As you know, AIDS Action Council convenes the coalition of National Organizations Responding to AIDS, which represents over 150 national groups concerned about a comprehensive federal response to AIDS. In our professional judgment, it would take $3 billion in funding in 1992, or $1 billion above the President's request, to begin to address the range of challenges posed by this epidemic. I am happy to submit a copy of our alternative budget proposal for the record.

We make this funding recommendation fully cognizant of the limitations imposed by the Budget Enforcement Act and our national commitment to reducing the deficit. But surely we as a nation can recognize the threat that AIDS poses to our national security and respond just as resourcefully as we have to perceived threats in the international arena.

In its tenth year, the AIDS crisis is no less dramatic than before. Indeed in many respects its demands on our nation's health care system are far more pressing than ever. Already, over 100,000 Americans have died of AIDS; the CDC estimates that there will be 60,000 newly diagnosed cases of AIDS this year alone; every day, approximately 125 people die of AIDS-related causes, 165 people are diagnosed with full-blown AIDS, and 110 people become infected with HIV.

As someone who both represents and has worked for community-based AIDS organizations, I can tell you that the suffering out there is real; it is terrible; and it is getting worse.

There is so much our nation must do to properly contain this epidemic: -Our nation still lacks a comprehensive strategy for and commitment to education and other prevention programs needed to stem the spread of HIV infection. What programs we have are chronically underfunded. There is a cruel irony in the fact that the President's budget request contains only a one percent increase in funding for prevention programs while it acknowledges that spending for Medicare and Medicaid will rise by 29 percent. We have neglected prevention, and now we are paying for that neglect in the cost of care. -Our nation's research efforts have made dramatic gains in our understanding of HIV disease. But research efforts are being crippled by underfunding and understaffing. A recent study conducted by the Institute of Medicine at the request of the NIH concluded that the AIDS research effort would benefit from a 25 percent increase in funding. We fully support that recommendation. -And because of the close connection between injection and other drug use and the transmission of HIV, it is critical that our nation's capacity to treat and prevent substance abuse be increased-and that HIV-related services be integrated into those programs.

But in the limited time I have today, I want to focus on the most neglected aspect of our nation's response to the AIDS epidemic: the care needs of people with HIV infection. In this fiscal year, AIDS Action Council's highest priority is to fulfill the promise of the Ryan White CARE Act and move toward full funding of the desperately needed programs created by CARE. The jump start given these programs last year must be more than matched this year, if we are to begin containing the burden posed by this epidemic on our nation's health care system.

The statistics I cited earlier are an every day reality for the AIDS service organizations throughout the country. They must cope with burgeoning caseloads and the disproportionate impact HIV is having on local health care delivery systems. Just last year the country's largest AIDS service provider, in New York, was forced to limit its services for the very first time.

Service cuts may be the harbinger of the future. The caseload in the 16 cities funded under the emergency assistance portion of the CARE Act has increased 20 percent in the last year. Allowing 5 percent for inflation, Title I funding would need to increase by 25 percent just to meet the same fraction of the need addressed in the 1991 appropriation. The funding already provided in Title I is making a dramatic difference in those 16 communities. But without significant increases, these communities will continue to fall behind in their battle to keep up with the growing

caseload.

The same can be said for the funding provided the states in Title II of the CARE Act. With the expiration of overlapping funding cycles in 1992, level funding will mean an actual decline in the level of care-related services states can provide. On top of a growing caseload, this will result in tragedy for thousands.

As you know, Title III of the CARE Act, which provides for early intervention services, was not funded last year. It is hard to know how many people have developed AIDS as a result. But we do know that some 600,000 HIV-infected Americans now need early intervention services-care that can delay or prevent their developing AIDS. Only a very small number are getting it. Indeed, the need for these services is so great that many of the Title I cities have set aside resources to provide such care because Title III was not funded.

Short of dramatic changes in our nation's entitlement programs, the three titles of the CARE Act, taken together, comprise a comprehensive Federal response to the care needs of people with HIV infection. We understand that asking for full funding of these programs at more than $500 million above the President's budget request-would represent a dramatic, and unprecedented, increase in funding. But we must remember that care is an area that has been neglected by the Federal government until last year. We must make up for lost time. That $500 million should have been spent over the past ten years; it must be spent now.

Mr. Chairman, literally hundreds of thousands of Americans with HIV infection and their families are looking with hope to this committee. Please don't disappoint them and send thousands to an early death.

TESTING AND COUNSELING STATUTE

Senator HARKIN. Mr. Bross, thank you very much for your testimony. Again you have a sympathetic ear here. We will do everything we can. The President's request is a 3.5-percent increase. Title III, the testing and counseling statute requires at least 35 percent of funding be spent on new services. My question is should we first insure existing services are not cut.

Mr. BROSS. The President's request of a 3.5-percent increase does not even meet inflation for this year. As I cited in my testimony, we are looking at a 20-percent increase in caseloads, just in the title I cities. So I think that in order to meet the needs of the people out there, we need to maintain at least current services. And with the President's request, we are really looking at a reduction in current services.

Senator HARKIN. You are asking for about $1 billion over what the President has requested.

Mr. BROSS. That is for AIDS programs throughout the Federal Government, sir. On the CARE Act specifically, we are only asking that Congress appropriate the moneys that were authorized last year. And that is $851 million.

Senator HARKIN. I understand. Mr. Bross, we will do our best. Mr. BROSS. I know you will, Senator. Thank you very much.

STATEMENT OF DR. MATHILDE KRIM, AMERICAN FOUNDATION FOR AIDS RESEARCH

Senator HARKIN. Our next witness is Dr. Mathilde Krim, American Foundation for AIDS Research. Dr. Krim, good to see you again. And welcome to the subcommittee. Your statement will be made a part of the record in its entirety.

Dr. KRIM. Thank you, Mr. Chairman. Yes; we submitted a written statement, and because of the very short time today, I will limit my presentation to emphasizing a few important facts that I would hope you would keep in mind during the appropriations process. I will comment specifically on behalf of AmFAR, the American Foundation for AIDS Research on the research needs related to AIDS.

One of the very important facts to remember is that we are facing today only the early phases of a worldwide epidemic of a deadly viral infection. The World Health Organization has predicted that the number of cases over the next 10 years will be tenfold larger than during the past 10 years-than what we have experience over the past 10 years. And also that there will be a demographic change in the epidemic, and that by the year 2000, 30 to 40 percent of all people with AIDS will be women and children.

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The second important fact is that this epidemic will not be selflimiting, it will not disappear by itself. There are good reasons for this statement, and if you are interested, I could list them later. The third important fact is that, therefore, only biomedical research can control, ultimately, eventually, the epidemic and stop it in producing treatments for people who are already infected and a vaccine to protect the uninfected.

The fourth important fact is that HIV infection invariably leads to AIDS and we have never yet saved the life of a person with AIDS. We have made progress. We have been able to prolong survival, but we have not saved anybody yet. A lot remains to be done. In the Federal Government, the agencies that have the heaviest responsibilities in the crucial research effort are the National Institutes of Health, the Alcohol Drug Abuse and Mental Health Administration, and the Centers for Disease Control. Progress in the war against AIDS, not only on behalf of American citizens, but on behalf of people all around the world, depends almost entirely upon new fundamental knowledge developed by or through the extramural programs of these three agencies. And they all are in need of significant additional support.

The capacity for scientific discovery is far from being fully reached at this time. For example, we found only 24 percent of all the approved grants admitted to the NIH. And for this reason, the American Foundation for AIDS Research support increase in funding for all basic biomedical research. It endorses, speaking of the work of the NIH specifically, it endorses the recommendations of a recent study conducted by the Institute of Medicine. And it particularly recommends to your attention a program of the NIH, called community program for clinical research on AIDS, or CPCRA, which is an innovative and cost-effective program that accelerates the pace at which promising experimental treatments are evaluated and made accessible to all those who need them, including women.

The CPCRA Program, I hope, will continue to receive funding, and, in fact, significantly increase support in the years ahead.

We also need much further research on addictive disorders in order to have a better understanding of these disorders so that treatment can be for rational and more cost effective treatments. It is an illusion to us for a national strategy for drug treatment on demand and education unless we have more rational and cost-effective treatments.

Finally, I would like to say that resources for these research efforts should not come from other domestic programs, nor should they be provided at the expense of medical care for those with AIDS. We just heard the extremely urgent needs in this area from the representative of the AIDS Action Council, nor should these resources come at the cost of prevention education for those at risk of AIDS.

We are well aware of the restrictions of the Budget Enforcement Act, but we know of the numbers, we know of the suffering, and we know how much the American people needs to understand why it must and how it can protect itself from AIDS.

PREPARED STATEMENT

AIDS has already claimed more American lives than all our recent wars, including Vietnam. Congress must now commit to spending what is needed to fight this war. Simply, the lives of over 1 million American men, women, and children, already infected with HIV, and the lives of all those many others who are bound to become infected over the next years, depend on it.

Thank you.

[The statement follows:]

STATEMENT OF MATHILDE KRIM

I am Mathilde Krim. I hold a Ph.D. degree and am Founding Co-Chair of the American Foundation for AIDS Research. I am honored by your invitation to speak before your Subcommittee on behalf of AmFAR and I first want to thank you for your dedicated past efforts in the fight against AIDS. But, much remains to be done. The AIDS epidemic has highlighted many deficiencies in our social welfare and health care delivery systems because people most at risk for, or suffering from, AIDS are often individuals who can neither access nor afford appropriate health care. Much of the very high cost of this epidemic will therefore be borne by the whole of society. This cost must be measured not only in dollars for medical care but in lives lost, suffering and loss of national productivity. To combat this epidemic Congress must address a variety of issues.

You will hear from other groups about social and medical care programs needed by those with HIV disease and AIDS. Today, speaking for AmFAR, I want to emphasize the importance of research in the face of the new and ever growing deadly epidemic and I want to stress the fact that only the results of research will make it possible to bring this particular epidemic under control. Indeed, because of the mode of transmission of the Human Immunodeficiency virus (HIV) that causes AIDS; because of the very long incubation period of AIDS (on average, 11 years, during which infected people are unaware of being infected but transmit the virus) and because no protective immunity results from HIV infection, this epidemic, unlike others will not be self-limiting. It will continue to grow and kill until research has produced a vaccine for the protection of the uninfected and effective treatments for the infected.

The agencies with the heaviest responsibilities in the crucial research effort are the National Institutes of Health (NIH), the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA), and the Centers for Disease Control (CDC). Progress in the war against AIDS depends almost entirely upon new knowledge developed by or through these agencies.

NATIONAL INSTITUTES OF HEALTH

Through both its intramural and extramural programs, the NIH has contributed most of the basic knowledge we have today about AIDS. The NIH identified HIV as the cause of AIDS and developed the first life-prolonging antiviral drug, now marketed for the treatment of HIV disease. The NIH is now studying many other drugs in order to develop the arsenal of treatments that will be necessary to turn this now fatal illness into a chronic manageable one. The NIH is also testing several preparations with potential as vaccines against HIV infection.

These advances could not have occurred if the NIH had not, over the years, steadily built a broad base of knowledge in the biological sciences and developed sophisticated technologies for the analysis of fundamental biochemical and biophysical mechanisms.

Our country's capacity for scientific discovery is far from being fully reached at this time: in 1990, only 24 percent of all peer review-approved requests for research grants were actually funded by the NIH. (Twenty years ago, nearly half of all approved grant requests were funded.) Therefore, AmFAR supports increased funding for all basic biomedical research at the NIH, and it joins with the Coalition for Health Funding and the Ad Hoc Group for Medical Research Funding in requesting $9.77 billion, overall, for the NIH in fiscal year 1992.

As for the NIH's AIDS Program, the Administration requested $851.2 million for fiscal year 1992, a 6 percent increase over the fiscal year 1991 budget. Such a small increase will not allow NIH to exploit the many potentially life-saving new treatment and prevention opportunities discovered through earlier work. AmFAR, in conjunction with the National Organizations Responding to AIDS, urges Congress to in

vest $1 billion for the NIH's fiscal year 1992 AIDS program, only slightly less than a 20 percent increase.

This proposed increase is justified by the high cost of clinical research, the testing of new treatments in human beings, which now can and must be expanded. It is also justified by an urgent need to intensify basic and clinical research on the many deadly opportunistic infections that plague people with AIDS and that continue, to this day, to be the immediate cause of their death.

The university-based AIDS Clinical Trials Group (ACTG) is the principal instrument for NIH-sponsored AIDS clinical trials. However, the ACTG's capacity is severely limited, and achieving demographic diversity in ACTG-funded clinical trials has been difficult, which remains a serious concern. Community-based primary care physicians participating in the clinical research effort as members of NIH-funded Community Programs for Clinical Research on AIDS (CPCRA) are greatly expanding the NIH's capacity to evaluate new treatments, to include trial participants from medically underserved groups and to offer them urgently needed access to promising experimental treatments.

The CPCRA is an innovative and cost-effective program that accelerates the pace at which new treatments are evaluated and made accessible to all those who need them, including women. The CPCRA program deserves continuing and much increased support.

In women and children with AIDS the spectrum of opportunistic diseases is different than in adult men, and so may be their response to treatment. Clinical trials must not only include them but, whenever appropriate, special trials must be designed for them. AmFAR commends the effort of the National Institute of Allergy and Infectious Diseases (NIAID) and the National Institute for Child Health and Human Development (NICHD) for having undertaken trials in pediatric AIDS and for coordinating their efforts in this area.

A recent report from the Institute of Medicine (IOM) on the NIH AIDS Program concludes that the NIH should continue to give AIDS research high priority and that current "opportunities and needs could justify an immediate increase of as much as 25 percent in NIH's budget for AIDS research." AmFAR commends the IOM's efforts in producing this report and it endorses its recommendations.

CENTERS FOR DISEASE CONTROL

The CDC is the primary Public Health Service agency responsible for tracking the epidemic of AIDS and for controlling the spread of HIV through broad ranging and all Important activities in education for HIV/AIDS prevention.

It is through the CDC's work that the mode of transmission of HIV became known and the epidemiological pattern of HIV infection and AIDS understood. Women and infants have recently been found by the CDC to be the two populations in whom the incidence of AIDS is now growing very rapidly, in fact, faster than in men. By the year 2000, the CDC predicts that women will make up 30 to 40 percent of all AIDS cases in the Unites States. As the demographics of the epidemic change, the CDC must be able to continue to track it so that sound public health policies and correctly targeted educational programs can be developed and implemented. The Administration has requested no new funding for fiscal year 1992. AmFAR joins with the National Organizations Responding to AIDS in requesting funding of $809.7 million for the CDC for fiscal year 1992.

ALCOHOL, DRUG ABUSE, AND MENTAL HEALTH ADMINISTRATION

The link between intravenous drug abuse and the spread of HIV imposes a very heavy burden of AIDS cases on society. A national strategy for AIDS prevention that includes drug treatment on demand and concomitant culturally appropriate education on risk reduction is crucial. It is also essential that further research on the behavioral and physiological aspects of addictive disorders be pursued intensively so that a better understanding of these disorders can lead to more rational and more cost-effective treatments. While the Administration's request of $244.9 million for ADAMHA does represent a significant increase, it is still inadequate. We join with the Ad Hoc Group on Medical Research Funding and the National Organizations Responding to AIDS in requesting funding of $331.8 million for fiscal year

1992.

The National AIDS Demonstration Research Project, under ADAMHA's National Institute on Drug Abuse, is the only federal prevention program in the country concerned with increasingly at risk intravenous drug users (IVDU's) not in drug treat ment facilities, sexual partners of IVDU's, prostitutes as well as runaway or "throw away" and delinquent youth. Data from the NADR project provides essential infor mation to both public health officials and the private sector. This project should be