International AIDS Society Newsletter, no. 16

IAS
INTERNATIONAL
SOCIETY
AIDS Research Priorities of the
U.S. National Institutes of Health:
Addressing the Pandemic
Neal Nathanson, M.D., Director, Office of AIDS Research, National Institutes of Health,
4C02 Bld 31, 31 Center Drive, NIH, Bethesda, MD 20892-2340, USA. Fax: [phone]

By every definition, AIDS is the great plague of
the 20th century; an epidemic of biblical proportions. AIDS has killed more than 16 million
people, surpassing tuberculosis and malaria as
the leading infectious cause of death worldwide, according to recent data from the Joint United Nations Programme on HIV/AIDS
(UNAIDS) and the World Health Organization
(WHO).
To address this pandemic, the Office of AIDS
Research (OAR) of the U.S. National Institutes
of Health (NIH) has established a comprehensive scientific agenda for the large and diverse
AIDS research program of the NIH. The OAR
develops an annual AIDS research strategic
plan and budget, based on the most compelling
scientific priorities that will lead to better therapies and prevention for HIV infection and
AIDS. Those priorities are determined through
a collaborative process involving experts from
both within the NIH institutes and from outside government, including academia and industry, and with the full participation of AIDS
community representatives.
The Unrelenting Pandemic
The impact of AIDS on developing nations and
many mid-developed countries is staggering,
with even greater potential disaster to come.
AIDS in Africa is killing ten times as many people as war, sabotaging economic development,
leading to massive social breakdown, and creating a generation of orphans. AIDS is reversing
decades of progress in public health, lowering
life expectancy, and significantly affecting international businesses. Lost productivity and profitability, the cost of sickness and death benefits,
and the decline in a skilled workforce in the
developing world will have worldwide economic impact. AIDS is affecting the military
capabilities of some countries as well as the
international peacekeeping forces. In response
to this crisis, the United Nations Security
Council declared that AIDS is an issue of national security, representing a new kind of threat
to political stability.

The Evolving Epidemic in the
United States
In the U.S., the incidence of new AIDS cases has
declined, due largely to expanded use of new
antiretroviral therapies that prevent progression of HIV infection to AIDS; however, the
previous decline in death rates has now leveled
off. Most significantly, in what can only be considered a public health failure, the annual incidence of new HIV infections has not declined
since 1990. This means that although therapeutic interventions are delaying death- at
least for a time- we have not slowed the epidemic. HIV infection rates are continuing to
climb in two major groups: women and minority populations of the U.S., including AfricanAmericans, Hispanics, Native Americans, and
Asian-Pacific Islanders. AIDS also affects the
disenfranchised in our society- the poor, the
homeless, and those with addictive or mental
disorders. Rates are also increasing in young
homosexual men and people over 50 years of
age. Further, drug resistant strains of HIV present a serious public health concern.
These data shape our most urgent research
priorities, which focus particular attention on
two critical populations: people living in developing countries and the minority communities
of the U.S. Our research agenda is twopronged: therapeutic research to treat those
who are already infected and prevention research to reduce HIV transmission.
Priority: International Research
As more than 90 percent of new infections
occur in developing countries, where current
therapeutic interventions are unaffordable and
undeliverable, NIH is increasing its international AIDS research portfolio and pursuing interventions that can be implemented in these
resource-poor and infrastructure-deprived
nations. For example, the recent NIH-sponsored clinical trial in Uganda demonstrated that
nevirapine, an antiretroviral drug costing less
than $4, given once to the mother and once to

the baby at birth, could reduce mother-to-child
transmission by 50%. The NIH vaccine research effort also represents our commitment to
addressing prevention needs worldwide. Clinical trials within both the new NIAID Vaccine
Trials Network and Prevention Trials Network
are expected to involve international sites. The
OAR recently supported the first international
conference on microbicides to stimulate new
research initiatives in this critical area.
To further our efforts and enhance international collaboration, the Fogarty International
Center is expanding its research and training
programs in many developing nations. The
OAR has established an International AIDS
Research Collaborating Committee to bring
together all of the Departments of the U.S.
government conducting AIDS research, along
with international partners such as UNAIDS
and the World Bank.
Priority: Health Disparities in the
United States
To address the disproportionate impact of the
HIV/AIDS epidemic on U.S. minority communities, the OAR is directing increased resources
toward new interventions that will have the greatest impact on these groups. These include
interventions that address the co-occurrence of
other STDs, hepatitis, drug abuse, and mental
illness; and interventions that consider the role
of culture, family, and other social factors in the
transmission and prevention of these disorders
in minority communities. The OAR has provided additional funds to projects aimed at:
increasing the number of minority investigators conducting behavioral and clinical research; targeting the links between substance
abuse, sexual behaviors and HIV infection;
increasing outreach education programs targeting minority physicians and at-risk populations; and expanding our portfolio of population-based research. In addition, NIH is
making significant investments to improve
research infrastructure and training opportuni