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 the 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 severy limited, and achieving demographic diversity in ACTG-funded clinical trials has been difficult, which remains a serious concern. Community-based primary care nyuciana 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

ail treatments.

The CPCRA is an innovative and cost-effective program that accelerates the pace *t which new treatments are evaluated and made accessible to all those who need Shem, nonding women. The CPCRA program deserves continuing and much ingraet 8.pport.

a women and children with AIDS the spectrum of opportunistic diseases is differen van 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 deagued for them. AmFAR commends the effort of the National Institute of Allergy and Infectious Diseases (NIAID) and the National Institute for Child Health and Piman 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 stades that the NIH should continue to give AIDS research high priority and szat current opportunities and needs could justify an immediate increase of as such as 25 percent in NIH's budget for AIDS research." AmFAR commends the KOM & 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 *.. Important activities in education for HIV/AIDS prevention.

it a 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 nlama 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 200, the CDC predicts that women will make up 30 to 40 percent of all ADS 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 surrectly targeted educational programs can be developed and implemented. The Admudastration 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.

ALOCHOL, DRUG ABUSE, AND MENTAL HEALTH ADMINISTRATION

The link between intravenous drug abuse and the spread of HIV imposes a very terry surden of AIDS cases on society. A national strategy for AIDS prevention va noves trug treatment on demand and concomitant culturally appropriate euros se raak reduction is crucial. It is also essential that further research on za secaroral and physiological aspects of addictive disorders be pursued intenBvey ate a better understanding of these disorders can lead to more rational sit ton selective treatments. While the Administration's request of $244.9 165 OF ADAMHA does represent a significant increase, it is still inadequate. We Ja wiz ze Ad Hoc Group on Medical Research Funding and the National Organiuma kaposing to AIDS in requesting funding of $331.8 million for fiscal year

National AIDS Demonstration Research Project, under ADAMHA's National Kamudina on Drug Abuse, is the only federal prevention program in the country conwest casingly at risk intravenous drug users (IVDUs) not in drug treatBest Kersal partners of IVDU's, prostitutes as well as runaway or throw wwwy wat weloppest youth. Data from the NADR project provides essential infornaar uw picbc bealth officials and the private sector. This project should be

fully funded rather than phased out as surprisingly called for in the President's budget.

The need for additional resources for expanded biomedical and other research is great. These resources should, however, not come from other domestic programs, nor should they be provided at the expense of medical care for those with AIDS or prevention education for those at risk for AIDS. AmFAR is aware of the constraints of the Budget Enforcement Act. But, we also know of the ever-growing numbers of people with HIV infection and AIDS, of the terrible toll of suffering extracted by AIDS and of the need of the American people for a better understanding of why it must, and how it can, protect itself from HIV/AIDS.

AIDS has already claimed more American lives than all our recent wars, including Vietnam. Congress and America must commit now to spending the critical level of resources necessary to fight this war. The lives of over one million American men, women and children already infected with HIV, and those of many others bound to become infected in the years ahead, are at stake.

Senator HARKIN. Dr. Krim, thank you very much for your testimony again this year. Your request is for a 17.5-percent increase for NIH, 64 percent for CDC. The AIDS Action Council, which just testified before you, said the highest priority is to first fund the Ryan White bill. Within our limited budget, what are your feelings on that?

Dr. KRIM. I said that the solution to the problem can come only through research. And, therefore, that must be a high priority. We have a moral obligation as a Nation to take care of our sick and our dying. So one is a practical priority, and the other one is a moral priority. And there is no way of balancing one against the other. We must do both.

Senator HARKIN. Thank you very much, Dr. Krim.

STATEMENT OF DR. PETER D. WALLACE, AMERICAN ACADEMY OF PEDIATRICS

Senator HARKIN. Next is Dr. Peter Wallace, American Academy of Pediatrics.

Dr. WALLACE. Mr. Chairman, I am Dr. Peter Wallace, a pediatrician in practice in Iowa City, IA. I am pleased to be here today on behalf of the infants, children, adolescents, and young adults in this country, as a representative of the 41,000 pediatricians of the American Academy of Pediatrics, and also note that this statement is supported by the 1,300 members of the Ambulatory Pediatric Association, and the 1,100 members of the Society for Adolescent Medicine.

I am especially pleased to be here on the first day of the hearings this subcommittee will hold pertaining to the many health, social, and education programs affecting America's youth. You have, and will hear from many organizations and individuals discussing the merits and needs of all these programs. As the time for decisions near, the academy urges you to remember one key fact: insuring the health of our children means providing for today's needs plus planning for tomorrow's.

Our testimony, as well as those who will come before you in the next few days, will give this subcommittee the information regarding present and future needs. Fortunately for all of us, most infants are born healthy, and continue to grow and develop if they have access to and receive basic health care services.

Unfortunately, there are still far too many that suffer needlessly from disease, injury, abuse, or a host of societal problems. Our task as pediatricians is to treat them all, to provide such services as we