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AIDS and Behavior: An Integrated Approach (1994)

Chapter: 6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH

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Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

6
Research Funding, Programs, and Priorities at NIAAA, NIDA, and NIMH

The committee was asked to assess the adequacy of the response of NIAAA, NIDA, and NIMH to the AIDS epidemic by evaluating the scope and content of their AIDS research program activities and the balance between biomedical and behavioral research. To adequately address these two issues, the committee conducted a grant-by-grant analysis of all AIDS research projects funded by NIAAA, NIDA, and NIMH from FY 1983 (the first year of AIDS funding) through FY 1992 (the most recent year for which complete data were available). In addition, the committee reviewed a range of documents and plans produced by the institutes that describe their AIDS programs and priorities.

This approach provided the committee with comprehensive budgetary and programmatic information about the institutes' research programs that was not available in one form from any source—the institutes, ADAMHA, SAMHSA, NIH, or any other PHS office. The committee's analysis was able to link specific grants to broad institute initiatives and to actual dollars committed to these various initiatives, bringing together disparate pieces of information to guide the assessment of the institutes' AIDS programs for each fiscal year and over time.

This chapter presents an overview and analysis of the institutes' AIDS research funding, programs, and priorities, as well as the grants funded between FY 1983 and FY 1992, including a summary

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

of the committee's main findings with respect to program activities and balance among scientific disciplines. The discussion is organized by institute, and the grant-based information is presented according to categories developed by the committee. Further information about how the grant-based analysis was conducted—including its limitations—may be found in Appendix A; the results from the research supported are included in the general discussions in Part I.

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. The committee did not wish to engage in this discussion, nor did it wish to assess the merits of funding AIDS research relative to funding other disease-related research. Rather, the committee chose to focus on the overall situation of AIDS funding at the former ADAMHA institutes and offices, from the beginning of the epidemic to the present, and to identify areas where serious inadequacies are evident.

The historical review of AIDS funding presented here is based on the most recent comparable budget information provided by NIH, NIAAA, NIDA, NIMH, and SAMHSA. Therefore, expenditures are displayed and discussed using the current organizational structure of the institutes and agencies being reviewed. For example, information about SAMHSA and NIH funding reflects the current organizational splits between research and services (designated by the 1992 ADAMHA reorganization). Information about total NIH funding includes the former ADAMHA research institutes.

Despite the best efforts of various budget offices, some sets of numbers may not always be completely consistent with other sets since data were derived from a multiplicity of sources and were tabulated for a variety of purposes. In addition, other problems associated with retabulating entire budgets (to make them comparable) after the reorganization arose, such as changes in what was defined as AIDS research from year to year within an institute (i.e., coding anomalies) and differences in rounding.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

CATEGORIZING AIDS RESEARCH

As mentioned earlier, the committee was charged with assessing the balance between biomedical and behavioral AIDS research at NIAAA, NIDA, and NIMH. Early in the study, however, the committee determined that these categories were too limiting for two reasons: because there were no clear definitions of "biomedical" and "behavioral," and because counterpoising these two categories masked the true level of cross-disciplinary research supported by the institutes. As the committee began to review the research portfolios grant by grant, it became apparent that labeling a project as either biomedical or behavioral was misleading, because significant portions of many projects included elements from both realms.

One option the committee faced was to find an alternative way of categorizing AIDS research, by looking at other schema employed by the Public Health Service. Since FY 1989, PHS agencies have used the following set of categories, called "Mason" categories (named after then Assistant Secretary for Health, James O. Mason): 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; and Clinical Health Services Research and Delivery, which includes health services grants. However, although the Mason categories are more comprehensive than the simple "biomedical-behavioral" distinction, the committee felt—as had an earlier IOM committee (IOM, 1991a)—that they were not sufficient to scientifically characterize the research programs of the institutes. In particular, it was not clear under which category(ies) psychosocial and social science research best fit. Also, prior to FY 1993, individual grants funded by the institutes could not be traced to specific Mason categories.

As a result of these problems, and in order to determine the balance of science among AIDS research grants, the committee developed its own simple matrix using four domains of science: biomedical/biobehavioral, epidemiological, psychosocial, social-structural, and two types of research: basic and applied. Figure 6.1 presents the committee's matrix.

"Biomedical/biobehavioral" research focuses on improving knowledge about basic biological mechanisms and processes, disease pathogenesis, and clinical issues related to progression and treatment of HIV/AIDS. "Epidemiological" research focuses on

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

FIGURE 6.1 Committee Codes.

of HIV and the natural history of infection and disease progression. This category also includes biostatistical research to develop and refine mathematical modeling techniques for improved forecasting of HIV seroprevalence. "Psychosocial" research includes efforts to understand psychological determinants of behavior and 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. Social-structural research includes research on health services, evaluation, and operations. "Basic" research studies the basic mechanisms underlying biological, neurological, behavioral, and social processes and outcomes, and includes theoretical work. ''Applied" research encompasses projects that test interventions.

The committee constructed an electronic database from abstracts of funded, extramural grants at NIAAA, NIDA, and NIMH from FY 1983 to FY 1992. Each AIDS grant was either single-coded with one of the four science categories or, where appropriate, multi-coded with two or more of the science categories. Generally, the committee considered the multi-coded grants to be cross-disciplinary research. In addition, each grant was coded as either basic or applied. (See Appendix A for more information about the committee's methodology.)

The committee found that a significant proportion of AIDS research at NIAAA, NIDA, and NIMH is cross-disciplinary, according to the committee's coding scheme (Figure 6.2). For example, in 1992, approximately one-third of all research project grants and research demonstrations (R18s) at NIAAA, NIDA, and NIMH were

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

FIGURE 6.2 Proportion of Multi-coded AIDS Research Grants at NIAAA, NIDA, and NIMH, 1987-1992. Note: Includes RPGs and R18s. Source: NIH CRISP system, and IOM committee database.

multi-coded. Since 1987, the proportion of multi-coded grants at NIAAA rose significant. At NIDA, about one-third of all grants were multi-coded from 1987 through 1992. Many of these multi-coded 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), including pharmacologic and behavioral interventions as well as enhancements for improving access and retention in treatment programs. The proportion of multi-coded grants at NIMH has actually fallen from 55 percent in 1987 to 28 percent in 1992. In 1987, NIMH's AIDS portfolio was much smaller and had a high proportion of psychoneuroimmunology grants, most of which were multi-coded. Because NIMH's AIDS program grew to include research efforts targeted to the development of behavioral interventions and basic knowledge in neuro-AIDS, multi-coded grants eventually represented a smaller proportion of the total.

Using the committee's coding for basic and applied AIDS research, the analysis also discovered that most extramural AIDS research grants funded by NIAAA, NIDA, and NIMH are basic research. As demonstrated in Figure 6.3, the majority of NIAAA grants were basic research, falling from 100 percent in 1987 to 87

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

FIGURE 6.3 Proportion of Basic AIDS Research Grants at NIAAA, NIDA, and NIMH, 1987-1992.

Note: Includes RPGs and R18s. Source: NIH CRISP system, and IOM committee database.

percent in 1992. Representation of basic research in NIMH's AIDS research portfolio also decreased from 85 percent in 1987 to 75 percent of the total in 1992. The proportion of basic research at NIDA has fluctuated, from as low as 44 percent in 1989 to 65 percent in 1992. 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. The two major categories are intramural, which is research conducted by the institute staff itself, usually in laboratories on or near the institute, and extramural, which is research conducted by nonfederal scientists at universities, health centers, and other settings around the country and the world.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

Extramural research mechanisms include research project grants (RPGs), centers, contracts, and other research. RPGs include: traditional investigator-initiated grants (R01s); research program projects (P01s); cooperative agreements (U01s), which support investigators at different sites working from a common research protocol with some variation in study population or mode of intervention; Small Business Innovation Research grants (SBIR-R43/44); and other research grants (including new investigator awards, first independent research support and transition [FIRST] awards, and methods to extend research in time [MERIT] awards). The vast majority of RPGs funded by NIAAA, NIDA, and NIMH are R01s. Research centers include specialized centers (P50s) and core grants (P30s), both of which support groups of researchers at a single institution working on a common theme. Other research includes research demonstrations (R18s), which typically test the efficacy of theory-driven pilot programs in an applied setting, cooperative clinical research (R10/U10), and research career program awards (K-series). There are two types of contract awards (N-series): research and development, and resource and support. Training includes individual awards (F-series) and institutional awards (T-series). Together, all of these mechanisms make up the extramural research program of an institute.

NIAAA, NIDA, and NIMH have utilized all mechanisms for supporting extramural AIDS research, but in different proportions. For example, the majority of NIAAA's extramural research grants and dollars have been committed to R01s. NIMH AIDS extramural funding has been largely committed to R01s and research centers (P50s). NIDA's extramural program has employed the widest variety of mechanisms, particularly by committing resources to research demonstration projects (R18s).

Although the committee attempted to obtain comprehensive, comparable information on all relevant funding mechanisms (i.e., extramural research project grants, contracts, intramural projects) from all three institutes, it was only able to do so for extramural grants. (Only NIMH provided complete information on its intramural program; and the contract data obtained were not comparable to the grant information.) Consequently, the analysis of grants presented below is limited to extramural research grants only. Discussions about contracts and intramural research reflect information gathered from sources other than the database. Moreover, because of the limitations of the available data (described in Appendix A)—most notably the fact that the institutes did not systematically nor consistently code grants as AIDS-related before

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

FY 1987—the specific analysis of the grants focuses primarily on the research portfolios beginning in FY 1987.

In the discussions of the grants in this chapter, the figures display the total proportion of research project grants, demonstration projects, and cooperative agreements (R01s, R18s, U01s, U10s, U18s) that were coded by the committee for each scientific domain. Percentages represent an institute's total level of commitment in a given scientific domain. Multi-coded grants appear in all relevant domains; for example, a grant that has both a bio-medical and a psychosocial component is included in both the "biomedical/biobehavioral" and the "psychosocial" categories in the figures (as a way of illustrating how many grants include at least a component of a given scientific domain). Center grants (P50) are not included in this analysis because of their unique structure; however, they represent a significant proportion of AIDS grants (especially at NIMH) and involve cross-disciplinary research. They are, therefore, discussed elsewhere in this chapter.

Details of the differential use of mechanisms embedded in the discussions of the institutes' AIDS programs below indicate that in general, when compared to non-AIDS research, a greater proportion of AIDS research at NIAAA, NIDA, and NIMH has been directed in some way by the institutes (see Figures 6.6, 6.7, 6.11, 6.12, 6.16, and 6.17). Investigator-initiated research includes traditional R01s, whereas directed research efforts are usually funded using contracts, cooperative agreements, research demonstrations, and, to a large degree, research centers. The institutes can also help guide the field by issuing a general Program Announcement (PA) or a Request for Applications (RFA). PAs and RFAs reflect the institutes' research priorities. A program announcement is broader than an RFA, and it usually contains suggested research areas. There is no money specifically set aside to fund grants submitted in response to a PA; such grants are funded out of the institute's general funds. An RFA, on the other hand, does have specific funds set aside for grants submitted in response to its release. RFAs usually are more specific than PAs and they specify certain selection criteria. Also, RFAs have one receipt date, whereas PAs remain active for longer periods of time.

Table 6.1 lists AIDS-specific and AIDS-related PAs and RFAs issued by NIAAA, NIDA, and NIMH since the beginning of their respective AIDS programs. It does not include general program announcements for FIRST awards, small grants, and fellowships.

The level of directed research in the AIDS programs—as evidenced by PAs, RFAs, and the funding of core and center grants—

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

TABLE 6.1 AIDS-Specific and AIDS-Related Program Announcements (PAs) and Requests for Applications (RFAs): NIAAA, NIDA, and NIMH

Date PA/PFA #

Title (funds availablea)

Mechanisms

Institute(s)

1/94

PA-94-023

HIV Therapeutics in Drug Abuse

R01-R29-R03

NIDA

11/93

PA-94-010

Research on Needle Hygiene and Needle Exchange Programs

R01

NIDA

11/93

DA-94-02

Behavioral Therapies Development Program ($3 million for first year) b

R01-R03-R29-IRPG

NIDA

10/93

AA-94-03

Alcohol and Minorities: Biomedical and Behavioral Research ($2 million for FY 94)c

R01-R29

NIAAA

10/93

AA-94-01

Biomedical and Behavioral Research on Alcohol and Womend

R01-R29

NIAAA

10/93

AA-94-02

Biomedical and Behavioral Research on Alcohol and Youthc

R01-R29

NIAAA

10/93

AA-94-05

Health Services Research on Alcohol-Related Problemsc

R01-R29-T32

NIAAA

10/93

AA-94-04

Underdeveloped Areas of Alcohol Abuse Prevention Researchc

R01-R29

NIAAA

9/93

PA-93-111

Partner Notification to HIV-infected Drug Users

R01

NIDA

9/93

PA-93-110

Health Care Services for Persons with HIV Infection

R01

AHCPR-NIAAA-NIDA-NIMH

9/93

PA-93-106

Drug Abuse Treatment for Women of Childbearing Age and Their Children ($5 million for FY 94)b

R01

NIDA

8/93

PA-93-100

Research Program to Improve Drug Abuse Treatment ($10 million for FY 94)b

R01

NIDA

7/93

PA-93-098

Drug Abuse Aspects of AIDS (Revised)

R01-R03-R29

NIDA

6/93

AI-93-14

Center for AIDS Research/Core Support Grant (NIMH set aside $1.5 million)

P30

NIAID-NIMH

5/93

PA-93-087

National Research Service Awards (NRSA) Institutional Training Grants for AIDS

T32

NIAID-NIMH

4/93

PA-93-080

Determinants of Effective HIV Counseling

R01-R03-R29

NIDA-NIMH

2/93

PA-93-47

Preventing Alcohol-Related Problems Among Ethnic Minoritiesc

R01-R03-R29

NIAAA

1/93

PA-93-44

The Spread of Tuberculosis Among Drug Users ($3 million for FY 93) d

R01-R03-R29

NIDA

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

12/92

PA-93-28

Research to Improve Drug Abuse Treatment, Entry, Retention, Compliance, and Effectivenessb

R01-R03-R29

NIDA

12/92

PA-93-27

Psychotherapy, Behavior Therapy, and Counseling in Drug Treatment b

R01-R03-R29

NIDA

11/92

PA-93-21

Drug Abuse Treatment of Criminal Justice-Involved Populationsb

R01

NIDA

10/92

PA-92-110

Development of Theoretically Based Psychosocial Therapies for Drug Dependenceb

R01-R03-R29

NIDA

10/92

PA-93-009

Neural, Endocrine, Immune, and Viral Interactions, Behavior and Mental Healthd

R01-R03-R29-P01-T32-K series-F series

NIMH-NINDS

7/92

PA-92-95

Neuro-AIDS: HIV-1 Infection and the Nervous System

R01-R29-P01

NIMH-NINDS

5/92

AA-92-03

Alcohol Research Center Grants ($1.7 million)d

P50

NIAAA

5/92

MH-92-11

The Role of the Family in Preventing and Adapting to HIV Infection and AIDS ($1.8 million for FY 93)

R01

NIAAA-NIDA-NIMH

3/92

PA-92-46

Research on the Prevention of Alcohol Abuse Among Youthc

R01-R03-R29

NIAAA

3/92

PA-92-58

Clinical Research on Human Development and Drug Abuse ($10 million for FY 93)d

R01-R03-R13-R29-F31-F32-T32-K20-K21

NIDA

10/91

PA-92-12

Research Grants on Alcohol and Immunology Including AIDS ($2 million for FY 92) (Revised)

R01-R03-R29

NIAAA

6/91

PA-91-75

Research on Relationships between Alcohol Use and Sexual Behaviors Associated with HIV Transmission

R01-R03-R29

NIAAA

12/90

PA-90-31

Drug Abuse Researchd (No longer used)

R01-R03-R13-R29-R43-R44-P01-R18

NIDA

6/90

PA-90-15

Children with HIV Infection and AIDS

R01-R29

NCNR-NICHD-NIDA-NIMH-NINDS

1/90

DA-90-05

Research Demonstration Program to Enhance Drug Abuse Treatment ($10 million for FY 90)b

R18

NIDA

1/90

DA-90-02

A Cooperative Agreement for AIDS Community-Based Outreach/Intervention Research ($3 million for FY 90)

U01

NIDA

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

Date

PA/PFA #

Title (funds availablea)

Mechanisms

Institute(s)

1/90

DA-90-10

Demonstration Research on Service Delivery in Non-Traditional Settings

R18

NIDA

1/90

PA

Drug Abuse Aspects of AIDS ($15 million for FY 90) (Revised in 1/93)

R01-R03-R29-P01

NIDA

10/89

PA

National Research Service Awards for Institutional Training Grants in HIV Infection and AIDS

T series

NIAAA-NIDA-NIMH

10/89

PA

National Research Service Awards for Individual Fellows in HIV Infection and AIDS

T series

NIAAA-NIDA-NIMH

11/88

DA-89-01

Research Demonstration Program to Reduce the Spread of AIDS by Improving Treatment for Drug Abuse ($10 million for FY 89)

R18

NIDA

9/88

PA

Research Grants on Alcohol and Immunology Including AIDS (Revised in 10/91)

R01-R29-P01

NIAAA

9/88

PA

Research on Severely Mentally Ill Persons at Risk of or with HIV Infection

R01-R29

NIMH

9/88

PA

Research on Behavior Change and Prevention Strategies to Reduce Transmission of HIV

R01-R03-R29-P01-K series

CDC-NCNR

NHLBI-NIA-NIAAA

NICHD-NIDA-NIMH

9/88

PA

Measurement, Course, and Treatment of HIV-Related Mental Disorders

R01-R03-R29-P01-P50-K series

NIMH

9/88

PA

Brain, Immune System, and Behavioral and Neurological Aspects of HIV

R01-R03-R29-P01-P50-K series

NICHD-NIMH-NINCDS

9/88

PA

Central Nervous System Effects of HIV Infection: Neurobiological, Neurovirological, and Neurobehavioral Studies

R01-R03-R29-P01-P50-K series

NICHD-NIMH-NINCDS

9/88

MH-86-16

AIDS Research Centers

P50

NIDA-NIMH

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

3/88

AA-88-02

Research Grants on Alcohol Related Behavior that Increases the Risk of AIDS and/or Research on Prevention Strategies to Reduce that Risk ($1 million)

R01–R29

NIAAA

1/88

DA-88-03

AIDS Community Outreach and Counseling Demonstration Research—Phase II ($10–12 million for FY 88)

R18

NIDA

12/87

PA

Behavioral Aspects of AIDS Prevention in Children and Adolescents

not specified

NICHD-NIMH

10/87

AA-88-01

Alcohol Research Center Grants on Alcohol and Immunologic Disorders ($1.5 million)d

P50

NIAAA

1/87

DA-87-20

Studies of Drugs of Abuse as Potential Cofactors in the Pathogenesis of AIDS

not specified

NIDA

1/87

DA-87-14

Treatment of Intravenous Drug Abusers to Reduce the Spread of AIDS

not specified

NIDA

1/87

DA-87-13

AIDS Community Outreach: Demonstration Project ($5 million for FY 87)

R18

NIDA

1/87

DA-87-12

Studies of Heterosexual and Perinatal Transmission of AIDS Associated with Intravenous Drug Abuse

not specified

NIDA

1/87

PA-87-01

Alcohol Research Grantsa

not specified

NIAAA

12/86

DA-87-11

Drug Abuse Aspects of AIDS (Revised in 1/90)

not specified

NIDA

11/86

DA-87-10

AIDS and the Prevention of Intravenous Drug Abuse ($1.35 million for FY 87)

not specified

NIDA

3/86

MH-86-16

AIDS Research Centers ($500,000 each for 2–3 centers for FY 86–87)

R01–R29

NIMH-NIDA

11/85

MH-86-09

Alcohol, Drug Abuse, and Mental Health Aspects of AIDS

R01–R29

NIMH-NIDA-NIAAA

a Funding information specified includes estimates that appeared in the PA/RFA and does not indicate what was actually spent.

b These PAs/RFAs call for research related to drug abuse treatment and may not include a specific reference to AIDS. However, drug abuse treatment research is one of NIDA's priority research areas for HIV/AIDS.

c These PAs/RFAs do not include a specific reference to AIDS, and refer only to highrisk sexual or drug-using behavior.

d These PAs/RFAs contain an explicit reference to HIV/AIDS, although HIV/AIDS is not the primary focus.

Source: AIDS Coordinators at NIAAA, NIDA, and NIMH.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

suggests active leadership among the institute staff in encouraging investigations of specific AIDS-related topics. This kind of leadership may be more necessary in a new research field, such as AIDS, since investigators must be recruited who have been establishing careers in other, related areas of science.

NIAAA

NIAAA first began funding AIDS research in FY 1987 (Figure 6.4). AIDS was just under 3 percent of the total NIAAA budget that year, and rose to 5 percent in FY 1988. Since then, AIDS funding increased 233 percent, from $2.4 million in FY 1987 to $8 million in FY 1992 (Figure 6.5). Total NIAAA funding (AIDS and non-AIDS) 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. Specifically, NIAAA's portfolio includes studies examining the relationship between alcohol and the immune system, and studies to

FIGURE 6.4 NIAAA Expenditures (AIDS/Non-AIDS), 1983–1993.

*Estimate. Source: NIAAA Budget Office.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

FIGURE 6.5 NIAAA AIDS Expenditures, 1983–1993. * Estimate. Source: NIAAA Budget Office.

understand the relationship between alcohol use and highrisk sexual behavior. Overall, the NIAAA AIDS program is small relative to those at NIDA and NIMH, and it has not yet included significant program initiatives on the order of those at NIDA and NIMH.

Because its AIDS program is small, NIAAA has never established an Office of AIDS and has never employed any full-time AIDS staff. Currently, NIAAA has two ''part-time" coordinators—one for social and behavioral research and one for biomedical research. These coordinators perform their AIDS-related activities in addition to what amounts to full-time responsibility for other activities, and they do so without significant institutional support.

NIAAA first allocated AIDS FTEs (full-time equivalents) in FY 1987 (Table 6.2). Since that year, four extramural FTEs have been allocated to AIDS, representing a part-time commitment from program, budget, and contracting staff who support the AIDS activities of the institute. There are no individuals outside of the intramural research program who are supported full time in AIDS personnel positions. From FY 1987 through FY 1993, NIAAA's AIDS FTEs rose 114 percent, compared to a 31 percent increase in the institute's

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

TABLE 6.2 NIAAA AIDS Staffing (FTEs) by Administrative Area, 1987–1993

 

1987

1988

1989

1990

1991

1992

1993*

Intramural research

3

3

8

9

10

7

11

RMS

4

4

4

4

4

4

4

AIDS Total

7

7

12

13

14

11

15

NIAAA Total

190

191

210

224

229

238

248

NOTE: *Estimate. RMS = Research management and support.

Source: NIAAA Budget Office.

FTEs overall. AIDS FTEs represented 6 percent of all FTEs in FY 1993.

Although the ADAMHA Reorganization Act mandated that NIDA and NIMH each establish an Office on AIDS, it was silent about NIAAA. Presumably this reflects a judgment based on the relatively small size of the NIAAA AIDS program. If so, this is a circular argument on the part of Congress: if the program is small (dollar and FTE size) then it is less significant; if it is less significant, then it will receive smaller appropriations for grants and FTEs. As a consequence, the size of the program will remain the same.

At NIAAA, the distribution of mechanisms used for AIDS research has changed from year to year (Figure 6.6), although the distribution of non-AIDS funding has remained relatively stable (Figure 6.7). The majority of AIDS funding at NIAAA includes RPGs, which increased from 45 percent of the AIDS total in FY 1987 to 73 percent in FY 1992. NIAAA's contribution to centers for AIDS research has fluctuated from as much as 30 percent of the institute's total AIDS budget in FY 1988 to as little as 1 percent in FY 1992. Use of contracts has been fairly minimal, as has NIAAA's commitment to AIDS training. As with its non-AIDS 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.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

FIGURE 6.6 NIAAA AIDS Funding by Mechanism, 1987–1992. Source: NIAAA Budget Office.

PROGRAMS AND PRIORITIES
BIOMEDICAL/BIOBEHAVIORAL RESEARCH

Since it first initiated its AIDS program, NIAAA has devoted much of its extramural and intramural research efforts to biomedical issues. NIAAA's broad research goal in this area is to elucidate how alcohol alters the immune system in ways that may compromise host defense against HIV. In October 1991, NIAAA issued a program announcement—Research grants on alcohol and immunology including AIDS—to stimulate research on effects of alcohol consumption on the biological and biochemical mechanisms involved in the etiology of immunologic dysfunction.

NIAAA's extramural research support has included research grants and supplemental funding to Alcohol Research Centers and grants for AIDS-related issues. Extramural research projects include a broad spectrum of basic and clinical immunological research, including investigations of (1) alcohol and susceptibility to infection;

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

FIGURE 6.7 NIAAA Non-AIDS Funding by Mechanism, 1987–1992. Source: NIAAA Budget Office.

(2) alcohol and immune system development to understand the possible role of alcohol as a cofactor of maternal transmission of HIV; (3) alcohol and cellular and humoral immunity to understand mechanisms of alcohol's effects on host resistance to HIV and related infections; (4) alcohol and neurohormonal immunomodulation to understand interactions between the nervous, endocrine, and immune systems; and (5) the murine AIDS model, which is used to understand how the virus attacks the immune system, and to test treatment modalities.

The NIAAA intramural research program primarily has focused on (1) alcohol's potential role as a cofactor in the etiology of AIDS and as a promotor of opportunistic infection in patients suffering from AIDS; (2) the effects of HIV on neuronal function; and (3) the basic mechanisms underlying lymphocyte immunosuppression. Selected research includes studies on the factors controlling T-cell maturation and proliferation, the effects of HIV proteins and related viral coat proteins on neuronal function, and the mechanisms

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

of HIV viral coat proteins to change neuronal metabolism leading to AIDS-related dementia. Most recently, intramural researchers of the Laboratory of Clinical Studies have been investigating highrisk behaviors leading to AIDS exposure using a nonhuman primate model of impulsivity and habitual behavior.

Epidemiological Research

Since 1988, NIAAA has funded studies that examine the relationships between alcohol and other drug use and highrisk sexual behavior, rates of HIV seroconversion, and the development and clinical course of AIDS. These research grants include: surveys to track incidence and prevalence of highrisk behaviors among alcohol treatment inpatients; cross-sectional surveys and prospective cohort studies to examine relationships among alcohol and drug use, highrisk behavior, and HIV seropositivity among various risk groups, including alcohol-dependent adults 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, and 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 . NIAAA has funded several grants to understand the relationship between alcohol use and highrisk sexual behavior and the development of strategies to prevent highrisk behaviors.

Most research thus far has focused on the determinants of highrisk behaviors among adolescents, women, and various racial and ethnic groups. Most recently, NIAAA has funded several projects to develop and evaluate AIDS preventive interventions. These include a culturally relevant school-based prevention program for Navajo youth and their families living on or near the Navajo Nation Reservation; an HIV risk reduction intervention for gay and bisexual males using skills-building techniques for reducing risky

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

sexual behavior and substance use (primarily drinking); and a safer sex intervention at a substance abuse agency in San Francisco.

Social-Structural Research

None of NIAAA AIDS research grants addressed social-structural factors until 1992, when two grants investigating social influences on risk behaviors were added to the institute's portfolio. One project uses a combined qualitative-quantitative methodology to investigate how the situational context (the place and circumstances under which one drinks) interacts with the use of alcohol and sexual behavior among adolescents. 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. Moreover, NIAAA periodically has varied its coding scheme so that certain grants were considered AIDS-related in some years and not in others. These factors significantly impeded the committee's ability to establish the integrity of the AIDS grant data from NIAAA. Nevertheless, some general statements can be made.

From the beginning of NIAAA's AIDS efforts in 1987, the majority of NIAAA extramural research grants and dollars have been traditional investigator-initiated grants (R01s). In 1987, all AIDS-related extramural grants at NIAAA were biomedical (Figure 6.8). In most cases, these projects examined the effects of alcohol on the immune system. In 1988, NIAAA's portfolio grew to include several grants investigating alcohol use and AIDS risk behaviors. These grants were either single-coded by the committee as epidemiological or multi-coded as epidemiological and psychosocial. However, most of the research grants in 1988 continued to be biomedical. By 1990, 70 percent of NIAAA's research grants had a biomedical component, approximately one-third had a psychosocial component, and 20 percent had an epidemiological component. None of NIAAA's research grants included a social-structural perspective until 1992, as mentioned above. By 1992, the extramural AIDS research portfolio had shifted from a biomedical research focus to a more balanced portfolio including biomedical, psychosocial, and epidemiological research.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

FIGURE 6.8 Proportion of NIAAA AIDS Research Grants, Coded for EachCategory, 1987–1992. Note: Includes RPGs only (R01s/R29s). Multi-coded grants areincluded in each relevant category. Source: NIH CRISP system, and IOM committee database.

NIDA

NIDA's AIDS program began in FY 1983. Although AIDS was less than 1 percent of the total NIDA budget in FY 1983, it rose to 14.5 percent in FY 1987 and 31 percent in FY 1993 (Figure 6.9). Approximately one-third of NIDA's budget now is devoted to AIDS research. 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. These include studies on effective pharmacologic and/or behavioral therapies to treat drug addiction, research on prevention strategies to reduce sexual and drug-using behaviors linked to HIV/AIDS, longitudinal studies to assess seroincidence, seroprevalence, and disease progression among drug users and their sexual partners, and research to examine the relationship between drugs of abuse and the immune system.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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FIGURE 6.9 NIDA Expenditures (AIDS/Non-AIDS), 1983–1993. * Estimate. Source: NIDA Budget Office.

FIGURE 6.10 NIDA AIDS Expenditures, 1983–1993. *Estimate. Source: NIDA Budget Office.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

FIGURE 6.11 NIDA AIDS Funding by Mechanism, 1987–1992. Source: NIDA Budget Office.

NIDA's portfolio has included a significant proportion of research demonstration projects (R18s) and cooperative agreements (U01s), in addition to traditional investigator-initiated grants (R01s). The bulk of NIDA's AIDS budget, however, remains allocated to RPGs, which made up as much as 63 percent of the total AIDS budget in FY 1987, and as little as 29 percent in FY 1989 (Figure 6.11). 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") were also significant in NIDA's AIDS program. Although "other research" was less than 1 percent of the AIDS budget in FY 1987, it comprised half of the AIDS budget in FY 1989. Because the data reported here are based on comparable budget tables, they do not include the NADR program (which was transferred to OTI—now called CSAT—in 1991). Inclusion of the NADR program however, would demonstrate that R18s were one of the most significant mechanisms for the NIDA AIDS research

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

program from FY 1987 through FY 1991. By adding the NADR funding, the "other research" category would make up approximately 34 percent of the total AIDS budget in 1987; 55 percent in 1988; 71 percent in 1989; 52 percent in 1990; and 39 percent in 1991.

Training programs were first initiated at NIDA in FY 1990, comprising one percent of the AIDS budget. Intramural research decreased slightly, from 5 percent of the NIDA AIDS budget in FY 1987 to 4 percent in FY 1992. When compared to the AIDS program, NIDA's non-AIDS program has consistently allocated a greater proportion of funding to RPGs, research management and support, and intramural research (Figure 6.12).

Although NIDA has had an AIDS coordinator since the mid-1980s, the institute only formally established on Office of AIDS in FY 1993, as required by the ADAMHA Reorganization Act. NIDA's AIDS program is designed to be decentralized, and it appears that the office has a fairly limited coordinating role. NIDA's

FIGURE 6.12 NIDA Non-AIDS Funding by Mechanism, 1987–1992. Source: NIDA Budget Office.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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TABLE 6.3 NIDA AIDS Staffing (FTEs) by Administrative Area, 1987–1993

 

1987

1988

1989

1990

1991

1992

1993*

Intramural research

1

1

1

3

15

15

15

RMS

0

13

31

50

59

59

59

AIDS Total

1

14

32

53

74

74

74

NIDA Total

205

260

282

342

356

399

395

NOTE: *Estimate. RMS = Research management and support.

Source: NIDA Budget Office.

Office of AIDS has no budgetary or oversight authority for the wide range of AIDS activities. The current director of the Office of AIDS is also the acting director of the Division of Clinical Research.

In addition, although the number of NIDA's AIDS FTEs increased from 1 to 74 between 1987 and 1991 (Table 6.3), all but two AIDS FTEs are divided among NIDA's divisions. In FY 1993, more than one-third of the AIDS staff were allocated to the Division of Clinical Research (which also received approximately one-third of the AIDS budget), and about one-fourth of the AIDS staff were allocated to the intramural research program (the Addiction Research Center). Many FTEs also were allocated to the Office of Planning and Resource Management (responsible for budgeting and grants management).

PROGRAMS AND PRIORITIES
Biomedical/Biobehavioral 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 and 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-modified HIV neurologic changes; and the physiological, biochemical,

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

and immunological mechanisms in the pathogenesis of drug-modulated HIV encephalopathy. Clinical research, predominantly conducted with humans, is focused on the immunologic effects of opiates, marijuana, cocaine, and other drugs. Such studies specifically focus on the effects of drug-related illness and pharmacotherapeutic agents for HIV and drug abuse treatment on immune function.

Other areas of biomedical/biobehavioral AIDS research at NIDA include research related to vertical transmission of HIV (pediatric AIDS projects), development of nonreusable syringes, medications development to create new pharmacological agents for treating substance abuse and addictive disorders, and treatment research to reduce drug use and related risky behaviors.

NIDA supports pediatric AIDS projects to investigate perinatal HIV transmission and progression of pediatric HIV-related diseases related to drug abuse. Projects include research to examine the relationships between drug use patterns and health status (including HIV status) of pregnant women and their impact on perinatal HIV transmission and pregnancy outcome. The Perinatal 20 Treatment Research Demonstration Program is a related NIDA initiative focused on treating and preventing drug use among women of childbearing age. Although it is not an AIDS initiative per se, it contributes to the overall strategy to prevent HIV infection among women of childbearing age and their infants.

NIDA's Medication Development Division was established in 1990 to promote the identification, evaluation, and development of new medications for treating drug addiction. Opiate treatment compounds under investigation include LAAM (levo-alpha-acetylmethadol), buprenorphine, naltrexone, and ibogaine. Crack cocaine treatment compounds include a variety of dopamine agonists and antidepressants such as amantadine, desipramine, and fluoxetine. Although this research is not AIDS-specific, NIDA considers it AIDS-related because it is directed at eliminating the kinds of drug use that put people at risk for HIV infection.

Epidemiological Research

The key role of injection drug use in both current epidemiologic patterns and transmission of HIV infection makes clear the importance of basic research to understand the complex behavioral and social dimensions of drug use in relation to HIV transmission.

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,

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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community-based outreach studies, and research on the role of the sex-for-crack phenomenon. The Seroprevalence Monitoring System is an ongoing contract that has implemented a surveillance system to monitor HIV infection among injection drug users in drug treatment programs. 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.

To better understand the dynamics of HIV/AIDS among drug users, NIDA has funded research to track HIV infection and risk behaviors among injection drug users, their sex partners, their families, and crack users. In 1984, NIDA funded its first longitudinal study to investigate risk factors for AIDS among drug users in New York City. Since the establishment of the Clinical Medicine Branch in 1987, NIDA has supported more than twenty prospective, longitudinal studies to understand the natural history of HIV transmission and disease progression among injection drug users both in and out of treatment and recruited from drug treatment programs, the criminal justice system, STD clinics, hospitals, and the street. These multidisciplinary studies incorporate biomedical, clinical, and psychosocial factors to investigate medical and behavioral risk factors for infection, clinical manifestations, immune function, and factors associated with seroconversion and disease progression.

In the face of mounting evidence that crack-smoking and sex-for-crack exchanges had the potential for spreading HIV to new populations, NIDA initiated a contract to explore the role of sex-for-crack in HIV transmission. Because the dynamics of the exchange processes were not fully understood, NIDA chose ethnography as the key research technique for studies of sex-for-crack exchanges conducted during 1990 in eight cities—Miami, Chicago, New York, San Francisco, Los Angeles, Denver, Philadelphia, and Newark. Ethnographers based in each city conducted participant observations in crack houses and other locales where crack was purchased and smoked and where sex-for-crack exchanges typically occurred. In addition, 340 crack users (233 females and 107 males) were interviewed at length regarding their drug-using and sexual behaviors.

This eight-city study indicated that crack use is closely linked with a variety of sexual behaviors that place people at risk for HIV. In addition, the study highlighted a substantial population

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

of crack-addicted women and men living in a culture that traditional AIDS prevention initiatives may not have been reaching. An immediate response by NIDA was to extend NADR, its community-based outreach projects (see Box 6.1), initially designed for out-of-treatment injection drug users and their sexual partners, to include crack smokers.

Box 6.1 National AIDS Demonstration Research (NADR) Program

NIDA's first generation of community-based outreach programs are collectively known as the National AIDS Demonstration Research (NADR) Program, and they endured from 1987 through 1992. NADR included 41 HIV/AIDS behavior change intervention projects in 61 communities. The target populations were out-of-treatment injection drug users and their sex partners, and the overall purpose of the effort was to evaluate the efficacy of research-based interventions designed to reduce or eliminate risky behaviors for AIDS transmission, including the sharing of injection paraphernalia, abuse of multiple drugs, and unsafe sexual activities. The projects offered free HIV antibody testing as well as counseling and risk reduction in a variety of settings.

Between 1987 and 1992, the NADR initiative reached more than 150,000 people. Comparison of baseline and follow-up data brought out many significant findings: 46 percent of participants reduced or stopped injecting drugs; 37 percent reduced or stopped sharing needles; 50 percent reduced or stopped borrowing needles; 60 percent reduced or stopped sharing other injection paraphernalia; 22 percent always cleaned their needles.

In addition, 33 percent of the injection drug users contacted by the NADR effort entered treatment after the intervention, and an additional 6 percent sought treatment but were unable to access it. 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 AIDS Community-Based Outreach/Intervention Research

The NADR program spawned a second generation of community-based outreach initiatives at NIDA, collectively known as the Cooperative Agreement for AIDS Community-Based Outreach/Intervention Research. With 22 projects at sites ranging from Anchorage to Miami and from Puerto Rico to Rio de Janeiro, this program began in 1990 and all projects are still in progress. The purposes of the projects are to: (1)

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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Psychosocial Research

NIDA has funded basic research on the determinants of AIDS risk behaviors, including sexual and drug-using behaviors. NIDA has also funded research grants focused specifically on AIDS prevention, and community-based AIDS prevention programs to get people into drug treatment in order to reduce their risk behaviors.

prevent the further spread of HIV infection among injection drug users, crack cocaine users, and others at risk for initiating injection behavior; (2) sample and monitor the serostatus of these populations in high- and low-HIV prevalence areas; and (3) evaluate the efficacy of controlled experimental interventions designed to eliminate or reduce HIV risk behaviors.

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 II percent of those tested for HIV antibodies were found to be seropositive.

The cooperative agreement program also included a number of multi-site studies designed to examine patterns of drug use, methods of obtaining drugs (and income and expenditures for drugs), and needle hygiene behaviors.

An important product of the NADR and cooperative agreement initiatives has been the development of a standard intervention that has had a marked effect in reducing drug-related HIV risk behaviors. Equally important, however, has been the finding that the interventions have been less effective in influencing drug users to reduce their sexual risk behaviors (NIDA Cooperative Agreement Steering Committee, 1992).

The cooperative agreement projects also included a number of contracts awarded to develop comprehensive community-based program development, intervention materials, and controlled evaluation trials for HIV risk reduction among the sex partners of injection drug users who are not themselves injectors. Data from these projects indicate that sex partners of injection drug users can be found in the community, will actively participate in risk reduction programs, and will substantially change risky behaviors, including reducing or stopping sexual practices with injection drug users and increasing condom use.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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As described below, most of NIDA's treatment research projects also employ psychosocial strategies and outcome measures.

In addition to being the second largest risk group for HIV/AIDS in the United States, injection drug users represent a population that appears difficult to affect with traditional AIDS prevention messages and programs. The potential for HIV acquisition and transmission from infected paraphernalia and unsafe sex is known to virtually all drug users. Yet most are accustomed to risking death (through overdose or the violence-prone nature of the illegal drug marketplace) and disease (hepatitis and other infections) on a daily basis, and this generally fails to inhibit their drug use. For these reasons, warnings that needle sharing or unsafe sex might facilitate an infection that could cause death perhaps five or more years in the future may not be effective for many injection drug users.

Within this context, in 1987, NIDA established its AIDS community-based outreach/intervention/prevention initiative, targeting out-of-treatment drug abusers. The decision to concentrate on out-of-treatment users was based on previous work that demonstrated that this population was considerably large, the most difficult to reach, and either unwilling or unable to cease illegal drug use. At the same time, prior research by NIDA-funded investigators had demonstrated that drug injectors could be located and identified in street settings, hospital emergency rooms, and in the criminal justice system, and that they could effectively be referred to human service programs.

As described in Box 6.1, NIDA's first generation of community outreach programs—NADR—reached approximately 150,000 out-of-treatment drug users and their sex partners. NADR evaluated interventions to reduce highrisk 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 partners.

Investigator-initiated grants have been conducted in a variety of treatment and community settings to assess various techniques of HIV risk reduction counseling for sex and drug-related HIV risk behaviors among drug users. Most of these projects use controlled experimental designs to examine education, counseling, skills training, peer support, and other psychosocial interventions. Collectively, these studies have shown that education and counseling can influence drug users to modify their HIV risk behaviors (however

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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ever, drug-related behaviors are more easily modifiable than sex-related behaviors).

Social-Structural Research

As articulated in NIDA's Five-Year Strategic Plan for AIDS research, one of the institute's primary objectives is to ''explicate the transactional and dynamic aspects and the social and behavioral factors that govern highrisk drug using and sexual behaviors" (NIDA, 1993). NIDA's plan also emphasizes the need for research to examine HIV risk behaviors over time and under different social circumstances using multidimensional, longitudinal studies.

Research on social factors has been integrated into existing studies, such as NIDA's treatment research initiative and community-based outreach cooperative agreement program described above. NIDA also supports research on the social networks of drug users and their role in HIV transmission. This research ranges from qualitative, ethnographic studies of the characteristics of social networks to quantitative methodological studies of advanced computer techniques for charting social networks.

In addition, NIDA's prevention agenda includes research associated with the provision of sterile drug injection equipment. Although there has been significant political pressure against it, NIDA has succeeded in funding research on needle and syringe disinfection and needle and syringe exchange evaluation (Box 6.2). Disinfection projects involve interdisciplinary basic and clinical research on the effectiveness of bleach in inactivating the HIV virus. Needle and syringe exchange research explores the effectiveness of altering an institutional dimension of injection drug use (that is, the availability of clean needles) in preventing the transmission of HIV.

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 6.3). Drug addiction often involves physical and psychiatric health problems in addition to environmental and social conditions that may contribute to addiction; therefore, effective treatment requires a comprehensive approach.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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Box 6.2 Needle Exchange Research

Needle exchange programs in the United States date back to 1986, when activists in Boston and New Haven began trading unused or "clean" needles for used ones. The first formal program was established in Tacoma, Washington in 1988 (Lane, 1993). Although NIDA still is restricted from funding needle exchange services, even as part of clinical research, it finally was able to fund an evaluation of the New Haven needle exchange program in 1992. NIDA has also recently funded evaluations of the needle exchange programs in San Francisco and Tacoma.

The evaluation of the New Haven needle exchange program, a program legally operated by the New Haven Health Department, represents the first federally funded needle exchange research in the United States. Rather than rely on changes in self-reported risky injection behaviors, this study employed mathematical and statistical models combined with data derived from a unique syringe tracking and testing system (or STT) (Kaplan, 1991; Kaplan and O'Keefe, 1993). This system allowed for anonymity, while testing for the presence of HIV-I proviral DNA using polymerase chain reaction (PCR) to obtain evidence of use by HIV-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. Researchers hypothesized that increasing the turnaround of needles would be equivalent to reducing needle circulation times, narrowing the window of time during which needle sharing can occur, and that if needles circulated for shorter durations of time, there would be fewer opportunities for needles to become infected, and the level of infection measured in needles would fall. The data derived from the STT revealed a significant drop in the portion of needles testing positive for HIV via PCR (Heimer, Kaplan, and Cadman, 1992; Heimer et al., 1993). Coincident with this trend was an increase in the portion of distributed needles returned to the program on a monthly basis, as well as a drop in observed needle circulation times (the time between needle distribution and return). The overall impact of the New Haven program was estimated to be a 33 percent reduction in new transmissions of HIV among the city's injection drug-using population (GAO, 1993; Kaplan, 1994; Kaplan and O'Keefe, 1993).

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

Because treatment research utilizes both pharmacologic and behavioral approaches, it is an area that cannot be easily categorized into one of the four scientific domains identified by the committee matrix. In fact, what makes these NIDA-funded research projects so unique is their emphasis on employing various combinations of pharmacologic, behavioral, and social approaches to improve the effectiveness of addiction treatment. NIDA has recognized that taking a cross-disciplinary approach in this area is the key to reducing risk of HIV transmission.

NIDA's treatment research grants are organized under three distinct categories: treatment research units (TRUs); experimental therapeutics research projects, and outcome evaluation research projects. TRUs have focused on cutting-edge treatment research, including controlled clinical trials of experimental therapeutics (psychotherapeutic and/or pharmacologic) for heroin and cocaine addiction and studies of medications development. 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. They include a wide variety of treatment strategies for cocaine and heroin addiction, including studies of fluoxetine, desipramine, buprenorphine, acupuncture, community reinforcement strategies, and behavioral interventions to enhance effectiveness of various medications.

Outcome evaluation research projects have focused on improving treatment effectiveness and reducing dropout rates using various psychosocial and social interventions. These include examining the impact of various treatment environments (inpatient or outpatient, varying program lengths and types) and enhancing treatment environments by adding case managers, individual counseling, or vocational training. All of these grants have used behavioral outcome measures and a few have also measured HIV seropositivity rates. Although these projects are still in progress, preliminary findings suggest that they have increased program capacity, treatment retention, and treatment effectiveness.

GRANTS

During the first decade of AIDS research funding at NIDA, a significant proportion of its AIDS grants were biomedical and psychosocial (Figure 6.13). The NADR Community Outreach Program was a significant focus of the AIDS program beginning in 1987.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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Box 6.3 Treatment Research

Treatment research at NIDA has grown tremendously owing to the urgency of the AIDS epidemic. Before the first indicators of the AIDS epidemic had come to the attention of clinicians and researchers throughout the world, the drug abuse problem in the United States appeared to be under control. While heroin use had hit high rates a decade earlier, during the late 1970s the low purity of street heroin was enticing few new users, and concern over the illicit use of cocaine was limited.

In addition, treatment programs were under severe financial constraints during the 1970s as per-slot funding failed to keep pace with inflation. In the 1980s, the "New Federalism" of the Reagan administration further reduced treatment availability (Fletcher, Tims, and Inciardi, 1993). That policy sought to reduce the federal role and give states greater discretion in allocating treatment funds. The passage of the Omnibus Budget Reconciliation Act of 1981 terminated direct federal support of treatment programs and transferred funds directly to states in the form of block grants for alcohol, drug abuse, and mental health treatment. Federal treatment funding through block grants was reduced by 25 percent to reflect savings in administrative costs. Unable or unwilling to increase state allocations to replace federal administration and monitoring efforts, many states gradually reduced their own levels of treatment funding, with consequent declines in the quality and availability of public drug abuse treatment services.

At about the same time, the availability of cocaine increased, permeating all socioeconomic strata and occupational groups. And when crack cocaine became widely available on the streets of urban and rural America, cocaine use quickly became epidemic, particularly in inner-city communities. The emergence of the cocaine epidemic in the early 1980s, furthermore, was concurrent with that of the AIDS epidemic. 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. Research showed that treatment could be effective in reducing drug use and criminal behavior, but changes in patterns of drug use, in characteristics of drug users, and in the organization and structure of the treatment system created uncertainty regarding past findings on the effectiveness of treatment. Anecdotal reports suggested that typical publicly funded, community-based treatment programs developed in the 1960s and 1970s to treat heroin addiction were challenged by new patterns of drug use and were under severe strain from excessive demand, understaffing, and chronic lack of adequate resources

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

and support needed to address such accompanying problems as psychiatric comorbidity and social, educational, and vocational deficits.

Although NIDA was no longer authorized to collect systematic data to monitor client flow and quality of care after 1981, surveys of the homeless, criminal justice clients, and the general household population provided evidence that the number of publicly funded treatment slots fell far short of need. It was estimated that on any given day in 1987–1988, some 5.5 million individuals needed drug treatment, while the public and private treatment capacity was estimated at only 329,000 (IOM, 1990).

Within this context there was an urgent need to expand the availability of treatment services and to improve their effectiveness—both to curb cocaine use and to slow the spread of AIDS among injection drug users. 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. The target populations of the effort included injection drug users as well as non-injecting drug abusers who were at risk through prostitution and sex-for-drugs exchanges.

Since 1989, approximately 30 projects have been funded through the research demonstration grant mechanism to develop, implement, and evaluate innovative treatment approaches. In addition to direct research costs, funds were provided for the support of research-related treatment costs, thereby creating new treatment capacity. The innovative projects included: special initiatives and programs targeting issues of perinatal substance abuse; enhancements to traditional treatment modalities such as methadone maintenance, residential treatment, and case management; alternative approaches for increasing retention in methadone, therapeutic community, and drug-free outpatient programs; new models for the treatment of cocaine addiction and the dually diagnosed; and such totally new initiatives as a work release therapeutic community for prisoners, and a modified day treatment therapeutic community for methadone clients.

All of these programs were funded under the R18 mechanism, but the legislation supporting this mechanism has now lapsed. There has been an attempt to stimulate new treatment research demonstrations under the R01 mechanism. However, given the high cost of treatment services associated with these projects, it is the opinion of many treatment researchers that without the R18 mechanism few new innovative projects will be funded.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

FIGURE 6.13 Proportion of NIDA AIDS Research Grants, Coded for Each Category,1987–1992. Note: Includes RPGs (R01s, R29s, R37s, U01s, but not R43/44s); all R18s(including NADR). Multi-coded grants are included in each relevant category. Source: NIH CRISP system, and IOM committee database.

All NADR grants are categorized according to the committee's codes as applied psychosocial research. Some also include a social-structural component and are coded accordingly. The Community Outreach Cooperative Agreement Program grants—the second generation of NADR—were initially funded in 1990 and all have a psychosocial component. 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-of-treatment injection drug users (and their sex partners in some projects), and are also coded as epidemiological. Several projects also measure changes in seroprevalence rates among study participants, and are coded as biomedical.

More than 80 percent of NIDA's AIDS demonstration grants (R18s), funded between 1989 and 1992, are multi-coded. Approximately

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

90 percent of them have a psychosocial component, 70 percent have a biomedical component, and approximately 33 percent also include a social-structural component.

In general, NIDA's AIDS program displayed a greater commitment to social-structural research than NIAAA's or NIMH's programs did, although this was still small relative to other categories of research. Furthermore, NIDA's grant portfolio was fairly well balanced between biomedical and psychosocial research until 1990, when it shifted toward favoring biomedical research.

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 high-risk behaviors and strategies to change those behaviors, as well as the mental health and neurological consequences of HIV infection.

NIMH first funded AIDS research in FY 1983, when the institute received $200,000 from supplemental funds to support several AIDS-related research project grants (R01s). While the total NIMH budget increased from $191.5 in FY 1983 to $560.5 million in FY 1992 (Figure 6.14), the AIDS budget increased from $200,000 in FY 1983 to $76.2 million in FY 1992 (Figure 6.15). 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.

NIMH funding generally has been committed to R01s and P50s (research center grants). RPGs make up the bulk of the NIMH AIDS program–98 percent of AIDS funding in FY 1984, 38 percent in FY 1987, and 45 percent in FY 1992 (Figure 6.16). Centers also have been a significant mechanism for AIDS research, representing 19 percent of the AIDS budget in FY 1986 (the initial year for centers), rising to 33 percent in FY 1988, and leveling off at approximately 20 percent in FY 1991. NIMH has supported more AIDS training grants than either of the other two institutes. Training grants represent approximately 5 percent of the total NIMH AIDS budget. Contracts have constituted a small part of the AIDS program—rising from less than 1 percent in FY 1989 to 3 percent in FY 1990. Although intramural research has been an important component of the AIDS program at NIMH, it fell from 18 percent of the total AIDS budget in FY 1987 and leveled off at about 11 percent in FY 1989.

Compared to NIMH's non-AIDS funding (Figure 6.17), the distribution

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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FIGURE 6.14 NIMH Expenditures (AIDS/Non-AIDS), 1983–1993.

*Estimate. Source: NIMH Budget Office.

FIGURE 6.15 NIMH AIDS Expenditures, 1983–1993.

*Estimate. Source: NIMH Budget Office.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

FIGURE 6.16 NIMH AIDS Funding by Mechanism, 1987–1992. Source: NIMH Budget Office.

of NIMH AIDS funding by mechanism has fluctuated greatly from year to year. 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 (with input from outside consultants and various divisions and offices within NIMH), develops the annual AIDS budget, and directs the AIDS extramural program. While the ADAMHA Reorganization Act required the creation of a formal AIDS office at NIMH, such an office already existed administratively within the office of the director. The program continues to be centrally directed, and the majority of NIMH's extramural FTEs are located within the AIDS office, the Division of Resource Management, or the Office of Extramural Affairs (to review grants, handle grants management activities, contract, budget, and perform other administrative functions). In FY 1993, only two FTEs were allocated to other program divisions. Although NIMH AIDS FTEs rose 230 percent from FY 1986 to FY 1993, they still represent less than 5 percent of the total FTEs (Table 6.4).

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

FIGURE 6.17 NIMH Non-AIDS Funding by Mechanism, 1987–1992. Source: NIMH Budget Office.

TABLE 6.4 NIMH AIDS Staffing (FTEs) by Administrative Area, 1986–1993

 

1986

1987

1988

1989

1990

1991

1992

1993*

Intramural research

3

14

12

17

25

25

25

25

RMS

0

0

7

10

21

21

21

21

AIDS Total

3

14

19

27

46

46

46

46

NIMH Total

779

819

869

861

868

903

934

984

NOTE: *Estimate. RMS = Research management and support.

Source: NIMH Budget Office.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×
PROGRAMS AND PRIORITIES
Biomedical/Biobehavioral Research

NIMH supports intramural and extramural research on the neuroscience and neurobehavioral aspects of AIDS. When clinical researchers documented that the AIDS virus directly infected the brain, the NIMH program expanded to investigate the mechanisms of CNS HIV-1 infection.

Biomedical/biobehavioral and clinical research at NIMH is classified into several main categories, although by necessity they often overlap: the effects of HIV/AIDS on CNS function (classified as neuroscience ); the neuropsychological, neuropsychiatric, and neurological sequelae of HIV infection on the CNS (classified as neurobehavior); and the biological interface relating stress and behavior to immune function (classified as psychoneuroimmunology).

Intramural research at NIMH has focused on the neuroscience of HIV infection and the development of animal models for more rapid exploration of the consequences of HIV infection in the brain. Intramural scientists have investigated interactions between HIV and the CNS, cognitive dysfunction and AIDS dementia, and treatment of the HIV effects on the brain. Specific intramural projects have included research on: the interaction between HIV-1 and cultured brain neurons, the role of quinolinic acid (QUIN) in CNS damage, the development of Peptide T as a potential treatment for improving neurocognitive functioning, and the impact of HIV infection on neurobehavioral functioning (visual learning, memory, and motor skills) in monkeys infected with simian immunodeficiency virus (SIV). 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 (NICHD) and the National Institute on Neurological Disorders and Stroke (NINDS), 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. Research on interactions between the immune system and the brain was intended to provide important knowledge about the molecular and cellular mechanisms that affect disease susceptibility and progression. More recently, in 1992 NIMH and NINDS jointly issued a program announcement to encourage individual

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

researchers (primarily neuroscientists) to work in partnership with researchers from the AIDS clinical trials units (ACTUs), the Multicenter AIDS Cohort Study (MACS), and the Women and Infants Transmission Study (WITS) on studies of HIV infection of the CNS. The overarching goal of AIDS-related neuroscience research is to understand the pathogenetic mechanisms involved in HIV-associated brain dysfunction. This encompasses clinical and laboratory research studies aimed at understanding the biology of HIV infection of the CNS and the mechanisms of brain dysfunction at the organismic, cellular, and molecular levels. Investigations cross many disciplines and range from clinical studies dealing with natural history, disturbed physiology, and neuroimaging, as well as clinical virology and immunology, to fundamental laboratory studies involving animal and cell culture models, as well as biochemical and molecular research.

Neurobehavioral research generally is more clinically directed and aims at defining and understanding the effects of HIV and various treatment on the neurodevelopment of infected and at-risk infants and children, and the neuropsychological, neuropsychiatric and neurological sequelae of HIV infection in infected and at-risk adults. This research involves methodological development, direct study of clinical presentation and natural history, and assessment of antiviral therapy and other interventions.

NIMH also has supported psychoneuroimmunology research in its AIDS program. This discipline focuses on the relationship between the brain (including its behavioral state) and the immune system. Its potential application to AIDS is supported by the hypothesis that behavioral states may modulate immune defenses against HIV and thereby alter the response to HIV exposure and the rate of progression to AIDS in those infected.

Epidemiological 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 highrisk 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. Not only is behavioral epidemiology critical for understanding risk factors associated with HIV transmission and disease progression, it is essential to the development and evaluation of preventive AIDS interventions.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×
Psychosocial Research

Psychosocial research investigating the determinants of risky sexual and drug-using behaviors, as well as strategies for changing these behaviors, is a major focus of the NIMH AIDS research portfolio. Beginning prior to the emergence of the epidemic and continuing into its first twelve years, political restrictions on sexual behavior and drug abuse research resulted in a relative dearth of knowledge about HIV risk behaviors. 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. Basic research in this area has critically informed AIDS preventive intervention research. In the realm of applied research, NIMH has supported theory-driven preventive interventions that focus on behavior change strategies for individuals or small groups at high risk. Many of these efforts have demonstrated successful behavior change, and their generalizability is being tested in prevention strategies across multiple populations and sites in an NIMH-initiated cooperative agreement begun in 1990. This program, the Multi-Site HIV Prevention Trial, is a longitudinal five-year study targeting the chronically mentally ill, injection drug users and their partners, prisoners, young gay men, highrisk adolescents, women, and STD clinic clients.

Basic and applied psychosocial research also have been the focus of two of the five NIMH-funded centers—the Center for AIDS Prevention Studies (CAPS) at the University of California, San Francisco (UCSF), and the HIV Center for Clinical and Behavioral Studies at Columbia University/New York State Psychiatric Institute (see below for more on the centers program).

Social-Structural Research

NIMH has funded several basic research grants to explore the social context of risk behavior. These grants examine the development of social groups and crowd characteristics during early adolescence and the impact of crowd affiliation on risky behavior; the feasibility of using social network data to operationalize socioecological constructs that may influence risky behavior; the features and effects of social relationships on behavior; and the

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

nature of structural barriers to AIDS health services and care (health services research). The NIMH agenda also emphasizes the importance of incorporating social factors into research on HIV risk behavior change and supporting research on preventive interventions at the individual, small group, institutional, and community level.

GRANTS

The most significant single domain of research at NIMH is psychosocial research, followed closely by biomedical research (Figure 6.18). Psychosocial research grants at NIMH include basic research on psychological mechanisms that underlie behavioral outcomes (including such topics as the relationship between emotion and cognition, stress and coping processes, decision-making processes, and sexual identity formation, behavioral and psychological responses to HIV testing and HIV status, and stress and coping among caregivers). Applied psychosocial research grants include

FIGURE 6.18 Proportion of NIMH AIDS Research Grants, Coded for Each Category,1987–1992. Note: Includes RPGs only (R01s, P01s, R29s, R37s, R43/44s, and U01s).Multi-coded grants are included in each relevant category. Source: NIH CRISP system, and IOM committee database.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

behavioral interventions for HIV prevention. Single-coded applied psychosocial grants use behavioral outcome measures only.

Many NIMH research grants are multi-coded for biomedical and psychosocial research components. Applied biomedical/psychosocial grants include: behavioral interventions for HIV prevention that incorporate outcome measures such as HIV seropositivity rates and/or STD rates in addition to behavioral outcome measures, and treatments and interventions for AIDS-related depression and emotional distress.

Basic biomedical/psychosocial grants include: natural history and descriptive studies examining the neuropsychological and neurobehavioral sequelae of HIV infection (studies that simultaneously gather information on biological parameters and psychosocial factors); research examining the relationship between psychosocial factors (including social stress, dominance ranking in social groups, social isolation, and social companionship) and the immune system generally with HIV disease progression specifically (in humans and non-human primates).

Most single-coded biomedical grants are basic research and include: psychoneuroimmunology and neuroimmunology research grants that focus on biological processes and mechanisms (mostly in animals, some in humans); research on neural-immune-endocrine interactions; research on neural cell functions; research on CNS pathology; and research on AIDS dementia complex. NIMH has funded several applied biomedical grants, that are therapeutic interventions.

NIMH's few grants with a social-structural component are all basic research and focus on understanding the role of social relationships and social networks in shaping an individual's behavior.

Although research centers account for a significant proportion of AIDS research funding at NIMH, they are not included in the table above. Because the centers have received funding from other institutes as well as NIMH, they are among the collaborative projects described below.

COLLABORATIVE PROJECTS

NIAAA, NIDA, and NIMH have collaborated on a number of AIDS research activities. For example, the three institutes issued joint program announcements in September 1988 for Research on behavior change and prevention strategies to reduce transmission of HIV (with four other NIH institutes and CDC) and for the Role of family in preventing and adapting to HIV infection and

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

AIDS. The institutes also have jointly sponsored multidisciplinary extramural AIDS research centers at institutions around the country.

AIDS RESEARCH CENTERS

AIDS research centers were first initiated in 1986 to provide support for coordinated, multidisciplinary research programs on the mental health and drug abuse aspects of HIV/AIDS. Since 1986, NIMH has supported five AIDS research centers. NIDA contributed some funding to three of these centers from 1986 through 1991.

The Center for Biopsychosocial Study of AIDS at the University of Miami was initially funded in 1986 to focus on biopsychosocial aspects of AIDS. At the intersection of biomedical and psychosocial research, the Miami center has investigated the relationship between lifestyle changes and disease progression as measured by neurocognitive and immune status.

Researchers at the UCSF Center for AIDS Prevention Studies (CAPS), also established in 1986, have conducted basic and applied research on sex and drug-related risk behaviors among a range of populations varying by sexual orientation, gender, race/ethnicity, and age. These projects include the National AIDS Behavioral Surveys (NABS), the AIDS in Multiethnic Neighborhoods (AMEN) study, studies of Latino and Latina Americans, and studies focused on improving sexual behavior research methods.

The HIV Center for Clinical and Behavioral Studies at the New York State Psychiatric Institute and Columbia University was established in 1987. 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.

Beginning in 1987, NIMH supported AIDS Research Centers to address key neurobiological and behavioral issues through inter-disciplinary research on the CNS effects of HIV, ADC, neuropsychiatric aspects of HIV infection, brain-immune interaction, and behavior change and prevention. The HIV Neurobehavioral Research Center at the University of California, San Diego was established in 1989 to investigate neurobehavioral functioning and to identify

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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specifically the effect of HIV on the CNS. Using neuropsychological, neuropsychiatric, and neuroimaging techniques, this center is investigating etiology, pathogenesis, and natural history of neuro-behavioral disturbances associated with HIV/AIDS.

The Research Center on Molecular and Cellular Mechanisms of AIDS Dementia at the Scripps Research Institute in La Jolla, California was established in 1990 to investigate the molecular and cellular mechanisms underlying ADC. Investigators at this center have conducted multidisciplinary research to define the biological actions of persistent virus infections of the brain, the profiles of cell-to-cell signals activated by these infections, and the nature of the effects of these signals on neuron function, by conducting comparative evaluations of brain pathophysiology in AIDS patients with that found in three animal models.

Currently, NIMH is still funding four of the AIDS research centers: the Center for AIDS Prevention Studies, the HIV Center for Clinical and Behavioral Studies, the HIV Neurobehavioral Research Center, and the Research Center on Molecular and Cellular Mechanisms of AIDS Dementia. As this report was being written, NIMH announced it had funded under the ''core" mechanism a new Center for AIDS Intervention Research (CAIR) at the Medical College of Wisconsin. This center will focus attention on HIV prevention and HIV mental health service intervention research.

TRAINING

Training has been an integral part of the AIDS programs at NIAAA, NIDA, and NIMH. NIAAA has funded training for AIDS-related alcohol research and has contributed to collaborative efforts to develop AIDS and substance abuse curricula for health care providers. NIDA initiated an AIDS training program in 1986 for counselors and administrators at drug abuse treatment programs. (This program was transferred to SAMHSA as a result of the ADAMHA reorganization.) NIDA also funds a number of training grants for predoctoral and postdoctoral students on research issues related to drug abuse and AIDS. NIMH training efforts are designed to prepare young scientists for careers in AIDS research. Training grants are awarded to individuals and to institutions committed to HIV-related mental health research, and the NIMH AIDS research centers provide training programs for new investigators. NIMH has trained more than 40,000 health care providers in the neuropsychiatric and psychosocial aspects of HIV/AIDS

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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through the NIMH AIDS Health Care Provider Training Program initiated in 1986.

THE NIH CONTEXT

Now that NIAAA, NIDA, and NIMH are located at NIH, they are part of the funding and programmatic agenda of NIH. An understanding of the overall AIDS budget and program context at NIH will provide some insight into how the former ADAMHA institutes will function in the NIH environment. Total NIH funding increased more than 100 percent between 1983 and 1993 (from $4.3 billion to $10.3 billion). While the growth in AIDS research in the same period appears to be explosive, it reflects the requirement to respond rapidly to a new disease with major public health implications (Figure 6.19). Seven NIH institutes and centers (including NIDA and NIMH) received the vast majority of AIDS funding during this period (Figure 6.20). In order of magnitude, based on FY 1992 expenditures, they are: the National Institute of Allergies and Infectious Diseases (NIAID), which received 43 percent; the National Cancer Institute (NCI), which received 16 percent; NIDA,

FIGURE 6.19 NIH Expenditures (AIDS/Non-AIDS), 1983–1993. Note: Includes NIAAA, NIDA, and NIMH for all years. *Estimate. Source: NIH Budget Office.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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FIGURE 6.20 NIH AIDS Research Funding by Component, 1992. Source: OAR and Division of Financial Management, NIH.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

which received 12 percent; NIMH, which received 7 percent; the National Center for Research Resources (NCRR) and the National Heart, Lung, and Blood Institute (NHLBI), which each received 5 percent; and the National Institute of Child Health and Human Development (NICHD), which received 3 percent. 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 1980s with the growing concern over pediatric AIDS, the number and ranking of the major players has remained fairly constant.

AIDS constituted a major portion of the budget for each of the seven institutes (Table 6.5). For example, in FY 1992 nearly half of NIAID's budget, nearly one-third of NIDA's budget, and 16 percent of NCRR's budget were devoted to AIDS. Just 2 percent of the cumulative total of the other institutes was for AIDS research.

While NIAAA, NIDA, and NIMH together represent a significant portion of the NIH AIDS budget, their funds are distributed quite differently from most of the other institutes. In FY 1992, NIAAA, NIDA, and NIMH together comprised $209.4 million or approximately 20 percent of the total NIH AIDS budget (NIAAA's portion is minor, however). According to estimates for FY 1993, the three institutes continued to account for 11 percent of the total NIH budget and 20 percent of the AIDS budget. Yet they

TABLE 6.5 AIDS Funding as Proportion of 1992 Budget, Selected NIH Institutes (Dollars in Millions)

Institute

AIDS

Total

% AIDS

NCI

165.7

1,947.6

9

NHLBI

46.2

1,190.1

4

NIAID

448.9

960.1

47

NICHD

34.7

518.6

7

NIMH

76.1

560.8

14

NIDA

125.3

399.1

31

NIAAA

8.0

171.5

5

NCRR

50.1

314.2

16

Other

94.6

3,948.4

2

TOTAL

1,049.6

10,010.4

10

 

Source: Division of Financial Management, NIH.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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funded more than 97 percent of NIH's behavioral research (as defined by the Mason categories), 64 percent of surveillance, 54 percent of neuroscience and neuropsychiatric research, and over 30 percent of health services research and research training. On the other hand, NIAAA, NIDA, and NIMH account for less than 1 percent of the funding for therapeutic agents and 12 percent of the funding for biomedical research, two categories that together represent nearly 60 percent of the total NIH AIDS budget. It is clear that NIAAA, NIDA, and NIMH play a critical role in the overall NIH AIDS research agenda and particularly in its biobehavioral and behavioral agenda.

However, at the time this report was written, the overall NIH agenda was in the process of being reformulated, reflecting the requirements of the NIH Reauthorization Act that vested new authority for AIDS planning and budgeting within OAR. In addition to new budgetary authority, OAR also was given responsibility for developing and coordinating a five-year strategic plan for AIDS research across the NIH institutes. The general outline of that plan has been developed, and five AIDS-related research categories have been identified: natural history and epidemiology; etiology and pathogenesis; therapeutics; vaccines; and behavioral research. (Social research for the most part will likely be subsumed under the "behavioral" category.) Coordinating committees composed of NIH staff and external experts will formulate strategies regarding research priorities, goals, and objectives within these categories, across institutes. (The plan also discusses training and infrastructure and information dissemination.) Eventually, OAR will attach budget allocations to various institutes based on these strategies.

It is not clear yet how these OAR-level activities will be linked with the AIDS program activities of specific institutes. For example, although the ADAMHA Reorganization Act required that NIDA and NIMH create an Office on AIDS, it did not specify how these entities should work with the NIH OAR. Without knowing at the time this report was written how these offices plan to work together, the committee believes that all three institutes should have an AIDS coordinator for whom this job is the primary responsibility. The coordinator should be provided 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. It is the committee's understanding that at least in some cases, such as at NIMH, this is already occurring.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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CONCLUSION AND RECOMMENDATIONS

CONCLUSION

The AIDS research programs of NIAAA, NIDA, and NIMH have developed over the past decade in response to growth and change in the HIV/AIDS epidemic itself. Increased recognition of the substance abuse and mental health aspects of AIDS is both a reflection of and encouragement for the institutes' involvement in AIDS research during this period. This is evidenced by the precipitous growth in funding of the institutes' AIDS programs, which has significantly outpaced growth in overall funding.

Characterizing and evaluating the content of the institutes' AIDS programs is a difficult task. Coding by any scheme—whether scientific domain or AIDS versus non-AIDS—is an imperfect science. Moreover, assessing the value of the research supported is hampered for applied research by a notable lack of evaluative studies, and for basic research by the recognition that the benefits of any study may not be discovered for some time after it is conducted—and that findings may end up benefitting a different area than that imagined by the investigators.

Nevertheless, the effort undertaken by the committee to assess the AIDS research programs of NIAAA, NIDA, and NIMH did reveal some important findings. Chief among these is that a significant amount of cross-disciplinary research is being supported. Much of this is directed 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, and social factors in the lives of individuals. The committee is encouraged by this, and would like to see the appreciation of cross-disciplinary research applied to investigator-initiated grants as well.

A related finding is that the overall balance between what could be considered "biomedical" and "behavioral" (primarily psychological) research at the institutes generally has improved over time (there is greater parity in the number and funding of grants in both domains). NIMH has most consistently balanced its portfolio; and NIAAA has moved quickly in the last couple of years to achieve greater balance. NIDA, however, moved away from its earlier balance toward favoring biomedical research, following the transfer of the NADR program out of its portfolio. In all cases, however, the ''behavioral" category is primarily composed of

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

psychosocial grants; social-structural research is notably undersupported at all three institutes.

A second important finding of the committee's analysis is that most AIDS research supported by the institutes is basic science research. 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. With respect to AIDS, although there have been significant developments in basic research on sexual behavior, drug addiction, and the effect of the HIV on the CNS, much remains to be learned.

Advances in AIDS research at NIAAA, NIDA, and NIMH—especially in the neurosciences and social sciences—will have significant implications for other areas of research at these institutes and others. These advances relate to broader phenomena, such as neurobiological drives toward addiction and sexual gratification, mental health and illness, and the role of social structure and culture in influencing individual behavior.

RECOMMENDATIONS FOR RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH

6.1 The committee recommends that NIAAA, NIDA, and NIMH each establish a position for a full-time AIDS coordinator. The coordinator should be provided 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 NIH Office of AIDS Research.

6.2 The committee encourages OAR to serve as a catalyst for cross-institute and cross-PHS agency research collaborations through its funding authority and leadership role.

6.3 The committee recommends that the OAR leadership include competence in biomedical, neuroscience, behavioral, and social science perspectives.

6.4 The committee recommends that NIAAA, NIDA, and NIMH ensure the maintenance of the behavioral and social science research programs of the three institutes within the NIH context. The committee supports the recommendation

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

of the National Commission on AIDS (1993b) to expand research in the following behavioral and social science research perspectives: behavioral epidemiology; cognitive science; cultural and ethnographic studies; intervention research; mental health research; behavioral aspects of technological interventions; and organizational studies. The committee adds to that list cost-effectiveness research and evaluation research.

6.5 The committee notes that, of all the types of AIDS research at NIAAA, NIDA, and NIMH, social science research is the most underfunded. The committee therefore recommends that the three institutes develop new initiatives to support research on the role of social, cultural, and structural factors in HIV/AIDS transmission, prevention, and intervention.

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.

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. These strategies should include those targeted to highrisk populations, such as drug-involved offenders, prisoners, women, and crack-cocaine users. 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.

6.9 The committee recommends that an effort be made to coordinate between institutes that have overlapping AIDS research programs (for example, HIV and CNS function at

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
×

NIMH and NINDS) by collaborating in the program development, 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. Therefore, the committee recommends that NIAAA, NIDA, and NIMH, with input from appropriate experts, develop a mechanism for collecting and reporting data on the gender, race/ethnicity, and socioeconomic status (class) of study populations in projects supported by the institutes. Such data collection and reporting should be guided by clear articulation of the role of these variables in the epidemic.

Suggested Citation:"6 RESEARCH FUNDING, PROGRAMS, AND PRIORITIES AT NIAAA, NIDA, AND NIMH." Institute of Medicine. 1994. AIDS and Behavior: An Integrated Approach. Washington, DC: The National Academies Press. doi: 10.17226/4770.
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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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