Now todays event is cosponsored by the center for aids research known as see far. Its a collaboration across the three Johns Hopkins schools the schools of Public Health medicine and nursing. And with support from the university provost. Founded seven years ago its committed to ending the hiv epidemic through the promotion of trans Disciplinary Research and importantly very importantly by training the next generation of hiv aids researchers both here in t the u. S. And abroad. The return on investment is quite clear. As just one example hiv funding for junior investigators has risen from 7 of nih funds from before cfar was established to 25 of all nih Research Funding now. This has created a larger pool of welltrained and empowered hiv experts who in the past decade have accelerated the work to get as near to the Necessary Solutions for this epidemic and getting us to the goals we are striving for. While hiv impacts the health of populations worldwide and particularly pleased that cfar has been on the forefront of supporting hiv research and programs here in our own city of baltimore. Limburg School Faculty are making a difference in participating in so many of the ending the hiv Epidemic Initiatives by collaborating with Baltimore City leaders and their state policymakers. This is a remarkable example of us working together to find programmatic and policy solutions that work across all levels of government to save lives, millions of the time. Who would like to close by offering a special thanks to cfar director chasten of the school of medicine into chris buyer who is the associate director of cfar. Thank you both for all you have done and continue to do and thanks to all of you for being here. Your determination and commitment to hiv is so critically important. Because of your worker dreams to and hiv is now on the horizon in the hope coming true by 2030. With that i will turn it over to over to dr. Chris buyer who will introduce todays guest. Chris. [applause] thanks so much and on behalf of jason and myself i want to thank you for all of your sustained support. It really has made a difference. We are delighted on behalf of cfar to welcome all of you to the special session and with our special guest in dr. Anthony fauci and jon burke ahead of the hiv Prevention Program of the cdc and therefore introduce them i want to make a few comments about why we think its so important that Academic Research institutions like ours that Johns Hopkins engaged in ending the hiv Epidemic Initiative and take on the role that we think we can play in helping to finally achieve the end of the hiv epidemic. I think before we do that we have to acknowledge perhaps two or three fundamental truths that you are going to hear about from both of our speakers today that are really i think very essential to thinking about the task ahead. The first of those is we have to acknowledge the hiv epidemic ine the United States particularly the new infections in the u. S. Has been stubbornly persistent. We have declined over a number of years and we have basically been in the plateau around 38,000 or so new infections were a number of years. So the first enormous goal that has been set by this initiative is a 75 reduction in new infections over the next five years. That is on a very different trajectory from where we are and where we have been. We have an enormous task ahead of us in primary prevention of hiv infection and delivering the new science and technology again that you are going to hear back from her guests that really could achieve reductions in new infections but we are going to have tout really engage those tt are risk for hiv acquisition if we are going to achieve those goals. The second challenge is hiv has always been marked by Health Disparities but as we have done better as a country hand over the last decade and Health Disparities are getting all thed more stark soea hiv is now very much geographically concentrated in the south and southeast basically a swap of the countries you will see that goes from baltimore down all the way to texas and across the south in the southeast so theres a geographic disparity. Course a marked and disparity in a concentration in africanamericans and native americans and that is particularly stark for africanamericanic women and africanamerican and latino men. We have a concentration by race and ethnicity in the concentration and vulnerable groups of people at a risk. We also of course have to deal with the emerging and quite different demography of the Opioid Epidemic and its impact on what we are seeing with new hiv cluster infections, really quite different that includes abuelaish and new england and the south and midwest. Finally the third area that i think we have all been surprised about after 30 years of effort here and a tremendous advantage in treatment and prevention is hiv remains a very stigmatized condition and the people who are both living with the virus or at risk for it are in very highly stigmatized roots so there is intersectional stigma and that relates to and ethnic minorities in this country that relates to sexual and genderin minorities d substance users but of course also adjusted the stigma around the hiv infections itself. And the persistence of that stigma remains a very important barrier to achieving these essential goals that we want to achieve. So we have to deal with stigma and we have to do with Health Disparitiesin and we have to del with reducing new infections and of course that means both getting the new prevention technologies to people and also getting the americans living successfully link to care and the virally suppress. The exciting thing is we really do have the scientific and technical capacity to do this and now the question is are we going to be able to achieve that as aub publichealth effort is a country and i think particularly for the young folks in the audience at younger investigators this is really going to be for the next decade or two decades an enormous implementation and technical challenge for your careers and they think its enormous way exciting. You are going to hear a lotot of rhetoric at the end of the day but it doesnt mean the end of aids research. Dont worry about that. Theres a long way to go to achieving these goals. Let meeoa turn now to a really delightful honor and task which is to introduce our first guess dr. Hensel the director of the National Institute of allergy and Infectious Diseases and dr. Fauci is one of the architects of ending the hiv initiative. This is also called as some of you will have heard this pepfar for the United States and thats perhaps isnt surprising because dr. Fauci was one of the architects of pepfar which of course has been a world changing Global Health innovation intervention the single largest commitment to a disease by government in Human History and really something that is enormous way important. Dr. Fauci, people always say about tony fauci that he needs no introduction but i think Everyone Needs an introduction so let mee just go on for a moment and say he is of course one of the most cited scientists in a field producers subpoena the president ial medal of freedom which is the highest honor a president can give. Hes played an extraordinary role in maintaining over decades now the Research Funding support for hiv aids and effort and for that all of us as investigators are deeply in his debt but more importantly everybody alive with hiv is in debt. It took 800 Clinical Trials to reach antiviral therapy and to be as effective as it is now without the sustained decades long support of the nih and funding that research we would not be where hiv is a manageable chronic condition and that is an extraordinary achievement of the saved will literally millions of lives. I will just add one more thing which is some of you may know im a past president of the International Aids Society and witty take on that path you get to give ann award. Called the ias president s award so when that felt fell to me to make that decision i had a short list of one person and so i would like to thanki you dr. Fauci for accepting the coming all the way to south africa to accept the award was a great honor and without further ado dr. Fauci. [applause] thank you very much christened that kind introduction. A real pleasure to be here with you this afternoon to talk about the subject that is at hand here ending the hiv pandemic. Im going to talk about it from the standpoint of whatt i call from science implementation. This is the paper that we put together describing right after actually we submitted it right before the president made the announcement on february 5 by the came out on line essentially the next morning and it was the. Version describing the plan which as was alluded to a moment ago was the 75 reduction in new infections in five years and 95 reduction in the 10 years to diagnose treat and prevent and respondes. You will hear more about that from dr. Brooks in the moment but what i would like to do is talk a little bit more in flush out what i refer to as the hiv vulnerability profile. Why did we feel we could actually end the epidemic given what we have . It starts off with a population that we have as a vulnerable population are both demographically and geographically so lets look demographically. You know the numbers. Its very prevalent here in a bald 13 of the population of the United States is africanamerican. If the new infections 43 are among africanamericans than 60 of those are among men and 75 are young menar who have sex wih men so as chris said we have a concentration of a vulnerable population. We also have a geographic concentration. What jon brooks and his colleagues at the cdc put together, this map it was stunning. It was 3007 counties in the United States and if you look at it up those counties plus the district of columbia accounts for more than 50 of all the infections in the United States. Thats extraordinary. 40 units out of 3007 units. Thats 50 of the population. So we have this plan. There are a number of agencies involved. Im going to focus just for a few moments on what the nihs role is and we were discussing this with some of the staff and students a little while ago. The khalid implementation science. Ti cdc will be responsible for going out and engaging in the community. Whether they are doing thatndga correctly which im sure they will but how do you make it even better from yeartoyear will depend on implementation science and that will be done through the centers for aids research one of which is right here in baltimore. If one looks at the map of the country and those red ribbons are for where the centers for age research are in the blue ribbons are where the age Research Centers are which is mostly Mental Health you can see an important overlap with some exceptions like in texas which unfortunately doesnt have that but we are going to be dealing with that by extending other cfars there. He rose to the occasion as it were of trying to get cfar who are doing an extraordinarily good job and other aspects of hiv aids, critical part of what we do but we needed to supplement them to do that extra mile of getting involved in this extraordinary efforts to end the epidemic. We took 65 supplements to 17 cfars. 36 of the 40 counties of high burden were involved with the cfar pearly collaborated with Health Officials in that it the optimal delivery of evidencebased intervention. I just had thef pleasure of listening to two hopkins people present Work Associated with the hopkins is cfar. The collaborative project was joyce jones in the linkage and retention care upon release from the maryland state prison by gene anderson. If everything that is done here is as t good as what i saw this morning you guys are in really good shape. So lets get on to the science. Besides the one plantation implementation we should not forget to how we got to where we are now and it really is the science that got us there namely the scientific races or even our ability to implement a program so let me talk about that for a few minutes. We have hiv treatment and prevention tool kits that have accumulated as chris said over decades of research with basic research and Clinical Trials including the drugs on the left hand toolbox in the prevention of callow days. I begin taking care of hivinfected individuals in the fall and winter of 1981 before was called aids, before we knew it was. At that time the patients that i admitted to my unit at the nih had a median expectancy of about a year which means as you know 50 of the patients are dead and when youre in following them about 95 of them were dead and two to three years. If you look now today when patients come into the same clinic which i should have actually have been having rounds today i but im here with you in baltimore but thats okay but if a patient came and it was reasonably newly infected and i put them on the antiviral application i could look them in the eye and tell them they would live an additional 50 plus years which would give them almost not quite but almost a normal life expectancy. In the 20 years from 1995 to 2015 almost 10 Million Deaths were averted andm almost eight million infections were a verdict in the saved 1. 05 trillion. For every dollar spent, 3. 5 in benefits were realized. What about the 55 reduction in debt from 2005 to 2018 . We have had some gamechanging scientific advances. The one that is linking to them has been the concept as simple pl it may seem but we didnt realize it the treatment equals prevention. In two ways treatment as prevention. The iconic hpv in 052 trial which showed couples if you start therapy early an individual who is infected as opposed to waiting till the guidelines triggered it at the time, the guidelines did not say everyone thats infected should be treated it decreased by more than 95 the likelihood he would transmit to your sexual partner. We followed up five years later and we started to look at the relationship between viral load and the chance of transmitting and there was a strong suggestion that if you are below the technical level that you wouldnt w transmit. Very few people believe that so we had to prove it. We did three studies. And to our amazement of very positive amazement out of more than 150,000, less sex acts not one hiv linked infection that led this is something we are hesitant to say before that actually treatment is equal prevention and undetectable does mean untransmittable. A very important concept. The next was preexposure prophylactics. One pill containing two drugs if taken optimally and consistently with more than 99 effective in preventing sexual transmission and acquisition of hiv. If you put those two things together, treatment is prevention and breaks grosser prophylactics and take a deep breath and think about that for a minute t theoretically if you put everybody on treatment, while almost everyone and put all at risk people on prep theoretically you could end the epidemic tomorrow really. But we dont live in a theoretical world. We live in the real world and the way you make that bridge of that gap is by implementation. Thats what its all about and thats what you guys are going to be doing. At now, in order to do that we have also got to optimize the toolkits that i spoke of in two ways. Maximal implementation. Why do we need maximal implementation . Lets look closely not just that the United States. 23 Million People are receiving antiretroviralll therapy, great news. The challenging is almost 15 Million People who should be on therapy are not on therapy. That has led to a very modest in fact even less than modest reduction in incidence globally. In fact its a less than 2 animal decrease in incidence since 2010 so as chris said although we are going down we kind of plateau to bet which is why would we put the plan together. Retention in therapy is also challenging. Up 100 is the day you go on therapy 48 months later only 60 of people are still on therapy. Youre not going to end the epidemic thatin way. Utilization of prep the 2020 u. N. Target says the 3 Million People should be on prep. There are only about 380,000 people as of last month who are in on prep. Now can we overcome those implementation gaps . Some groups have actually been successful particularly in San Francisco with the Rapid Program in which they were aggressive in going into the community identifying people putting them on therapy immediately and if they are at risk putting them on prep immediately and following them up closely. It resulted in a rapid dramatic increase in new diagnoses in San Francisco. Youre probably going to hear from jon brooks in the bit that new york is doing the same thing. Governor cuomo decided if San Francisco can do it new york can do it and in fact it has gone down. We in d. C. T in collaboration wih the d. C. Pepfar program and the d. C. Department of health have tried to mimic what was being done in sano francisco and began the new diagnoses have gone down dramatically in my city of washington d. C. Now, in addition to implementation you need to develop new and improved tools. Why . Because we have to make treatment and prevention more userfriendly for people because as much and as strange as it seems they dont optimally utilize separate the two ways of developing new improved tools. The first is the arena of treatment. How do you improve treatment . There are a couple of ways. The goal is to try and get people off daily a r. T. A few ways to do that, you can eradicate the virus but im not going to spend time talking about that. Thats highly aspirational. Not impossible but i want to concentrate on ending the epidemic before you get too concerned about eradicating the virus. What we can do to make things userfriendly as longacting antiretroviral. Its amazing how people are much more amenable to receiving an injection every couple of months rather than a pill every day. Its almost kind of intuitive but its the truth. Theres no doubt about that. There are a number of studies starting off with one monthly and goes to one every month of an injectable antiretroviral. Another way of gaining antiretro viral bilicki, there are 200 and it bodies that have been isolated and identified from hivinfected individuals. We have now used them in humans to try and replace antiretroviral therapy. It is study together with the university of pennsylvania and a single antibody. A significant delay in the rebound of the virus. Michelle and others have done a combination of two antibodies. Where are we going with this . The ultimate goal or endgame is about every six months to have somebody get a transfer for anybody and never have to take an antiretroviral drug. You come into the clinic webs every six months with the longacting antibody and thats your antiretroviral therapy. What about w prevention . How are we going to prove prevention . We canan improve exposure prophylactics the same principle by long acting prep. Either artbased prep for me to give studies but one is about 4500 men and transgender women in multiple countries. The same principle. Testing with an injectable could be as good as or better than tripodo. Another study in Subsaharan Africa involved 3200 women. Those of you in mexico city it was a presentation of the plan that gave levels of drugs for one year that would be predictive of being suppressive to prevent infection. They could get an implant to stick into someone one year that is going to be a true gamechanger. The other is getting back to the antibodies. They are being used in the study now both in Subsaharan Africa and in the United States and southst america as a preventive measure. With the long acting one if you can prevent hiv by having someone with an intermittent infusion of an antibody again in Southern Africa and south america and even United States people would rather have an injection or infusion than taking a pill every single day. Finally theres the issue of vaccine. We are talking about ending the epidemic and i think we can do it before we get a vaccine. If we wanted durable end to the epidemic i think we are going to have a vaccine together with the things that ive just been speaking about. Very quickly thereve been two major pathways. The first was to empirically test a number of vaccines. We did that without success for a number of years and then in 2009, we had a hit in the head was a vector prime in a protein boost in the famous now thailand study which gave a 31 efficacy, 31 is an interesting signal but its not good enough for primetime. But it allows us to do was to amplify that because we knew what the correlate if immunity is. Increases strength and durability. As we speak today we are doing that in three major trials in Southern Africa and in south america. The first we launched three years ago this month in the date will likely come around around 2021. This is very much mimicking one rv 144. And we took a little further in the study started two years ago this month and that is the trial which a quarter ofo a land different sector and add a mosaic primary protein boost. The third one that just came out a couple of months ago is them mossadegh trial which is add a 26 vector with a mosaic trim in a mosaic loose. Thats taking place not in Southern Africa but south america and the United States. Finally the thing that is highly aspirational but theres a lot of elegant science going on is assuming that an assumption broadly t inducing antibodies. It makes a lot of them but only after person him or herself as have the virus for two years or longer. The antibodies have done something for a vaccine for dave identified a least six or seven neutralizing episodes namely that protein component that the antibody binds to. Now the challenge is to take those neutralizing epitopes put them in the form of an immunogen and a lot of studies are going on right now. What about a vaccine . How good is good enough . It told the 31 is not good enough. I dont think theres a chance in the world we are going to get a 90 8 in the fifth hiv vaccine like we have for the measles but i will settle for 50 to 60 effective vaccines together with preventive modalities. In fact galvani data model and should get a 50 ethic vaccine you could dramatically affect it. We have an enormous fully effective toolkit for both prevention and treatment. We need to maximally utilize them. We need to maximally implement them in way to add new treatment and prevention modalities that are both userfriendly and hopefully like the vaccine gamechanging. If we do that we will end the epidemic in the United States and we will end the epidemic globally. Thank you. [applause] and he is an extraordinary speaker too. Thank you so much tony. That was really inspirational and lays out a lot of the signs that many of the young investigators are going to be engaged in going forward. Thats enormous fully helpful. Please hold on to your questions for dr. Fauci. Well have time for q a with both speakers at the end of dr. Burkes presentation and by the way cspan is recording this so if you want to be on Television Come up with a good question. Its now its my honor to introduce the next speaker dr. Jon burks who is a medical epidemiologist with the cdc and jon has had an extraordinary career at the cdc in hiv prevention but also p. Diddy Epidemiologic Intelligence Service training there and has led a number of other efforts for the cdc. He was the cdc team lead for the response to Hurricane Katrina which many of you remember was an enormous Public Health challenge. He also led the cdc teams on sars and during the anthrax challenge we had some years ago. He has a medical degree from what we call here the other h, harvard. We dont hold that against you. And then did training at harvard and was on the faculty at emory to the cdc. The cdc of course is one of the absolute key federal agencies engaged in the hiv epidemic rates of partnership with the nih and several others, Indian Health service and stamps on her so that cdc plays an extraordinarily Important Role as wellknowny controlling and working with municipalities and cities, states and counties that are really going to be the frontlines for ending the hiv epidemic. Thats why its so important to have the cdc here with us today and jon, over to you. [applause] i have to raise this up a little bit to make sure you can hear me and thank you for coming to this and thank you for the opportunity and the school of Public Health for the temptation to speak today. His terrific to see tony setting up the Science Behind knowing whats going to works to end the hiv and putting a plan into action is not as simple as it sounds and thats where the money lies. What i want to do today is walk through with you some of the details around her plan to action and i first want to explain i have no financial affiliation with this club and im going to give brief background on the key rations and philosophy of the hiv Epidemic Initiative and review some of an opportunitys for what is minutia detailing with a couple of Innovative Solutions highlighting the challenges of the three pillars diagnosing treatment and preventing. Let me remind folks leave than dealing with hiv for too long. Right now the u. S. Spends 28 billion annually to take care of hiv infection to prevent hiv infection but thats enormous amount of money that we should necessarily had to spend. As i will point out is chris and tony pointed out before we have not seen a substantial decline in the number of new infections each year were a number of years now and if we did nothing for the next 10 years 40,000 americans would become infected with the hiv infection. We have made enormous strides and im sure all of you well know in reducing the impact of hiv and new infections as illustrated by this figure at the bottom looking at incidents by year. Its not only new infections between 30 and 40,000 also there are some significant threats out there to our success. Not the least of which is a resurgence in nonsterile drug use ramping up across the country beginning to affect published of people who didnt consider at risk to hiv previously now praise the issue complacency. Many people think its not my job to test antibodies in somebody elses job andt thats something that to work on. As dr. Fauci pointed out the most powerful tools in history. What are they epidemiologic sebile that led us to the figures of a 90cent 90 reduction over 10 years and how we going to do a . Basically the first up is you want to reduce the prevalence of the person capable of transmitting the infection. Our goal is to achieve an incidence of less than one in 100,000 americans and thats the World Health Organizations definition of a able to read a cave. What happens is over time eventually the death people experience at the end of their Natural Light exceeds infections and at that place prevalent start to decline. There were four principle means that are familiar to people who work with any form of infectious disease. You need to treat those who got it effectively approach those who dont have risk and offer means of getting the infection themselves in keep an eye on whether clusters of disease occurs he the country them and eradicate them as rapidly ass possible but some people ask his and 75 an ambitious goal for the first five years and let me show you their people just north of his new york city. You are aware the governor of the city and the mayor kicked in extra funding to the states annual budget and they have a ferry big goal of their but think plan too reduce infections by 75 or to reach a new goal of 750. These are data from their plans most recently but todays wall street journal has the next number for 2018 and they are continuing this project tree. Granted the whole country is not like new york city but this is a combination of whats possible and ambitious. We think theres something we can do. Want to remind folks that this is an hhs agency initiative. People think the nih and the cdc when i think about hiv hrsa is a large player in the office of the assistant secretary of Health Leaders from each of these offices cms samhsa and hrsa brought together a vision of this plan moving forward. Federal action to date. Just remind folks since the presence announcement in february number of things have happened. One of the large is the main implementation grants. This is a work reeling out that will be going out or have gone out for applications from the cdc hrsa hiv bureau hrsa by mary care which is deeply engaged in distributing prep to folks as well as testing testing people e Indian Health service. A number of them have landed here and theres a lot of work thats being done here today. Three cities receive will be called jumpstart funds one point 5 million bid this was inar juy but six months from july so years and to show some you can achieve early to assess from other resources. One citys is baltimore. The prep or ram youve heard about a prep program made possible by donations to Public Health and human services. This is going to go on line we hope the first week of december and we look forward to folks being across the country. This program is open to everyone. Finally they put out planning grants. These are administered by cdc hearse and samhsa and i just want to point out the purpose of these grants is not to reinvent the wheel. We know there are many places across the country that have longstanding bodies have been helping communities apply treatment. Ending the epidemic efforts are already underway in many places so its not an entirely new idea. We want to galvanize people to bring them together and refocus the plans i have an alliance with the four people pillars we have described. With a particular emphasis which we havent stresses much as we should have on getting the local community involved. We want people affected by hiv being part of the Planning Committee as well as organizations not piercing gaze. We need to get the next generation of people onpl board this forward. What i want to talk about is three pillars diagnose treat and prevent them for the opportunity for an debate of ideas seen recently and then some of the challenges. Early diagnosis is absolutely essential to ending the hiv epidemic in america. You cant get treatment unless you know you have the infection. Or charlie we are not doing a great job around that right now. Over half of people newly diagnosed with the infection in three years, 25 were seven years and most people recently diagnosed seven plus 10 in the year prior to their diagnosis werent offered hiv testing sebesta tremendous missed opportunity. Why is this so important . First we need people to be diagnosed early. 20 of people today diagnosed with hiv infection and if you havent seen all i recently come down to grady hospital. We have plenty of them. Secondly as dr. Fauci mentioned undetectable is untranslatable. People who suppress their viral load are at risk of transmitting the infection. Thats another important reason to find people out of care not to press or dont know they are infected yet it is we estimated the of new infections are from these persons who havent had the benefit of full hav effective care. This is really a great opportunity with this initiative. We can begin to do things we have wanted to do for a long time. We are going to be working hard to make it simple. Thats been a barrier. One of the things we really want to push his automatic order Entry Systems versus when they come and have no evidence of prior testing. Its difficult but it can be done. There are many places in the literature that have donebe it. We also want to establish repeae who are at risk and need to be screened on a regular basis. Thats another pretend he became begin to work on. Also want to talk about family e they are. We asked people to come to us to get tested. We need to think about other methods bringing it to them and tweeting those approaches for the different populations. How you want to test is different thanki p. How you want to test people who use drugs. Let me show you some data from the folks at cdc and emory looking away can do with the te. As a 12 month lot to did not study. They divided people into two groups. 2600 msm participated in on line or music site and if they were in rolled in the Intervention Group favored event for self test and baseline surveys they had to complete. Then they would be interviewed again every three months, four times over the 12 month period. At each point he could then replenish the past. What i want to point out here is they also could share this test package with people in their social network if they got extra test. We didnt say this explicitly and they were told to share them but if they wanted to share them we said sure thats fine. Let me show you what the results are to the study by the ways the evaluation of rapid self testing among the msm project. On the top leinart data from those who arest firsttime testers. 17 were firsttime testers. Take a look at the new diagnoses comparing the people who engage in the south testing protocol versus those who were told to go out and get tested next year. You have substantiallyth more nw diagnoses and look at the social network are these 13 have persons were able to engage 2200 purses with an affection almost equivalent to what the self tese ambassadors if you will for test we wanted to reach who may not have wanted to come in and be tested. We also doubled the number of firsttime testers by 17 people at never tested before going to a doctor in a test center is a barrier for some people but almost all self tester to tested were half of the control folks. Where they was interesting in both groups repeat testing tests substantially greater so this at risk group of people msm are active who tested with a fork can see her work basically beginning to see that more so than those in the control group. I think its extraordinary opportunity. Challenges, just want to read besides the places the issue. Im not responsible for testing youd know where the epidemic has ended i dont have to worry about it. Thats somebody elses job, we have got to change that. We also need to build our technical capacity in the Health Care Leadership to implement screening. You need champions in Different Health care settings as well as medical organizations to say this is the way to go. I will point out there are currently only three improve approved home test and we like to see more and we are working with the fda but presently we only have one. Want to talk about treatment. As youwo know we do an okay jobt getting people by really depressed in america. We want to see expanded rapid engagement retention care meeting people where they are in rapidly detecting people who possibly disengage one of the ways we do that is engage with Surveillance Data returned by people who may be out of care. Learning takes a long time. Could we catch people earlier and what about a pharmacy where user data appears on line today from a group in detroit looking at refills of pharmacy prescriptions by means of identifying people earlier and working to provide help to find that person could look at what they found. First of all the standard of care arc to 92 people versus one person to find 195. They found more people with more accepted linkage to care and the lowest intensity. Took 41 minutes per person and standard of care versus 15 minutes in a pharmacy. This is not fairly intended to be a replacement for care but this may be an adjunct away to move and improve our capacity to capture more people. I also want to note in terms of treatment one of the big carriers as managing people that disorganized lives. Mental health and incarceration but also competing demands. A lot of people cant come to see us and thats hard. Lastly about prevention first focusing on prophylactics you are probably aware that 1. 1 million americans are in need of trip in less than 20 are receiving it and a study published this summer we have seen large increases in the awareness of prep and the use of prep among msm. There remains important disparities in this diagram and 2017. We really needse to work on this and we need to increase prep to reach under populations. And also began to innovate and disseminate new models to treat patients to share the burden. It is want to show here these are enormous number of new ideas on how to get prepped to people through the antiEpidemic Initiative. We are increasing demand expanding capacity for primary care and you can call the one intended number to administer prether californias looking at putting prep and pharmacies and walgreens is in this game and twitterbased access. How many pic you have ever seen a way to getting prep on line . These really could work in the future. They are convenient, discreet and highly excitable and teleprep may work beautifully in rural areas like elysium a an iowa where they have programs in placegr now that i will wont tk about all of these formulations but one heres tony showed us their great formulations and they are great for treatment. Barrels of great for prep and we look forward to the benefit of those working in prep as well. Persistent challenges one of the biggest is identifying people who need prep and engaging them. How many times have you a doctor say my patient is not the kind of person. The patient is not recognizing that either person needs prep and they have to help people understand who is at risk and why they are at risk in consumers want. Theres a lot of research about the preferredd method. Also i want to touch on the Spring Service program. We have seen increases and we have been concerned about injection in part because of the scott county outbreak. There might be real concerned about new infections by people who inject drugs and we have seen a a threat pushing back on the progress we have made. Looking at the number of new infections from injection drug use is something we have seen an overall increase but there are worrying trends. If we do analysis and we look at race age and location we are seeing what seemed are seeing with seemed to be early upticks on dwight young People Living in rural areas and those are places where we know a lot of rescues of people who arent necessarily perceiving themselves traditionally of being open to hiv infection. Ffp needs to be a place to get conference of care. Need to tell people about the benefits and in terms of cost savings and develop innovative waysne to deliver. Im justt going to skip as quickly and point out that in scott county integrating a saran Service Program with access we were able to drive down hiv infections. In greener the number of people receiving, daily number of people receiving syringes and infections came down but we didnt begin to take them away until we got people more engaged into addiction care. Thats the blue line going up. We have to tell the public why these programs are good for them. There are a lot of reasons why but this is an opportunity for the anthropologists and social sciences to do some research to show these things dont increase crime. They dont put Public Safety at risk and they come some people say these are too costly with no real benefit or no return on my investment or thats simply not true. This is work that my folks at hopkins published earlier this week as well looking at what the cost benefits of the Service Programs were in alta more and north lb albio. In philadelphia theres a return on investment is 234 billion per year. Thats a lot of money to be used for good purposes. This is the kind of work we need money leads to power an edge we can show people the benefit to their wallet that will drive them to what you want them to do. Im just going to note that how many are you zero are aware that las vegas has syringe vending machines . They do and thats a great thing to explore. Challenges. There are always going to be community and political resistance as well as legal barriers and we also many of our services we were talking about the fact that doctors dont know what necessarily about administering but they need to. We also know people in the addiction site dont test their patients for hiv routinely and may not know who to refer to. You got to bridge those gaps. My last words and turbine folks this is an extraordinary opportunity. Their challenges and risks but ending the hiv epidemic in america as possible working together and inle the words of y boss bob redfield i want to people to think disruptively not disruptively. Thank you very much. [applause] thanks so much jon. I was just marvelous. Sorry. We now have some time for questions for speakers and we are going to have mobile microphones and well have somebody at the mic so please go ahead. Approach yourong are talking about should be rolled out with young people. Hiv infection, we are seeing the infections are going up specifically among latino and youth. Coming up for your solutions is important. All of these hillside, the one that i would want to highlight mostly, we can help young people recognize that they are at risk. Im sure you know what a challenge that is. Rather than the south, communities where theres a lot of other social stigma associated with withered we would also provide them with medication. It is now fda approved. I believe it is 71 pounds or less, theres not a limit. One of the other challenge is going to developed by this. That doesnt out them. A lot of folks are their parents Insurance Plan until edge of 26. Wait want to ensure that they have access to that that went out that inadvertent disclosure happening. A lot of local jurisdictions artwork and ways of doing that. We look forward to hearing about more of that. W one of the issues and what i said about the first slides come about implementation science. Its doing things right and what is clear is that men who have with men and transient gender women i that may not be the same as africanamericans and whites. Adolescents are clearly at risk population and is very different than the others. This one of the nuts we have to crack and to understand how to best implement in the adolescent population. Some very good question. Hi and thank you for your your presentation. I come from state department of health background. I hope new jersey right there epidemic plan. We came up time and time again, is hiv criminalization in the ndUnited States. Currently criminalized transmission of hiv knowingly and this is stigmatizing and prevents people from getting tested. Im wondering is there any plans in the federal epidemic plan to address hiv novelization. Dr. Anthony fauci first of all let me see in a church on would see the same thing, i am completely against any criminalization of hiv at all. Thats number one. Number two, this is the federal plan and the criminalization is always at the local loophole who i dont say you are going to be able to see something that comes from the federal government about the decriminalization because it will though many of us in the field, clearly are very much is that. Because that is really part of the statement. Im a student here at hopkins. I have a few questions the first one talking about your thoughts on medical miss trust. Working here at hopkins, we have participants we asked them in the comments are, the direct mistrust about what is it. This prolonged treatment of it. Have a huge question about that. And secondly it comes to the treatment pillar of this whole initiative, what are your thoughts about how to better have collaboration between people in different sectors. A lot of the times which are about people who have these other competing priorities with Mental Health or housing or anything like that. That kind of takes initiatives that are outside of this hiv specific initiative really hit at this Epidemic Initiative. Who those two questions. Dr. Anthony fauci you really raised it an important issue. There is medical mistrust. We cant deny that. It is a real barrier to many of the things we want to do in particular critical for your us in this initiative. Ly not just here in baltimore for your a work in atlanta, it comes up all of the time. How do you address this. I dont have an easy solution but i will tell you some of the things i have seen network, having a key opinion leader in a jurisdiction, and the town. Likely at some people in atlanta and go out pretty or two pair and explain that they are doing this and taking and it is working. You should say about it is it too. Part of the selftest idea, you are able to distribute it to others, they were their own investors. Same thing when people take prep. We are going to try to model applique. The question of treatment, more and more collaboration across federal agencies, i dont say weve ever worked who closely and i spoke to hirsch as often as i do almost every day now. About making all of these years start to grind together in a way to achieve we are putting out. We have systems right now that are operating separately but we are trying to work in going to be part of the evident plans to have folks do this. Political leadership makes a huge difference. He can get political leaders in your jurisdiction to come on board and see this is important to us. That brings people to the table. And oil those years to get them moving in the right direction. One more thing we see this in a lot of different sectors, the importance of integrating hiv prevention and treatment and care into other aspects of individuals lives because you might often hear you want me to take prep, i have a lot of other things im worried about. I am homeless, injection drug user and im probably going get shot in the next month. Santa have an integrated approach. Not just hiv in isolation. You see that very often and we gotta make sure that we look at every other aspect of a person news life. Before we focus is it too much on the vacuum on hiv. Thank you for your a great talk. Could both of you, indonesia is absolutely huge goal but some of the things we see now with prep use is now an uptick and other stds. I was wondering, is our plan built into this or plans were already have to also treat the other stds that we are staying has brought taken. Because of prep. Absolutely. Dr. Anthony fauci are fun, i cant speak yet to what the announcements going to look like but we have a large investment nationwide, we want to see prep brought out to the clinics we say its a terrific to befor your us accessing those people who are at highest risk. This part of our guidelines is routine std screenings. The beauty of that is once you have this group of people who have a risk you begin screening them regularly and you can begin to reduce that prevalence. I am not sure the final cap is been written on thisci with some of the studies the early increases in stds and prep clinics may bid than just people who would not been tested for your it. But those who have been routinely testing every three or four months, they seem plant whose art rates going down. I say is going too go down. Ultimately prep is going to lead to a decrease in other stds. Because of prep is implemented correctly when he come and get tested and treated, it may not be in the first few months but at the end of the curve, say its going to start coming out. I say it it is. I agree with you. Prep is driving the rates up and people who need prep, who are ready or engaging in this behavior, who if anything is your pointing outcome is going to bring it down. I would add that we also know that there are important stds, syphilis, epidemic in a way. People leaving with hiv. Not just a prep issue. We really have to address people leaving with these other things. Given the question. Hi. The department of epidemiology. Who the goalde is been set. Clearly defined, we love that in Public Health. What will be when the lag will be. Dr. Anthony fauci dishman hs group of people working on a set of indicators how is it going to be and what the data sources going to be. Some of them, main indicators, big indicators is hiv. But there is a very long like there. We may not know for your several years to come but we have other other indicators that we can continue produce to help people sort of redirect the direction or ship is going to. It takes time and linkage to care. Those are being drone mostly from federal data systems but we are using particularly our surveillance system. A part of the funding will encourage the system to improve and with no repetitive have good results. There will be a dashboard, that posts for the nations as a whole who where we are but each of the indicators. An individual jurisdictions will be able to get their own numbers. Suns have a caveat everybody. If we are successful, youll start to to see an increase in hiv diagnoses, before you see a decrease incident issue. Because if we are doing it correctly, we will be testing more people who are already t fected in the diagnoses will go up. We are concerned about that because we know the general public is going see, thats his plan of years, if we are doing it right, it will go up in the incidence will go down. Who please help communicate to people why that epidemiology profile will happen that way. I want to thank you for the epidemiologic [laughter]. Has brought new. Im at hopkins. To that end, in termsms of thers a problem now but we cannot get centralized samples of all of the new diagnostic diagnosed individuals to be able to test for your biomarkers of recent infection. Is there anything since this is now a governmentwide initiative, to either take all of the new well have samples from newly diagnosed people and sent in for your sequencing to have the been tested for your other biomarkers for your anything to collect that to be able to give the cdc the ability to better estimate the numbers of new infections or incident infections in the u. S. I dont know how much i can see about that in detail because being worked on now its in development. A population of an individual loophole to assess what we are. It is been a lot of interest of these incidents. We are working on that now. Theyre often tough barriers when working with Public Health. Having to move specimens around from those people who did not consent to that kind of testing. And what we had to do with that has no clinical utility. But we are looking into it and this is an opportunity to look at it again. I can call you all over again and have you do this. [laughter] i say were coming to the end. Thank you both for your your Incredible Service in this initiative. When asked the question about the fact that there is hiv in immigrant t communities but it y be very scared tomu see medical services in part because it may Enter Administration proposal keep them from ever becoming citizens or in part just because of the fear of enforcement. Hows that factored into your thinking when when your maps overlap in areas with a lot of immigrants. Dr. Anthony fauci and is very tough to give an answered to that. Obviously this is the Public Health official as you are, we would like to see no one be denied any access or implementation of healthcare based on their immigration scotus. To me that is a Public Health mandate that should be, unfortunately its not being noimplemented. Thats the way i strongly feel but im not privy to change that but i will see that we treat everybody who comes in. We treat everybody who calls in. We dont care who you are. You are part of the public. We need to take care of you. Who whatever can be done, to reduce the barriers as people coming in. It was an interesting project in houston where this is the big issue, they were large crossborder community. They engaged from folks who are themselves, undocumented. It is to go out into the community and begin to try to explain to the folks that as currently it stands to bring them into care. That sort of peer navigator model. It is a perfect solution but there hopefully some ways to be gain to gain trust to at least get people into care. Hello, thank you for the presentation. My name is melanie reese. Im a 20 year fiber with hiv. On the executive director of older women embracing life. When this plan first was put out, there were five pillars. Workforce development went away. Because the thought process i guess is Workforce Development and each one of those other four pillars is going to happen. Is there going to be funding that is going to allow that Workforce Development. Dr. Anthony fauci you are actually right and by the way, its good to see you again. I, this is been a topic of a lot of conversation. The reason went away as you pointed out, we realized this is really a cross pillar permeating issue. And by isolating it we were afraid that we would make people feel like it was something separate from all of the things we are trying to do that being said, we hear from the field all the time our biggest need is more people to do the work that is necessary. And as terry pointed out to be great to people who dont just focus on hiv they can do a lot of other services and is better for the Public Health. It is better for them as well professionally. We have funds from the unit hiv epidemic, they can be used as our president cdc, for your bringing workforce aboard. How that is going to be negotiated at the local loophole really depends on what you can help contribute to the people driving your plan. To get them to do what you say is need it in your community. They are waiting to hear from you about what the best thing to do is. And how to reach people most efficiently. Were looking at a number of different ways trying to hand that not just for the Public Health workforce that were worried about. The other side is the clinical workforce. For your a lot of people who treat hiv are aging out and with hiring. We need to find ways to people getting older. We need too find ways of bringig into the workforce, new folks who are interested in this but also can be engaged in taking care of people the rest of their lives leaving with this infection. I will our last comment. Those of us who are longterm survivors, we are aging. There is really nothing in place because we are the first cohorts of those driving with hiv there aging. Who do mine if i mention your name. [laughter] in the baltimore ci city. We have a coalition, or hiv and longterm care. It aging. We are trying to tackle how theyre going to be treated in rehabilitation and nursing homes, assisted leaving, because we do want to see what happened in the beginning of the treatment. No one seen happen for your those of us who are aging. Okay. We need funds to support a coalition. [laughter] [applause]. Dr. Anthony fauci i really admire the attitude he want to make sure that other people dont ever have to go through what you have had to go through. Youve a lot to teach. In the workforce and how to help manage folks who theyea dont fe the same kind of barriers who thank you. I guess i would just add that when we talk about getting the epidemic in ending the epidemic, but we also mean a course is that everybody in this country leaving with hiv now is would live long lives. Who the issue that you raised, about aging and longterm survival, is the reality irregardless of how well we do. I say we all know that this of course a very important part of our work as well. We have a very active work as you know. Who with that im afraid we have come to the end what is really been a wonderful conversation, to wonderful presentation. We really want to thank you who much for your coming and thanks again for your hosting us. On a thank the directory and a team thats helped who muchho up in the deans office is the part. Please everyone join me in thanking them. [applause] [background sounds]sumer duringe weak we are showcasing book tv programs normally available we can zero cspan2. Tonight and 87, books on u. S. Intelligence, response discusses live undercover comingofage in the cia. Followed by philip mudd, on cia Detention Centers used to interrogate prospective terrorists after 911. Stephen kenner on his book on coupling, the head of cia news mk ultra mind control program. Book tv tonight on cspan two. Select the next generation of Internet Technology is starting to come online in some of the u. S. Cities. Nancy talked about to try to Teach Technology and why its important. Panel discussion on the security challenges associated with it. [background sounds] good afternoon everybody. Everybody who was looking at us fruitfully and in line in the security line to going to get in, and everybody who will be watching us sometime soon on a cable network. I am jane harman, president and ceo of the boston center. Today we are prepping a very complicated issue that is, you might be doubling of policymakers, in washington and all over the world. At least three parts of that problem are, the u. S. , china, and the five g supply chain. The Wilson Center has just produced, leaving my prop. This is the prop. A spectacular policy brief by Melissa Griffith who is in the front right here. You will see her ill obit. Which is entitled, there is more to worry about than what way. I say you get the gist of this. She will explain in detail but run, dont walk. During this to get this and read it. Meanwhile, what captures the attention around 5g is the china based weight has led the way in developing the superfast networks which will power some carving car Virtual Reality and other cuttingedge Technology Since Chinese Companies are required by law to comply with information requests from Chinese Intelligence Services u. S. Officials are properly concerned that companies who want to incorporate this Chinese Technology will end up compromising the data in the data of the users. Otherwise it could be complicated for your mice
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