What Research Is Most Urgently Needed?

The most urgently needed research is that which is essential for containing the HIV/AIDS epidemic. In particular, we need to track emerging behavioral risk factors and to aim preventive procedures at these risk factors with as much precision as possible.

Tracking Emerging Risk

A most urgent area for research is in developing improved methods of identifying emerging risks within large populations. For example, in the United States we need to know as early as possible what settings, regions, and subpopulations are likely to show increases in seroconversion to HIV. The best strategy for this identification is to track increases in known behavioral risks, which when combined with sufficiently high HIV prevalence predicts regions of particular vulnerability. Regional strategies are needed for regularly tracking increases in these behaviors in order to effectively offer known prevention strategies before seroconversion occurs. These regional strategies must be coordinated with the National HIV tracking system. Research is needed on how to collect this information regionally. How can studies collect representative data/behavioral information from regional populations in ways that are fully acceptable to the local communities involved? This regional strategy of risk tracking can draw on two areas of established research. First, clearly established risky behaviors serve as reliable harbingers of seroconversion. These include behaviors that directly increase the likelihood of HIV transmission, such as unprotected sex and needle sharing and practices that make these behaviors more likely, such as alcohol abuse in adolescents. Second, methods for inquiring about these risky behaviors have been established and validated. Careful evaluation of the most cost-efficient approaches to regional tracking is needed, as well as approaches to ensure that strategies used are compatible with community values and maximum effectiveness.

Young People

The epidemic in the United States is currently shifting to young people, particularly those who are gay, members of racial and ethnic minorities, and out-of-school adolescents. Because adolescents may be at risk for HIV infection in their early to mid teens, it is important to establish interventions for youth at an earlier age before the onset of risk behavior (sexual activity and drug use). Thus, the U.S. program of research must give highest priority to providing effective prevention programs for these subpopulations. Programs already shown to be effective for these subpopulations must be improved to ensure long-term maintenance of the reduction in risky behavior. Current interventions should be widely disseminated, and improved interventions, as they become available, should quickly replace those that have been less effective. Dissemination should include careful training of providers, monitoring to ensure fidelity of delivery, continuous evaluation of effectiveness, and modification where required by community and cultural needs and circumstances.

HIV-Positive Individuals

Effective interventions with people who are HIV positive can enable them to practice safer sex and safer needle use and thus help to contain the HIV epidemic. There is a startling paucity of well-developed interventions specifically designed for HIV-positive persons. Moreover, as biological treatment for those who are HIV-positive improves, the need for these preventive services will become even more pressing.

Women

It is essential to continue development of interventions to reduce heterosexual transmission of HIV to women as well as their risk of drug abuse behavior. These interventions should focus on the effect of community expectations of women and power differentials in their relationships with men. Moreover, additional research with female condoms and microbicides may facilitate preventive interventions that enhance women's control of exposure to HIV risk.

Linking Scientific Findings to Law and Policy

Most urgent is the need to rapidly bridge the serious gap that is widening between clear scientific results and the law and policies of the United States. As this statement has noted forcefully, there is clear scientific evidence supporting needle exchange programs, drug abuse treatment, and interventions with adolescents as essential components of our National program to contain the AIDS epidemic. Even as evidence rapidly accumulates on the success of these programs, however, legislation has been passed to make provision of these interventions extremely difficult. There is no more urgent need than to remedy this dangerous chasm. National leaders, legislators, scientists, and service providers must unite to understand fully this growing catastrophe. Why are voters unaware of these issues? What pressures and circumstances of government make it unresponsive to these compelling public health needs and effective programs? What are the limits in scientific communication that may obscure the legislative import of these scientific findings?

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