treating it? Why have you dropped funding for AZT, when all the new reports come out showing how effective AZT can be in the early stages? And what is the focus of the increase in AIDS funds in the various agencies under your control? Just sort of paint us a picture of what is happening. Dr. MASON. I would be delighted to do that, Mr. Chairman. And if I might refer you to several charts that I prepared, and there are handouts at each one of the desks. The first chart shows the magnitude of the current problem, and I emphasize that the estimated number of infected individuals in the United States is approximately 1 million. The range is 0.8 million to 1.3 million, and this is an estimate based upon studies that are- Senator REID. Excuse me. We cannot hear. We cannot hear or see. Could you move that a little closer. Senator HARKIN. Pull your mike in a little bit, Dr. Mason. Senator REID. Maybe so Senator Adams could see this, could you move that over here? [Pause.] Dr. MASON. I hope you can see that now. The last time I was told people could not hear me I spoke louder and said, is that better? And someone in front said: It is louder, but it is no better. [Laughter.] We will try to carry on. Approximately 1 million cases, this is an estimate. So there is an interval there of 0.8 million to 1.3 million based on current estimates. As you know, the Public Health Service has recently revised their estimate downward. We probably were too high 2 or 3 years ago and, as better data becomes available, we are getting it better in line with what is really happening out there. Senator HARKIN. That is one of my questions. I will interrupt you right here if you do not mind. Dr. MASON. That would be fine. Senator HARKIN. There has been a reduction in that estimate. You say the only reason for that is just better data has come in? Dr. MASON. Better data. Probably with data that was available when the first estimates were made-that was 3 years ago-where we said there was one to 12 million infected, we were probably high. It is interesting at that time that various people were estimating as many as 40 million people were infected and CDC came in and said it is only 1 to 12 million, and there was a lot of criticism that they were too low. But even CDC at that time was higher than what we now feel. So there has been a slow increase in the number of infected over the last 3 years, and we are not able to measure directly how fast that is, but obviously as a nation it is not spreading like wildfire. However, among certain risk groups, particularly IV drug abusers and their heterosexual partners, we still estimate that we have rapid spread of this disease. The cumulative number of cases reported through December 31, 1989, is almost 118,000. You can see that during 1989, 35,000 cases were reported, which represents a 9-percent increase over 1988. There were 640 pediatric cases reported in 1989, and almost 60 percent of the pediatric cases reported are born to mothers who are using intravenous drugs or who are sexual partners of intravenous drug users. I would like to mention that, in the context of the distribution of these cases that you see on the chart, that a disproportion of those cases are in our minority population: 27 percent among our black population, 15 percent among our Hispanic population, and that is approximately double their ratio in the total population. We are delighted to report that during 1989, the number of cases associated with blood transfusions fell 12 percent among adults and 39 percent among children. At present, with our careful education of donors, testing and voluntary exclusion, convincing those who are at high risk not to give blood for transfusions, we are beginning to see a significant difference in the number of transfusion-associated AIDS cases. The next chart, please. REPORTED AIDS CASES BY YEAR OF REPORT It shows the reported AIDS cases by year of report. And you notice the progression of both total cases as well as in the small inset, the pediatric cases. You notice that there appears to be somewhat of a leveling off in 1989 compared with the rate of increase in previous years. We want to caution you not to jump to any conclusions that the disease is in fact slowing down to that extent. We are not totally sure why that slowdown occurred in 1989, but there could be, first of all, reporting delays. We know that one large city and a State reported numerous cases right after the end of the year and they will be reported in 1990. So you get artifacts in reporting. We know that behavior change has occurred, particularly in the white homosexual population, and that started a number of years ago, and this is undoubtedly having some effect in the occurrence of new cases. Finally, the use of these new drugs that have been developed by biomedical research and rapidly licensed by FDA is also beginning to have an impact, particularly when these are used as an early intervention before symptoms develop. So these people who are infected are slowed down in the progression of their disease, and so the disease is not reported as AIDS. We think all three of those items are responsible for the trend that is apparent there. Next chart, please. 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 Year *Projections include inflation by 18% in recognition of underreporting to CDC. Beginning in 1989 an upper and lower range is displayed. Estimates are based on February 1990 projections. This again shows what has happened and gives you projections through the year 1993. It is important to emphasize that, since the average incubation period of this disease from onset of infection to where clinical symptoms occur, is approximately 9 years, that all of the cases or nearly all of the cases that will occur between now and 1993, will occur in individuals that are already infected. Changes in the pattern of transmission in the next 3 or 4 years will not significantly affect the number of cases that will occur. The next chart, please. This shows the projected cases for the year 1993, and by that year the cumulative cases diagnosed will vary between 390,000 and 480,000. By then the cumulative number of deaths will have been from 285,000 to 340,000; and individuals who could benefit from care or treatment will be in the range of 580,000 to 640,000. This group will be people with symptoms of AIDS, as well as infected individuals who as yet are asymptomatic, but are significantly immunosuppressed, and they can be treated with AZT, aerosolized pentamidine or with other therapies or prophylactic drugs. The next chart summarizes the research accomplishments of the past years, the investment in biomedical science. I will not read each of those lines, but you can see that the research accomplishments are indeed significant. Things are coming out of the pipeline that are having a very meaningful effect. The next chart shows approved AIDS drugs and the indications for which they are used. And again, I think this is very impressive in terms of what has been accomplished. Of course at the top of the list is Zidovudine or AZT, which is effective in suppressing HIV, the retrovirus that causes the disease. The other drugs are useful in treating or preventing the opportunistic infections that occur in people with AIDS because they have been immunologically compromised. The next chart simply summarizes prevention accomplishments, and for example, under the third bullet, expanded counseling, testing, and partner notification programs, more than 2 million Americans have been tested in public sites since 1985 as a result of these prevention programs. We know today that the public's knowledge about HIV infection and how it is transmitted has increased significantly. There is more knowledge out there and there is less disinformation. We are now concentrating on targeting information particularly to those groups whose behaviors put them at risk. The next chart shows annual deaths in the United States from selected causes. I include this chart because I think it puts HIV infection in perspective. We have to remember that the reported number of cases here increased to 44,000, to adjust for the approximately 18 percent that are not reported. It shows in the context of deaths what is happening. Many ask, if that is all the deaths that are occurring, why are we spending so much, why are we so concerned about HIV infec tion? I just wanted to mention that we are spending as much as we are because the epidemic continues to grow. Although we are concerned about the other diseases on the chart, most of the rates in the context of tobacco-related illness or diet-related illness and these other things are relatively stable, while with HIV infection we are dealing with an epidemic, and if we do not get on top of that we will pay for it later. We need to invest now. We need to develop information that has never been available. Finally, this is a fatal disease, not to say that other diseases on the chart are not fatal. We also have great spinoff benefits from what we are now learning in the context of biomedical research into the cause of AIDS. Had it not been for good cancer research, we would not have as rapidly identified the cause of HIV or we would not have a diagnostic test. A lot of the drugs, like AZT, were previously screened in the context of cancer chemotherapy. So just as we help to move into the HIV infection because of our investment in cancer and other diseases, what we are investing in HIV will enable us to know more about the immune system, vaccines, and other retroviruses that cause disease in man. Finally, you asked about new programs and what we are spending. The increase of $109 million that is proposed, which is a 7-percent increase, will allow FDA, for example, to increase the rapidity with which they review, evaluate, and approve new drugs and, as the backload of new drugs begins to occur as a result of biomedical sciences, provide the staffing so that we will not get behind. It provides to CDC an increase of $66 million for evaluations to document the effectiveness of various counseling techniques on behavior change. It will enable them to find out more about the rate of spread of this disease. NIH will have an increase of $57 million or 8 percent over 1990 to fund additional clinical trials, work on vaccine development, and other research activities. ADAMHA will have an increase of $15 million, or 7 percent, to look at biomedical research, neuroscience, and neuropsychiatric training, risk assessment, prevention activities, buildings and facilities. The new Agency for Health Care Policy and Research will have an increase of $2 million to expand the AIDS cost and service utilization survey. And finally, in the Office of the Assistant Secretary for Health, there will be an increase of 11 percent to support minority health grants and AIDS program coordination. Senator HARKIN. Dr. Mason, thank you for a very good overview of the whole AIDS program. How much money are you requesting for pediatric AIDS? Dr. MASON. In total in pediatric AIDS, our increase is $155 million. That represents an increase of $29 million or 23 percent in an important area. Senator HARKIN. A 23-percent increase? Dr. MASON. Yes. |