Question. What States have been chosen to operate the McKinney Act demonstration programs, and when do you expect to see results?

Answer. At this time, no States have been chosen to operate the McKinney Act demonstration programs. A program announcement is being drafted and should be published by late Spring. Decisions will be made in the fourth quarter on the two to three States which will receive project awards. Project durations could then extend for up to 36 months before we expect final results to be available.

Question. Why was the Office of Human Development Services chosen to administer these demonstration projects, despite the fact Congress appropriated the funds to the Family Support Administration?

Answer. These funds will be administered by the Family Support Administration's Office of Community Services (OCS), not by the office of Human Development Services (OHDS).

PEDIATRIC AIDS INITIATIVE

Question. Would you support targeting funds to Title X clinics for outreach, counseling and testing for HIV-positive women and others at risk for HIV infection, and to provide contraceptive services to these high-risk women?

Answer. We certainly agree that Title X clinics provide a good locus for the activities you mention. In fact, funds provided to these programs through the Family Planning Program have traditionally been used for outreach, counseling and testing for a broad array of services which have included diagnosis and treatment of sexually transmitted diseases (SIDS), as well as for contraceptive services to high-risk and low income women. Although the 1991 Title X clinics budget does not contain any funds specifically targeted to HIV services for HIV-positive and high-risk women, we know that these services are provided with varying intensity, based on geographic incidence of infection, across the nation.

Also, these clinics seldom operate solely on federal Family Planning Program funds. In addition to State, local, and private resources, these clinics are eligible to apply for HIV/AIDS funds available through other agencies of the Public Health Service, including state CDC funds and grants from the Office of Minority Health.

AIDS PREVENTION ACTIVITIES

Question. Since 1989, we have spent over $1 billion on AIDS prevention activities. The FY 1991 budget requests a total of $421 million for this activity. What can you tell us about the effectiveness of these expenditures?

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Answer. AIDS prevention/education activities do appear to be having a positive impact on changing behaviors that would place people at risk of HIV infection. We believe this may be one of the factors that could account for the apparent slowdown, since 1987, in the rate of increase of reported AIDS cases, particularly in homosexual men. Another measure of the effectiveness of AIDS prevention activities is that rates of syphilis in gay white males appear to have declined. example, infectious syphilis rates for all white males in San Francisco decreased 90% between 1984 and 1989, from 250 to 25 cases per 100,000 population, reflecting safer sexual behavior among this population. Approximately 85% of white males with syphilis in San Francisco were gay or bisexual. Nationally, between 1982 and 1989, syphilis rates for all white males declined 68%, from 10.3 to 3.3 cases per 100,000 population. This decline has occurred despite a rising incidence of the disease in the heterosexual population. Also, rates of HIV seroconversions, or new infections, among participants in a cohort study in San Francisco have declined from 20% in 1982 to less than 2% in 1984, and have since remained constant at less than 2% per year.

Since HIV counseling and testing began in public sites in 1985, nearly 2.2 million tests are reported to have been performed and almost 137,000 of these have been reported as positive. Pre- and post-test counseling is a key prevention strategy for motivating and assisting people to change their high-risk behaviors and maintain low-risk ones. Results of 38 studies on HIV counseling and testing indicate that highrisk behaviors can be decreased through these intervention efforts. Six of these studies on IV drug users have shown decreases in risky injection practices. For example, Sacramento, California demonstrated a 23% decline in the proportion of IV drug users who continued sharing needles or using non-disinfected drug paraphernalia after participating in an AIDS education/testing program located in drug treatment centers between 1986 and 1988.

Furthermore, surveys indicate that general public awareness of AIDS issues has increased, and levels of misinformation about how the disease is and is not transmitted a potential cause of discrimination -- has declined since the PHS "America Responds to AIDS" campaign was initiated in 1987. Public demand for AIDS information continues to expand. The National AIDS Hotline currently receives an average of 2,800 calls a day, or 84,000 calls a month, for a total of 3,879,817 since 1987; and the National AIDS Clearinghouse is currently distributing over 1,000,000 documents each week.

It is still too soon for much more program effectiveness data to be available since a significant amount of CDC funds were not devoted to AIDS information/education projects until 1987, with $103 million, and 1988 with $209 million, compared to 1986 with $34 million. However, CDC continues to

incorporate evaluation as a basic component of its AIDS activities. In 1989, program activities which constituted 94% of CDC's AIDS budget had evaluation activities in place or planned. Additional efforts are planned in the 1991 budget to evaluate the efficiency as well as the effectiveness of alternative prevention approaches, that is, which approach is "best"?. Specifically, in 1991, CDC plans to spend an additional $8.3 million to compare the effectiveness of alternative AIDS counseling techniques, such as peer vs. professional counseling, and to assess the effectiveness of street outreach and bleach distribution programs in reducing rates of HIV infection among IV drug users and their sex partners.

Question. Do you feel we have made significant progress in changing the attitudes that would lead to the prevention of the spread of AIDS?

Answer. As the above answer indicates, significant progress has been made in changing many people's attitudes toward behaviors that could place them at risk of AIDS and HIV infection. The recent news of declining HIV incidence in some groups, particularly gay men, is encouraging and indicates that public education does work, and that more people are listening to the message on avoiding AIDS and are changing their behaviors.

However, this decline is not uniform across all groups of high-risk populations, particularly minorities and IV drug abusers. A recent upturn of sexually transmitted diseases in the gay population of Seattle Washington suggests that AIDS prevention messages must be reiterated both for current and new members of the gay community. It is clear that further prevention efforts are still needed to ensure that our AIDS message reaches all Americans. Consequently, we are requesting an increase of $61 million in 1991, primarily in CDC, to expand our AIDS/HIV prevention and education efforts to over $425 million.

$15 MILLION EXTRAMURAL CONSTRUCTION PROGRAM

Question. Mr. Secretary, as you know, the Committee included $15 million for an extramural construction program to be managed by NIH. A number of projects were discussed by the Congress as being eligible and of interest by the Congress for funding under this limited program. These included projects in Maine, New Mexico, Montana, Mississippi, Georgia, and Colorado. Could you tell us the status of this program, and when will the awards be made?

On February 16, 1990, NIH will publish in its Guide to Grants and Contracts two requests for applications (RFAS) for extramural facilities construction projects. One RFA will announce the availability of up to $10 million for a mouse breeding facility to replace the capacity lost last year

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when a major laboratory facility was destroyed by fire. second RFA will announce the availability of $3 million for general biomedical research facility construction. addition, the National Cancer Institute will use $2 million of the 1990 extramural construction funds to support two previously approved applications for construction of cancer research centers.

NIDA OUTREACH TO DRUG ABUSERS

The FY 1991 budget proposes to cut funding for NIDA demonstrations over $18 million. The entire cut would come out of a program of HIV/AIDS demonstrations, designed to find effective ways of recruiting IV drug abusers into treatment.

Question. What results have these demonstration projects shown? What are the most effective methods of getting IV users into treatment?

Answer. The AIDS/IV drug abuse demonstration projects were designed to demonstrate the effectiveness of various techniques for encouraging intravenous drug abusers into treatment and reducing behaviors which would increase their risk of HIV infection. Early assessment indicates that these demonstration projects have been worthwhile. The

demonstrations showed: the importance of IV cocaine use in the spread of AIDS; that we can identify and educate the sexual partners of IV drug abusers; that expanded traditional heroin treatment programs (i.e., methadone) is not enough to combat cocaine abuse; and that there are a large number of people who have used drugs for many years who have never been in treatment. NIDA will be completing these projects during this fiscal year. Once the projects are completed, the results of these studies will be published and disseminated to the drug abuse treatment and prevention field.

Question. Given that substance abuse, especially IV drug abuse, accounts for the fastest growing segment of the HIV population, why have you chosen to discontinue these important projects?

Answer. The AIDS/IV drug abuse demonstration projects were designed to demonstrate the effectiveness of various techniques for encouraging intravenous drug abusers to enter treatment and that behaviors which would increase their risk of HIV infection can be reduced. We believe these demonstration projects have been worthwhile. While NIDA will no longer be funding demonstration projects in this area, we will still support research on the effectiveness of new and innovative outreach techniques. These studies will be supported with increases in our AIDS research program and will be more tightly controlled than the demonstration programs were. This approach is expected to increase the reliability of the information drawn from these studies and represents a second

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generation of studies in this area.

Question. What can you tell us about your commitments to mental health and alcohol abuse initiatives?

Answer. I remain strongly committed to helping

individuals, families and communities address the complex issues related to mental illness and alcohol dependence. This commitment includes both improving scientific understanding of how to diagnose, prevent, and treat these disorders, as well as continuing to work with States and the private sector to improve service delivery.

The Department's request for the National Institute of Mental Health (NIMH) includes an increase of $28 million for research. We are committed to making the 1990s the "Decade of the Brain" in our pursuit of research on the brain, including schizophrenia, the most chronic and disabling of the major mental illnesses. Our 1991 request includes, among many initiatives, the funding of a new center for excellence in molecular neurobiology as called for in the National Plan for Schizophrenia Research.

The research component of the National Institute on Alcohol Abuse and Alcoholism increases by 5 percent. Under our proposal, NIAAA will have received a 31 percent increase between 1989 and 1991. In the service areas, the ADMS Block Grant will have received a 71 percent increase for alcohol abuse activities from 1989 to 1991.

Question. You have stated in the past that providing drug addicts with clean needles or other paraphernalia is unacceptable. But many drug addicts are on treatment waitlists or may not yet be seeking treatment. Considering the rapid spread of HIV and AIDS among this population and their sexual partners and the unfortunate children born to this population, what is your position on completing research demonstration projects currently underway that are providing bleach to IV drug abusers to assess its effectiveness in reducing the spread of AIDS and the HIV virus?

Answer. The Public Health Service does not oppose programs to distribute bleach as part of a comprehensive drug abuse outreach program. Since bleach is readily available legally, we view its distribution as only giving drug users the means to protect themselves and others from a fatal infection until they can be brought into treatment. Programs of this type, currently funded by HHS, have shown no evidence of having contributed to the spread of drug abuse. In 1991, CDC is requesting an increase of $4.1 million to evaluate the effectiveness of street outreach and bleach distribution programs in reducing HIV infection rates in IV drug abusers and