>> GOOD MORNING, EVERYBODY. GOOD MORNING. I'M MARTHA SUMMERMAN. I'M THE DIRECTOR OF THE NATIONAL INSTITUTE OF DENTAL AND CRANIOFACIAL RESEARCH. ON BEHALF OF DR. ROGERS, ROGER GLASS, THE DIRECTOR OF THE FOGARTY INTERNATIONAL CENTER AND BOTH OF OUR ORGANIZATIONS IT IS MY GREAT PLEASURE TO WELCOME YOU TO THE 11th ANNUAL DAVID E. BARMES GLOBAL HEALTH LECTURE AND TO WELCOME EVERYONE WHO MAY BE ATTENDING VIA THE WEBCAST. WE ARE TRULY HONORED TO HAVE WITH US AMBASSADOR ERIC GOOSBY, THE U.S. GLOBAL AIDS COORDINATOR AND OUR GUEST SPEAKER FOR TODAY. DR. FRANCIS COLLINS WILL BE INTRODUCING HIM MOMENTARILY BUT FIRST I WOULD LIKE TO JUST DESCRIBE A LITTLE BIT THIS EVENT AND WHY IT'S SO SPECIAL FOR ALL OF US. THE ANNUAL BONDS LECTURE HONORS THE LATE DAVID BONDS, PUBLIC HEALTH DENTIST, CLINICIAN, AND EPIDEMIOLOGIST WHOSE LONG CAREER ADVANCED THE UNDERSTANDING OF ORAL HEALTH, HEALTH PROMOTION AND NON-COMMUNICABLE CHRONIC DISEASES. WITH HIS EXTENSIVE KNOWLEDGE HE SERVED AS A CONSULTANT IN MORE THAN 100 COUNTRIES AROUND THE GLOBE. DR. BARNES CAME TO NIH IN 1997 AFTER HIS TENURE AT THE WHO AND WAS A MEMBER OF THE NIH COMMUNITY FOR FOUR YEARS BEFORE HIS DEATH IN 2001. AS A SPECIAL EXPERT FOR INTERNATIONAL HEALTH AT THE NIDCR, DR. BARNES HELPED TO SHAPE THE GLOBAL MISSION OF OUR INSTITUTE. THIS LECTURE SERIES WAS ESTABLISHED IN 2001 TO PAY TRIBUTE TO HIS INSPIRATIONAL DEDICATION TO RESEARCH AIMED AT IMPROVING HEALTH FOR PEOPLE IN LOW-INCOME COUNTRIES. HIS WORD RAISED AWARENESS THAT GLOBAL HEALTH ISSUES ARE NOT UNFORTUNATE EVENTS THAT HAPPEN TO PEOPLE IN OTHER COUNTRIES AND FAR AWAY LANDS. GLOBAL HEALTH ISSUES ARE ALSO NATIONAL, REGIONAL AND LOCAL ISSUES. PLEASE JOIN ME NOW IN WELCOMING TO THE PODIUM THE NIH DIRECTOR, DR. FRANCIS COLLINS, WHO WILL INTRODUCE OUR ESTEEMED GUEST. [APPLAUSE] >> THANK YOU, MARTHA. IT IS A REAL PRIVILEGE TO BE ABLE TO INTRODUCE THIS YEAR'S BARNES LECTURE DELIVERER. MY FRIEND, AMBASSADOR ERIC GOOSBY. ERIC BEGAN HIS MEDICAL CAREER IN HIS HOMETOWN OF SAN FRANCISCO IN THE EARLY 1980s AFTER COMPLETING MEDICAL SCHOOL RESIDENCY TRAINING AND A FELLOWSHIP SPECIALIZING IN INFECTIOUS DISEASES AT UCSF. IN HIS PRACTICE AT SAN FRANCISCO GENERAL HOSPITAL HE WAS ONE OF THE FIRST PHYSICIANS TO TREAT PATIENTS WITH AIDS. AND HE HELPED INTEGRATE HIV TREATMENT PROGRAMS WITH METHADONE CLINICS WHICH ENROLL INCREASING NUMBERS OF PATIENTS INFECTED WITH HIV TO IV DRUG USE. ERIC MOVED TO WASHINGTON 20 YEARS AGO TO TAKE UP THE POSITION OF DIRECTOR OF HIV SERVICES AT THE HEALTH RESOURCES AND SERVICES ADMINISTRATION AND AT HRSA HE BECAME FIRST DIRECTOR OF THE NEWLY-FORMED RYAN WHITE HIV AIDS PROGRAM, A PROGRAM TO THIS DAY PROVIDES SERVICES TO INDIVIDUALS AND FAMILIES THROUGHOUT THE U.S. AND ITS TERRITORIES WHO ARE AFFECTED BY HIV AIDS BUT OTHERWISE LACK RESOURCES TO OBTAIN PROPER CARE. IN 1994, ERIC WAS NAMED DIRECTOR OF THE HHS OFFICE OF HIV AIDS POLICY, ADVISING CONGRESS ON THE FEDERAL HIV AIDS BUDGET AND OTHER MATTERS. THERE HE CREATED WHAT IS CALLED THE PANEL ON ANTIRETROVIRAL GUIDELINES FOR ADULTS AND ADOLESCENTS. THAT PANEL BY THE WAY IS NOW CE CHAIRED BY CLIFF LANE. SO 1997, ERIC ALSO DIRECTED THE CLINTON WHITE HOUSE NATIONAL AIDS POLICY OFFICE AND HELPED LAUNCH AND RENT A PROJECT THAT BECAME THE MINORITY AIDS PROJECT AIMED AT ADDRESSING RACIAL DISPARITIES IN HIV AIDS.p( IN 2001 ERIC LEFT GOVERNMENT SERVICE, RETURNED TO SAN FRANCISCO TO BECOME CEO OF THE NEWLY-CREATED PANGIA GLOBAL AIDS FOUNDATION, HE DIRECTED THAT EARLY WORK FOCUSING ON BROADENING ACCESS TO ANTI-ANTIRETROVIRAL THERAPY. THE FIRST AMBITIOUS PROJECTS WERE IMPLEMENTED IN RWANDA, SOUTH AFRICA AND UGANDA AND BROADENED TO INCLUDE LARGE SCALE TREATMENT ACCESS PROJECTS IN ASIA AND EASTERN EUROPE. HE DIRECTED THAT FOUNDATION UNTIL 2009 HEN ERIC WAS TAPPED BY THE STATE DEPARTMENT TO BECOME U.S. AMBASSADOR AT LARGE AN GLOBAL AIDS COORDINATOR. NOW HE LEADS THE PRESIDENT'S EMERGENCY PLAN FOR AIDS RELIEF, PEPFAR, A PROGRAM HE OVERSEES MOST ABLY. IN 2010 NIH AND PEPFAR JOINED FORCES IN A PROGRAM CALLED THE MEDICAL EDUCATION PARTNERSHIP INITIATIVE. THAT'S HOW I GOT TO KNOW HIM BETTER BECAUSE WE TRAVELED TOGETHER TO SOUTH AFRICA TO OVERSEE THE INITIATION OF THIS ENTERPRISE AS WELL AS TO REVIEW A NUMBER OF OTHER RESEARCH EFFORTS GOING ON WITH NIH SUPPORT AND CLOSELY LINKED TO PEPFAR. IN THAT PART OF THE WORLD ARE AS YOU KNOW HIV AIDS AND TUBERCULOSIS CONTINUE TO BE ENORMOUS PROBLEMS. SO IN HIS ROLE NOW, THE AMBASSADOR SERVES AS A CRITICAL PLAYER ON THE WORLD STAGE IN THIS EFFORT TO TRY TO TURN THE TIDE OF THIS DREADFUL PANDEMIC WE KNOW AS HIV AIDS. HE DOES SO WITH VISION, WITH PASSION, WITH REMARKABLE LEADERSHIP SKILLS. SO PLEASE JOIN ME IN WELCOMING MY FRIEND, AMBASSADOR ERIC GOOSBY. [APPLAUSE] >> THANK YOU. THOSE ARE REALLY VERY KIND WORDS. IT'S AN HONOR TO TO BE HERE TODAY AND I THANK YOU FOR THE HONOR TO DELIVER THIS PRESTIGIOUS TALK IN MEMORY OF DR. DAVID BARNES. I WANT TO THANK THE NATIONAL INSTITUTE OF DENTAL AND CRANIOFACIAL RESEARCH IN THE FOGARTY INTERNATIONAL CENTER FOR THE INVITATION. OF COURSE I'M DEEPLY APPRECIATIVE TO DR. FRANCIS COLLINS FOR HIS LEADERSHIP AND FRIENDSHIP. I WOULD ALSO LIKE TO ACKNOWLEDGE GOOD FRIEND AND FELLOW LAIBORRER IN THE FIGHT, DR. ANTHONY FAUCI. DR. BARNES DEDEVOTED HIS LIFE TO IMPROVING PUBLIC HELP. AND INDEED TO FOCUS ON THE COMMON GOOD. FROM WHAT I HAVE READ ABOUT HIM, HIS PASSION, COMMIT LMENT AND TIRELESSNESS WERE SO CLEAR TO EVERYONE AROUND HIM. IN HIS CAREER AT WHO AND AT NIH, DR. BARNES STRADDLED TWO WORLDS. HE HAD ONE FOOT IN THE WORLD OF SCIENCE AND THE INVESTIGATION OF THE ROOT CAUSES OF ORAL DISEASE AND HEALTH. AND THE OTHER IN IMPLEMENTATION. AND QUESTIONS OF HOW TO MAKE AVAILABLE THE BENEFITS OF SCIENTIFIC ADVANCES SUCH AS FLOUR DAITION AVAILABLE TO ALL. HE EMPHASIZED THE NEED TO CATEGORIZE INFORMATION, IMPLEMENT COST-EFFECTIVENESS, INTERVENTION, MONITOR PROGRAM IMPLEMENTATION, INCLUDING REGULAR SURVEILLANCE OF PROGRESS. THESE TOOLS ENABLED THE WORLD TO SET GOALS FOR PUBLIC HEALTH INTERVENTIONS AND MEASURE PROGRESS TOWARD THEM. I MENTION THIS BECAUSE MANY OF THE CONCEPTS DR. BARNES HELPED TO DEVELOP REMAIN CENTRAL TO THE SUCCESS OF PUBLIC HEALTH PROGRAMS AND ESPECIALLY THE PROGRAM THAT I AM HONORED TO LEAD, THE PRESIDENT'S EMERGENCY PLAN FOR AIDS RELIEF, PEPFAR. PEPFAR IS AN INTERAGENCY, THE UNITED STATES GOVERNMENT PROGRAM, LED BY THE DEPARTMENT OF STATE AND COORDINATING THE EFFORTS OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES FAMILY OF AGENCIES. THE U.S. AGENCY FOR INTERNATIONAL DEVELOPMENT, THE DEPARTMENT OF DEFENSE, PEACE CORPS AND OTHERS. MY OFFICE'S ROLE IS TO LEAD THIS UNIFIED EFFORT ON GLOBAL AIDS IN RESPONDING TO THE LATEST SCIENCE, EPIDEMIC TRENDS, AND NEEDS OF THE PEOPLE WE SERVE. THROUGHOUT TODAY'S DISCUSSION IT'S IMPORTANT TO REMEMBER THAT PEPFAR WAS CREATED OUT OF THE GENEROSITY OF THE AMERICAN PEOPLE WITH THE LEADERSHIP OF PRESIDENT BUSH AND A BIPARTISAN CONGRESS. UNDER PRESIDENT OBAMA, IT IS EXPANDED AND CONTINUES TO BE AN ESSENTIAL EXPRESSION OF OUR COMPASSION FOR THOSE AT RISK OR LIVING WITH HIV AND IN AREAS OF THE WORLD LESS ABLE TO SUPPORT LIFE-SAVING SERVICES. CONGRESS AUTHORIZED PEPFAR IN 2003, REAUTHORIZED IT IN 2008 FOR FIVE MORE YEARS UNTIL 2013. IN ADDITION TO THE PUBLIC HEALTH IMPACT OF THIS PROGRAM, CONGRESS HAS RECOGNIZED THE HEALTH DISPLEA MACY BENEFIT OF THIS WORK. PEPFAR SHOWS THE WORLD THE HEART OF THE AMERICAN PEOPLE AND OUR DESIRE TO WORK WITH THEM IN PARTNERSHIP TO MEET HUMAN NEEDS. ACTIONS SPEAK LOUDER THAN WORDS AND PEPFAR IS AN EXAMPLE OF THIS TRUTH. SECRETARY CLINTON RIGHT HERE SPOKE TO THE IMPORTANCE OF DEVELOPMENT AS WELL AS DIPLOMACY AND DEFENSE. AS PART OF THIS DEVELOPMENT AGENDA WE'RE NOT ONLY SAVING LIVES TODAY BECAUSE IMPROVING PUBLIC HEALTH REQUIRES CREATING A LASTING DURABLE IMPROVEMENT IN THE CAPACITY OF OUR PARTNER COUNTRIES TO ADDRESS THEIR NEEDS. PROVIDING AID OF ANY TYPE BY ITSELF DOES NOT CREATE THAT CAPABILITY. A COUNTRY'S RECEIPT OF FOREIGN ASSISTANCE FRIENDS HAS NOT BEEN DEMONSTRATED BY ITSELF TO LEAD TO EXPANSION OF SERVICES TO ITS PEOPLE OR TO GROW ITS ECONOMY SO IT CAN BETTER MEET HUMAN NEEDS. IN SOME CASES IN FACT, EXTERNAL AID HAS SUPPLANTED FINANCIAL COMMITMENT ON THE PART OF THE COUNTRY ITSELF. AN UNACCEPTABLE OUTCOME. PART OF OUR CHALLENGE IS THUS TO ENSURE THAT WE MOVE SCIENCE INTO PROGRAMS. WE ARE ALSO SUPPORTING THE DEVELOPMENT OF CAPABLE LEADERSHIP, GOOD GOVERNANCE, PEACE AND STABILITY AND SENSIBLE ECONOMIC AND SOCIAL POLICIES. CLEARLY THAT INCREASES THE DEGREE OF DIFFICULTY OF WHAT WE'RE DOING, IT'S OFTEN MEANS NEW WAYS OF DOING BUSINESS, AND THAT KIND OF CHANGE IS RARELY EASY. AS WE EXPERIENCED IN PEPFAR, BUT WE WANT OUR IMPACT TO LAST. THERE REALLY ARE NO SHORT CUTS. AS I READ ABOUT DR. BARNES I FIND THAT PEPFAR HAS STRONG PARALLELS TO HIS CAREER. WE ARE UNIQUELY PRIVILEGED TO SIT AT THE INTERSECTION WHERE THE WORLDS OF SCIENCE AND IMPLEMENTATION COMBINE TO PRODUCE PUB HICK HEALTH IMPACT. -- PUBLIC HEALTH IMPACT. IN THIS WORK NIH IS A CRITICAL PARTNER. SO MANY EARLY BREAK THROUGHS AROUND THE PATHOPHYSIOLOGY AND TREATMENT OF OPPORTUNISTIC INFECTIONS AND HIV LEADING TO ADVANCES THAT CONTINUE TODAY FLOW FROM NIH'S SCIENTIFIC MANDATE. THESE ADVANCES HAVE BEEN FUNDAMENTAL TO THE STEPS PEPFAR MADE IN RAPIDLY EXPANDING THE HIV RESPONSE IN LOW INCOME COUNTRIES WITH HIGH BURDENS OF HIV DISEASE. THIS LINK BETWEEN KNOWLEDGE GENERATION AND RAPID DEPLOYMENT IN THE EPICENTER OF THE PANDEMIC MAKES FOR A POWERFUL COMBINATION. TODAY I WOULD LIKE TO TOUCH ON FIVE ASPECTS OF PEPFAR THAT EXEMPLIFY THIS INTERSECTION BETWEEN SCIENCE AND IMPLEMENTATION. I'LL START WITH HOW THE US GOVERNMENT HAS CONTRIBUTED TO THE SCIENCE OF SELECT INTERVENTIONS THAT ARE CRITICAL TO THE HIV RESPONSE AND HAS LED IMPLEMENTATION AND DEVELOPED AVENUES FOR EXPANDED IMPACT. USING THESE INTERVENTIONS AS EXAMPLES, I'LL ADDRESS HOW WE ARE BUILDING ON THIS SCIENTIFIC FOUNDATION TO WORK TOWARDS AN AIDS-FREE GENERATION, A GOAL UNTHINKABLE SEVERAL YEARS AGO. THEN IN LIGHT OUR CONSTRAINED BUDGET ENVIRONMENT I'LL REFLECT HOW PEPFAR IS PURSUING THE AMBITIOUS GOAL THROUGH EFFICIENCIES AN SMART INVESTMENT. AT THAT POINT I'LL CONSIDER HOW PEPFAR HAS OPENED THE NEW FIELD OF IMPLEMENTATION SCIENCE, TAKING ADVANTAGE OF OUR UNIQUE POSITION OF TRANSLATOR OF SCIENCE TO IMPACT AND HOW WE TAKE THIS TO THE NEXT LEVEL BY EXAMINING KEY QUESTIONS. FINALLY I'LL DESCRIBE HOW WE'RE USING THE PEPFAR PLATFORM TO ENSURE SUSTAINABILITY OF THE GLOBAL EFFORT. THIS MEANS DEVELOPING CAPACITY OF HEALTH SYSTEMS AND THE NEXT GENERATION OF LEADERS AND THE HEART OF THE HIV PANDEMIC TO WORK NOT ONLY ON HIV BUT WORK ON THE RANGE OF HEALTH AND DEVELOPMENT ISSUES THEY WILL FACE. FIRST I WOULD LIKE TO BRIEFLY TALK ABOUT THREE INTERVENTIONS, TREATMENT FOR HIV INFECTION, INTERVENTIONS FOR THE PREVENTION OF MOTHER TO CHILD TRANSMISSION, AND VOLUNTARY MALE CIRCUM SITION. I'LL DESCRIEP HOW PEPFAR HAS TAKEN THEM FROM STUDY RESULTS TO WIDESPREAD IMPACT TO CHANGE THE COURSE OF THE EPIDEMIC. I CHOSE THESE INTERVENTIONS NOT BECAUSE THEY REPRESENT THE FULL SPECTRUM OF PEPFAR BUT BECAUSE THEY'RE CENTRAL TO THE RELATIONSHIP BETWEEN SCIENCE AN IMPACT THROUGH OUR PROGRAMS. LET ME BEGIN BY FOCUSING ON TREATMENT. THE STORY OF THE IDENTIFICATION OF HIV IS ONE WHICH PEOPLE IN THIS ROOM ARE VERY FAMILIAR. NIH PLAYED THE PIVOTAL ROLE IN THIS AND SUCCEEDED IN A REMARKABLY SHORT PERIOD OF TIME, A FEATURE THAT CONTINUED TO DEFINE THE FAST-MOVING FIELD OF HIV. YOUR RESEARCH SUPPORTED THE IDENTIFICATION OF AN INITIAL TREATMENT WITH THE FDA APPROVED FOR THE TREATMENT OF HIV INFECTION IN 1987. AFTER YEARS OF WATCHING PEOPLE DIE WITHOUT EFFECTIVE INTERVENTION, IT WAS MONUMENTAL TO HAVE A TREATMENT THAT AT LEAST DELAYED THE ONSET OF AIDS AND DEATH. ONE OF THOSE PEOPLE WAS RYAN WHITE, AFTER WHOM CONGRESS NAMED THE PROGRAM THAT I WAS PRIVILEGED TO BE FIRST MEDICAL DIRECTOR TO PROVIDE RESOURCES FOR THE CARE OF HIV POSITIVE PEOPLE. IN 1992, AGAIN AFTER SUBSTANTIAL CONTRIBUTIONS FROM HIV INVESTIGATORS, DDC WAS APPROVED WHICH WAS PAIRED WITH SYDOVADINE. THE FIRST HIGHLY EFFECTIVE ART CAME IN 1994 IN MY ROLE THE OFFICE OF HIV AIDS POLICY UNDER SECRETARY SHELELA, I WAS PRIVILEGED TO FOUND THE GUIDELINE PROCESS IN 1995 WITH TONY FAUCI AND JOHN BARTLETT AS FIRST CHAIRS. PROTEASE INHIBITORS WERE THEN APPROVED IN THE ERA OF HIGHLY ACTIVE TRIPLE COMBINATION THERAPY WAS LAUNCHED. DUE IN LARGE PART TO RYAN WHITE CARE AN TREATMENT BECAME AN EXENGATION AMONG HIV -- EXPECTATION AMONG HIV POSITIVE INDIVIDUALS IN THE UNITED STATES, AND OTHER HIGH INCOME COUNTRIES. WE NOW HAVE 27 ANTIRETROVIRAL DRUGS AND COMBINATIONS APPROVED FOR TREATMENT OF HIV DISEASE. WE ALSO KNOW HOW TO RECOGNIZE, DIAGNOSE AND TREAT OPPORTUNISTIC INFECTIONS THAT ARE MAJOR CAUSE OF MORBIDITY AND MORTALITY. IN TERMS OF GLOBAL IMPLEMENTATION, PEPFAR HAS TAKEN THIS INTERVENTION, ONCE THOUGHT TO BE ONLY POSSIBLE TO DELIVER IN HIGH INCOME SETTINGS AND SUCCESSFULLY DEPLOYED IT IN OVER 30 HIGH-IMPACT COUNTRIES. IN 2003, ONLY ABOUT 50,000 PEOPLE IN SUB SAHARAN AFRICA WERE RECEIVING TREATMENT, TODAY'S PEPFAR ALONE SUPPORTS 3.9 MILLION ON TREATMENT GLOBALLY. THE VAST MAJORITY OF THEM IN SUB SAHARAN AFRICA. THE OBAMA ADMINISTRATION INCREASED THE NUMBER OF PEOPLE DIRECTLY SUPPORTED ON TREATMENTS SINCE TAKING OFFICE BY 124%. THE AFFECTS ON INDIVIDUALS RECEIVING TREATMENT ARE OF COURSE PROFOUND. A STANFORD UNIVERSITY STUDY DEMONSTRATED THAT OVER A MILLION DEATHS WERE AVERTED IN THE FIRST FOUR YEARS OF PEPFAR ALONE. A NUMBER WE EXPECT HAS AT LEAST DOUBLED SINCE THIS TIME. IN ADDITION TO LIVES SAVED DIRECTLY, TREATMENT ALSO REDUCES VERTICAL TRANSMISSION FROM MOTHER TO INFANT, ANOTHER BENEFIT I WILL DISCUSS IN MORE DETAIL LATER. WHAT HAS BEEN RECOGNIZED MORE RECENTLY THANKS IN LARGE PART TO NIH FUNDED HPTNO 52, OTHER IMPORTANT STUDIES SUCH AS PARTNERS IN PREVENTION, ARE TREATMENTS EFFECT ON SEXUAL TRANSMISSION. WITH AN EARLIER TREATMENT 052 DEMONSTRATED 96% REDUCTION IN LINKED HIV TRANSMISSIONS BETWEEN DISCORDANT COUPLES SHOWN HERE. IN OTHER WORDS, WE'RE ADDING ANOTHER CRITICAL REASON TO TREAT PEOPLE WITH WITH HIV. MANY STUDIES HAVE ALSO BEGUN TO DOCUMENT THE WIDER SOCIETAL BENEFITS OF TREATMENT. AS SHOWN HERE, A STUDY AMONG TEA PLUCKERS IN KENYA REPORTED DECREASES IN PRODUCTIVITY AMONG HIV POSITIVE INDIVIDUALS BEFORE TREATMENT. FOLLOWING TREATMENT PRODUCTIVITY WAS REGAINED AS THE HEALTH AND WELL BEING OF THE INDIVIDUAL IMPROVED. STUDIES HAVE ALSO SHOWN TREATMENT BY KEEPING PATIENTS AND PARENTS ALIVE, RATHER, HAS TREMENDOUS AFFECTS ON FAMILIES. INDEED, FOR EVERY 1,000 PEOPLE WHO SUPPORT ON TREATMENT FOR ONE YEAR WE AVERT THE ORPHAN HOOD OF 449 CHILDREN. 449 CHILDREN. THAT IS ANOTHER DIMENSION OF THE CONCEPT OF TREATMENT AS PREVENTION. IT'S ALSO HELPFUL TO LOOK AT THE COSTS AVERTED FOR TREATMENT. FOR EXAMPLE, THE LIFETIME COSTS OF BABY WHO AVOIDED BEING INFECTED WITH HIV DUE TO EFFECTIVE PMTCT WHICH I'LL DISCUSS NEXT, THROUGH THIS LENS THE COST PER ADDITIONAL LIFE YEAR GAINED DROPPED TO ABOUT $150. WHEN YOU ADD TO THIS THE PRODUCTIVITY GAINS I MENTIONED EARLIER, A RESEN STUDY OF THE GLOBAL FUND FOUND THAT THE COSTS OF TREATMENT PROGRAMS SHOWN BELOW THE LINE WERE ACTUALLY OUTWEIGHED BY THE SOCIETAL ECONOMIC BENEFITS SHOWN ABOVE THE LINE. TURNING TO MOTHER TO CHILD TRANSMISSION. NIH BUILT ON THE SUCCESSFUL DEVELOPMENT OF HIV TREATMENT LEADING TO THE USE OF ANTIRETROVIRAL DRUGS FOR PREVENTION OF VERTICAL TRANSMISSION OF HIV. IN 1994 THE AIDS CLINICAL TRIAL STUDY 076 REPORTED THAT AZT USED DURING PREGNANCY AND DELIVERY DRASTICALLY REDUCES TRANSMISSION OF HIV FROM MOTHER TO CHILD. THIS LED TO AN AZT DRUG REGIMEN BEING ADOPT AS AN OFFICIAL GUIDELINE WITHIN MONTHS FR. 1992 TO PRESENT VERTICAL FRANCE MISSION IN RESOURCE RICH COUNTRIES PLUM METED FROM APPROXIMATELY 25% OF CHILDREN BORN TO WOMEN LIVING WITH HIV TO LESS THAN 1%. WITH THE LEADERSHIP OF HIV THIS TRIAL HAS BEEN BUILT UPON AND CURRENT REGIMENS FOR PREGNANT WOMEN RESULT IN VERY LITTLE TRANSMISSION EVEN DURING EXTENDED BREAST FEEDING. IN THE GLOBAL CONTEXT I AM PROUD TO NOTE PEPFAR HAS INCREASED ITS LEADERSHIP IN THIS EFFORT. IN 2011 ALONE, PEPFAR TESTED NEARLY 10 MILLION PREGNANT WOMEN. OF THOSE, MORE THAN 660,000 PREGNANT WOMEN WERE FOUND TO BE LIVING WITH HIV AND ARVs FOR THESE WOMEN ALLOWED MORE THAN 200,000 INFANTS TO BE BORN HIV-FREE IN 2011 ALONE. THESE ARE THE HIGHEST PMTCT RESULTS OF ANY YEAR IN PEPFAR'S 8 YEAR HISTORY. IN YIEWN WE LAUNCHED THE GLOBAL PLAN WARDS THE ELIMINATION OF NEW PEDIATRIC INFECTIONS AND KEEPING MOTHERS ALIVE WITH MICHELLE CITY BAY, THE EXECUTIVE DIRECTOR OF UN AIDS TESTIMONY PLAN HAS AT ITS CENTRAL GOAL TO REDUCE THE NUMBER OF NEW PEDIATRIC INFECTIONS BY 90% BY 2015. FIRST, THE PLAN FOCUSES ON NATIONAL OWNERSHIP. THERE ARE 22 COUNTRIES WHICH CARRY GREATER THAN 90% OF THE GLOBAL MPCT BURDEN. ALL COUNTRIES WERE INTEGRAL PART OF THE TEAM THAT CREATED THE PLAN AND WERE FOCUSED PEPFAR COUNTRIES. THIS PLAN REFLECTS THEIR VIEWS INCORPORATES THEIR VIEWS AND WILL BE IMPLEMENTED BY THE COUNTRY TEAMS. COUNTRIES MUST LEAD THE RESPONSE WITH THE REST OF THE WORLD RIGHT BESIDE THEM SUPPORTING THEIR NATIONAL PLAN THROUGH FINANCIAL AND TARGETED TECHNICAL ASSISTANCE. SECOND, THE PLAN CALLS FOR UNIFIED ACTION AND LEADERSHIP AT ALL LEVEL, GOVERNMENT, CIVIL SOCIETY, PEOPLE LIVING WITH AIDS, SAFE AND COMMUNITY-BASED ORGANIZATIONS, DEVELOPMENT PARTNERS, THE PRIVATE SECTOR AND OTHERS. EVERYONE MUST PLAY A ROLE IN THIS RESPONSE. FINALLY THE PLAN INCLUDES AMBITIOUS BUT ACHIEVABLE TARGETS TO CHART OUR PROGRESS. BY STRESSING THE DUAL PRINCIPLES OF SHARED RESPONSIBILITY AND SPECIFIC ACCOUNTABILITY, THE PLAN WILL HELP US HOLD OURSELVES AND EACH OTHER ACCOUNTABLE TO HIGH-QUALITY SUSTAINED CARE LINKED IN TO TREATMENT FOR MOTHER AND CHILD AFTERWARD. THE FOCUS ON VOLUNTARY MEDICAL MALE CIRCUM SIXTH GREW OUT OF MANY OBSERVATIONAL STUDIES SHOWING GIVEN THE PROPENSITY OF THE FORE SKIN THE ALLOW PASSAGE OF THE VIRAL, REMOVAL OF THE FORE SKIN RESULTED IN DECREASED MALE ACQUISITION OF HIV INFECTION. EVIDENCE DEMONSTRATING THE EFFECTIVENESS OF MALE CIRCUM SITION AND PREVENTING SEXUAL TRANSMISSION WAS RELEASED IN 2005 FROM THE ORANGE FARM RANDOMIZED CONTROL TRIAL IN SOUTH AFRICA. THIS WAS FOLLOWED BY RESULTS IN 2006 FROM CHARLES IN UGANDA, AND KENYA. ALL THREE RANDOMIZED CONTROL TRIALS CONFIRMED THAT MALE CIRCIMSITION PERFORMED WELL BY WELL TRAINED AND EQUIPPED MEDICAL PROVIDERS IS SAFE AND REDUCES THE RISK OF HETEROSEXUAL SITUATION OF HIV AMONG MEN BY AS MUCH AS 60%. EXTENDEDDED FOLLOW-UP OF PARTICIPANTS FIVE YEARS POST TRIAL INDICATED THAT PROTECTIVE EFFECT INCREASED TO 68, 70%. FOLLOWING THE RELEASE FT TRIALS IN 2007 WHO AND UN AIDS CONVENED STAKEHOLDERS TO REVIEW THE BODY OF EVIDENCE FROM THE THREE TRIALS AND WELT OF EARLIER ECOLOGICAL STUDIES. THE CONSULTATION RESULTED IN A FIRM ENDORSEMENT OF THE EVIDENCE AND RECOMMENDED THE IMPLEMENTATION AND SCALEUP OF PROGRAMS IN SETTINGS TO GENERALIZED HIGH PREVALENCE HIV EPIDEMICS AND LOW LEVELS OF MALE CIRCUMCISION. IN PAST YEARS PEPFAR LED THE SCALE FOR CIRCUM SIXTH WITH INVESTMENTS TO CREATE A CONDUCIVE POLICY ENVIRONMENT WE HAVE BEGUN TO SEE GOVERNMENTS REALIZE THIS IS ONE OF THE MOST EFFECTIVE WAYS TO REDUCE NEW INFECTIONS AMONG MEN IF A PRE-REQUIRED DIALOGUE IS KEPT. PEPFAR SUPPORTS MALE CIRCUMCISION IN 14 COUNTRIES AN WORKS IN PROGRAM PLANNING AND IMPLEMENTATION. MODELING STUDIES PREDICT THAT THE BENEFITS OF MALE CIRCUMCISION ARE LIKELY LARGE IN POPULATIONS WITH HIGH PREVALENCE OF PRIMARY HETEROSEXUALLY DRIVEN HIV AND LOW MALE CIRCUMCISION. THERE ARE NUMEROUS COUNTRIES AND REGIONS PARTICULARLY EASTERN AND SOUTHERN AFRICA THAT FIT INTO THIS CATEGORY. IT'S ESTIMATED ONE HIV INFECTION IS AVERTED FOR EVERY 5 TO 15 CIRCUMCISIONS PROVIDING A LIFETIME BENEFIT MAKING IT A COST EFFECTIVE INTERVENTION. AND IS HIV PREVALENCE DECREASES AMONG SUR COUPLE SIZED MEN THER(WK=Ww3JN/< MEN THERE'S INDIRECT PROTECTIVE EFFECT FOR WOMEN. ULTIMATELY THE WHOLE POPULATION ESPECIALLY OVER 10 TO 20 YEAR TIME HORIZON. PEPFAR HAS INVESTED OVER $204 MILLION TO DATE AND HAS SUPPORTED APPROXIMATELY 1 MILLION MALE CIRCUMCISIONS. PUTTING ALL THE ESSENTIAL COMPONENTS IN PLACE TAKES TIME AND IT'S IMPORTANT TO BE SURE THAT THERE'S THE APPROPRIATE BALANCE OF DEMAND AND SUPPLY. DATA FROM TANZANIA SHAZ SHOWN SUCH PREPARATION ALLOWED THE COUNTRY TO REACH THE TIPPING POINT AND THERE IS NOW A GREATER INCREASE IN THE NUMBER OF CIRCUMCISIONS BEING PERFORMED. THE PROMISE OF NEW CIRCUMCISION DEVICES WILL ACCELERATE THE SCALEUP. UN AIDS HIGHLIGHTED THE POTENTIAL OF THESE INTERVENTIONS AND THEIR INVESTMENT FRAMEWORK MODEL PUBLISHED EARLIER IN YEAR IN THE LANSETT. THEY SHOWED THAT THE COMBINATION OF THESE HIGH IMPACT INTERVENTIONS ALONG WITH OTHER IMPORTANT SUPPORTIVE INTERVENTIONS TO REDUCE STIGMA CHANGE BEHAVIORS AND RAISE DEMAND FOR EFFECTIVE PREVENTION CAN RESULT IN A MAJOR REDUCTION IN NEW INFECTION AND BENDING OF THE CURVE OF THE HIV EPIDEMIC. THE VISION IN AN AIDS-FREE GENERATION THAT SECRETARY CLINTON OUTLINED TON STAGE -- ON THIS STAGE ON THIS CAMPUS LAST MONTH HAD THESE INTERVENTIONS AT ITS CORE. IN HER WORDS, I QUOTE, NOW WE KNOW BEYOND A DOUBT IF WE TAKE A COMPREHENSIVE VIEW OF OUR APPROACH TO THE PANDEMIC, TREATMENT DOESN'T TAKE AWAY FROM PREVENTION, IT ADDS TO PREVENTION. SO LET'S END THE OLD DEBATE OVER TREATMENT VERSUS PREVENTION AND EMBRACE TREATMENT AS PREVENTION. IN OTHER WORDS, THE WORK OF NIH, MEDICAL OFFICERS AND OTHER KEY STAFF PLANNING AND RUNNING TRIALS, THE COURAGE OF PATIENT IT IS FACE THE UNKNOWN WITH BASIC LABORATORY WORK TO DEVELOP BETTER TARGETED DRUGS AND THE COMMITMENT OF IMPLEMENTERS TO SCALE UP AND CHALLENGE -- IN CHALLENGING CIRCUMSTANCES ENABLED A MAJOR POLICY STEP BY THE US GOVERNMENT. WE NOW RECOGNIZE TREATMENT AS A CRITICAL ELEMENT OF COMBINATION PREVENTION AND ARE WORKING TOWARD THE CREATION OF AN AIDS-FREE GENERATION. THIS VISION BUILT ON OUR WORK TOGETHER, HAS NOW RECEIVED ITS MOST IMPORTANT ENDORSEMENT BY PRESIDENT OBAMA. ON WORLD AIDS DAY AT AN EVENT INCLUDING PRESIDENT CLINTON AND BUSH, AND MANY OTHERS, THE PRESIDENT ANNOUNCED AMBITIOUS NEW GOALS FOR EVIDENCE-BASED COMBINATION PREVENTION. AMONG THESE WAS AN INCREASE IN OUR TREATMENT TARGET BY 50%. TO 6 MILLION PEOPLE SUPPORTED ON TREATMENT IN THE NEXT TWO YEARS. RECOGNIZING THE EXTRAORDINARY OPPORTUNITIES THAT EXIST WITH THE NEW TOOLS, THE PRESIDENT NOTED THAT, QUOTE, AS A MATTER OF POLICY, WE'RE NOW INVESTING IN WHAT WORKS. WITH THIS SET OF TOOL IT IS GLOBAL COMMUNITY IS NOW POISED TO REDUCE INCIDENCE TO A LEVEL WHERE INSTEAD OF STARTING TWO PEOPLE ON TREATMENT FOR EVERY THREE OR FOUR NEW INFECTIONS, WE CAN REVERSE THAT. INDEED WE CAN REDUCE THE NUMBER OF NEWLY INFECTED PEOPLE TO BELOW THE NUMBER NEWLY ELIGIBLE FOR TREATMENT EACH YEAR AS SHOWN IN THE SLIDE FROM UN AIDS. ON WORLD AIDS DAY, PEPFAR ALSO COMMITTED TO AN ADDITIONAL 4.7 MILLION CIRCUMCISIONS IN THE NEXT TWO YEARS, AS WELL AS TO START 1.5 MILLION WOMEN ON ARVs TO PREVENT MOTHER TO CHILD TRANSMISSION OVER THESE SAME TWO YEARS. LIKE THE TREATMENT GOAL, THESE ARE AMBITIOUS TARGETS AND REPRESENT OUR CONTRIBUTION TO A VIGOROUS GLOBAL EFFORT. THIS IS THE POWER OF JOINING SCIENCE AN IMPLEMENTATION. AND OF DEVELOPING POLICIES BASED ON EVIDENCE. AS PASTEUR APTLY SAID, SCIENCE KNOWS KNOW COUNTRY BECAUSE KNOWLEDGE BELONGS TO HUMANITY AND IS THE TORCH WHICH ELIMINATES THE WORLD -- ILLUMINATE IT IS WORLD. YOU IN THIS ROOM AND INSTITUTION ARE PART OF THE CONTINUUM OF CREATING AND APPLYING SCIENTIFIC KNOWLEDGE FOR THE GOOD OF THE PLANET. IN DOING SO YOU ARE ANSWERING THE CALL TO CREATE CAPACITY SO THAT COMBINATIONS WE MAKE ARE LASTING ONES. AS WE PURSUE THIS GOAL, WE ARE MINDFUL OF THE ECONOMIC CONTEXT IN WHICH WE ARE WORKING. HOW IS PEPFAR ACCOMPLISHING SO MUCH AND ABLE TO TAKE ADVANTAGE OF THESE SCIENTIFIC ADVANCES IN A LEVEL BUDGET ENVIRONMENT? WE ARE DOING IT THROUGH AN INTENTIONAL PROCESS OF PRIORITIZING SMART INVESTMENTS, MAKING OUR PROGRAMMING MORE EFFICIENT, AND LEVERAGING THE INVESTMENTS OF COMPLIMENTARY FUNDING STREAMS SUCH AS THE GLOBAL FUND AND NATIONAL GOVERNMENT RESOURCES. MAKING SMART INVESTMENTS IS REALLY INVESTING IN WHAT WORKS AS THE PRESIDENT SAID, THE COMMONERS CALL THIS AL KAYTIVE EFFICIENCY, PUTTING YOUR MONEY INTO THE INTERVENTIONS THAT HAVE THE BIGGEST IMPACT ON OUTCOMES YOUBCA CARE ABOUT. IN OUR CASE, THESE OUTCOMES ARE HUMAN LIVES SAVED, REDUCTIONS IN HIV INFECTION AND THE COUNTRIES IN WHICH WE WORK. WE'VE DONE THIS AS I REFERENCED BEFORE THROUGH FOCUSING THE BULK OF PREVENTION DOLLARS ON INTERVENTIONS SHOWN TO HAVE THE GREATEST IMPACT. WE'RE ALSO ACHIEVING WHAT ECONOMISTS TERM TECHNICAL EFFICIENCY. THIS IS TAKEN THE FORM OF MAKING OUR PROGRAMS LESS EXPENSIVE THROUGH LOWERING COMMODITIES, SWITCHING FROM AIR TO SEA, LAND FREIGHT, AND THROUGH THE COLLECTION AND USE OF ECONOMIC AND FINANCIAL DATA IN PROGRAMMING. THROUGH THIS APPROACH WE HAVE LOWERED THE PEPFAR COSTS OF SUPPORTING AN INDIVIDUAL ON TREATMENT FROM NEARLY $1,100 PER PATIENT PER YEAR TO $335 AND IT CONTINUES TO FALL. DURING MY TIME AS COORDINATOR PEPFAR AGGRESSIVELY ACCELERATED THE DEVELOPMENT OF COSTING STUDIES OF TREATMENT AND OTHER PROGRAMS AND HAS FUNDED INNOVATIVE WORK, EXAMINING THE COST EFFECTIVENESS OF SERVICE DELIVERY MODELS. PEP FAFER HAS ALSO PIONEERED THE USE OF OUTCOME LINKED EXPENDITURE ANALYSIS EXERCISES AMONG PREVENTION, CARE AND TREATMENT PARTNERS IN SEVERAL COUNTRIES. WE'RE WORKING TO QUICKLY ROOTNIZE THIS ACTIVITY PEPFAR-WIDECH THESE DATA ARE SHARED WITH PARTNER GOVERNMENTS AND USED IN DECISION ANALYTIC AND COST PROJECTION MODELING, SPONSORED BY PEPFAR AND OTHER PARTNERS TO IMPROVE NATIONAL PROGRAM PLANNING. BETTER ACCESS TO UPDATED ECONOMIC AND FINANCIAL DATA AND INDICATORS WILL ALLOW FOR PEPFAR PROGRAMMERS AND NATIONAL GOVERNMENTS TO BETTER MAKE RAPID COURSE CORRECTIONS TO IMPROVE PLANNING AND EFFECTIVENESS AND TO AVOID INEFFICIENT USE OF RESOURCE. WE ALSO HAVE POTENTIAL TO ACHIEVE BETTER TECHNICAL EFFICIENCY WHEN INVESTING IN MODELS OF SERVICE DELIVERY THAT ARE INTEGRATED. PEPFAR IS ONE KEY PLATFORM ON WHICH THE OBAMA ADMINISTRATION IS BUILDING THE GLOBAL HEALTH INITIATIVE SUPPORTING ONE STOP CLINICS OFFERING AN ARRAY OF HEALTH SERVICES. THIS MEANS DRIVING COSTS DOWN, DRIVING UP IMPACT, AND SAVING MORE LIVES. THROUGH PEPFAR INVESTMENTS WE HAVE PUT SYSTEMS OF CARE IN PLACE THAT COUNTRIES ARE LEVERAGING TO IMPROVE THEIR CITIZENS OVERALL HEALTH FOR ALL DISEASES. IN ADDITION THROUGH THE GLOBAL FUND, REFORM PROCESS NOW IN PLAY, AND THE DAILY EFFORTS OF OUR COUNTRY TEAMS WE ARE LEVERAGING OUR INVESTMENTS THROUGH BETTER COORDINATION WITH THE GLOBAL FUND AND THE ELIMINATION OF PARALLEL SYSTEMS. THE FUND REPRESENTS A CRITICAL VEHICLE FOR OTHER DONORS TO CONTRIBUTE TO OUR SHARED RESPONSIBILITY TO ADDRESS THIS GLOBAL BURDEN, COUNTRIES THAT WOULD NEVER DEVELOP A BILATERAL PROGRAM. THE UNITED STATES IS THE LARGEST CONTRIBUTOR TO THE FUND AND WE'RE NOW WORKING CLOSELY WITH IT TO ENSURE THAT EACH DOLLAR ACHIEVES MAXIMUM BENEFIT AS PART OF A COMMON EFFORT TO SUPPORT OUR PARTNER NATIONS. ANOTHER FOCUS IS WHAT WE CALL COUNTRY OWNERSHIP. WORKING EVEN MORE CLOSELY WITH THE GOVERNMENTS IN CIVIL SOCIETY OF THE COUNTRIES AND PARTNERSHIP, PART OF THIS DISCUSSION IS ASKING COUNTRIES TO ASSESS WHAT COMPLIMENTARY RESOURCES THEY CAN BRING TO THE TABLE. IN SOME CASES THEY HAVE RESPONDED WITH WITH STRONG FINANCIAL COMMITMENTS SUCH AS IN SOUTH AFRICA AND GOVERNMENTS IMPRESSIVE RECENT INCREASES AND INVESTMENTS IN THEIR HIV PROGRAM. COUNTRY OWNERSHIP ALSO TAKE IT IS FORM OF LEADERSHIP AND PRIORITIZATION, IMPLEMENTATION, AND ACCOUNTABILITY AT THE LOCAL LEVEL. MANAGING THESE PROGRAMS. THROUGH THE 21 PARTNERSHIP FRAMEWORKS WE HAVE SIGNED WITH PARTNER COUNTRIES WE'RE WORKING TO PUT THEM IN THE DRIVER'S SEAT OF THEIR NATIONAL HIV RESPONSES. FOR HIV, AS FOR OTHER DEVELOPMENT ISSUES, COUNTRIES MUST LEAD THEIR OWN RESPONSES AND WE MUST MODEL OUR COMMITMENT TO THE SUPPORTIVE PARTNERS AS THEY ASSUME INCREASING RESPONSIBILITY. OUR ABILITY TO SCALE THESE INTERVENTIONS IS BASED ON OUR EVALUATION FRAMEWORK. WHICH FORCES ON IMPLEMENTATION SCIENCE AND IMPACT EVALUATION. IN THE SECOND PHASE OF PEPFAR CHARACTERIZED BY AN INCREASE EMPHASIS ON SUSTAINABILITY, PROGRAMS MUST DEMONSTRATE VALUE AND IMPACT IN ORDER TO BE PRIORITIZED WITHIN COMPLEX AND RESOURCE-CONSTRAINED ENVIRONMENTS. IN THIS CONTEXT THERE IS A GREATER DEMAND TO CAUSALLY ATTRIBUTE OUTCOMES TO PROGRAMS. BETTER ATTRIBUTION CAN BE USED TO INFORM MID-COURSE CORRECTIONS IN THE SCALE UP OF NEW INTERVENTIONS OR TO RE-EVALUATE INVESTMENTS AND PROGRAMS FOR WHICH IMPACT IS LESS CLEAR. TO MEET THESE DEMANDS PEPFAR IS ADOPTING AN IMPLEMENTATION SCIENCE FRAMEWORK TO IMPROVE THE DEVELOPMENT AND EFFECTIVENESS OF OUR PROGRAMS AT ALL LEVELS. AS WE RECENTLY DESCRIBED IN AN ARTICLE IN JADE IMPLEMENTATION SCIENCE IS THE STUDY OF METHODS TO IMPROVE THE UPTAKE, IMPLEMENTATION AND TRANSLATION OF RESEARCH FINDINGS AND TO ROUTINE AND COMMON PRACTICES MOVING THEM FROM BENCH TO BEDSIDE. WE USED IMPLEMENTATION SCIENCE TO EVALUATE THE OPERATIONAL EFFECTIVENESS OF THE SOUTH AFRICAN NATIONAL PROGRAM FOR PREVENTION OF MOTHER TO CHILD TRANSMISSION. INVESTIGATORS EXPLORED THE SURVIVAL OF HIV FREE INFANTS ACROSS PROGRAM SITES AND IDENTIFIED SPECIFIC SOURCES OF VARIATION SUCH AS HEALTH SYSTEM FACTORS FOR EXAMPLE, THAT LIMITED ANTI-NATAL VISITS AND LACK OF SYPHILIS SCREENING IN INDIVIDUAL BEHAVIORS SUCH AS BREAST FEEDING PRACTICES. BY FRAMING THE PROBLEM THROUGH IMPLEMENTATION SCIENCE THE STUDY REVEALED OPPORTUNITIES FOR IMPROVING PROGRAM PERFORMANCE THAT COULD BE TRANSLATED INTO IMMEDIATE SOLUTIONS SUCH AS IMPROVING THE QUALITY OF CARE AND INFANT FEEDING COUNSELING. IN THIS WAY, IMPLEMENTATION SCIENCE IS PROVEN TO BE A VALUABLE TOOL NOT ONLY TO IMPROVE PROGRAM EFFECTIVENESS BUT ALSO TO EXPLAIN WHAT WORKED, WHY, AND UNDER WHAT CIRCUMSTANCE. WE HAVE ENJOYED AN INTENSIFIED RELATIONSHIP WITHIN SCIENCE WITH THE NIH AND OUR OTHER U.S. AGENCIES THAT ARE CRITICAL TO DELIVERING GLOBAL HEALTHCARE, INCLUDING CDC AND US AID. THIS HAS TAKEN NUMEROUS FORMS. INCLUDING CORROBORATION AROUND RAPID EXPANSION OF THE LARGEST KNOWN ROLL-OUT OF SUPPORT FOR IMPLEMENTATION SCIENCE ACTIVITIES. TOGETHER WE HAVE RAPIDLY FUNDED THREE LARGE IMPLEMENTATION SCIENCE RFAs THAT HAVE GENERATED MANY EXCELLENT PROPOSALS THAT LEAD TO IMPORTANT QUESTIONS BEING ANSWERED QUICKLY AND WITH RIGOR. WE HAVE ALSO CO-INVESTED WITH NIH ON A TARGETED RFA FOR VERTICAL TRANSMISSION, AND WITH NIDA FOR ONE ON HIV SERVICES FOR PEOPLE WHO INJECT DRUGS. IT IS SUCH A PLEASURE TO WORK WITH NIH ON THESE COLLABORATIONS GIVEN THE DEPTH OF EXPERIENCE AND KNOWLEDGE OF PEOPLE LIKE FRANCIS COLLINS, TONY FAUCI, HAROLD VARMUS, ROGER GLASS, LYNN MOFFESON AND NOR VA VOL -- NOR VA VOLKOW TO NAME A FEW. WE HAVE RECENTLY AWARDED THREE GROUND-BREAKING GRANTS FOR TRIALS OF COMBINATION REVENGS USING THE BEST AVAILABLE TOOLS OF IMPLEMENTATION SCIENCE, SCALED TO HIGH LEVELS TO ALLOW US TO RIGOROUSLY EVALUATE THE POPULATION LEVEL EFFECTS OF COMBINATION PREVENTION. WE HAVE ALSO LAUNCHED A NEW ENDEAVOR WE CALL IN-COUNTRY IMPACT EVALUATION. THROUGH THIS PROCESS WE HAVE ENABLED OUR COUNTRY TEAMS TO USE A FRACTION OF THEIR BUDGET TO WORK WITH ACADEMIC AND LOCAL PROGRAM EXPERTS TO APPLY RIGOROUS METHODS OF IMPACT EVALUATION TO CRITICAL PROGRAM DECISIONS. PROPOSALS FOR THESE EVALUATIONS WILL INCLUDE THE USE OF COUNTER FACTUALS AND OTHER INNOVATIVE DESIGNS SUCH AS STEPPED WEDGE ROLL-OUTS AND WILL INTENSIVELY REVIEW BY OUR ARE REVIEW TEAMS INCLUDING EXCERPTS FROM NIH AND CDC. BY OPENING UP YET ANOTHER AVENUE FOR RIGOROUS RESEARCH WE HOPE TO HAVE A BURST OF PUBLIC HEALTH RELEVANT DATA OVER THE NEXT SEVERAL YEARS THAT WE CAN USE TO SHAPE THE PROGRAM TO BE AS IMPACTFUL AS POSSIBLE AS THE CHANGING NEEDS OF THE POPULATION EVOLVE. ONCE AGAIN, IT'S IMPORTANT TO NOTE THAT OUR EFFORTS ARE PART OF A LARGER CONTEXT THAT EXTENDS TO ALL DEVELOPMENT ACTIVITIES. THE CHALLENGE TO BUILD AN EVIDENCE BASE, EVALUATE IMPACT AND DIRECT PROGRAMS ACCORDINGLY IS NOT LIMITED TO HIV OR EVEN HEALTH PROGRAMS BUT EXTENDS TO THE ENTIRE DOMAIN OF DEVELOPMENT. AT PEPFAR WE SEE OURSELVES AS PART OF THIS LARGER PICTURE AND ARE COMMITTED TO SHARING LESSONS WITH COLLEAGUE WHOSE WORK IN OTHER AREAS. ONE OF THE MOST IMPORTANT PIECES OF OUR WORK IS TO ENSURE WE DON'T WIN OUR BATTLES AGAINST THE EPIDEMIC BUT LOSE THE LARGER WAR TO DEVELOP LOCAL CAPACITY TO LEAD NATIONAL HEALTH AND DEVELOPMENT RESPONSES. INDEED AS PART OF THE GLOBAL HEALTH INITIATIVE PEPFAR HAS SERVED ADS THE PRIMARY ENGINE FOR BUILDING SYSTEMS THAT CAN PROVIDE OTHER SERVICES. WE ARE MOVING QUICKLY TO LEVERAGE LOW HANGING FRUIT ENSURING SUPPLY CHAINS AN VEHICLES DELIVERING HIV COMMODITIES ARE ALSO DELIVERING BED NETS AND OTHER VITAL SUPPLIES. AS WE MOVE ON WE'RE EXPLORING THE POWER OF OUR SITE IT IS ADDRESS DISEASES SUCH AS CERVICAL CANCER AND OTHER CHRONIC DISEASES LIKE HIV THAT REQUIRE REPEATED FOLLOW-UP SUCH AS TB, HYPERTENSION, DIABETES, CORONARY ARTERY DISEASE. I HAVE PUT IN THE PLACE A NUMBER OF INITIATIVES BORNE OUT OF MY EXPERIENCE TO IMPROVE THE SUSTAINABILITY OF HIV AND BROADER HEALTH AND DEVELOPMENT PROGRAMS. FIRST, WE'VE RECOGNIZED THE CENTRALITY OF LABORATORIES AN TRAINED LABORATORY SPECIALISTS TO IMPROVE THE ABILITY OF CLINICIANS TO DELIVER CALL CARE AND TREATMENT AND TRACKING THE STATUS OF THE EPIDEMIC THROUGH SURVEILLANCE. TO DIAGNOSE A DISEASE SPECIFICALLY WITH A SPECIFIC TREATMENT. SEVERE SHORTAGES OF KEY PERSONNEL, WE TAKE FOR GRANTED IN THE UNITED STATES HAVE REDUCED OTHER HEALTH SYSTEMS ABILITY TO DIAGNOSE DISEASE WHETHER HIV, MALARIA, TB OR RENAL DISEASE. EARLIER THIS YEAR WITH CDC AND NIH SUPPORT WE SUPPORTED THE LAUNCH OF THE AFRICAN SOCIETY FOR LABORATORY MEDICINE OR ASLM. ASLM IS A PAN AFRICAN PROFESSIONAL BODY HEAD QUARTERED IN ADA SOBOBA TO ADVANCE LABORATORY MEDICINE PRACTICES SCIENCE SYSTEMS ANNETTE WORKS IN AFRICA. IT RANGES FROM WORK FORCE DEVELOPMENT TO TECHNICAL ASSISTANCE WITH A FOCUS ON ACCREDITATION AND CALL CONTROL MANAGEMENT. WITH THE EXCEPTION OF SOUTH AFRICA, ONLY 8.2% OF LABS IN SUB SAHARAN AFRICA ARE INTERNATIONALLY I CREDITED. IN ORDER TO ENSURE THE MILLIONS OF PATIENTS IN AFRICA WHO RELY ON PUBLIC LABS RECEIVE CALL SERVICES, ASLM IS WORKING DIRECTLY WITH MINISTERS OF HEALTH AND THE WHO AND OTHER PARTNERS TO CREATE A MORE INFORMED AND CONNECTED CADRE OF LABORATORY SCIENTISTS WHO WORK WITHIN ACCREDITED LABS AN LAB SYSTEMS. ASLM IS WORKING WITH LAB SCIENTISTS TO CREATION OF PEER REVIEWED JOURNAL, AFRICAN JOURNAL OF LABORATORY MEDICINE, WHICH LAUNCHED THIS MONTH. IN ADDITION TO INCREASING THE VISIBILITY OF LAB MEDICINE IN AFRICA T JOURNAL SERVES AS A FORUM FOR SHARING RESEARCH, TRAINING, ACADEMIC AND INDUSTRY NEWS. I WOULD ALSO LIKE TO HIGHLIGHT TWO OTHER PROGRAMS. THE MEDICAL EDUCATION PARTNERSHIP MENTIONED BY FRANCIS AND THE NURSING EDUCATION PARTNERSHIP INITIATIVES. LAUNCHED OVER THE LAST TWO YEARS, THEY SEEK TO ALLEVIATE SUB SAHARAN AFRICAS SHORTAGE OF TRAINED HEALTHCARE PROFESSIONALS AND PARAPROFESSIONALS WHILE DEVELOPING SUSTAINABLE LOCAL CAPACITY TO PRODUCE SKILLED DOCTOR, NURS AND MIDWIVES FOR GENERATIONS TO COME WHO HAVE INHERENT BELIEF IN INTELLECTUAL HONESTY AN CLINICAL EXCELLENCE. OVER THE FIVE YEARS OF THIS INITIATIVE, MEPE WILL RECEIVE $130 MILLION FUNDED FROM PEPFAR AND NIH AND ADMINISTERD THROUGH THE FOGARTY INTERNATIONAL CENTER AND HRSA TO DISTRIBUTE TO AFRICAN INSTITUTIONS AND DOZEN SUB SAHARAN AFRICAN COUNTRIESCH THESE FUNDS GO TOWARDS DEVELOPING MEDICAL EDUCATION, CLINICAL TEACHING, INVESTING IN INNOVATIVE TECHNOLOGIES AND THRENGTENING EDUCATIONAL RESOURCES, FOCUSING ON CLINICAL EXCELLENCE AND TEACHING AND PRACTICE. FUNDING FROM THIS PROGRAM IS ALSO USED TO SUPPORT THE RESEARCH CAPACITY OF MEPE INSTITUTIONS, AND THE CONTRIBUTIONS THAT AFRICAN RESEARCHERS AND SCHOLARS ARE MAKING TO THE LARGER BODY OF HIV KNOWLEDGE AS WELL. IN A SIMILAR FASHION, THE NURSING INITIATIVE PROVIDES TRAINING AND TECHNICAL SUPPORT TO NURSING MED WIFERY PROGRAMS THROUGHOUT SUB SAHARAN AFRICA. MEPE IS LAUNCHED IN THREE COUNTRIES, THAT FACE EXTREME CHALLENGES IN MEETING THE NEEDS FOR TRAINED NURSES AND MIDWIVES AND WILL SOON EXPAND TO ADDITIONAL COUNTRIES. MINISTRIES OF HEALTH, ARE KEY TO MEPE SUCCESS AND THEY EMBRACE THESE OPPORTUNITIES TO SUBSTANTIALLY REVIEW AND PRIORITIZE SUPPORT IN DEVELOPING A STRONG NURSING WORK FORCE. WHEN I TALK ABOUT DOING DEVELOPMENT DIFFERENTLY, THESE PROGRAMS FOCUSED ON LABORATORIES, PHYSICIANS AND NURSES ARE PRIME EXAMPLES OF WHAT I MEAN. THEY BUILD ON AFRICA'S GREATEST RESOURCE OF ALL, ITS PEOPLE. THEY'RE FOSTERING INDIGENOUS CAPACITY TO STRENGTHEN HEALTH SYSTEMS AT A SUSTAINABLE MANNER F. WE'RE ABLE TO MAKE A TRULY DIFFERENT AND LASTING IMPACT ON OUR HEALTH AND DEVELOPMENT PROGRAMS, WE MUST SUPPORT THIS KIND OF WORK ACROSS MANY DISCIPLINES, FOCUSED ON INSTITUTIONAL EXPANSION AND CAPABILITY. WITH SO MUCH ACCOMPLISHED AND SO MUCH YET TO DO, WHAT DOES THE FUTURE HOLD? IN TERMS OF FURTHER IMPROVING OUR COMBINATION PREVENTION PACKAGE, THERE IS A LOT TO BE HOPEFUL FOR WITH CONTINUING RESEARCH ON PRE-EXPOSURE PROPHYLAXIS, MICROBICIDES, THEY PUT WOMEN IN CHARGE OF THEIR PROTECTION AS WELL AS VACCINES. MEANTIME WE MUST EXPAND THE IMPACT OUR PROGRAMS BY INCREASING COVERAGE OF HIGH IMPACT INTERVENTIONS. AND WE MUST USE THE SMARTEST POSSIBLE STRATEGIES TO APPLY OUR FUNDING AS EFFECTIVELY AS POSSIBLE. I WOULD ALSO ASK AND AM ASKING OUR PROGRAMS HOW MUCH FURTHER CAN WE DEVELOP TRUE COUNTRY OWNERSHIP AND CAPACITY TO LEAD? AS I NOTED, THIS WILL BE EVERY BIT AS IMPORTANT AS THE TOOLS WE HAVE TO IMPLEMENT THE HIV RESPONSE AND I'M FIRMLY COMMITTED TO FURTHER ORIENTING THIS PROGRAM TOWARD THAT GOAL. ON WORLD AIDS DAY IN THE NEW YORK TIMES MUSICIAN AND ACTIVIST BONO ASKED HOW SO MUCH HAD BEEN ACHIEVED IN THE GLOBAL AIDS RESPONSE IN SUCH A SHORT PERIOD OF TIME. HIS ANSWER? AMERICA LED. AMERICA HAS INDEED LED STARTING WITH CITIZENS WHO UNDERSTOOD THE GOOD THAT CAN COME WITH FUNDS THAT REPRESENT A SMALL PIECE OF THE NATIONAL BUDGET. IT INCLUDES THE COMMITTED PEOPLE AND ORGANIZATIONS THAT HAVE GIVEN MIGHTILY OF THEIR TIME AND EFFORT, AMERICA WILL CONTINUE TO LEAD AS PRESIDENT OBAMA AND SECRETARY CLINTON HAS SO CLEARLY OUTLINED. BUT WE WILL AN MUST DO IT RECOGNIZING THAT TO TRULY BE SUCCESSFUL, OTHER NATIONS BOTH DONOR AND PARTNER NATIONS MUST SHARE IN THIS RESPONSIBILITY. THESE ARE FORMIDABLE CHALLENGES TO BE SURE. BUT THE PROGRESS WE HAVE MADE IN TRANSLATING SCIENCE TO IMPACT IN ORDER TO ACHIEVE OUR COLLECTIVE VISION OF AN AIDS-FREE GENERATION IS TRULY HEARTENING. NELSON MANDELA REMINDS US, IT ALWAYS SEEMS IMPOSSIBLE UNTIL IT'S DONE. LET'S REMEMBER THAT VISION AS WE CONTINUE THE LONG BUT WINNABLE FIGHT AGAINST HIV AND OTHER HEALTH AND DEVELOPMENT CHALLENGES USING EVERY SCIENTIFIC PUBLIC HEALTH AND POLITICAL TOOL WE CAN TO HELP WIN. TO BUILD HEALTHCARE FOR THE PLANET THAT IS EFFECTIVE, AVAILABLE AND SUSTAINABLE. I WANT TO THANK MY COLLEAGUES BOTH IN THIS ROOM BUT ALSO MY PEPFAR TEAM AT OGA, THE COORDINATORS IN THE COUNTRY, ALL THEM, ALL 80 COUNTRIES, OUR COLLEAGUES AT CDC, US AID, PEACE CORPS, DEPARTMENT OF DEFENSE. I ESPECIALLY WANT TO THANK MY SENIOR MANAGEMENT TEAM. SPECIFICALLY ON THIS PRESENTATION I WANT TO THANK CHARLES HOLMES, CAROLYN RYAN, DEBORAH (INDISCERNIBLE), NANCY PADIUM AND KATE GLANCE FOR THE WORK THEY PUT INTO THIS PRESENTATION. SO THANK YOU VERY MUCH. [APPLAUSE] >> THANK YOU, ERIC. VERY COMPREHENSIVE INSPIRING PRESENTATION. WE HAVE TIME FOR SOME QUESTIONS. THERE ARE MICROPHONES IN THE AISLES, PLEASE APPROACH THOSE IF YOU WANT TO ASK A QUESTION SO PEOPLE LISTENING TO THE VIDEOCAST CAN HEAR THE QUESTION. WHILE PEOPLE ARE THINKING ABOUT THAT, ERIC, LET ME COMMENT HOW IMPRESSIVE IT IS THAT CURVE YOU SHOWED OF COST OF KEEPING SOMEONE ON ANTIRETROVIRALS DOWN NOW TO $335, THAT'S AN AMAZING CURVE. BUT WON WONDERS -- ONE WONDERS HOW MUCH OF THAT CAN CONTINUE, WHERE ARE THE FIXED COSTS, WHAT DO YOU SEE AS POTENTIALLY FEASIBLE OVER THE NEXT COUPLE OF YEARS AND CONTINUING TO DRIVE THAT DOWNWARD? >> WELL, THAT NUMBER, THE 335 IS A -- IS DRUG COSTS AS WELL AS THE MEDICAL INFRASTRUCTURE NEEDED TO DELIVER THE CARE. NURSES, DOCTORS, THE INSTITUTION ITSELF, THE BUILDING, THE PROCUREMENT DISTRIBUTION SYSTEM THAT GETS THE COMMODITIES THERE. WE ARE AS LOW AS $85 PER PATIENT PER YEAR. AND THAT'S AN AVERAGE OF $335. I THINK THAT WE'LL PROBABLY GET ON AVERAGE A DROP OF ANOTHER 120 OR SO AND THAT WILL BE ABOUT IT. THIS IS WITH FIRST-LINE THERAPY, NOT SECOND LINE, AS WE MOVE INTO SECOND LINE THAT NUMBER IS GOING TO POP BACK UP 2 TO 3, REALLY THREE TIME IT IS COST OF FIRST LINE THERAPY. WE STARTED AN AGGRESSIVE DIALOGUE WITH PHARMACEUTICAL COMPANIES TO TRY TO DEVELOP FORMULATIONS AND ESPECIALLY PEDIATRIC FORMULATIONS OR SECOND LINE THERAPY THAT WILL START OFF WITH GENERIC DRUGS FROM THE GET GO. WE NOW ARE REALLY 98% GENERIC IN PEPFAR, ABOUT 2% BEING MOSTLY SECOND LINE THERAPY THAT'S BRANDED. >> THANK YOU, VERY MUCH FOR YOUR TALK, DR. GOOSBY, VERY MUCH ENJOYED. IT'S DR. RICK BURZON FOR LERLY WITH U.S. AID NOW WITH THE NATIONAL INSTITUTE OF MINORITY HEALTH AND HEALTH DISPARITIES. I WANT TO ASK YOU, THE WHOLE ISSUE OF EVALUATION IS SO CRITICAL TO THE WORK THAT WE DO BECAUSE IT'S CRITICALLY IMPORTANT TO KNOW WHAT WORKS AND WHAT DOESN'T WORK. IT'S AN ISSUE OF ALLOCATION OF RESOURCES AND EFFICIENCY AND SO FORTH. I WAS WONDERING IF YOU COULD EXPAND A LITTLE BIT ON THE EFFORTS OF PEPFAR TO MOVE FORWARD WITH EVALUATION WORK, WORK THAT CAN BE DONE IN A TIMELY FASHION SO THAT WE KNOW AS QUICKLY AS POSSIBLE WHICH PROGRAMS ARE EFFICACIOUS AND WHICH PROGRAMS ARE COST EFFECTIVE AND WHICH PROGRAMS TO PUT OUR DOLLARS IN. >> THANKS, RICK. WE HAVE -- OUR TRADITIONAL MONITORING AND EVALUATION SYSTEMS IN PLACE FOR ALL THE PROGRAMS BUT WE HAVE ALSO PUT TWO OTHER LAYERS ON TOP OF OUR M AND E. REALLY LOOKING AT IMPACT EVALUATION AS THE CORE INFORMATION GENERATOR FOR THOSE ISSUES THAT YOU OUTLINED. WE REALLY BELIEVE THAT WE CAN WITH A SMALLER SAMPLE ON IMPACT EVALUATION BETTER UNDERSTAND IMPACT OF THE INTERVENTIONS THAT WERE SUPPORT -- THAT WE'RE SUPPORTING AS THE POPULATION'S NEEDS AND AS OTHER RESOURCES COME IN TO ALTER THE REFLECTION OF THAT IMPACT. IT GETS COMPLICATED AND WE HAVE GOTTEN A LOT OF HELP IN HOW TO THINK THROUGH METHODOLOGIES THAT ALLOW US TO DISCERN THOSE DIFFERENCES. RELATIVE ADDITIVE IMPACT, SEE THE COMBINATION AND REFLECT THE CONTRIBUTION, THE SYNERGY MAKES OF TWO DIFFERENT INTERVENTIONS TOGETHER. I BELIEVE WE ARE WELL-POSITIONED WITH A THIRD LAYER THAT IS PROSPECTIVELY LOOKING AT COMBINATION PREVENTION INTERVENTIONS IN PARTICULAR AND THEIR IMPACT ON DROPPING INCIDENTS SPECIFICALLY. SO THE M AND E, THE IMPACT EVALUATION AND PROSPECTIVE CONTROL STUDIED REALLY ARE HOW WE'RE APPROACHING IT. GETTING THOSE FEEDBACK LOOPS TO INFORM THE PROVIDER AND THE CLINIC AT THE HOSPITAL, SO THEY ARE MOTIVATED, GETTING THAT INFORMATION FED BACK TO THEM, SO THEY REALIZE THAT THE REPORTING EFFORTS WHICH IS CONSIDERABLE, IS NOT A WASTE OF TIME, HAS BEEN THE BIGGEST BARRIER TO GENERATE THAT TO BE QUITE HONEST WITH YOU. I KNOW WE ALL KNOW. >> HENRY MASUR, ERIC. ONE OF THE ISSUES YOU TOUCHED ON WERE SOME OF THE COMORBIDITIES WITH HIV. I WAS WONDERING IF YOU COULD EXPAND A LITTLE BIT ABOUT THE ISSUES OF TB. WE ARE AWARE TB IS OBVIOUSLY A MAJOR CO-FACTOR WITH HIV IN CAUSING COMORBIDITY AND ATTACKING HIV IS ONE APPROACH, HOW IS PEPFAR INTEGRATING WITH TB PROGRAMS TO TRY TO IMPROVE HUMAN HEALTH FROM BOTH ASPECT OF HIV AND ITS COMPLICATION? >> THANKS, HENRY. I THINK PEPFAR UNDERUTILIZED THE COMORBIDITY OF TB AND THE SUB SAHARAN AFRICAN SETTENING PARTICULAR. IT'S THE LEADING CAUSE OF DEATH IN HIV POSITIVE PEOPLE IN SUB SAHARAN AFRICA. TB, IT NOT PNEUMOSISTIS CRANEIA, IT'S TB. WE HAVE AGGRESSIVELY THE LAST THREE YEARS LINKED TO TB TREATMENT SITES. TB SITES ARE TESTING FOR HIV AND LINKAGES OF REFERRAL ARE FORMALLY PUT IN PLACE, NOT A LOOSE REFERRAL BUT A FORMAL REFERRAL. WHERE WE CAN WE HAVE PUT HIV AND TB TREATMENT ON THE SAME SITE THAT WORKS THE BEST. WE HAVE REALLY FOCUSED ON REVOLUTIONIZING THE USE OF X-RAYS MORE IN ADDITION TO MICROSCOPIC DIAGNOSIS FOR ACID FAST FACILLI, IDENTIFICATION TAKING A RADIO GRAPHIC CHANGE AS A DIAGNOSTIC EQUIVALENT, AS WHO HAS CHARACTERIZED FOR YEARS BUT WAS POORLY IMPLEMENTED IN SUB SAHARAN AFRICA. THEN WITH THE DEVELOPMENT OF THE ABILITY TO IDENTIFY MULTI-DRUG RESISTANT TB WITH GENE EXPERT AND THINGS LIKE THAT, WE'RE ON FOREFRONT OF PLACING THOSE AS POINT OF SERVICE CONTACT DIAGNOSTIC CAPABILITY IN AS MANY SITES AS WE CAN WITH REALLY DRAMATIC RESULTS. THE LAST AREA IS IN INH PROPHYLAXIS FOR HIV POSITIVE COMMUNITIES WHERE TB IS OF A CERTAIN PREVALENCE. WE'RE LOOKING AT THAT PROSPECTIVELY. WE BELIEVE THAT THERE'S ANOTHER BENEFIT THAT WILL BE REALIZED FROM THAT, BUT IT'S TRICKIER TO DOCUMENT. SO I THINK THAT LOOKING AT HIV AND TB AS JOINED AS THE HIP, WE DO MORE FOR TB THAN THE US GOVERNMENT AND U.S. AIDS PROGRAMS DO IN THEIR TB PROGRAM IN THE PEPFAR PROGRAM. U.S. AIDS FOCUSING ON MULTI-DRUG RESISTANT OUTSIDE THE PEPFAR PORTFOLIO. WE TAKE ON BOTH HIV TB AND MD RTB IN 33 COUNTRIES IN SUB SAHARAN AFRICA AND ABOUT 14 OUTSIDE OF SUB SAHARAN AFRICA. SO HIGH PRIORITY FOR US. WE ARE REALLY ANXIOUS TO CLOSE THAT GAP AND TURN IT AROUND. >> HI. THANKS SO MUCH FOR COMING TO TALK WITH US TODAY. I'M JULIA ROYAL. I RECENTLY RETIREED FROM THE NATIONAL LIBRARY OF MEDICINE AND CURRENTLY CONSULTANT FOR MEPE. I JUST RETURNED YESTERDAY AFTERNOON FROM UGANDA WHERE I WORKED FOR MANY YEARS AND WAS ABLE TO SEE THEIR EFFORTS UP CLOSE. MY QUESTION HAS TO DO WITH MEPE AND THE LAST TEN CENTIMETERS. I'LL EXPLAIN THAT A LITTLE BIT WHEN -- IF ALL GOES WELL WITH THE MEPE PROGRAM AND THEY PRODUCE WONDERFUL HEALTH PROFESSIONALS, READY TO GO OUT INTO THE FIELD, HOW DOES THAT LAST TEN CENTIMETERS SORT OF IN A STUDENTS' BRAIN GET ADDRESSED AND ENCOURAGED SO THEY ACTUALLY WILL AT LEAST MAYBE SERVE A YEAR OR TWO IN THE RURAL AREAS? THE BRAIN DRAIN ISN'T JUST TO THE U.S. AND THE UK AND OTHER PARTS, IT'S ALSO WITHIN AFRICA. BUT IT'S TO THE URBAN AREAS. I WONDERED IN YOUR VAST EXPERIENCE PERSONALLY AS WELL AS YOUR EXPERIENCE WITH OTHER PEPFAR PROGRAMS, WHAT MIGHT YOU ADVISE? IT IS A STRUGGLE EVERYWHERE AND A NUMBER OF TIMES I HAVE BEEN IN A CONVERSATION WITH SOMEONE WHO SPENT TWO YEARS TRAINING WITH TB DIAGNOSIS AND TREATMENT AND HAVE THEM BE WHISKED TO AN NGO OR LEAVE THE COUNTRY, IT'S A DIALOGUE THAT USUALLY CENTERS AROUND NOT WANTING TO BE SUPER RICH BUT WANTING TO TAKE CARE OF ACTIVITIES OF DAILY LIVING, KIND OF A LIVING WAGE. TOO MANY OF THE COUNTRIES IN WHICH WE WORK DO NOT PAY HEALTH PROFESSIONALS ENOUGH MONEY TO TAKE CARE OF THEIR NEEDS, GET THE KIDS TO SCHOOL, BUY THE BOOKS, BUY THE UNIFORM. THAT MORE OFTEN THAN NOT IS THE REASON PEOPLE ARE MOVING. THEY LIKE THE MONEY BUT THEY LOVE THEIR COUNTRY AND THEY -- IF THEY HAD A CHOICE IN MY EXPERIENCE WOULD STAY. I THINK GOVERNMENTS NEED TO LOOK AT THEIR CIVIL SERVICE SYSTEM, I THINK THE CORE PROBLEM IS THE GOVERNMENT NEEDS TO REFORM ITS CIVIL SERVICE STRUCTURE SO THEY CAN IDENTIFY THOSE INDIVIDUALS WHO ARE EMPLOYED IN JOBS THAT BENEFIT SOCIETY IN A SPECIAL WAY OR UNIQUE WAY OR DEMONSTRABLE WAY AND PAY THEM ENOUGH TO STAY. DOCTORS, NURSES, ON AND ON AS TO HOW AND WHERE YOU DRAW THE LINE BUT I DON'T THINK ANYONE WOULD ARGUE WITH DOCTORS AND NURSES. I THINK THAT'S THE FUNDAMENTAL DEFECT THAT WE NEED TO ADDRESS. >> LAST QUESTION TO ROGER GLASS. >> LOVELY TALK. YOU WORKED DOMESTICALLY AND INTERNATIONALLY ON AIDS AND YOU SHOW THAT REMARKABLE CURVE OF THE DECLINE IN PRICE FOR AIDS TREATMENT AND INCREASE IN COVERAGE. SO MY QUESTION TO YOU IS, ARE THERE ANY LESSONS FROM THE PEPFAR EXAMPLE OF INCREASED COVERAGE IN LOWERING COSTS THAT MIGHT BE OF DIRECT RELEVANCE HERE IN THE UNITED STATES WHERE WE CONTINUE TO HAVE AN HIV PROBLEM? >> THANKS, ROGER. IT IS REALLY COMPLICATED IN THE UNITED STATES. THE LAYERS OF AUTHORITY, THE PROTECTION FOR PATENTS. LEGAL CAPABILITY FOR BOTH SIDES OF AN ISSUE TO CONVERGE, AND ARREST MOVEMENT. PRETTY MUCH STOPS A LOT OF THE KIND OF GET IT DONE ATTITUDE THAT YOU CAN ALLOW TO PLAY OUT IN THE RESOURCE SETTINGS THAT WE'RE IN. I THINK BEING CLEAR ABOUT HIGH IMPACT IS A BIG LESSON. THOSE INTERVENTIONS THAT HAVE THE LARGEST BANG FOR THE BUCK NEED TO BE UNDERSTOOD AND IMPLEMENTED BETTER IN THE UNITED STATES, TARGETING HIGH RISK GROUPS FOR OUR EPIDEMIC IN THE UNITED STATES, MORE AGGRESSIVELY. NEEDS FOB PART OF THE -- NEEDS TO BE PART OF THE PACKAGE. THERE'S BEEN A HUGE MATURATION AND UNDERSTANDING OF HIV AND HIGHLY IMPACTED POPULATIONS, AFRICAN AMERICAN, HISPANIC IN PARTICULAR, INJECT -- THE ROLE INJECTION DRUG USERS PLAY IN MOVING THE VIRUS TO BOTH WOMEN AND PEDIATRIC POPULATIONS, THE REVOLVING DOOR OF PRISON POPULATIONS. WE NEED TO BETTER UNDERSTAND THE PUBLIC HEALTH INTERVENTION AND NOT THE SOCIETAL REACTION OR POLITICAL ISSUES AROUND THE BEHAVIOR. THE BEAUTY OF MEDICINE AND SCIENCE IS WE DON'T HAVE TO MAKE THOSE JUDGMENTS. WE SHOULD BE CLEAR ABOUT MAKING THE INTERVENTION. I THINK SOMETIMES OUR COLLEAGUES GET FATIGUED IN YELLING FIRE IN THE HOUSE AND NOT HAVING IT HEARD, I THINK HEALTH PROFESSIONALS ARE THE CLEAR VOICE OF REASON AND DIALOGUE THAT WOULD BE NICE TO INCREASE AGAIN ONE MORE TIME THE VOLUME IN CALLING FOR THOSE TYPES OF REFORMS. PRESIDENT OBAMA HAS TRIED TO FIX SOME OF THE AIDS DRUG ADAP PROGRAM IN THE UNITED STATES BEING LOCKED BY STATES, BLOCKED BY STATES THAT SET ELIGIBILITY CRITERIA BELOW THE POVERTY LINE. SO BARRING ACCESS. THOSE TYPES OF ISSUES STILL PERSIST. THEY WERE THERE IN THE 90s, THEY'RE STILL THERE. AND I THINK THE PRESIDENT HAS GOTTEN MORE AGGRESSIVE AROUND IT IN LAST TWO YEARS WITH A PLAN THAT'S IN PLAY. BUT THERE ARE LESSONS LIKE THAT THEY CAN'T ALL BE IMPLEMENTED IN THE UNITED STATES IN THE SAME WAY. >> I DON'T THINK WE COULD HAVE POSSIBLY HAD A MORE APPROPRIATE AND ELOQUENT PRESENTATION THAN WE HAVE HAD TODAY FOR THE BARNES LECTURE, ERIC, ON BEHALF OF ALL OF US AT THE NIH I WANT TO THANK YOU FOR YOUR LEADERSHIP, YOUR DEEP KNOWLEDGE OF THE SCIENCE OF THIS ENTERPRISE AND YOUR PERSONAL PASSION FOR ENDING THIS WORLD-WIDE PANDEMIC. WE HAVE A SENSE OF OPTIMISM THAT HAS NOT REALLY BEEN WITH US FOR MUCH OF THE LAST 20 YEARS AND YOU PERSONALLY HAVE CONTRIBUTED SO MUCH TO GET US TO THAT POINT. SO THANK YOU SO MUCH FOR BEING HERE. LET US THANK OUR SPEAKER AGAIN. [APPLAUSE]