About the Director

Mr. Chairman and Members of the Committee:

Racial and ethnic background, variations in socioeconomic status, levels of education and occupation all intersect in complex ways to expose disparities in health status. These health disparities are likely due to many factors, including accessibility of health care, increased risk of disease due to occupational exposure, and different susceptibilities for disease because of underlying genetic, ethnic, or familial factors. Many examples of health disparities in the United States are related to infectious and immunologic diseases, the key research areas of the National Institute of Allergy and Infectious Diseases (NIAID). For more than fifty years NIAID has recognized the importance of the differential risks and susceptibilities among populations for infectious and immunologic diseases, and has conducted research to mitigate these disparities with new and improved therapies, vaccines and other interventions. Indeed, vaccines are perhaps our most powerful tools against health disparities - by eliminating a disease from a population, disparities in the expression of that disease are also eliminated.

NIAID Strategic Plan for Addressing Health Disparities

As part of a broad National Institutes of Health (NIH) effort to eliminate health disparities, NIAID has developed a strategic plan for addressing health disparities. The NIAID plan has three overarching goals. The first is to conduct and support research on diseases known to occur disparately in populations, including studies to identify the environmental, occupational, social, genetic or biochemical factors that increase risk for, and susceptibility to, infectious and immunologic diseases. The second goal is to increase the participation of and support for minority scientists interested in research on health disparities, which includes increasing the number of minority physicians and scientists in training. The third goal of the NIAID plan is to bolster ongoing efforts to communicate research developments to the population groups affected by health disparities.

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Health Disparities and HIV/AIDS

A central NIAID research focus is HIV/AIDS, a global scourge that has exacted its greatest toll among the poor and disenfranchised. Currently, there are 36 million people living with HIV/AIDS worldwide. In 2000 alone, there were 5.3 million new HIV infections worldwide, more than 95 percent of which occurred in developing countries with few resources to provide HIV-related care. In the United States, HIV/AIDS continues to affect minorities disproportionately. The rate of adult/adolescent AIDS cases reported in the United States in 1999 (per 100,000 population) was 84.2 among Blacks, 34.6 among Hispanics, 11.3 among American Indians/Alaska Natives, 9.0 among Whites, and 4.3 among Asians/Pacific Islanders. The rate of new HIV infections has reached an unacceptable plateau of 40,000 per year in this country. Against this grim backdrop, the development of potent anti-HIV drugs has provided considerable hope for HIV-infected individuals. Combinations of three or more anti-HIV drugs (highly active antiretroviral therapy or "HAART") have helped to greatly reduce the number of AIDS deaths and new AIDS cases in the United States, among all racial and ethnic groups. NIH-supported investigators conducted pivotal research that ultimately led to licensure of the seventeen anti-HIV drugs approved in the United States, and defined how best to use these drugs in different clinical settings. The NIAID has taken strong steps to ensure minority participation in our HIV clinical trials, natural history studies and prevention studies such that enrollment reflects the national epidemic. In this regard, in 2000, African-Americans and Hispanics comprised 41 percent and 16 percent, respectively, of participants in these studies; females comprised 43 percent.

The upward trajectory of the global HIV/AIDS epidemic and the unacceptably high plateau reached in this country underscore the urgent need for methods of preventing HIV transmission. In order to develop and test new strategies to prevent the spread of HIV here and abroad, NIAID recently launched two international research programs: the HIV Prevention Trials Network (HPTN) and the HIV Vaccine Trials Network (HVTN), with research sites in the United States, Latin America, Europe, Africa, Asia and the Caribbean. The HPTN focuses on several key areas of prevention research, including behavioral modification, interventions to prevent mother-to infant HIV transmission and the development of topically applied microbicides that women could use to protect themselves against HIV and other sexually transmitted pathogens. The HVTN will conduct all phases of clinical vaccine trials, from evaluating candidate vaccines for safety and the ability to stimulate immune responses, to testing vaccine efficacy.

In the past, attempts at pursuing prevention efforts in resource-poor settings such as Sub-Saharan Africa have been hampered by the fact that little could be offered to the people who participated in prevention efforts. Now, with dramatic reductions in the price of antiretroviral drugs, it appears that antiretroviral treatment may be feasible for many people in southern Africa and other poor regions. Building on the research infrastructure NIAID has helped establish in Africa and elsewhere in the developing world, we intend to work with our international colleagues to link the provision of anti-HIV therapy to efforts in prevention research, with the goal of facilitating a comprehensive approach to the AIDS pandemic in poor countries.

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Health Disparities and Other Infectious Diseases

In addition to HIV/AIDS, minority populations also have much higher rates of certain other infectious diseases than do non-minorities. For example, 76 percent of active tuberculosis (TB) cases reported in the United States in 1999 were among racial and ethnic minorities, according to the Centers for Disease Control and Prevention (CDC). The disproportionate impact of TB among minorities is due largely to problems related to urban poverty, overcrowded living conditions, HIV infection and inadequate treatment or compliance with TB therapy. Globally, TB kills 2 million people a year, and TB deaths are increasing for the first time in 40 years, according to the World Health Organization. To combat this global scourge, NIAID sponsors a broad portfolio of research, including epidemiological studies to better understand the genetic and environmental factors that contribute to the prevalence of TB in different populations. Of particular note, the availability of the genomic sequence of M. tuberculosis will provide access to new targets for diagnostics, therapeutics and vaccines, as well as important information regarding the genetic basis of resistance of the microbe to anti-TB drugs.

Another important contributor to health disparities is the Hepatitis C virus (HCV), a blood-borne pathogen that infects cells of the liver. African-Americans are infected with HCV at twice the rate of non-minority populations, and are less responsive to therapy than are Hispanics, Asians, or Caucasians with similar disease characteristics. To address the challenges posed by this virus, NIAID supports nine Hepatitis C Cooperative Research Centers devoted to understanding the HCV infection and disease process. Two of the centers focus on minority populations.

Minority groups are also disproportionately affected by sexually transmitted diseases (STDs) other than HIV, including syphilis and gonorrhea. Due to a combination of biological and social factors, women face the greatest risk of acquiring an STD and of serious long-term complications from these infections. NIAID conducts and supports many research projects to improve STD prevention methods -- including the development of vaccines against sexually transmitted pathogens -- and to find better ways to diagnose and treat these diseases. Among the projects to address the health disparities caused by STDs, NIAID is conducting four large clinical studies that focus on adolescent minority populations.

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Health Disparities and Asthma

Asthma affects more than 17 million Americans, resulting in more than 130 million days of restricted activity and nearly 500,000 hospitalizations annually, according to the CDC. The burden of asthma is disproportionately high among children, especially those who reside in the inner-city. African-Americans are hospitalized for asthma three times more frequently than other U.S. residents, and African-Americans and Hispanics living in inner-cities are two to six times more likely to die from asthma than are Caucasians. For the past decade, NIAID has focused on reducing the disproportionate burden of asthma among inner-city minority children with the National Cooperative Inner-City Asthma Study (NCICAS). Investigators of the NCICAS have developed a successful behavioral and educational intervention capable of substantially reducing asthma severity in these pediatric populations. Now, NIAID and the Centers for Disease Control and Prevention are collaborating to implement this successful intervention in a new 4-year program that will reach 6,000 children in 23 inner-city health care delivery sites through the U.S.

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Health Disparities and Other Immune-Mediated Diseases

Other immune-mediated diseases contribute to the health disparities seen in the United States. In particular, autoimmune diseases have a dramatically disproportionate effect among women and some minorities. Among the most exciting areas of research in this area involves the induction of immune tolerance: selectively blocking inappropriate immune responses while leaving protective immune responses intact. By inducing immune tolerance, it may also be possible to prevent graft rejection in transplant patients without the long-term use of immunosuppressive drugs that dampen protective immune responses as well as destructive ones, thereby placing patients at increased risk of infection and malignancies. NIAID has developed a multi-faceted research effort in immune tolerance. In the fall of 1999, NIAID established the Immune Tolerance Network (ITN), in collaboration with the Juvenile Diabetes Research Foundation International and the National Institute of Diabetes and Digestive and Kidney Diseases. The ITN is an international consortium of more than 70 research groups, involving scientists conducting basic research as well as clinical investigators testing promising "tolerogenic" treatment regimens. To date, more than a dozen ITN clinical trials have been approved for implementation in four areas: islet transplantation, kidney transplantation, autoimmune diseases, and asthma and allergic diseases.

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Conclusion

NIAID intends to continue and strengthen our efforts to address health disparities as a critical part of fulfilling our overall scientific mission. We must continue to advance research on the diseases that contribute to health disparities, increase outreach to minority populations, and foster the training of a new cadre of minority scientists. Together, these efforts will help us address the crucial NIAID research agenda in a manner that includes all segments of our population.

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Accompanying Posters

Slide 1: NIAID Strategic Plan for Addressing Health Disparities
Slide 2: Rate of Adult/Adolescent AIDS Cases by Race/Ethnicity, United States, 1999
Slide 3: Major NIAID-Supported AIDS Clinical Trials Networks
Slide 4: The Impact of Asthma: A Growing Health Disparity
Slide 5: NIAID Inner-City Asthma Studies
Slide 6: Elimination of Disease with Vaccination Leads to Elimination of Health Disparity

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