Book Review

AIDS and Behavior: An integrated approach

N Engl J Med 1995; 332:1388-1389May 18, 1995

Article

AIDS and Behavior: An integrated approach
Edited by Judith D. Auerbach, Christina Wypijewska, and H. Keith H. Brodie. 338 pp. Washington, D.C., National Academy Press, 1994. $39.95. ISBN: 0-309-05093-6

The determinants and consequences of the human immunodeficiency virus (HIV) go beyond virology. The AIDS epidemic has challenged contemporary notions of infectious disease and immunology, health and health care, sex, and science. Like all chronic illnesses, AIDS profoundly affects people in every aspect of their lives. In addition to facing a severe health challenge, persons infected with HIV must also respond to complicated social, economic, and legal conditions. We must move forward in our approach to understanding, preventing, and treating AIDS by considering clinical care and clinical research in the broad context of economic, social, cultural, and political realities. AIDS and Behavior: An Integrated Approach attempts to promote this broad perspective.

Unlike most books, which are initiated by individual investigators or collaborative teams, this book is the result of a congressional mandate. In 1992 the United States Congress directed the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) to contract with the Institute of Medicine to evaluate the mission, programs, management, and funding levels of ADAMHA's AIDS research and service programs. In response, the Institute of Medicine convened the Committee on Substance Abuse and Mental Health Issues in AIDS Research, a 14-member committee of distinguished professionals from a variety of disciplines. Shortly thereafter, two major policy changes influenced the committee's work: the ADAMHA Reorganization Act of 1992 separated research and service functions, and the NIH Revitalization Amendment increased the authority of the National Institutes of Health (NIH) Office of AIDS Research to determine budgeting and program priorities for AIDS research at all NIH institutes. To prevent its evaluation from being relegated to a study of the politics of science, the committee moved forward with its evaluation of AIDS research and services within the institutes, and this book is the result.

The book has two parts. Part I, “Research Findings and Opportunities,” summarizes AIDS research in neurobiology, psychology, and the social and behavioral sciences. Research related to substance use, sexual behavior, and mental health is considered in three chapters: “Understanding HIV Transmission,” “Understanding the Determinants of HIV Risk Behavior,” and “Disease Progression and Intervention.” Each chapter provides a well-written and thorough review of the current literature and articulates directions for future research. Although comprehensive, this approach has several shortcomings. First, in an attempt to be broad, each chapter covers a spectrum of material, but the reader is often left longing for more in-depth analysis. Second, in an attempt to be integrative, the chapters include both biomedical and behavioral-science research, but rarely synthesize this material. Third, other than discrete sections on race and sex, the social context of behavior, including issues of culture, class, and community, do not receive sufficient attention. Finally, discussions of general public health considerations are limited to interventions in schools, clinics, and legislative chambers. Markedly absent is any mention of adolescents and how their behavior often places them at risk for HIV.

Part II, “Managing the AIDS Research Programs at NIAAA [National Institute on Alcohol Abuse and Alcoholism], NIDA [National Institute on Drug Abuse] and NIMH [National Institute of Mental Health],” provides information about the operating context of the institutes, research funding, programs and priorities, and linkages between research and services. This is a comprehensive report on the history of AIDS research within these institutes. For many investigators, especially those new to the NIH system, this review will promote understanding of the structure of research support. It provides an extensive review of past funding, refers to current priorities, and makes recommendations for the future. In its greatest challenge to the current system, the committee suggests that restrictions on federal funding of needle-exchange programs for injection-drug users should be removed; they base this recommendation on scientific data indicating that the programs are effective. The committee highlights the importance and the difficulties of “technology transfer,” whereby researchers inform policy and the provision of services — and service providers and policy makers inform research priorities. The committee reminds us that social science has been most underfunded and calls for new initiatives to support research on the role of social, cultural, and structural factors in the transmission and prevention of AIDS and interventions for the disease. The committee suggests that the current NIH review procedures are often prejudicial to innovative and collaborative projects. Yet these are precisely the kinds of projects that are most needed.

AIDS and Behavior: An Integrated Approach provides perspective and background that can be used as a foundation on which to build the next decade of AIDS research. It is a comprehensive summary of the existing literature, with approximately 750 scientific references. The committee's numerous recommendations set an ambitious agenda for scientists and policy makers. These recommendations would have been even more useful had they been ranked or prioritized, either within each chapter or across the entire book.

Ultimately, behavior determines the risk of HIV infection. With neither a cure nor a vaccine expected before the turn of the century, AIDS prevention is essential. The initiation and maintenance of safer behavior must be encouraged. The true integration of behavior and biology can inform research, prevention, and treatment. The committee states that “The AIDS epidemic requires better integration of these basic biological, psychological, and social science perspectives in order to achieve the complex understanding that will lead to more appropriate and effective AIDS prevention and intervention efforts.” Integration is necessary for a more complete understanding of the complex factors that contribute to HIV transmission and disease progression. AIDS and Behavior: An Integrated Approach has initiated the dialogue. It is up to us to rise to the challenge with scientific rigor, courage, and compassion.

Jeannette R. Ickovics, Ph.D.
Yale University School of Medicine, New Haven, CT 06520-8205