We

Secretary for Health, we provide a forum to coordinate these health education programs. In addition, the ODPHP National Health Information Center provides a central one-stop resource for consumers and professionals with health questions that are referred directly to the appropriate Federal or private information resource for followup, as appropriate, or that are answered directly when no other information resource is available. In addition, the Office of Disease Prevention and Health Promotion is leading a Department-wide initiative to disseminate health messages on immunizations, smoking, alcohol, nutrition, and physical activity through all the Department's 25,000 grantees and regular contacts during 1991. are exploring joint activities and information products with the Agency for Health Care Policy and Research (AHCPR) to educate consumers to be partners in a quality health care system and to take greater responsibility for self management of their health. Also, consumer oriented materials will be prepared for each of the AHCPR practice guidelines as they are released, and these will be coordinated with all PHS clearinghouses to ensure distribution. addition, AHCPR is actively working with other PHS components on the PHS Life Sciences Education and Sciences Board to increase public awareness and understanding of life sciences as it relates to the health care system and to enhance life science education programs and curriculum development at all levels, especially in grades K-12.

In

DESERT STORM

Recent

Question. I am interested in your views on the impact of the Operation Desert Storm call-up of military reserve personnel. newspaper accounts of doctors, nurses, and other health professionals being called for Operation Desert Storm note that the call-up has further aggravated personnel shortages in underserved areas.

Happily, the war appears to be ending now. What is your view of proposed legislation granting funds to facilities experiencing warrelated personnel shortages?

Answer. The strategy I would suggest for dealing with any health staffing shortage problem would be to first rely upon DOD to exempt military reserve personnel from active duty in most serious cases of community hardship where loss of health care staff are involved. Second, I would count on the resourcefulness of state and local governments and professional organizations to solve temporary shortages with volunteers, retirees, staff sharing mechanisms, and other innovations.

For serious problems after these efforts have been made, we would use the Commissioned Corps Ready Reserve to the extent possible to match personnel to the needs of the communities. This capacity would be augmented with those willing to volunteer from the roster of retired medical officers. Finally, If needs could not be filled using the reserves, we would detail some officers from the active Commissioned Corps to serve in temporary details in the underserved sector. I want to assure you that I would act quickly to temporarily deploy Commissioned Corps personnel, irrespective of possible voluntary solutions, if a true emergency situation is brought to my attention.

AIDS AMONG WOMEN

As

Question. As you know, there has been a lot of activity lately around women's health issues, especially with regard to research. one of the people working on this issue, I am particularly concerned about the projected increased incidence of AIDS among women, now the fastest growing category of AIDS patients. Many of these women are pregnant or nursing mothers, who are likely to pass the virus on to their children. Tragically we know very little about the social and

behavioral issues that put women--and others for that matter--at risk for contracting AIDS.

In order to understand how to change high risk behaviors and to evaluate AIDS prevention programs, scientists have been telling us for years that they need to have some basic behavioral data that would be collected through the NIH's Survey of Health and AIDS Risk Prevalence, or the so-called SHARP study. Despite peer review and approval by a wide array of non-academics including several religious leaders, this study has been held up by your Department for over 3 years.

Last year in our Committee report we indicated our dismay with the Department that this survey continued to be delayed and we "urge{d} the Department to approve the feasibility phase of SHARP promptly." (S. Rpt. 101-561 pp.215) We were delighted to learn that the Administration included $3 million dollars to launch the full scale version of this survey and applaud your commitment to this effort. We also understand, however, that the feasibility phase that the Committee urged the Department to approve last year, is still being held up in your office. Can you please explain this apparent inconsistency and tell the Committee when you plan to direct the NIH to proceed with this effort?

Answer. The proposed feasibility study for the National Survey of Health and AIDS Risk Prevalence (SHARP) is still under consideration in the Department. However, based on the results of the Dallas pre-test of the seroprevalence survey, we believe we can proceed with the study without further feasibility activities. However, this remains a sensitive issue. At this time it is not possible to provide a more definitive statement on the future of the project.

To preserve the option of proceeding with the national survey while the departmental review is underway, HHS has requested $3.0 million in the FY 1992 budget. This amount represents costs associated with initiating the national survey in that year.

AIDS FUNDING

Question. Dr. Mason, how much money did you request of the Secretary for HIV programs in your original presentation for FY 1992, as compared to the final level in the President's budget?

Answer. The FY 1992 HIV/AIDS request to the Secretary was $2,033,021,000 (including the Food and Drug Administration and the Indian Health Service). The FY 1992 President's Budget request for HIV/AIDS is $1,950,261,000.

DUPLICATION OF AIDS EFFORTS

Question. Dr. Mason, the natural history and transmission studies relating to HIV sponsored by PHS agencies are critical contributions to our understanding of this epidemic. I am concerned, however, by the number of different agencies involved in these studies. As I understand it, there are cohorts being studied at NIAID, NCI, NIDA, and CDC. Are any of these studies duplicative, so that they might be merged or possibly reduced in number to save on limited funds?

Answer. CDC and NIAID conduct studies of the natural history of HIV disease. While these studies are addressing some of the same issues, each study has unique qualities either in the study design, the study participants, or the major emphasis. Having independent studies also allows for prompt confirmation of results from one study by the other study.

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Question. Is the data collection in these studies such that they can be compared or merged in a meaningful way, so that together, larger cohorts could be formed?

Answer. CDC and NIAID staffs are in constant contact through review panels, scientific meetings, working groups, telephone consultation, etc. to look for ways to collaborate and to prevent duplication of efforts. As an example, a productive collaboration was recently established by combining CDC's heterosexual transmission study sites with NIAID sites into one multicenter study. In addition, CDC has recently established a working group with colleagues at several other PHS agencies to develop a common protocol for studying the natural history of HIV disease in women.

Question. What level of interaction is taking place among these agencies to assure that these studies are complementary and coordinated?

Answer. The data collection for the natural history studies in women will use a common protocol that will enable PHS agencies to collect comparable data for a single large cohort. The CDC and NIAID are in the process of combining their heterosexual transmission studies by adopting a similar protocol which will result in comparable data that will be merged resulting in a more meaningful analysis of research questions. NIDA has worked to assure that HIV natural history and transmission studies that are funded complement, rather than duplicate each other and also that, as much as possible, they complement work being done by other agencies or institutions. This has involved close coordination between NIDA program staff and both NIDA grantees and representatives from other agencies. ADAMHA and CDC have established a formal work group for facilitating coordination and collaboration between the two agencies.

AIDS AMONG WOMEN

Question. Dr. Mason, there has been growing interest in the course of HIV infection among women. There seems to be significant indication that the course of the disease is different for women, which calls for some investigation into the natural history of AIDS among women. Since 1984, the NIH and CDC have been following cohorts of gay men. These studies have provided invaluable information. While the PHS is funding several studies of transmission heterosexual and from mother to child I am not aware of any natural history studies of HIV in women. What plans does the PHS have to do similar natural history studies of HIV infection in women? Could resources be identified to begin such a study in FY 1991 so there will not be further delay in pulling such a cohort together?

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Answer. The National Institute of Drug Abuse (NIDA), ADAMHA has sponsored a large-scale natural history and drug abuse prevention research program focusing on HIV infection in women and infants; subpopulations studied include women who are homeless or who live in rural areas, and those who engage in prostitution. NIDA also supports a study on the natural history of AIDS among female prisoners who are drug users.

CDC plans to fund several new studies in FY 1991 and to supplement existing studies to address several issues unique to women, including the natural history of HIV infection. The major objectives of these studies are to examine possible gender differences in disease manifestations, incubation period, and survival; to address the effects of pregnancy and contraception methods on the natural history of HIV disease in women; and to determine the effects of HIV disease and immunosuppression on other co-existing infections or conditions such as pelvic inflammatory disease and other sexually transmitted diseases (e.g., syphilis, herpes simplex, vaginal candidiasis, and human papilloma virus infection). Request for Proposals will be published in the Federal

Register, probably within the next month, soliciting research proposals addressing these issues.

The NIH is currently planning to expand studies of the natural history of HIV infection in women using a two-stage approach. The first stage will include short-term projects that can be initiated during FY 1991 and continued during FY 1992 to collect and analyze data that already exists in women's health clinics and to analyze data from existing cohorts for gender differences. The results of these short-term projects will provide the foundation for the design of a long-term study of a full cohort of women which is projected to begin late in FY 1992.

MINORITY AIDS EFFORTS

Question. Dr. Mason, the PHS is to be commended for its recognition of the disproportionate impact AIDS has had on minority communities. However, I am concerned about the coordination and duplication of programs targeted at minorities at risk. The budget justification from OMH says: "grants are made to national minority and community-based organizations to conduct health education and prevention activities directed to minority groups." (p.31) The CDC justification says that the CDC Office of Minority HIV Policy Coordination is "providing funds directly to approximately 100 national, regional, and community-based organizations which represent or serve minority populations." (p.95). How do these differ? is the reason for separate administration of these programs?

What

Answer. CDC's direct-funded community-based organizations (CBOs) serving racial and ethnic minority populations must be nonprofit and must serve minority populations within the 31 high AIDS incidence metropolitan statistical areas, and the memberships of their governing bodies must have at least 50 percent racial and minority representation. CBOs currently funded by Office of Minority Health (OMH) may serve high, medium or low HIV incidence geographic areas, both urban and rural. OMH tends to fund organizations in areas with a lower incidence of HIV/AIDS. OMH-funded grants range from $50,000 to $75,000 annually, compared with CDC's which range from $20,000 to $225,000 annually.

Both CDC and OMH maintain ongoing collaboration to ensure that grantees of either agency are not funded to conduct the same activities. This is essential in ensuring that funds are wisely allocated and that a range of community needs are addressed.

CDC and OMH are currently discussing the relative benefits of separate administration, conjoint administration or the transfer of the OMH program to the sole administration of CDC. It is quite possible that OMH will merge and/or transfer its national and local HIV grants program with those of CDC.

Question. Similarly, the OMH justification says that it will "continue to support data collection and studies related to the knowledge, attitude and behavior of minority populations relative to AIDS as well as the incidence of AIDS among minority groups." (p.31) At the same time, the CDC justification lists numerous surveys to assess HIV knowledge and attitudes (p.96). How are these different and how are these coordinated? Could they be merged and save on the additional administrative costs?

Answer. The CBOs funded by either OMH or CDC may be involved with data collection and studies as part of their activities; these efforts are likely to represent different research methodologies and sample populations.

Merging efforts in at least some of these research areas in which it is feasible may benefit both CDC and OMH, as well as enhance the quality of data collection, replications and interpretation.

This is being investigated as part of the initiative to develop a single administration for all of these efforts.

Question. Dr. Mason or Dr. Roper: The CDC budget reflects significant increases in prevention programs for a range of diseases; but funding is level for HIV. Given the epidemic nature of HIV, why hasn't the CDC request included increases in prevention activities? The President's budget states that prevention activities overall go up only 1% while income support rises by 36% and treatment spending rises by 24%. Wouldn't it make sense to increase prevention activities in hopes of stemming the tide of this rise in entitlement spending?

Answer. The Administration had many competing health problems from which to choose. We are currently investing a substantial amount of resources in HIV/AIDS activities, greater than almost any other disease. HIV/AIDS has been receiving substantial increases for the past several years. We believe that this year it important to address some of the other health priorities. I would add that both NIH and ADAMHA have broad authority to reprogram funds between AIDS and non-AIDS and will do so if unparalleled scientific opportunities arise.

RYAN WHITE CARE FUNDING

Question. Dr. Mason: No increases are requested for funding of the Ryan White CARE programs at HRSA and CDC. Given the rising number of AIDS cases and the increasing burden on our public hospitals as reported in recent studies, why is the Administration not increasing funding for these programs?

Answer. In FY 1991 Congress authorized a total of $855 million for the activities under the Ryan White legislation, For this authorization, Congress appropriated $323 million. We have continued these programs at the same level as Congress, although we remain concerned about a fragmented, disease-specific approach to providing health care. I would also note, that through the Medicare and Medicaid, we will invest a substantial amount in AIDS treatment services. In FY 1992 we estimate we will spend $1.36 billion, an increase of 30 percent over FY 1991.

Question. Dr. Mason, I would like to follow up with a question regarding Title III of the CARE bill, which provides for early intervention services for people with HIV infection. As you know, these services are designed to provide testing, counseling and drug treatment that will delay the onset of full-blown AIDS. In its budget justifications, the NIH reported that there is "an apparent decrease in the expected incidence rate of AIDS in the U.S. population. This decrease was abrupt and began in 1987. The most plausible explanation for the decrease is the impact of therapy on preventing seriously immune compromised persons from progressing to AIDS....It is noteworthy that decreases were most prominent in groups with the best access to care, but were not seen in groups (e.g. drug abusers) who have limited access to therapy." (p301) This would seem to underscore the need for expansion of the early intervention programs in Title III, since this is what they were designed for. Why hasn't the PHS requested more funding in this area?

Answer. We have multiple health problems in the United States that need to be addressed. The FY 1992 for Ryan White is maintained at the FY 1991 level and budget increases are directed to other high priority areas such as Project Healthy Start, National Health Service Corps Recruitment, and the Health Care for the Homeless. Some of these programs also will increase services for people who are HIV infected, although they are not specifically targeted for this group.

Question. Dr. Roper, how much money did the CDC request of the Assistant Secretary for HIV programs, as compared to the final level