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and the National Institute of Neurologic Disorders and Stroke. AIDS research builds on the Institute's non-AIDS mental health neuroscience research.
Question. Given the importance of preventing the transmission of HIV, and the key role of prevention research in this area , wouldn't it be valuable to transfer some of the responsibility for the neuroscience work to NIH and expand the prevention work at NIMH?
Answer. The broad and balanced NIMH AIDS portfolio enables the Institute to address a range of inter-related critical issues related to the mental health and behavioral aspects of HIV infection and AIDS. The findings of the neuroscience work may prove crucial in developing effective programs to prevent disease progression.
Question. Repeatedly, expert advisory groups have indicated that we need more research on behavior change. Most recently the Institute of Medicine (IOM) report on the NIH repeated the "particularly pressing needs for behavioral research on AIDS." Are there enough funds for ADAMHA and specifically NIMH and NIDA to address the behavioral AIDS research needs? How much would NIMH and NIDA need to adequately address the AIDS behavioral research issues?
Answer. Adequate funds are available in the President's request for this area. The President's FY 1992 budget would support approximately $39.6 million for AIDS behavioral research, including support for three AIDS research centers with a major focus on behavior change and prevention. While professional judgments may differ on funding levels adequate to the challenges of AIDS behavioral research, we believe this allocation of resources is appropriate given competing budget priorities.
AIDS-RELATED BEHAVIOR RESEARCH
Question. NIMH is currently conducting about $40 million worth of research focusing on the prevention of high-risk behaviors and population based risk assessment and prevention, is that correct?
Answer. The President's FY 1992 budget proposes approximately $39.6 million for AIDS behavioral research. Over two-thirds of this amount, approximately $27.4 million, is focused on behavior change research. Priorities within AIDS behavioral research are to (1) improve the understanding of the distribution and antecedents of HIV risk behaviors, (2) test behavioral approaches to prevent the further spread of HIV, and (3) develop strategies to prevent and treat the mental health consequences of HIV. Research on behavior change is a key priority. Activities are underway to strengthen the ongoing research on behavior change, stimulate new studies, and review and disseminate emerging findings from NIMH-supported studies.
Question. This has been a steadily increasing aspect of the Institute's AIDS research portfolio. What kinds of information do we now have from these research studies that can be applied in the field?
Answer. In April 1991, NIMH will convene 17 principal investigators of studies that are testing preventive interventions with gay men, women, children, and adolescents. This meeting will provide a forum to review and assess the emerging state of knowledge regarding successful AIDS prevention approaches. One of the major goals of this conference is to identify findings that can be applied in prevention programs in the field and to explore mechanisms for effective dissemination of prevention research results to community organization and program planners.
Many successful HIV prevention strategies are based on the cognitive behavior model. Important variables include sensitizing
individuals to personal risk and developing intentions and competencies for successful behavior changes, including training in relevant behavioral skills. Needed skills include approaches to assertion, self-management, conversation, and social problem solving.
Question. I understand for instance, from reports coming from the ADAMHA AIDS Advisory Committee, that a NIMH research advisory panel indicated that we know so much about prevention activities among gay and bisexual men and so little about prevention in other groups, that is appropriate to shift our research focus away from preventing AIDS among gay men to focus on other "at-risk" populations. What can you tell us about interventions?
Answer. Unfortunately, we still do not have all these answers. NIMH continues to support studies to identify successful prevention strategies for gay and bisexual men, including a focus on efforts to prevent relapse to unsafe behaviors among those men who initially were able to change risk behavior patterns. Factors that have been found to be relevant to adapting new behavior patterns for white, gay men include knowledge of HIV and transmission; perceiving oneself to be vulnerable; accurate estimation of personal risk; self-efficacy beliefs that the needed changes can be successfully made and that if the change is made, it will achieve the desired result. Other strategies have included additional interventions such as community organizing, social marketing, and efforts to promote changes in group norms concerning risk-taking behaviors.
Question. Are we at a point where we have all the knowledge we need to design effective prevention interventions for this population?
Answer. We do not believe so. Most of the controlled HIV prevention research using behavioral models has been conducted with individuals or small groups at high risk for infection. Little experimental research has been undertaken at the institutional levels, e.g., schools and worksites, and communities. We have learned that intensive intervention with individuals and small groups does result in positive behavior change; however, for some populations, maintaining positive changes over time is very difficult. We have very little information about effective prevention approaches for subgroups of gay men, including younger men and ethnic and racial minority men.
Question. What about the other at-risk populations?
Answer. The collaborative study that NIMH is sponsoring with NIDA, NIAAA, NICHD, CDC, and HRSA is focusing on developing and testing behavioral interventions for other populations at-risk. Populations currently under study in this project include inner-city Black adolescents and adults. Other populations of interest include Hispanics, incarcerated individuals, hard-to-reach gay and bisexual men, persons with severe and persistent mental illness, and women.
MENTAL HEALTH SERVICES RESEARCH
Question. Last year we heard a great deal from mental health providers about the importance of mental health issues to persons with HIV infections. I understand that last year NIMH convened a workshop to look at issues related to the chronically mentally ill and AIDS. While this is critical work, I also understand there are significant mental health service delivery issues for the general population of HIV infected individuals such as the absence of adequate models of mental health services and the absolute absence of organized service delivery systems for the general population. Given the important role of NIMH in service delivery research, what kind of work are you undertaking in this area?
Answer. NIMH is collaborating with the Health Resources and Services Administration (HRSA) to include mental health services in ongoing HRSA AIDS projects and to develop strategies to evaluate the effectiveness of mental health interventions for people across the spectrum of HIV disease. One upcoming activity is a HRSA/ NIMH conference to explore mental health services research needs and the role of social workers as case managers for HIV disease.
Mental health services research is a priority area within the NIMH AIDS research effort. Activities are underway to stimulate the development of studies to elucidate the structure, process, and financing of mental health services for HIV-related mental disorders and psychological distress.
Based on a meeting of clinicians and researchers with expertise in HIV-related mental health counseling, NIMH has developed a national counseling strategy that includes components in a recommended continuum of care from pre- and post- antibody test counseling to ongoing treatment and support for those infected with and affected by HIV infection and AIDS.
PREVENTION RANDOMIZED FIELD TRIALS
Question. NIMH is conducting a field trial of prevention interventions designed to improve our knowledge of effective AIDS prevention programs. In its reports on AIDS and behavior, the National Academy of Sciences has repeatedly called for randomized field trials of prevention interventions. Is the NIMH program a response to this recommendation?
Answer. The NIMH multi-site AIDS prevention trial, conducted under a cooperative agreement in collaboration with NIDA, NIAAA, NICHD, CDC, and HRSA, is in response to a number of recommendations, including those of the National Academy of Sciences.
Question. I understand that the NAS recommendation was based in part on the successes of the NCI smoking cessation community intervention field trials and the NHLBI cardiovascular disease interventions. These programs were multi-billion dollar programs. Are we adequately funding this initiative?
Answer. Yes. The trial was initiated in FY 1990 to increase knowledge of AIDS prevention strategies. Three extramural research sites and a coordinating center received initial support totaling approximately $1 million. This study is designed to develop and test behavioral strategies to prevent the spread of HIV in different population and geographic sites. The FY 1992 budget proposes to support 7 sites and the coordinating center. Since the trials have not yet identified and demonstrated effective prevention approaches, it is premature to consider a program of the magnitude of those conducted for smoking cessation and prevention of cardiovascular disease. However, the NIMH AIDS prevention study draws heavily upon knowledge gained from these other large scale trials.
How much did this program receive in FY 1991?
Answer. In FY 1991, the NIMH AIDS budget includes $3,154,000 for this multi-site program.
How much is the President requesting for this program
Question. in FY 1992?
Answer. In FY 1992, the NIMH AIDS budget includes $3,189,000 for this multi-site program.
MENTAL HEALTH AND AIDS TRAINING
Question. Training of mental health personnel is a critical part of making mental health services available to persons with HIV infection. I understand that the model program that NIMH had developed to train such personnel about the mental health aspects of HIV has been significantly revised such that there are no programs explicitly training mental health providers now. Is this true?
Answer. Current programs are training both health and mental health care providers. The emphasis is to integrate AIDS mental health education into ongoing regional training efforts that are already underway and to train a broad range of health care providers.
Question. Why has the focus of the program shifted entirely to the training of medical personnel through add-on grants to the Health Resources and Services Administration's AIDS Education and Training Centers?
Answer. In FY 1990 and FY 1991, the program has integrated AIDS mental health education with ongoing HRSA health training programs through the Education and Training Centers (ETCS). The FY 1990 request for applications indicated that this could be accomplished through grants to the ETCs or to mental health organizations with specific plans to link with one or more ETCS. This new approach is being, tested initially in a small numbers of programs where both health and mental health care providers are trained.
DRUG ABUSE OUTREACH SERVICES
Question. NIDA is to be commended for taking leadership on AIDS in the area of substance abuse. One of the most notable efforts has been the program of outreach to IV drug users not in treatment. This effort has spawned a whole host of research peers and now even a report from the Centers for Disease Control documenting how effective these efforts have been. Last year the Congress restored almost $11 million to these projects from the amounts cut by the Administration in its FY 1991 proposed budget. I understand that once again the Administration has proposed cutting these programs. What is the amount of the cut proposed by the Administration?
Answer. In FY 1991 the Congress added $9.8 million, after sequestration reductions, to partially restore funding the outreach demonstration program. A letter indicating the availability of these funds has been sent to the eligible grantees, inviting them to submit their requests for noncompeting extensions of their grants. Of the original 42 three-year projects, the remaining three are scheduled to receive their last year of funding in FY 1991, a total of $3.4 million for the three projects.
Question. Why is the Administration proposing to undermine the only interventions we have in place to deal with one of the populations most vulnerable to HIV infection?
Answer. The FY 1992 President's Budget request includes funds for the continuation of efforts by NIDA for the prevention of AIDS through programs of outreach to drug abusers not in treatment. These efforts include a research program, as well as the demonstration program for which Congress restored funding in the FY 1991 appropriation.
The request includes $10.2 million in research demonstration funds for NIDA's outreach activities, a 4 percent increase. These funds will be used to develop a new program in this area that will build on the previous efforts, provide for expanded demonstration of the outreach models that have been found most effective, and extend the types of population groups involved in these programs.
Specifically, in FY 1992 NIDA will develop a demonstration grants program that will permit the replication and further testing of outreach/intervention protocols seen as effective in the earlier research demonstration studies funded by the Institute. The Institute will study the transferability of apparently successful interventions as well as assess the efficacy of those strategies with different populations.
The Institute will also be continuing in FY 1992 an active program of research studies in the area. NIDA has developed and awarded a grants program under the title, "A Cooperative Agreement for AIDS Community-Based Outreach/Intervention Research." That program allows for the continuing refinement of outreach/intervention strategies, and for their assessment under rigorous study conditions. Thus, the Institute will be able to build on the work and findings already obtained from NIDA's demonstration program. Moreover, this research activity allows the Institute to emphasize the study of outreach/intervention strategies targeted to runaway/homeless youth involved with drugs, to out of treatment crack and cocaine users, and to the sexual partners of intravenous drug users. Because this grants program is organized as a cooperative agreement, NIDA will continue to be able to obtain standardized data on the characteristics of the out-of-treatment drug user in cities across the country.
In addition, NIDA is in the process of developing a strategy to monitor drug use and other related risk-taking behaviors over time in the cities encompassed under this grants program. Thus, this new research initiative in FY 1991 will allow us to understand changing drug use patterns and behaviors in a population largely unknown to us just a few years ago. Currently, NIDA has funded 6 grants under this program and expects to fund an additional 4-6 grants this fiscal year.
Several outreach/intervention studies being supported by NIDA are specifically targeted to three population groups seen as of particular concern. Outreach/intervention protocols and associated research designs are now under way for (1) intravenous drug users who have placed themselves on waiting lists for drug abuse treatment, but for whom treatment is not currently available; (2) runaway youth involved with drugs who are accessed through runaway outreach or shelter programs; and (3) female intravenous drug users and sexual partners. These programs will continue in FY 1992.
Question. What specific plans does the Administration have for maintaining these efforts in place?
Answer. In an effort to maintain AIDS outreach/intervention services, NIDA will make use of the extended time provided to the existing outreach demonstration projects through the FY 1991 appropriation. Continuation support for outreach services activities has already been obtained in 7 of the 14 States in which research demonstrations projects were scheduled to end in FY 1990. NIDA has developed a Joint Planning Group with representatives from the State drug abuse authorities, the Office for Treatment Improvement (OTI), and the Office of National Drug Control policy (ONDCP) to continue the process of planning for the maintenance of services funded by the Federal Government under this and other Federal demonstrati programs. That group has met several times and developed important recommendations for joint State-Federal participation in demonstration programs. That body will also be exploring strategies for technology transfer to assure that findings from the outreach/intervention studies can become a part of State and local policy and practices.
Question. Last year, the Congress passed the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act and funded it with