Let me welcome you to the school of Public Health, im Alan Mckenzie i am privileged to be the dean of the school. Thank you for joining us today. Today for what will be a compelling conversation. One that will provide great hope that we can make a difference in the fight against aids. But also it will remind us there is still much, much to be done. Importantly, we will need to double down on our efforts if we need to set out in the bold tenure federal initiative championed by the nh and cdc and by our special guest doctor Anthony Fauci and doctor john brooks. Here at the Bloomberg School of Public Health we have talked about the power of Public Health health, the power that comes from doing the fundamental research and translating the research into programs and policies that make a difference. The power that comes from strong partnerships across disciplines, public and private sectors and across community. In the power that comes from advocating solutions of the state, local and national levels. The fight against hivaids exemplifies how sustained commitment to these powers can make a true difference. Todays conversation will be facilitated by our own chris buyer, the professor of Public Health and human rights. Doctor breyer in my humble opinion is a true publichealth hero. A researcher and practitioner who is committed to solutions to some of the worlds most challenging Public Health problems. He is a longtime hivaids researcher with extensive experience with Collaborative Research and Training Programs and hivaids with key populations. He is also wellknown for his overriding commitment to securing health and human rights for all. As director of the john hopkins, the program, doctor breyer provided fellowships for 1400 International Scholars in hiv aids Prevention Research and treatment. Chris is one of the bloombergs most remarkable graduates in his success in research and practice with the continuing ongoing commitment from the policy leaders at the cdc and nih make for a powerful combination and have helped bring us to where we are today and on the cusp of ending hiv epidemic in america and across the world. Todays event is cosponsored by the center for aids research and it is a collaboration across the three john hopkin schools in the schools of Public Health, medicine and nursing. With support from university for the office of provost. Founded seven years ago it is committed to ending the epidemic through the promotion of Disciplinary Research and importantly by training the next generation of hivaids research here in the u. S. And abroad. The return on investment is quite clear, one example, hiv funding for junior investigators has risen from 7 of nih funds to 25 of all nih Research Funding now. This has created a larger welltrained and powered hiv experts who in the past decade have accelerated the work to get us nearer to the Necessary Solutions for this epidemic and getting us to the goal were striving towards. While hiv impacts the health of populations worldwide i am particularly pleased that it is been on the forefront of supporting hiv research and programs here in our own city of baltimore. The Bloomberg School faculty is making a difference in participating in so many of the hiv epidemic by collaborating with leaders and state policy makers. This is a remarkable example of us working together for policy solutions that work across all levels of government to save lives millions at a time. I would like to close by offering a special thanks to our director dick chasen of the school of medicine and again, to chris buyer the associate director. Thank you both for all you have done and you continue to do and thank you to all of you for being here, your determination and commitment to hiv is so critically important because of your work our dreams to end hiv is now on the horizon and we hope coming true by 2030. With that i will turn the program over to doctor chris breyer who will introduce todays guest. applause thank you so much ellen and on behalf of chase and i want to thank you for your support. It has made a difference. So we are delighted on behalf and to welcome all of you to the special session and with our special guest doctor Anthony Fauci and john brooks the head of the hiv Prevention Program at the cdc and just before i introduce them i want to make a few comments about why we think its so important that Academic Research institutions like Johns Hopkins engage in the initiative and take on the roles that we think we comply in helping to finally achieve the end of hiv epidemic. I think before we do that we have to acknowledge two or three fundamental truths that you will hear about from our speakers today and theyre very essential to thinking about the tasks ahead in the first of those we have to acknowledge the hiv epidemic and the new infections in the u. S. Has been stubbornly persistent, we had declined over a number of years and basically been in a plateau with around 38000 or so infections for a number of years. So the first enormous goal that has been top of the initiative is 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 in primary prevention of hiv infection and delivering new science and technology that you will hear from our guests that could achieve reductions in new infections but we will have to engage the folks who are at risk for hiv acquisition if we will achieve those goals. The second challenge hiv has always been marked by Health Disparities but as we have done better as a country and over the last decade the Health Disparities are getting all the more stark. Hiv is now very much geographically concentrated in the south and southeast and basically it goes from baltimore down to texas and across the south and southeast. There is a geographic disparity. There is a concentration in africanamericans and native americans and that is particularly stark for africanamerican women and for africanamerican and latino men who have sex with men. We have a concentration with race and ethnicity in a concentration of vulnerable groups and people at risk. We also have to deal with the emerging and quite different demography of the Opioid Epidemic and its impact on what we see with new clusters and quite a different map with the south and the midwest. Finally the third area that i think we have been surprised about after 30 years of effort and the tremendous advances in treatment and prevention is that hiv remains a stigmatized condition and the people who are living with the virus or at risk are in a very highly stigmatized groups and there is intersectional sigma stigma which relates to ethnic minorities in sexual gender minorities to substance users and of course also the stigma around hiv infection itself in persistence about that stigma remains very important barrier to achieving the goals that we want to achieve. So we have to do is stigma and Health Disparities and reducing new infections and that means both getting the new Prevention Technology to people and getting the american living with this virus successfully linked to care and finally suppressed. The exciting thing and you hear a lot about this from her guest is that we do have the scientific and technical capacity to do this and now the question will we be able to achieve that as a Public Health effort as a country. I think particularly for the young folks in the audience and younger investigators this is really going to be for the next decade or two decades the enormous implementation science and technical challenge for your careers and i think its enormously exciting. You will hear it does not mean the end of aids research. There is a long way to go to achieving these goals. Let me turn to a delightful honor who is to introduce our first guest doctor Anthony Fauci, the National Institute of Infectious Diseases and he is one of the architects of ending hiv initiative and this is often called as some of you wouldve heard, that is not surprising because dr. Fauci he is also one of the architectural. Which of course has been a world changing Global Health intervention and the largest commitment to disease by a government in human history. And really something that is enormously important. Doctor fauci, always say that he needs no introduction but i think Everybody Needs an introduction. To let me go on for a moment and say he is one of the most sided scientist in any field and a recipient of the president ial medal of freedom which is the highest honor that the president can give and hes playing an extraordinary role in maintaining over decades the research and funding support for the hivaids epidemic. And for that, all of us as investigators are deeply in his debt, but more importantly everybody allied with hiv it took a hundred Clinical Trials to reach therapy to be effective as it is not proved without the sustained decadelong support of the nih in funding that research we would not be where hiv is a manageable chronic condition in an extraordinary and saved millions of lives. I will add one more thing that some of you may know im a past president of the International Aid society and when you take on that task you have to give an award. It is called the is president s award and when that fell to me too make that decision i had a short list of one person. I would like to thank you dr fauci for accepting and coming all the way to south africa to accept the award is a great honor giving it to you and without further ado, dr fauci. applause thank you very much chris, for the very kind introduction. Its a real pleasure to be with you this afternoon to talk about the subject at hand in ending hiv pandemic and all talk about it from the standpoint of science to implementation. This is a paper that we put together and were describing right after we submitted it before the president made the announcement on february 5 but it came online the next morning and it was the print version describing the plan which was a 75 reduction in new infections in five years and 90 reduction in ten years to diagnose and prevent and respond to outbreaks. You will hear a little bit more about that from doctor brooks in a moment. What i would like to do is talk more and flush out what i refer to as the hiv vulnerability profile. Why did we feel that we could actually end the epidemic given what we have. It starts off with the population that we have as a vulnerable population. Both demographically and geographically. Lets look demographically, its very prevalent in baltimore, 13 of the population of the United States is africanamerican and of the new infections 43 are among africanamericans and 60 are among men who have with men and 75 are young men who have sex with men. So we have a concentration of a vulnerable population and we also have a geographic concentration and when john brooks and his colleagues at the cdc put together this map it was stunning, there was 3007 counties in the United States and if you look at 38 of the counties plus the district of columbia plus san juan, that account for more than 50 of all the inspections in the United States, that is extraordinary, 40 units out of 3007 units. They had 50 of the population. So we had this plan, a number of agencies involved and ill focus just for a few minutes on what the nih role. We were discussing the stocks a little while ago and we call the implementation science. The cdc and others will be responsible for going out and engaging in the community and whether they are doing that correctly which im sure they will but how you make it even better from yeartoyear will depend on implementation science. That will be done through the center for aids research which is right here in baltimore. If one looks at the map of the country and the red ribbons are for the aids research and the blue ribbons are the aids Research Center which is mostly Mental Health, you can see an important overlap with some exceptions like in texas which unfortunately does not have that but we will be dealing with that by extending other cfars there. We rose to the occasion of trying to get them for doing a good job in other aspects of hivaids, a critical part of what we do. But we needed to supplement them to do the extra mile of getting involved in the extraordinary effort to end the epidemic. So we did 65 supplements to 17 cfars. 36 of the 48 counties were involved with the cfars, we collaborated with Health Officials and we studied the optimum of delivery of evidencebased intervention. I just had the pleasure of listening to two hopkins people present Work Associated with the hopkins cfars and the baltimore collaborative project with joyce jones and the linkage and retention and repair upon release from the maryland state prison. If everything is done here is as good as what i saw this morning you guys are in really good shape. So, lets get on to the scientific basis. Beside the implementation, i think we should not forget how we got to where we are now, it really is a science that got us there. Mainly the scientific bases for even older ability to implement the program. Let me talk about that for a few minutes. We have hiv treatment and prevention toolkits that have accumulated as chris said, over decades of research with basic research and Clinical Trials including the drugs on the lefthand toolbox in the prevention on the right hand. Where has that brought us . I began taking care of hivinfected individuals in the fall and winter of 1981. Before it was called aids, before we knew what it was. At that time, the patients i admitted to my unit at the nih in a meeting in the expectancy of about a year which means 50 of your patients are dead and one year end following them about 95 were dead in two to three years. If you look back today and if patients come in to the same clinic which i should have been having rounds today but im here with you in baltimore. But if a patient came in who is reasonably newly infected and i put them on a combination, 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. What are the returns of that, in the 20 years from 1995 to 2015, over 10 Million Deaths with almost 8 million infections were inverted and we save 1. 05 trillion dollars. For every dollar spent, 3. 5 in benefits were realized. What about deaths, of 55 reduction in death from 2005 to 2018. We had Game Changing scientific advances. The one that is linked them is the concept of simple as it may seem but we did not realize it is treatment equals prevention. In two ways, treatment has prevention, the iconic hpp and 052 trial which showed different couples if you saw therapy early in individual who is infected as opposed to waiting to the guidelines triggered at the time and guidelines did not say everyone should be treated, you decreased by more than 95 and the likely it you 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 it was a strong suggestion that if you were below the level that you would not transmit, very few people believe that so we had to prove it. We did three studies, two opposites attract into our amazement and very positive amazement out of more than 150,000. Sex acts not one single linked transmission which allowed us to say about scientific basis that we were hesitant to say before that actually treatment does equal prevention and undetectable does mean an transmittable, a very important concept. The next was prophylaxis. One pill containing two drugs if taken optimally and consistently was more than 99 effective in preventing sexual transmission and acquisition of hiv. If you put those two things together, treatment is prevention and take a deep breath and think about that for a minute, theoretically if you put everybody on treatment, almost everyone and put all at risk people on prep, theoretically, you could in the epidemic tomorrow. But we dont live in a theoretical world we live in a realworld in the way that you make the bridge of the gap is by implementation. Thats what it is about and thats what you guys will be doing. In order to do that, we have also got to optimize this toolkits in two ways. Maximal implementation, why do we need maximum implementation. Lets look globally not just the United States, 23 Million People are receiving antiretroviral therapy. Great news prechallenging news almost 15 Million People who should be on therapy are not on therapy. That has led to a very modest and even less the modest reduction in incidence globally and in fact, there has been less than 2 annual decrease of incidents since 2010. So as chris said, although were going down, we have plateaued a bit which is why we put the plan together. Retention in therapy is also challenging, if 100 is the day you go on therapy, 48 months later only 60 of people are still on therapy, you will not end the epidemic that way, utilization of the 2020 un target says that 3 Million People should be on prep, theres only about 380,000 people as of last month who were on prep. Can we overcome implementation gaps . Some groups have been successful and particularly in San Francisco with the rapid and treat all program in which they go into the community identify people, put them on therapy immediately and if at risk putting them on this immediately and followup very closely. Resulting in a dramatic decrease in a new diagnosis of San Francisco. You will probably hear from john brooks in a bit, that new york is doing the same thing, the governor decided if San Francisco can do it, new york and representative. In fact it has gone down. We in d. C. , in collaboration with the d. C. Program in the d. C. Department of health have tried to mimic what was being done in San Francisco and again, the new diagnosis has gone down dramatically in my city of washington, d. C. In addition to implementation you need to develop new and improved tools, why . We have to make treatment and prevention more userfriendly for people because as much and strange as it seems they dont optimally utilize that. Theres two ways to develop new and improved tools, the arena of treatment. How do you include treatment, there are a couple of ways. The goal is to trying get people off daily art, few ways to do that, you can eradicate the virus, i will not spend time talking about that, that is highly aspirational. Not impossible but i want to concentrate on ending the epidemic before i get too concerned about eradicating the virus. With all due respect at attempts to eradicate in the virus. What we can do to make things userfriendly is retroviral. Its amazing how people are much more to receive an injection every couple months rather than a pill every day. Its a most counterintuitive but its the truth. Theres no doubt about that. These are number of studies starting off with one and going to every other month of injectable. Another way to avoid daily retroviral therapy is neutralizing anybody. There are 200. The have been identified from being. We have used them in humans to replace any retroviral therapy. We did a study from my lab with the university of pennsylvania. With a single antibody give it as a past as a significant delay in the rebound of virus. Michelle and others have done a combination of two antibodies. Where are we going with this, the ultimate goal or end game is about every six months for anybody to get a transfer and never have to take in antiretroviral drug. Youve come into the clinic once every six months with a long acting antibody and that your therapy. What about prevention, how will we prove prevention. We can improve preexposure pro collective, the fund same fundamental principle by long acting prep where we have two good studies, one is about 4500 men who have with men and trans gender women in multiple countries, the same principal testing as an injectable could be as good as or better, another study. So those of you who were there or in mexico city there was a presentation of an implant that gave levels of drugs for one year that would be predictive of being suppresses to. The others getting back to the antibodies as i mentioned there was neutralizing antibodies in their being used in a study both in africa and in the United States and south america as a preventive measure with a long acting one if you can actually prevent hiv by having somebody with an infusion of an antibody. Again in Southern Africa and south america, even the United States people would rather have an injection or an infusion then taking a pill every single day. Finally the issue of vaccine. Were talking about ending the epidemic and i think we could do before we get a vaccine. If we want a durable and to the epidemic i think will have a vaccine together with the things i have been speaking about. Very quickly there are two major pathways, the first was to test a number of vaccines. We did that without success for a number of years and then in 2009 we had a hit, the hit was a crime in a protein boost in the study 144 which give us 31 to c. This is very much a mimic the finally the issue of vaccine. Were talking about ending the epidemic and i think we could do before we get a vaccine. If we want a durable and to the epidemic i think will have a vaccine together with the things i have been speaking about. Very quickly there are two major pathways, the first was to test a number of vaccines. We did that without success for a number of years and then in 2009 we had a hit, the hit was a crime in a protein boost in the study 144 which as we speak today, were doing not in major trials in Southern Africa and in south america. The first is inaudible we launched it three years ago this month the day will likely come out is around 2021. This is a very much mimic against the protein boost then we took it a little further than a study that was started two years ago this month and that is the trial which is the different factor and that 26 vector what the prime in the protein boost. The third one that got started a couple of months ago is the most say go trial which at 26 vector with the mosaic boost. That is taking place in south america and the United States. Finally, the thing thats highly aspirational but a lot of elegancies going on, is assuming the assumption being that neutralizing antibody is what we need to induce is a problem. The body doesnt like to induce neutralizing antibodies. It makes a lot of them but only after him or herself has had the virus for two years or longer. The antibodies have done something for us and they have identified at least six or seven neutralizing epitaphs and the component that the antibody binds too. Now, the challenge is to take those at the taupes, put them in the form and try to induce a broadly neutralizing antibody. A lot of studies are going there right now. What about a vaccine . How good is good enough . I told you 31 is not good enough i dont think there is a chance of the world would ever get a 98 percent hiv vaccine like for mesial but i would settle 50 or 60 percent together with the nonprintable modalities and there was a model that shows the other 50 percent even if you did status quo and nothing else you could dramatically impact. s on my last slide is that we have an enormously to maximally utilize them and to implement them in with new treatment modalities and the Game Changing. And in baltimore in the United States and globally. applause and hes an extraordinary speaker. Please hold your questions. And by the way cspan is recording this. John brooks is a medical epidemiologist with the cdc and it is Epidemiology Service training there and other efforts and the response to Hurricane Katrina which was a huge Public Health challenge and humanitarian challenge. And the anthrax challenge. He has a medical degree from the other h, harvard we dont hold that against you. Now the cdc is one of the key federal agencies with the nih but then the cdc plays easy store nearly important roles as well. And then to be on the frontlines. And now john over to you. applause so i have to raise this up to make sure that you can hear me. To thank you for this and for the opportunity to speak today. Tony did this beautiful job to set up the science what we know will work. And thats where it lies. But i want to walk through with you with details around the planned action. With no affiliations to disclose into the Key Information with that hiv initiative and then to detail a couple of Innovative Solutions for the three pillars above diagnose and treat and prevent we been living with hiv too long over 700,000 americans have lost their lives since we first started to keep count in 1981. That is an enormous amount of money that we should be having to spend. But as pointed out before we have not seen a substantial decline of infections were a couple of years now and if we did nothing for the next ten years 400,000 will become infected with hiv. And then to reduce the impact of new infections and with this incident. But they also have significant threats out there to our success not the least of which is the resurgence of drug use ramping up across the country with those that we didnt consider previously and also complacency. But then somebody elses job and thats it we have to work on to make this work. And to end that hiv epidemic that the most powerful tools in history. What were the principals leading to the figures a 75 a 90 percent reduction and how will we do it . So first with the person that transmit the infection. So that they cannot pass it on to others the goal is less than 100,000 americans americans with the ongoing epidemic to be able to eradicate it. So over time is that people experience than they exceed new infections from that point forward. So there were four principal means for people who work in any form of infectious disease. To treat those effectively and preone approach those and then keep an eye if those hotspots occur to treat them and eradicate them. Some people say isnt 75 an ambitious goal for the first five years . But as you are aware the mayor kicked in some extra funding to the state annual budget with an auspicious goal to reduce new infections by 75 percent. In the next number 42018 with that trajectory. And this is a combination of whats possible and ambitious. And thats what they think about cdc with hiv. At the assistant secretary of health. And then television to the plan. So that one of the large ones that happened is to do it they are laying out for applications for cdc Hiv Aids Bureau versus primary care to be deeply engaged with people much more regularly. And then that arc grants. And three cities receive jumpstart funds of 5 million. But you can achieve some early success with infusion of capital and some other resources those cities is baltimore. You have heard the prep program and then to go online the first few weeks of december and those across the country this is open to anyone looking for prep for people that are uninsured and then the Planning Grant and then not to reinvent the wheel many places that are longstanding bodies for those treatment funds. And now those efforts are underway in many places and not an entirely new idea. And then to bring it together to refocus those plans to realign them with the four ideas we described. And with a particular emphasis and now getting the local community involved. People that have hivpositive to be part of these Planning Communities are not previously engaged we need to get the next generation on board to move this forward. I want to talk about diagnose, treat and prevent and those opportunities of innovative ideas and the challenges we are facing. So early diagnosis is vital. You cant get treatment unless you have the infection. And of those recently diagnosed seven out of ten in the year prior to their diagnosis past through the system if work offered hiv testing and thats a tremendous opportunity because first we have to get them diagnosed early for their own health but 20 percent of people today diagnosed with hiv present with an opportunistic infection are less than 200 please come down to brady hospital. Secondly, undetectable is an transmittable if they is submitted they have no wish to translate the infection thats another reason why its important to find people that dont know their infection because we estimate 80 percent of new infections of those who dont have the benefit. And those that want to do for a long time. Is a what i really want to push to automatically order Entry Systems that order a test for a person if they come in with no evidence of prior testing. Its difficult but it can be done and there are many examples of places that have done it successfully. Also with repeat testing strategies and for people that have to be screened on a regular basis. I also want to talk about expanding access to hiv testing asking people to come to us to get tested. Self testing and bring it to them. And tweaking those approaches for the different populations. And of a study of this monday from cdc looking what you can do for can do for testing. They divided people into two groups. 2600 roughly that were drafted to participate. They were given four self test. So four times over the 12 month period at each point that they could replenish those test kits. And they could share those test packages of the network they got extra they were not told to share them but they got them if they wanted we said thats fine. Let me show you the results. So that you stamp so the data from all bottomline for those that were firsttime testers so look at a new diagnosis. For those with three or four times the next year. With a new diagnosis. And in the social network with the positivity rates that was almost backwards if you will for testing reaching that level we wanted to reach. Also we doubled the number of firsttime testers. 17 percent ever tested before. With half of the control. So theres that room at risk of people and they are beginning to do that more so that was a promising opportunity. So this complacency issue that it is an epidemic that has ended i dont have to worry about it that is somebody elses job we have to change that. We also have to really build up to implement screening. And for them to say this is the way to go but we would like to see more working with fda. So that treatment it is an okay job not a great job. And to see expanded rapid engagement of people who possibly disengaged and are using to identify people. But that tcell count takes a long time. Could we move this back. And for a group in detroit it is a means as identifying people earlier. Look at what they found with the standard of care are 92 people versus one person and it took 41 minutes per person standard of care versus 15. s is not intended to be a replacement but an adjunct and i want to note the big barriers with Mental Health long time. Could we move this back. And for a group in detroit looking at a refill means as identifying people earlier. Look at what they found with the standard of care are 92 people versus one person and find 195. It took 41 minutes per person in standard of care versus 15. It is not intended to be a replacement but an adjunct and to improve our capacity to find people. I want to note the big barriers with Mental Health Substance Abuse incarceration. And thats hard. So with prevention focusing on preexposure. 1. 1 million need prep and 20 are not getting it. Less than 20 percent america the large increases in with the nose ethnic disparities. And with those latinos we really need to work on this with those populations and engage primary care in prep and then to increase access the newest number of how to get touch with people straining capacity for primary care. And then the interfaith access. And to be discreet and teleprep they work these could work in the future, there convenient, discreet and highly susceptible and tell a prepwork beautifully in rural areas like louisiana and iowa where you have programs in place. I will talk about all these formulations but i want to bake here that they showed us or theres great formulations coming along and our great for treatment. There also made for prep. We look forward to the benefit of those working in prep as well. Persistent challenges and one of the biggest was identifying the prep in engaging them. How many times we had a doctors say, my patient is not that kind of person or the patient was caught recognizing that i need prevalent to help people understand, who is at risk and why are their risk and understand what Consumers Want and theres a lot of researchers not only just for this country. I want to talk about Syringe Service programs. Weve seen increase were concerned about injections in part because of the scott county outbreak. We created a figure showing concern about new infections that inject drugs over the past three years, we have seen clusters of these areas and a concern thats a real threat pushing back in the promise we made. Looking in the of the number of infections the drug use at least of the time of our surveillance document weve seen an overall increase. There are some worrying trends. If we give you some analysis and we go by age and location, were seeing some early upticks on young people and living in rural areas. Those are places that we know a lot of people that are necessarily perceiving themselves as being at risk for hiv infection. We need to involve ss p and being more a place and a comprehensive care i need to tell people about the Community Benefit and in terms of cost savings and delivering. I will skip this real quickly to point out that scott county, this is worked in integrating a Syringe Service program to mit, we were able to drive down hiv infections and we are a number of people receiving a daily number stitt of people getting syringe is and we didnt get to a number of them to take away and leave gotten more and more engaged into the kitchen care and the blue lines going up. We have to tell the public why Syringe Service is good for them. Theyre a lot of reasons but this is an opportunity for the anthropologist and social scientists in the room to do some research to show that these things dont increase crime. They dont put Public Safety at risk and they are to these are too costly with no real benefit and that is simply not true. This is some folks that has published earlier this week as well. And looking at what they cost benefit and in baltimore and in fig philadelphia and they estimated that in philadelphia and 240 Million Dollars and that could be used to really good purposes and thats the kind of work we need, money speaks to power and if you could show people i dont mean to sound mercenary but if you could show people the benefit to their wallet to what you want them to do, we have another bending machine and las vegas now has Syringe Service vending machines and they do. That is a great thing to explore. Challenges are always going to be community and Political Legal barriers and we also many of our services are talking earlier about the fact that doctors dont know a whole lot necessarily about the mit but they need to and on the addiction side they dont tester patients routinely and they dont know who to refer for seekers in those gaps. My last words i want to remind folks and there are challenges and risk bite ending the epidemic in america and working together and doctor bob we will feel destructively destructively innovative because thats never going to need and thank you very much. applause thank you so much. That was just marvelous. Now we have some time for some questions for our speakers we will have mobile microphones but somebodys ready at the microphone to go ahead. Thank you for that amazing presentation. I want to talk about adolescence with that four pronged approach should be rolled out with young people they are an extraordinarily High Risk Group specifically among the latino. And all of these apply to youth. But the one that i would highlight mostly is we have to help young people recognize they are at risk and you know what a challenge that is dealing with the minority community. With that social stigma. For persons 35 kilograms or less. It is not an age limit. But the challenge is to provide this in a way that does not out them. A lot of people are on their parents are on their insurance parents plan and a lot of local jurisdictions are working on ways to work on that. An interesting issue with the implementation science to do things right. What is clear that what works for men having sex with men, not be the same for transgender women. Because adolescence that is distant from the other. And at the best to implement. Thank you for your presentation i have a state Department Health background and help new jersey in their plan. We came up time and time again looking at our plan and other states is criminalization with hiv. And then you transition that unknowingly and that it prevents people from getting tested. Is there a plan to address hiv criminalization that . First of all let me say im sure john will say the same thing i am completely against any criminalization of hiv at all. Number one. Number two this is a federal plan criminalization is at the local level they think to see criminalization because its all local even though we are clearly very much against that because that is part of the stigma. I have two questions with prep. And with the medical mistrust surrounding prep and then to have participants and with that prolonged treatment and second when it comes to the treatment pillar with this whole initiative what are your thoughts to have better collaborate on collaborations these other competing priorities of Mental Health. And with those initiatives that are outside hitting these initiatives. So you raise an important issue that there is medical mistrust it is a real barrier to what we want to do especially with this initiative. How do you address this stigma . To have a key opinion leader in the town and if we had people in atlanta, they are taking it and its working. But then to go out. Two peer to explain and with this self test idea. And with regard to that question is more and more collaboration and speaking with the cfars almost as i do every day as they all start to achieve with the systems that are operating separately. If you can get political leaders to come up and say this is important for us but this would get them moving in the right direction. And with the importance of integrating with those individuals lives. That i have home list and ill probably get shot sometime in the next month and then to have that integrated approach. And every other aspect of a persons life and to have that huge goal and also an uptick of other stds. But what about that uptick . Absolutely. We have a large prevention of std we want to see prep brought out and this is a terrific venue to the highest risk. But it is routine std screening and once you have a group of people at risk and you treat them frequently then to reduce incidence. I dont know the final chapter has been written on this but the early studies and to have routine testing. I do think it will go down. I think prep will lead to a decrease of other stds. And then to get tested. It may not be the first few months to a year because prep drives the rates at prickle people that need prep already engage in the behavior of putting them at risk of std. There are important stds like syphilis epidemic on the way not just the prep issue we have to address those. From the department of epidemiology. So the goal is set so when is the lag when the goal is met and when we know . What data systems are using and what those indicators will be. The main indicators is the hiv incidents. And those that produce to redirect that direction some is the prep uptake. So we are using the surveillance systems. So ultimately to be a dashboard that pose for the nation as a whole and individual jurisdictions. So if we are successful you will start to see an increase of hiv diagnosis before you see a decrease in incidents because if we are doing it correctly because those that are already infected. But if we are doing it right it will go up and incidents will go down. So please help to communicate we expect that evidently me dash epidemiologic profile. I have heard that in new york and San Francisco. It is not new. To that end, we cannot get centralized samples of all new diagnosis recent infection to take all new blood samples from newly diagnosed people with those biomarkers or anything to get the cdc the ability to better estimate the new infections in the us. What to say about that in detail there is some stuff being worked on right now. To assess where we are and now we are working on that now. And we have some tough barriers working with Public Health from those who did not consent to that type of testing and now has a clinical utility. We can look at it again we could clone you all of our have you go here. laughs thank you for your incredible service. I will ask the question about the fact that there is hiv in communities that may be scared to Seek Medical Services to ever see them becoming citizens so how is that factored into your thinking when the maps overlap with areas of alot if immigrants . Its tough to give an answer to that we would like to see no one be denied access based on their immigration status thats a Public Health mandate that should be not be implemented. But its not within our purview to change that. But our philosophy is retreat everybody we dont care who you are you are part of the public. We need to take care of you. And that community. And to go out into the community and explain to folks that it is currently stands or is no threat. And appear navigator model. And there are some ways they can begin trust. Hello, thank you for the presentations. Im a 20 year survivor with hiv in the executive director of older women embracing life. When this plan first was put out we had 5 pillars. Workforce development went away because the other 4 pillars will happen. Will there be funding that will allow for that Workforce Development and this is a topic of a lot of conversations. And by isolating it and we hear from the field all the time and to do the work that is necessary. And that it turns out better from them as well. And then to be used to bring the workforce on board and what you helped to contribute to those to get them to do what you think is needed what the best thing to do is. And looking at a number of different ways and the other side was a clinical work. And they are aging out and to bring into the workforce you folks who are not only interested in this but can be engaged to take care of People Living with this infection. Those that had a longterm survivor and we are the first cohort that are laughs aging and doris baker do you mind if i mention your name . The Baltimore City and coalition and hiv aids care where we try to tackle how we will be treated in rehabilitation, nursing home, assisted living, because we dont want to see what happened in the beginning of the treatment happen for those of us that are aging. So we need funds to support our coalition. applause i really admire the attitude you want to make sure nobody else has to go through what you have to go through and you have a lot to teach. With those barriers that you faced so thank you. And when you get control of the epidemic and that everybody living with hiv now will have long lives so the issue that you raise about aging and longterm survival is a reality regardless of how well we do ending this initiative and we all know that. We have a very active group in aging. So with that we have come to the end of what has been a wonderful conversation we really want to thank the doctors for coming and the dean for hosting this and the director and the team who helped so much and please everyone join me to thank them. applause
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