Investigator Qualifications: How does the investigator plan to leverage his/her qualifications and experience to address challenging issues in HIV/AIDS research on drug abuse? Provide evidence to support your claim of innovativeness and creativity in your research. You may describe past studies in which you used your talents to overcome obstacles and solve problems in order to address important and novel research questions. For example, which personal qualities and experiences demonstrate your inclination to challenge paradigms and take intellectual risks, develop unique collaborations, integrate diverse sources of information, or develop novel approaches when new challenges or opportunities arise?
Historically, certain epidemics have done great damage to social institutions: the Black Death in a 3-year sweep through Europe wiped out enough laborers to cause a major restructuring of the economy of the continent. The HIV/AIDS epidemic, although often compared to the Black Death, has not affected U.S. social institutions to any such extent. Although it had by the end of 1991 infected perhaps 1 million people, brought devastating sickness to 206,392, and death to 133,233, it had not significantly altered the structures or directions of the social institutions that we studied. Many of the responses have been ad hoc and may be reversed when pressures subside. Others may be more lasting, but only because they reinforced or accelerated changes already latent or budding within the institutions.
The complexity of the disease remains another major challenge for the provision of services. HIV disease attacks virtually every organ system of the body. The diverse and uncoordinated nature of the U.S. health system—reinforced by the reimbursement practices of the multiple plans that pay for care—has been often criticized for its failure to provide comprehensive, coordinated primary care and for too great a reliance on specialists and subspecialists. And it is just such comprehensive, primary care that is necessary to cope with a disease that is chronic and disabling and not limited to any one organ system. The urgent need for coordinated community-based care for AIDS patients has pushed the development of improved case management approaches.
growing, however, that the burden of the epidemic may further dissuade young physicians from entering specialties such as internal medicine or from practicing in a geographic location where the burden of caring for patients with HIV disease is perceived to be high. The care of AIDS patients in terminal stages of the disease falls very heavily on hospital-based nurses. Like the practice of oncology nursing, it is an emotionally as well as professionally demanding experience. It is impossible to assess the extent to which the HIV/AIDS epidemic has exacerbated staffing problems in hospitals and other institutional settings that care for AIDS patients; however, a shortage of nurses has been identified as a major obstacle to improved care of AIDS patients.
The HIV/AIDS epidemic has sent more than 200,000 patients into that system over the last decade and may, in this decade, send up to 1 million more. A substantial proportion of these patients are drawn from the pool of the uninsured or patients who rapidly exhaust their insurance benefits due to job loss or benefit restrictions. The people who became HIV/AIDS patients challenged the provider community on a number of fronts: they were generally young and previously healthy people who engaged in life styles that affronted many in the provider community. Before the modes of transmission were well understood, many health care personnel feared contact with AIDS patients, and both hospitals and private physicians struggled with unfamiliar problems of how to provide sensitive and responsive care while preserving the privacy of AIDS patients and protecting staff and other patients from infection. These problems have been complicated by the fact that many AIDS patients cannot pay for care, and thus the subset of the health care delivery system that provides care to indigent patients has absorbed the brunt of the epidemic. In the handful of cities that are the focus of the epidemic, there is a serious strain on the provider community, particularly public and voluntary teaching hospitals; in other cities, the capacity of hospitals to absorb AIDS inpatients is not as pressing a concern as are the stigma and inadequate reimbursement associated with AIDS care.
For this particular announcement, note the following: The Avant-Garde Award Program for HIV/AIDS Research (DP1) applications are meant to support individual scientists of exceptional creativity who propose pioneering -- and possibly transforming -- approaches that, if successful, will have a major impact on a broad area of biomedical or behavioral research. Avant-Garde Award applications do not require preliminary data, scientific aims, or a detailed research plan. Accordingly, reviewers, in both review phases,will emphasize the following:
A constant theme of this report and of the AIDS literature is the stigma, discrimination, and inequalities of the AIDS epidemic. At its outset, HIV disease settled among socially disvalued groups, and as the epidemic has progressed, AIDS has increasingly been an affliction of people who have little economic, political, and social power. In this sense, AIDS is an undemocratic affliction. In "democratic epidemics" (Arras, 1988), communicable illnesses cut across class, racial, and ethnic lines and threatens the community at large. In traditional societies with limited medical knowledge and technology, epidemics fall on most, if not all, of the people. In the modern world, particularly in industrial societies, inequalities in morbidity and mortality are often more social than biological phenomena. With HIV/AIDS, the concentration of the epidemic from its beginnings was among those who were, for a variety of reasons, members of marginalized social groups. In this case, the biology of viral transmission matched existing social inequalities and resulted in an unequal concentration of HIV/AIDS in certain regions and among certain populations (see Grmek, 1990). This pattern has created tension between the social and geographical localization of the epidemic and the need to mobilize resources to deal with the epidemic from among individuals, groups, and institutions that are removed from the social groups that are at the epicenter of the epidemic. As the epidemic becomes endemic in already deprived and segregated populations, this tension will be intensified.
The Avenir Award (DP2) grant supports innovative research that has the potential to produce a major impact on HIV/AIDS biomedical or behavioral research. A DP2 grant application does not have extensive background material, and the essay focuses on the goals of the Avenir Award program.
Second, even in institutions with very defined purposes and strong constraints—institutions as different as religious groups and correctional agencies—the response to the epidemic has reflected awareness of the scientific realities, as well as the social implications, of HIV/AIDS. Traditionally based doctrinal constraints in the case of religious groups and the stringent requirements of civil punishment in the case of correctional agencies are powerful forces that could and did dictate rigid and narrow response. Yet, powerful as those forces were, they did not negate more reflective responses that contributed to containment of the epidemic and respected the rights of individuals. We are concerned, however, that as the epidemic strikes with greater force in socially and economically deprived communities, the directions toward more communal involvement and respect for civil and personal liberties might be constricted and diverted.
Does the project address an important problem or a critical barrier to progress in the field? If the aims of the project are achieved, how will scientific knowledge, technical capability, and/or clinical practice be improved? How will successful completion of the aims change the concepts, methods, technologies, treatments, services, or preventative interventions that drive this field? Given that the overarching goal of the Avant-Garde Award Program for HIV/AIDS Research is to support cutting edge and possibly transformative research that addresses important challenges in HIV/AIDS that are relevant to drug abuse, does the application address a crucial biomedical or behavioral issue in a way that has the potential to major contribution to the HIV/AIDS field? What is the likelihood that the proposed work will open new avenues of research and/or lead to new HIV/AIDS prevention and treatment interventions that may benefit substance users?
It is the panel's opinion that the limited responsiveness of institutions can in part be explained because the absolute numbers of the epidemic, relative to the U.S. population, are not overwhelming, and because U.S. social institutions are strong, complex, and resilient. However, we believe that another major reason for this limited response is the concentration of the epidemic in socially marginalized groups. The convergence of evidence shows that the HIV/AIDS epidemic is settling into spatially and socially isolated groups and possibly becoming endemic within them. Many observers have recently commented that, instead of spreading out to the broad American population, as was once feared, HIV is concentrating in pools of persons who are also caught in the "synergism of plagues" (see Wallace, 1988): poverty, poor health and lack of health care, inadequate education, joblessness, hopelessness, and social disintegration converge to ravage personal and social life. These coexisting conditions foster and aggravate HIV infection and AIDS. Our study of New York City (see ) illustrates this dramatically for one epicenter of the epidemic. We believe that the patterns shown there are repeated throughout the country: many geographical areas and strata of the population are virtually untouched by the epidemic and probably never will be; certain confined areas and populations have been devastated and are likely to continue to be.