WASHINGTON -- The federal government hasn't done enough to prevent the spread of AIDS, chiefly because politicians haven't wanted to confront candidly the two primary means of transmission: sex and intravenous drug abuse.
That's the conclusion of a study by the Institute of Medicine, part of the National Academy of Sciences, which reviewed a decade of federal spending on AIDS. It concludes that the government must spend more on behavioral research and prevention programs, including needle exchange programs for heroin users.
Use of federal funds for needle exchanges is now banned.
"The weight of evidence suggests that needle exchange does more good than harm" in avoiding the spread of the human immunodeficiency virus, said Keith Brodie, chairman of the study committee and president emeritus of Duke University.
"We need to look at what is working and apply it to a broader range of settings. This is true not just of needle exchanges, but of other interventions as well."
The study was released yesterday, less than a week before the government's AIDS czar, Kristine Gebbie, is scheduled to leave office. Ms. Gebbie, a nurse, resigned after months of criticism about President Clinton's failing to live up to his campaign promise to make AIDS a top priority.
Advocacy groups welcomed the study. It "echoes a long-standing challenge offered by the AIDS communities," said Christine Lubinski, deputy executive director of the AIDS Action Council, the umbrella group for AIDS service organizations.
In "an era of death and despair," Ms. Lubinski said, "now is the time to implement the HIV prevention research agenda and remove political barriers to life-saving prevention strategies."
The federal approach to prevention -- especially during the Reagan-Bush years -- failed to address the most basic methods of AIDS transmission, the study said, although it mentioned no politicians by name. For example, politicians refused to authorize public-service advertising for condom use. Nor would they pay for long-term research into why young gay men and others are willing to risk unprotected sex.
"Development [of a prevention strategy] was inhibited by a political climate . . . that made it difficult, and on some occasions impossible, to conduct research on the very behaviors in question: drug use and sex," the report states.
"For example, although numerous scientific and policy reports called for a federally sponsored, national survey of sexual behavior to help determine the nature and level of risk for HIV transmission in the general population, federal and congressional restrictions did not allow it."
The Institute of Medicine's study, commissioned by Congress in 1992, examined 10 years of spending at three National Institutes of Health agencies leading the fight against HIV. It concluded that the agencies are weighted too heavily on medical research, even though it's clear that breakthroughs on a cure are years away.
The agencies are the National Institute on Drug Abuse, the National Institute of Mental Health and the National Institute on Alcohol Abuse and Alcoholism.
In 1992, 89 percent of the agencies' combined budgets -- more than $200 million -- was spent on research. Eleven percent went for services, including education and treatment, the study found.
The most ever allocated for services was in 1989.