organization of the National Institutes of Health (NIH)

 

167

5.4

 

Budget Calendar

 

172

5.5

 

Budget Planning Cycle, FY 1994

 

173

5.6

 

NIMH AIDS and Non-AIDS Applications, 1989–1993

 

179

5.7

 

NIDA AIDS and Non-AIDS Applications, 1989–1993

 

180

5.8

 

NIAAA AIDS and Non-AIDS Applications, 1989–1993

 

180

6.1

 

Committee Codes

 

189

6.2

 

Proportion of Multi-coded AIDS Research Grants at NIAAA, NIDA, and NIMH, 1987–1992

 

190

6.3

 

Proportion of Basic AIDS Research Grants at NIAAA, NIDA, and NIMH, 1987–1992

 

191

6.4

 

NIAAA Expenditures (AIDS/Non-AIDS), 1983–1993

 

198

6.5

 

NIAAA AIDS Expenditures, 1983–1993

 

199

6.6

 

NIAAA AIDS Funding by Mechanism, 1987–1992

 

201

6.7

 

NIAAA Non-AIDS Funding by Mechanism, 1987–1992

 

202

6.8

 

Proportion of NIAAA AIDS Research Grants, Coded for Each Category, 1987–1992

 

205

6.9

 

NIDA Expenditures (AIDS/Non-AIDS), 1983–1993

 

206

6.10

 

NIDA AIDS Expenditures, 1983–1993

 

206

6.11

 

NIDA AIDS Funding by Mechanism, 1987–1992

 

207

6.12

 

NIDA Non-AIDS Funding by Mechanism, 1987–1992

 

208

6.13

 

Proportion of NIDA AIDS Research Grants, Coded for Each Category, 1987–1992

 

220

6.14

 

NIMH Expenditures (AIDS/Non-AIDS), 1983–1993

 

222

6.15

 

NIMH AIDS Expenditures, 1983–1993

 

222

6.16

 

NIMH AIDS Funding by Mechanism, 1987–1992

 

223

6.17

 

NIMH Non-AIDS Funding by Mechanism, 1987–1992

 

224

6.18

 

Proportion of NIMH AIDS Research Grants, Coded for Each Category, 1987–1992

 

228

6.19

 

NIH Expenditures (AIDS/Non-AIDS), 1983–1993

 

232

6.20

 

NIH AIDS Research Funding by Component, 1992

 

233

7.1

 

ADAMHA AIDS Budget Authority, 1983–1992

 

243

TABLES

3.1

 

A Sample of AIDS Preventive Intervention Research Projects Funded by NIAAA, NIDA, and NIMH

 

100

Page xvii Cite
Suggested Citation:"FRONT MATTER." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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6.1

 

AIDS-Specific and AIDS-Related Program Announcements (PAs) and Requests for Applications (RFAs): NIAAA, NIDA, and NIMH

 

194

6.2

 

NIAAA AIDS Staffing (FTEs) by Administrative Area, 1987–1993

 

200

6.3

 

NIDA AIDS Staffing (FTEs) by Administrative Area, 1987–1993

 

209

6.4

 

NIMH AIDS Staffing (FTEs) by Administrative Area, 1986–1993

 

224

6.5

 

AIDS Funding as Proportion of 1992 Budget, Selected NIH Institutes

 

234

7.1

 

SAMHSA AIDS Program, 1986–1994

 

242

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AIDS and Behavior: An Integrated Approach Get This Book
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HIV is spreading rapidly, and effective treatments continue to elude science. Preventive interventions are now our best defense against the epidemic—but they require a clear understanding of the behavioral and mental health aspects of HIV infection and AIDS.

AIDS and Behavior provides an update of what investigators in the biobehavioral, psychological, and social sciences have discovered recently about those aspects of the disease and offers specific recommendations for research directions and priorities.

This volume candidly discusses the sexual and drug-use behaviors that promote transmission of HIV and reports on the latest efforts to monitor the epidemic in its social contexts. The committee reviews new findings on how and why risky behaviors occur and efforts to develop strategies for changing such behaviors. The volume presents findings on the disease's progression and on the psychosocial impacts of HIV and AIDS, with a view toward intervention and improved caregiving.

AIDS and Behavior also evaluates the status of behavioral and prevention aspects of AIDS research at the National Institute of Mental Health, the National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism.

The volume presents background on the three institutes; their recent reorganization; their research budgets, programs, and priorities; and other important details. The committee offers specific recommendations for the institutes concerning the balance between biomedical and behavioral investigations, adequacy of administrative structures, and other research management issues.

Anyone interested in the continuing quest for new knowledge on preventing HIV and AIDS will want to own this book: policymakers, researchers, research administrators, public health professionals, psychologists, AIDS advocates and service providers, faculty, and students.

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