GOOD AFTERNOON, EVERYONE. I AM DANA SAMPSON FROM THE NIH OFFICE OF BEHAVIORAL AND SOCIAL SCIENCES RESEARCH, OR OBSSR. THANK YOU FOR JOINING US TODAY FOR THIS SPECIAL SYMPOSIUM. WE ARE CONVENING IN HONOR OF THE MANY SIGNIFICANT CONTRIBUTIONS OF BEHAVIORAL AND SOCIAL SCIENCE TO HIV/AIDS RESEARCH THUS FAR AND FURTHER, TO HIGHLIGHT WAYS IN WHICH IT WILL CONTINUE TO ADVANCE THE UNDERSTANDING, TREATMENT AND PREVENTION OF THE DISEASE MOVING FORWARD. 2011 MARKS 30 YEARS SINCE THE FIRST U.S. REPORTED CASES OF AIDS. THE DISEASE CAUSED BY THE HIV VIRUS. SINCE 1981, THE DISEASE HAS ADVANCED IN VARIOUS WAYS, INCLUDING FROM LOCALIZED OUTBREAKS TO A GLOBAL PANDEMIC, FROM AFFECTING SPECIAL POPULATIONS TO NEARLY EVERY POPULATION, AND FROM AN AUTOMATIC DEATH SENTENCE TO A TREATABLE DISEASE. OVER THE PAST THREE DECADES, MORE THAN 60 MILLION PEOPLE HAVE BEEN INFECTED WITH THE HIV VIRUS AND NEARLY 30 MILLION PEOPLE HAVE DIED OF AIDS. EARNING HIV/AIDS THE TITLE OF THE WORLD'S LEADING INFECTIOUS KILLER. THE WORLD HEALTH ORGANIZATION COVERING -- CURRENTLY ESTIMATES TWOzV MILLION PEOPLE THROUGHOUT THE WORLD DIE EACH YEAR FROM HIV/AIDS. EXTRAORDINARY PROGRESS HAS BEEN MADE IN THE FIGHT AGAINST THIS DISEASE SINCE 1981, THOUGH NOT IMMEDIATELY OBVIOUS FROM SUCH GRIM NUMBERS. INDEED, MOMENTOUS IMPROVEMENTS HAVE BEEN MADE, INCLUDING EFFECTIVE REDUCTION FROM BOTH AIDS CASES AND MOTHER TO CHILD TRANSMISSION AS WELL AS INCREASED LIFE EXPECTANCY FOR HIV POSITIVE PERSONS. AS A RESULT OF THREE DECADES OF PROGRESS, HIV RATES IN THE UNITED STATES HAVE STABILIZED WITH ONE EXCEPTION, THE NUMBER OF AMERICANS NEWLY INFECTED WITH HIV HAS REMAINED STABLE IN RECENT YEARS BUT NEW INFECTIONS ROSE ALMOST 50% AMONG YOUNG BLACK MEN WHO HAVE SEX WITH MEN. HENCE WHILE OVER ALL DOMESTIC HIV RATES ARE STABLE, THERE IS WORK TO BE DONE TO ADDRESS THIS DISPARITIES. MOREOVER, THE CURRENT NATIONAL RATE REMAINS TOO HIGH ENCOURAGING US TO LOOK AHEAD TOWARDS THE NEXT GENERATION OF RESEARCH AND DETERMINE HOW BEST TO ACCOMPLISH THE ULTIMATE GOAL OF ERADICATING HIV/AIDS. TODAY AN ESTIMATED WORLDWIDE TOTAL OF 2.6 MILLION NEW HIV CASES ARE DIAGNOSED ANNUALLY, INCLUDING 50,000 NEW CASES HERE IN THE UNITED STATES. PRESENTLY, APPROXIMATELY 1.2 MILLION PEOPLE ARE LIVING WITH HIV/AIDS IN THIS COUNTRY. THESE NUMBERS ARE PARTICULARLY TRAGIC AS WE END THE THIRD DECADE OF OUR FIGHT AGAINST THIS DEADLY DISEASE. THE DISEASE IS DISTINCT FROM MANY OTHER INFECTIOUS DISEASES WITH A NEAR 100% FATALLY RATE AND SPREAD PRIMARILY THROUGH SEXUAL ACTIVITY AND DRUG USE. IT IS THEREFORE UNIQUE IN THAT AIDS IS A COMPLETELY PREVENTABLE DISEASE. FIRST AND FOREMOST, IT IS A CONSEQUENCE OF BEHAVIOR. IT IS NOT WHO YOU ARE BUT WHAT YOU DO THAT DETERMINES YOUR HIV EXPOSURE RISK. BEHAVIORAL AND SOCIAL SCIENCE THEREFORE PLAYS A PARAMOUNT ROLE IN HIV/AIDS RESEARCH CONSIDERING EVERY STRATEGY THAT CAN BE UTILIZED FOR PREVENTING THE ACQUISITION OR TRANSMISSION OF HIV HAS ONE OR MORE ASSOCIATED BEHAVIORAL COMPONENTS THAT CAN INFLUENCE ITS EFFICACY. FURTHER, A WIDE ARRAY OF INDIVIDUALS INTERPERSONAL, SOCIAL AND ENVIRONMENTAL FACTORS CAN INFLUENCE THE RISK OF HIV INFECTION. CONCLUDING THE 30th YEAR THE RESEARCH COMMUNITY FOCUSED ON CONTROLLING AND VERBY ENDING THE PANDEMIC THROUGH AGGRESSIVE PURSUITS OF SPECIFIC COMPONENTS OF THE RESEARCH AGENDA AS DESCRIBED IN THE PAPER RELEASED IN JUNE AUTHORED BY NIAID, DOCTORS DIEFFENBACH AND FAUCI TITLED 30 YEARS OF HIV AND AIDS AND FUTURE CHALLENGES AND OPPORTUNITY. THE PAPER DETERMINED ENDING THE PANDEMIC REQUIRES A FOCUS ON THREE PRIMARY RESEARCH AND IMPLEMENTATION GOALS, EXPANDED HIV TESTING, INNOVATIVE PREVENTION TOOLS AND A CURE WHICH BRINGS US TO THE FORMAT OF TODAY'S EVENT. AND IT WOULD NOT BE POSSIBLE TO COVER ALL THE WAYS IN WHICH BEHAVIORAL AND SOCIAL SCIENCE CAN PROPEL THE NEXT GENERATION OF HIV/AIDS RESEARCH. RATHER THE TARGETED FOCUS OF THIS SYMPOSIUM IS TO SHARE EXAMPLES OF HIV RESEARCH PROJECTS EMPLOYING BEHAVIORAL AND SOCIAL SCIENCES AIMED AT THE AFOREMENTIONED RESEARCH AND IMPLEMENTATION GOALS. SO IT IS NOW MY PLEASURE TO BRIEFLY INTRODUCE TODAY'S ESTEAMED SPEAKERS WHO WILL OFFER PRESENTATIONS ON THEIR HIGHLY REGARDED WORK ACROSS THE GLOBE. OPENING REMARKS WILL BE PROVIDED BY LEAD AUTHOR OF THE INSPIRATIONAL PUBLICATION, DR. CARL DIEFFENBACH. HE SEVERS AS THE DETECTOR OF THE DIVISION OF AIDS AT THE NIH NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS DISEASE. OR NIAID. AND OVERSEES A GLOBAL HIV/AIDS RESEARCH PORTFOLIO OF MORE THAN ONE BILLION DOLLARS AND A STAFF OF MORE THAN 150 FEDERAL EMPLOYEES. UCLA'S DR. THOMAS COATES WILL ADDRESS THE TOPIC OF EXPANDED TESTING. DR. COATES IS DIRECTOR OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES, PROGRAM IN GLOBAL HEALTH AND ENDOWED PROFESSOR OF GLOBAL AIDS RESEARCH WITH A DIVISION OF INFECTIOUS DISEASES AT THE UNIVERSITY. HIS AREAS OF EMPHASIS AND EXPERTISE ARE HIV PREVENTION, THE RELATIONSHIP OF PREVENTION AND TREATMENT FOR HIV AND HIV POLICIES. IN 2002, DR. COATES WAS CITEDDED IN "SCIENCE" AS BEING THE FOURTH HIGHEST FUNDED SCIENTIST IN THE CLINICAL, SOCIAL AND BEHAVIORAL SCIENCES AND IS A MEMBER OF THE INSTITUTE OF MEDICINE. COLUMBIA UNIVERSITY'S DR. WAFAA EL-SADR WILL ADDRESS THE TOPIC OF EFFECTIVE PREVENTION STRATEGIES. DR. EL-SADR IS DIRECTOR OF THE INTERNATIONAL CENTER FOR AIDS CARE AND TREATMENT PROGRAMS AT COLUMBIA UNIVERSITY'S SCHOOL OF PUBLIC HEALTH. SHE IS ALSO PROFESSOR OF CLINICAL MEDICINE AND EPIDEMIOLOGY AND LEADS THE UNIVERSITY'S GLOBAL HEALTH INITIATIVE. SHE IS A RECOGNIZED LEADER IN GLOBAL HEALTH WITH INTERESTS IN. IV, TB, MATERNAL AND CHILD HEALTH, CAPACITY EF BUILDING AND HEALTH SYSTEMS STRENGTHENING. SHE IS A MCCARTHUR FULLO AND A MEMBER OF THE INSTITUTE OF MEDICINE. HARVARD UNIVERSITY'S DR. BANGSBERG WILL TALK TO SEEKING A CURE THROUGH ADHERENCE. HE IS DIRECTOR OF THE INTERNATIONAL PROGRAM OF THE HARVARD UNIVERSITY CENTER FOR AIDS RESEARCH WITH APPOINTMENTS IN THE HARVARD SCHOOL OF MEDICINE AND UGANDA'S MOW BAR UNIVERSITY OF SCIENCE AND TECHNOLOGY. HIS RESEARCH FOCUSES ON SOCIAL BEHAVIORAL FACTORS RELATED TO HIV TREATMENT ACCESS, ADHERENCE AND OUTCOMES AND IMPOVERISHED POPULATIONS IN WHICH SHE HAS RAISED OVER 40 MILLION DOLLARS IN FUNDING. DR. BANGSBERG HAS OVER 120 PUBLICATIONS AND IN 2007, WAS THE SECOND HIGHEST RANKED NIH FUNDED RO1 INVESTIGATOR IN HIV/AIDS. TO LEARN MORE ABOUT THESE SPEAKERS, PLEASE REFERENCE THE COMPREHENSIVE BIKE FEES DOCUMENT PROVIDED TODAY ALSO AVAILABLE ON THE OBSSR WEBSITE. TO ENSURE EQUAL AND ADEQUATE TIME FOR PRESENTATION, EACH WILL BE 30 MINUTES, CONCLUDING WITH AN ADDITIONAL 5 MINUTES FOR A SINGLE CLARIFYING QUESTION FROM THE AUDIENCE. WE WILL ADJOURN AFTER A WRAP UP PROVIDED BY THE OBSSR DIRECTOR AND NIH ASSOCIATE DIRECTOR FOR BEHAVIORAL AND SOCIAL SCIENCE RESEARCH, DR. ROBERT KAPLAN. FOLLOWED BY AN OPEN FORUM FOR PARTICIPANTS TO QUERY TODAY'S SPEAKERS. AND NOW WITHOUT FURTHER ADIEU, PLEASE JOIN ME IN WELCOMING OUR FIRST SPEAKER, DR. CARL DIEFFENBACH. [APPLAUSE] >> THANK YOU FOR THAT VERY KIND INTRODUCTION. IT IS A PLEASURE TO BE HERE TODAY AND SEE SO MANY FRIENDLY FACES AND COLLEAGUES. SO I AM GOING TO TRY TO FRAME TODAY AND TALK A LITTLE BIT ABOUT WHERE WE HAVE BEEN BUT MAINLY FOCUS ON WHERE I THINK WE ARE HEADED. SO IN 30 YEARS OF AIDS, WE HAVE MADE SIGNIFICANT PROGRESS IN A NUMBER OF KEY AREAS, EVERYTHING FROM ETIOLOGY, PATHOGENESIS, TO BEING ABLE TO֜ DIAGNOSE THE DISEASE TO NATURAL HISTORY PATHOGENESIS AND TREATMENT IS ONE OF OUR GREAT SUCCESSES AS WE JUST HEARD, PREVENTION AND EVEN A LITTLE BIT OF PROGRESS ON VACCINE DEVELOPMENT. ALL OF THIS COMES TOGETHER TOWARDS OUR COMMON GOAL. ALL OF US ARE WORKING TOWARDS THE SAME GOAL OF CONTROLLING AND ULTIMATELY ENDING THE GLOBAL PANDEMIC. THE THRUST OF THE MANUSCRIPT THAT WE AUTHORED DEALT WITH THREE KEY AREAS. THE NEED TO SCALE UP DELIVERY OF PROVEN THERAPIES, BEING ABLE TO PERFORM RESEARCH THAT CAN LEAD TO A CURE AND BE ABLE TO PREVENT NEW INFECTIONS. NOW, I CAN'T UP STAGE OUR SPEAKER WHO WAS ON CAMPUS YESTERDAY, SECRETARY OF STATE, HILLARY CLINTON, REALLY COVERED THE FIRST ONE BETTER THAN I COULD EVER COVER. SO I'M GOING TO NOT TALK ABOUT THAT BUT I'M GOING TALK MAINLY ABOUT PROGRESS IN THE AREA OF PREVENTION. AND YOU CAN SEE FROM THIS SLIDE THAT I HAVE PROIATED FROM MIKE COHEN, THAT PREVENTION CAN OCCUR AT MANY STAGES FROM ACTIVITIES THAT ARE PRESENT IN THE ENVIRONMENT, PRESENT IN THE CULTURE OVER A LONG PERIOD OF TIME, BEHAVIORAL AND STRUCTURAL INTERVENTIONS, ALL THE WAY THROUGH TREATMENT AS PREVENTION WHICH IS SORT OF THE NEW KID ON THE BLOCK. SO I'M GOING SPEND A FEW MOMENTS TALKING ABOUT THE PROMISE AND THE LIMITATIONS OF ANTIVIRAL THERAPY, I THINK THIS IS ONE OF THE KEY FEATURES THAT WILL BE COVERED TODAY. FIRST AND FOREMOST, WE HAD THE RESULTS THIS PAST SUMMER OF HPTN052 WHICH DEMONSTRATED UNEQUIVOCALLY THAT TREATMENT PROVIDED TO AN HIV-INFECTED PARTNER AND MOST IMPORTANTLY WITH SUSTAINED VIRAL LOAD REDUCTION OF UNDER 400 COPIES OF VIRUS PER MILLIMETER LED TO A 96% REDUCTION IN TRANSMISSION AMONG LINKED PARTNERS. THIS IS A PROFOUND FINDING AND REPRESENTS MAJOR STEP FORWARD. THIS IS PROOF OF PRINCIPLE THAT TREATMENT AS PREVENTION WILL WORK. HOWEVER, THIS IS REALITY HERE IN THE UNITED STATES, THIS IS WHAT WE CALL THE CASCADE OR THE CLIFF, OR NIAGRA FALLS OR WHATEVER YOU WANT TO CALL IT. BUT FUNDAMENTALLY, THIS IS WHAT WE FACE TODAY. THIS IS WHY THE LINKAGE OF BEHAVIOR AND BIOMEDICAL RESEARCH IS SO CRITICAL. IN EVERY 100HIV INFECTED PEOPLE, WE KNOW OF 79 OF THEM WHO ARE HIV POSITIVE. OF THAT 79, 47 ARE LINKED TO CARE ON AVERAGE. OF THAT 47, 26 END UP ADHERING AND HAVING SUSTAINED REDUCTION IN VIRAL LOAD. NA MEANS THAT EASILY 3/4 OF THE PEOPLE THAT NEED TO BE ON TREATMENT, NEED TO HAVE ADHERENCE, ARE NOT CONTROLLED. THIS IS OUR CHALLENGE. HOW CAN WE COME TOGETHER TO IMPROVE THE NUMBERS OF THIS CASCADE IN THESE RULES OF DIMINISHING RETURNS? I THINK IT'S IMPORTANT THAT WE SETTLE ON SOME PHILOSOPHIES AND SOME APPROACHES. TO ME, THE ONE FUNDAMENTAL FEATURE THAT HAS BECOME ABUNDANTLY CLEAR IS FOR AN INDIVIDUAL, THE KEY ENTRY POINT FOR ALL HIV PREVENTION AND TREATMENT IS TESTING. CLEARLY WE ARE GOING TO NEED TO FIGURE OUT HOW TO TEST AND HOW TO TEST BETTER AND IF FOR CERTAIN POPULATIONS, TEST REGULARLY. UNDERSTANDING THE BEHAVIORS OF THE SOCIAL DRIVERS THAT BOTH IMPEDE TESTING AND IMPROVE TESTING WILL MAKE A BIG DIFFERENCE. SO, FROM OR TO TAKE A STEP BACK FROM NOT JUST BEHAVIORAL RESEARCH BUT ALSO SOCIAL SCIENCE RESEARCH, CAN WE DEVELOP STRUCTURAL INTERVENTIONS THAT CAN LEAD TO COMMUNITY MOBILIZATION THAT WILL REALLY CHANGE THE DYNAMIC AROUNDzV HIV TESTING? CAN WE MAKE KNOWLEDGE OF HIV STATUS SOCIALLY DESIRABLE OUTCOME? IN ORDER TO DO THAT WE ARE GOING TO NEED TO FIGURE OUT WAYS AT ALL LEVELS OF DEALING WITH STIGMA. SO WHAT WE HAVE COME TO APPRECIATE -- AND I THINK THAT'S WHY YOU HAVE SOMEBODY WHO IS A Ph.D. IN BIOPHYSICS LEADING OFF THIS SYMPOSIUM TODAY, IS THE GRAND APPRECIATION OF THE NEED TO SEAMLESSLY LINK BIOMEDICAL RESEARCH WITH SOCIAL AND BEHAVIORAL RESEARCH, BECAUSE WITHOUT THE TWO COMING TOGETHER, WE WILL NEVER SOLVE THIS DISEASE. SO THIS INTEGRATION REALLY LEADS TO A NEW INTERDISCIPLINARY PLATFORM AND THIS IS THE BASIS OF COMBINATION THERAPY -- COMBINATION PREVENTION RESEARCH. COMBINATION EVERYTHING WE ARE ABOUT. SO WHAT WE NEED IS TO BE ABLE TO HAVE THIS REACH DISCIPLINE DEFINED FINE THE IMPEDIMENTS OF DRIVERS AND UPTAKE AND DEVISE THE WAYS TO INCREASE THE DURABILITY OF THE INTERVENTIONS. WE CAN'T HAVE BIOMEDICAL PROGRESS ALONE BECAUSE ULTIMATELY, WE NEED BEHAVIORAL RESEARCH AND IT NEEDS TO BE ANNOTATIVE PROCESS BETWEEN THE TWO. NOW I'M JUST GOING TO SAY A WORD ABOUT CURE BECAUSE I WAS ASKED TO. AND I THINK IT'S IMPORTANT THAT WE THINK ABOUT THIS BECAUSE ULTIMATELY WE CAN PREVENT ALL THE NEW INFECTIONS IF WE STOP TOMORROW. WE WOULD STILL HAVE OVER 33 MILLION PEOPLE LIVING WITH AIDS AND HIV. THEREFORE IT IS IMPORTANT THAT WE ENGAGE IN RESEARCH LIKE THIS, PARTICULARLY HERE AT NIH. SO IT ALL STARTS WITH THE DEFINITION AND FOR ANY DISEASE, THE DEFINITION OF A CURE IS PERMANENT REMISSION IN THE ABSENCE OF THE REQUIREMENT OF THERAPY. SO WHY DO WE NEED A CURE? AS I SAID, A MOMENT AGO, IF WE STOPPED ALL HIV TRANSMISSIONS TODAY, WE WOULD STILL HAVE 34 MILLION PEOPLE LIVING WITH AIDS. WHAT WE NEEDED TO BE ABLE TO DO ULTIMATELY TO CONTROL THE EPIDEMIC, IS TO SHRINK THE POPULATION FROM WHICH TRANSMISSION CAN OCCUR. THAT'S ANOTHER REASON. AND ADDITIONALLY, IF YOU THINK ABOUT IT FROM THE STANDPOINT OF MOTIVATING CLIENTS, IF YOU COULD SAY TO SOMEBODY, IF DIAGNOSED, YOU HAD EVEN A 50 OR 60 OR 70% CHANCE OF UNDERGOING A TREATMENT THAT WAS AFFORDABLE AND SAFE, THAT YOU COULD BE CURED, I THINK IT WOULD BE AN ENHANCEMENT IN A WAY OF ENCOURAGING PEOPLE TO RECEIVE HIV TESTING. AND THIS IS A PERSONAL LEAVE. ONLY A COMBINED APPROACH OF TREATMENT AT SCALE, COMBINATION PREVENTION AND CURE WILL RESTART TO ACHIEVE THE LEVEL OF PROFOUND IMPACT THAT WE WANT TO HAVE ON THE HIV PANDEMIC. SO, ULTIMATELY THERE ARE TWO KEY WAYS THAT WE CAN TALK ABOUT A CURE. ONE IS THE TRUE ERADICATION OF THE VIRUS IN TERMS OF CREATING A STERILIZING CURE, AND THE OTHER IS THROUGH A CREATION OF AN IMMUNE RESPONSE OR SOME SORT OF RESPONSE IN THE BODY THAT LEADS TO PERMANENT SUPPRESSION OF VIRUS REPLICATION WITHOUT ERADICATION. BUT THE KEY PIECE OF THIS IS IT ALSO MUST BE COUPLED WITH A RESPONSE TO THE VIRUS THAT DOESN'T ALLOW FOR THAT INDIVIDUAL TO BE INFECTIOUS. SO, YOU CAN HAVE A PERMANENT SUPPRESSION WITHOUT THE ABILITY TO TRANSMIT AND THEN I THINK WE'LL BE SOMEWHERE. AND I THINK WE'LL MAKE MORE PROGRESS FIRST AND FOREMOST ON THE FUNCTIONAL CURE AND THEN EVENTUALLY GET TO A PLACE WHERE WE CAN TRULY ERADICATE. SO I'M GOING SPEND A MOMENT OR TWO TALKING ABOUT THE LAST BULLET, PREVENTING NEW INFECTIONS. THIS SLIDE, FOR MEEKS CAPTURES THE CHALLENGE THAT WE FACE IN LINKAGE OF BEHAVIOR AND BIOMEDICAL. SO IF YOU THINK ABOUT PRE-EXPOSURE PROPHYLAXIS, WE HAD A RANGE OFyM RESULTS IN USING PRO EXPOSURE PROPHYLAXIS TO PREVENT HIV INFECTIONS, FROM THE FEN PREP TRIAL WHICH HAD NO EFFICACY TO THE RECENT TRIAL THIS SUMMER DONE BY CONNIE KELLER MAN GROUP, WHICH HAD 73% EFFICACY. WHAT WAS THE DIFFERENCE BETWEEN THESE? THE DRUGS WERE THE SAME. THE DIFFERENCE WAS THAT IN EACH OF THESE TRIALS, WE ARE NOT TESTING THE EFFICACY OF AN ANTIVIRAL. WE ARE TESTING THE LINKAGE OF A BEHAVIORAL INTERVENTION TO ENCOURAGE PEOPLE TO TAKE THESE AGENTS AND THEIR EFFICACY. IN THE COUPLE STUDY, THEY HAD PROFOUND ABILITY TO ENHANCE THE BEHAVIOR, TO ADDANCE THE ADHERENCE IN THE FEN PREP TRIAL. OBVIOUSLY IT WAS AN AB JECT FAILURE. IN WORK BEING DONE IN FEM PREP AS WELL AS OTHER MICROBICIDE TRIALS RIGHT NOW, WE ARE SEEING ESSENTIALLY NO BLOOD LEVEL IN PATIENTS IN THESE KINDS OF SITUATIONS AND WHAT CONNIE AND JARRED AND THE FOLKS AT UNIVERSITY OF WASHINGTON ARE SEEING, IS EXTREMELY GOOD LEVELS OF THE ANTIVIRAL IN THE BLOODSTREAM AND TISSUE OF THE PATIENTS. SO WE HAVE OBJECTIVE MEASURES OF THE FAILURE ON OUR PART AS SCIENTISTS TO EFFECT THE BEHAVIOR NEEDED FOR PILL TAKING. SO, JUST SOME CLOSING REMARKS. AND SORT OF MY THOUGHTS ON WHERE WE AND ARE WHERE WE NEED TO BE. HIV TESTING IS THE ENTRY POINT FOR ALL PREVENTION STRATEGIES WHETHER YOU TEST AND YOU'RE HIV POSITIVE AND GO INTO TREATMENT, AND TREATMENT IS PREVENTION OR YOU'RE HIV-NEGATIVE AND NEED TO GO INTO MORE CLASSICAL PREVENTION STRATEGIES. FOR THE FORESEEABLE FUTURE, ART, ANTIVIRAL THERAPY WILL BE THE CORNERSTONE OF ALL PREVENTION STRATEGIES AND IT'S OUR CHALLENGE TO BE ABLE TO OPTIMIZE THE TESTING, THE LINKAGE AND RETENTION AND CARE AND THE ABILITY TO OBTAIN FULL VIRAL SUPPRESSION. THAT WILL BE OR THAT WILL BE THE SUCCESS OR FAILURE OF ALL OF THESE COMBINATION PREVENTION STRATEGIES. LESLIE -- LASTLY, SOCIAL SCIENCE RESEARCH, SHOULD ESTABLISH AND PROMOTE STRATEGIES IN MESSAGES WHERE KNOWLEDGE OF YOUR HIV STAT SUSSOCIALLY DESIRABLE AND TREATMENT OF HIV INFECTION IS SOCIALLY RESPONSIBLE. IN THE END, IT IS IT OUR RESPONSIBILITY AS WELL TO IMPROVE HIV THERAPY IN TERMS OF SAFETY, TOLERABILITY AND DURABILITY AND EASE OF USE. TOGETHER, WE HAVE OR WE CAN BUILD THIS COMPLETE RANGE OF STRATEGY THAT IS CAN ASSEMBLE IN COMBINATION PREVENTION BUT AS I SAID, TREATMENT AS PREVENTION WILL BE THE CORNERSTONE BUT EVERYTHING NEEDS TO BE CONSIDERED AND THEN ADDED AT AN APPROPRIATE LEVEL. WITH THAT I'LL STOP AND TURN THE MICROPHONE BACK OVER. [APPLAUSE] >> THANK YOU. NOW PLEASE JOIN ME IN WELCOMING UCLA'S DR. THOMAS COATES. >> THANK YOU VERY MUCH. IT'S AN HONOR TO BE HERE TODAY. IT'S AN HONOR TO PRESENT AT THIS FORUM AND A PLEASURE TO SPEAK TO ALL OF YOU. THE OFFICE OF OBSSR ORGANIZED THIS FORUM AND THANK YOU.zV AND A BIG THANKS TO NIH TO THE APTN, TO NIAID, TO THE OFFICE OF AIDS RESEARCH AND PARTICULARLY TO NIMH FOR SUPPORTING THIS EFFORT. IT'S BEEN GRATIFYING AND WONDERFUL. SO, AS WE KNOW, AND AS DR. DIEFFENBACH MENTIONED, ONE OF THE MAJOR CHALLENGES IN HIV EPIDEMICS IS THE FACT THAT -- AND PROBABLY ONE OF THE GENIUSES OF THE EVOLUTION OF HIV, IS THE FACT THAT IT HAS SUCH A LONG LATENCY PERIOD AND IT CAN PRED BEFORE PEOPLE REALIZE THEY HAVE IT OR ARE SPREADING IT. AND WE, MANY YEARS AGO, THOUGHT OF THIS IDEA OF TESTING AN INTERVENTION THAT WOULD DESTIGMATIZE AND NORMALIZE AND I LIKE THE USE OF THE TERM, MAKE IT SOCIALLY RESPONSIBLE. THIS IS WHAT YOU DO TO BE A GOOD CITIZEN. YOU FIND OUT IF YOU HAVE HIV. AND TO ENHANCE DISCLOSURE, WE THOUGHT MAYBE THERE IS WAYS OF ORGANIZING AN INTERVENTION THAT COULD TAKE OR CAPITALIZE ON PREVENTION OPPORTUNITIES. SO IN THIS STUDY, NIMH PROJECT ACCEPT, WE STUDIED TWO APPROACHES. A COMMUNITY-BASED HIV COUNSELING AND TESTING WHICH INVOLVES COMMUNITY PREPARATIONS OUTREACH, MOBILIZATION, MOBILE VCT AND POST-TEST SUPPORT SERVICES AND THIS ACTUALLY -- WE DIDN'T PLAN THIS AS PART OF THE ORIGINAL INTERVENTION, BUT ONGOING DATA FEEDBACK AND FIELD ADJUSTMENTS. IT TOOK A LOT OF FEEDBACK TO TEAMS TO REACH OUR GOALS AND I'LL TALK ABOUT THAT DYNAMIC VERSUS A STANDARD CLIENT-BASED VCT. NOW, BECAUSE OF THE NEED TO EXPAND HIV TESTING, THERE HAVE BEEN LOTS OF DIFFERENT APPROACH THAT IS HAVE BEEN LOOKED AT IN THE LITERATURE. CERTAINLY AFRICA, PARTICULARLY SUB-SAHARAN AFRICA WAS ONE OF THE EARLY ADOPTERS OF RAPID HIV TESTING TO MAKE THE TESTS MORE POSSIBLE. THEN THERE WAS THE ROUTINE HIV TESTING AND THEN COUPLES HIV TESTING THAT SUZANNE ALAN, MANY YEARS AGO DISCOVERED AND KEPT PROMULGATING AND CONTINUES TO PROMULGATE. THEN THERE WAS THE IDEA OF MAYBE IF YOU GO TO HOUSE-TO-HOUSE AND THEY PILOTED THIS IN UGANDA AND IN KENYA, AND THE RESULTS WERE VERY GRATIFYING. WHEN YOU INVOLVE THE WHOLE FAMILY AND DISCLOSURE IS PART OF THE PROCESS, YOU GET VERY HIGH UPTAKE RATES. WORKPLACE HIV TESTING AND OUT IN LATEST CALL IS FOR INTEGRATION WITH OTHER SERVICES. TB AND HIV IS AN OBVIOUS ONE. AND THERE IS NOW A STUDY IN SOUTH AFRICA LOOKING AT INTEGRATED MATERNAL NEWBORN CHILDHOOD HIV CARE WHICH MAKES SENSE. NOW, PART OF THE GLOBAL HEALTH INITIATIVE OF THE OBAMA ADMINISTRATION IS INTEGRATION OF SERVICES ACROSS THE RANGE EVER SERVICES. I'LL TALK ABOUT THAT LATER IN THE TALK. IT'S NOT SO EASY. IT SOUNDS GREAT BUT IT'S NOT SO EASY AND I'LL TALK ABOUT THE REASONS WHY. SO THE PACKAGE WE PUT TOGETHER, WE THOUGHT WAS A COMPLETE PACKAGE. OUTREACH IS THE KEY, MOBILIZING COMMUNITIES AND POPULATIONS, PROVIDING VOLUNTARY COUNSELING AND TESTING THAT IS EASILY ACCESSIBLE AND EASILY AVAILABLE, POST TEST SUPPORT SERVICES AND THEN AS I MENTIONED, THE KEY OF DATA AND USING DATA TO REFINE THE WAY THOSE SERVICES ARE OFFERED WAS ESSENTIAL. THE STUDY SITES WE HAD FOUR IN AFRICA, THE REGION OF SOUTH AFRICA IN NEPAL, WHICH IS EXPERIENCING ONE OF THE MOST SEVERE HIV EPIDEMICS IN THE WORLD, IN URBAN JOHANNESBURG, IN MUTOKO, RURAL ZIMBABWE AND RURAL TANZANIA AND WE HAD A FIRST SITE IN THAILAND. SO THESE AREsTHE FIVE STUDY SITES. AND EACH OF THEM RECRUITED A DISTINCT NUMBER OF COMMUNITY PAIRS, THE COMMUNITIES WERE ROUGHLY 6000 TO 10,000 PEOPLE IN SIZE. TANZANIA, THAILAND, SOUTH AFRICA AND EVEN IN URBAN SOWETO, IT WAS POSSIBLE TO FIND COMMUNITY PARIS AND RURAL SIM BAB WAY. THESE ARE OUR COLLABORATORS. QUITE A CAST OFICATORRERS. INCLUDING THE STATISTICAL CENTER AT CHARLES UNIVERSITY IN PRAGUE, THE DATA CENTER IN INDIA AND COLLABORATORS FROM ACADEMIC INSTITUTIONS IN THE UNITED STATES AND ALL OVER THE WORLD. ONE OF OUR COLLABORATORS IS HERE, WHERE ARE YOU MIKE? FROM THE MEDICAL COLLEGE OF SOUTH CAROLINA IS HERE. SO THIS IS THE DESIGN OF THE STUDY. THERE WAS A BASELINE SURVEY WHICH IS THE PROBABILITY-BASED SAMPLE OF COMMUNITY MEMBERS. AND THE WAY WE DID IT IN SOUTH AFRICA AT LEAST IS SINCE THERE WERE NO MAPS OF HOUSES, WE SENT OUT AIRPLANES. WE TOOK AERIAL PHOTOGRAPHS, YOU NUMBER THE HOUSEHOLDS AND RANDOMLY SECT THE HOUSE HOSED, YOU CAN GPS THEM, YOU KNACK ON THE DOOR, ASK FOR THE HEAD OF THE HOUSEHOLD, WHICH COULD BE A MAN, WOMAN OR CHILD, AND YOU SAY, THIS IS WHAT WE ARE DOING, CAN WE RECRUIT THE ELIGIBLE MEMBERS OF YOUR HOUSEHOLD? THEN WE HAD COMMUNITY RANDOMIZATION, THREE YEARS OF INTERVENTION. THE POST-TEST ASSESSMENT IS DONE ACTUALLY. SHI HAVE CHANGED THAT SLIDE. WE ARE COLLECTING ALL THE SAMPLES TOGETHER. WHICH INCLUDED AN ASSESSMENT OF A RANDOM ASSESSMENT OF 18-32-YEAR-OLDS AND EACH INTERVENTION AND CONTROL COMMUNITY OF ABOUT 52,000 AND ALSO INCLUDED A BEHAVIORAL SURVEY AND WORKING ON BIOLOGIC ASSAYS TO MENTION INCIDENTS. THERE WAS A QUALITATIVE COHORT AND A COST EFFECTIVENESS COMPONENT. SO THIS IS JUST AN EXAMPLE. SO THIS IS THE AIRPLANE VIEW. AND YOU CAN SEE THAT THIS AREA HAS AREAS OF CLUSTERS OF HOUSES AND THERE IS A NATURAL BOUNDARY LIKE THESE VALLEYS. AND LIKE MANY AREAS BUILT-UP, THIS IS PRINCIPALLY ZULU COUNTRY. LIKE MANY AREAS BUILT-UP DURING THE APARTHEID ERA, THERE WERE NOT A LOT OF ROADS BUILT BETWEEN COMMUNITIES. ALL THE ROADS IN THIS CASE WENT INTO DURBAN WHERE PEOPLE WERE ALLOWED TO GO IN FOR DAY WORK BUT THEN HAD TO COME BACK TO THEIR COMMUNITIES AT NIGHT. SO, IN ADDITION TO THE AERIAL MAPPING, WE DID PARTICIPATORY MAPPING. WE TALKED TO THE COMMUNITY AND LAID OUT THE MAPS AND ASKED WHERE THE SERVICES WERE AND IT RESULTED IN A MAP SOMEWHAT LIKE THIS WHERE WE COULD MAP WHERE THE CLINICS WERE AND WHERE THE HOSPITALS WERE AND KNOW WHERE WE WERE GOING TO BE ABLE TO REFER PEOPLE, BE IT CLINICS OR HOSPITALS AND THIS BECAME MORE AND MORE IMPORTANT AS ART BECAME MORE AND MORE AVAILABLE AND IT WAS ONE OF THOSE THINGS THAT HAPPENS DURING THE COURSE OF DOING A STUDY LIKE THIS, THAT IS THAT WHEN WE STARTED ART AVAILABILITY WAS NOT EACH A POSSIBILITY. AND WHEN WE FINISHED, ART AVAILABILITY IS QUITE PREVALENT IN SOME OF THESE AREAS. SO THIS GIVES YOU AN EXAMPLE. THIS IS ANOTHER PICTURE HERE. THESE ARE SOME OF THE HOUSING STRUCTURES AND YOU CAN SEE THE VARIETY OF STRUCTURES, INCLUDING MODERN BRICK HOMES AS WELL AS MORE TRADITIONAL HUTS AND SOMETIMES PEOPLE WILL, SOME OF THE FAMILY WILL LIVE IN THE MORE TRADITIONAL HUTS AND SOMETIMES THEY WILL RENT THOSE OUT TO OTHER FAMILIES THAT NEED A PLACE TO LIVE. THIS IS A PICTURE OF THE MOBILE VCT VAN AND THIS WOULD BE THE VAN SET UP THAT WOULD BE SET IN A PLACEyM WHERE PEOPLE WERE TRANSPORTED A LOT. NOW, OF COURSE, THERE IS ELLEN. THAT'S A GREAT PICTURE RIGHT HERE. THIS WAS THE KICKOFF OF THE PROJECT IN NATAL. THIS IS OR THIS GENTLEMAN HERE IN THE MIDDLE IS ENICOSEY, THE CHIEF OF THE ZULU AREA. THE GENTLEMAN AROUND HIM ARE THE TRIBAL COUNCIL. THEY ARE VERY IMPORTANT PEOPLE. AND THERE WAS THE KICKOFF LUNCH ON THAT WE HAD FOR THE CONFERENCE. THEY HAVE A VERY INTERESTING TRADITION IN ZULU CULTURE, AND THAT IS WHEN THE CHIEF OR ANY OF THE COUNCILLORS GET UP TO SPEAK, THE INTRODUCTION IS NOT AS DANA DID, A VERY LOVELY RECITATION OF OUR ACADEMIC ACHIEVEMENTS, IT'S A SONG. AND THEY PRAISE THE SINGER, SINGS FOR 15 OR 20 MINUTES ABOUT ALL THE ACCOMPLISHMENTS OF THE CHIEF. I SUGGESTED THAT MY STAFF LEARN HOW TO DO THAT. [LAUGHTER] THEY HAVEN'T BEEN INTERESTED IN TAKING IT UP BUT IT'S GREAT. ANY WAY, THE CHIEF GOT UP AND GAVE A VERY INSPIRING TALK AND HE SAID, HOW CAN I LEAD A NATION IF THAT NATION IS DEAD? WE NEED YOUR SERVICES. AND I NOT ONLY PROMISE YOU MY SUPPORT, I PROMISE YOU MY PROTECTION. WHICH MEANT THAT NOBODY MESSED WITH US. AND THE PROTECTION WAS PROBABLY VERY, VERY IMPORTANT. AS YOU CAN SEE, ONE OF THE TRIBAL LEADERS IS COMING OUT OF THE CARAVAN WITH HIS TEST RESULTS. THEY ALL GOT TESTED. AND IT REALLY INSPIRED THE COMMUNITY TO TEST. WE HAPPENED UPON EVENT TESTING AND WE PARKED THE CARAVAN NEXT TO THE HIGH SCHOOL. THE HIGH SCHOOL STUDENTS HAD A DEBATE, SHOULD PEOPLE BE TESTED, SHOULD PEOPLE NOT BE TESTED AND MOST OF THE HIGH SCHOOLERS CAME TO GET TESTED. YOU SEE THE KINDS OF EVENTS THAT WE DID. IN THAILAND, OF COURSE WE HAD TO MODIFY THE INTERVENTION FOR A DIFFERENT CULTURE. AND THERE THEY ADOPTED THE THEME, BRING PEOPLE TO WORK TOGETHER TO FIGHT AGAINST HIV/AIDS. WE WORKED WITH RELIGIOUS LEADERS, THE BUDDHIST MONKS, TO HELP SPREAD THE MESSAGE, WE PUT ON CONCERTS IN THE COMMUNITY. THIS IS RURAL TANZANIA WHERE WE HAD DIFFERENT KINDS OF CHALLENGES AND EVEN GOT HEAVIER DUTY VEHICLES TO TRANSPORT AROUND AND SOMETIMES HAD TO DEAL WITH RAINS AND FLOODING AND OTHER SUCH EVENTS. AND THIS IS AN EXAMPLE OF THE SETUP IN RURAL TANZANIA. BUT WE DID MAKE IT A POINT BECAUSE PART OF THE OBJECTIVE HERE WAS TO DESTIGMATIZE HIV. TO GO TO WHERE THE PEOPLE ARE. DON'T HIDE THE SERVICE. AND LET IT BE VISIBLE, AS VISIBLE AS POSSIBLE. WE WANTED TO DRAW CROWDS, CREATE INTEREST. SO IN TANZANIA, THEY USED THE BOOM BOX AS A WAY OF BRINGING THE CROWD OUT TO COMMUNITY DANCING AND COMMUNITY EVENTS AND HAD A LOT OF JOINT EFFORTS. IN SOWETO, WHICH IS VERY POPULAR AS ONE OF THE PLACES WHERE APARTIED WAS OVERTHROWN, THEY WENT VERY VISIBLE. VIBRANT COLORS, AND VIBRANT-COLORED VANS. YOU NOTICE AGAIN THIS ONE OF THE CHALLENGES OF DOING ONE OF THESE STUDIES. NOTICE THE NUMBER ON TOP OF THE VAN. IT'S BECAUSE WE HIRED A COMPANY CALLED, TRACKER, AND IF A VAN GOT STOLEN, THEY SENT OUT THE HELICOPTERS TO RETRIEVE THE VAN. IT HAPPENED ONCE BUT IT WORKED. THIS IS THE MOBILE VAN. CHRIS GORDON, OUR PROJECT OFFICER WITH THE PROJECT STAFF AND AS YOU CAN SEE, ACTIVE IN VARIOUS COMMUNITY MOBILIZATIONS. SO ALL OF THIS RESULTED IN OVER 86,000 HIV TESTS. YOU CAN SEE THE BREAKDOWN BY CBVCT AND SVCT COMMUNITIES. 50,000 INDIVIDUALS WHEN WE EXCLUDED REPEAT TESTS. WHAT IS INTERESTING, 140,000 POST-TEST SUPPORT SERVICES. NOW, ONE OF THE MAIN RESULTS IN THE THREE COMMUNITIES WHERE WE CAN GET ACCURATE COUNTS IN THE SCCT COMMUNITIES AND I'LL TALK ABOUT THOSE IN OUR NEXT PAPER. YOU CAN SEE THE UPTAKE HIV TESTING WAS MUCH GREATER IN THE CBVCT IN THE THREE COUNTRIES IN WHICH WE WERE ABLE TO ASSESS IT. THIS IS OUR FIRST OUTCOME PAPER PUBLISHED IN LANCIT INFECTIOUS DISEASE NO, SIR 2011 AND THIS YEAR MIKE SWEAT WAS THE FIRST AUTHOR ON THAT PAPER. WE REACHED A RELATIVELY YOUNG GROUP OF CLIENTS AND WE WERE VERY HAPPY ABOUT THAT. YOU SEE HERE THE MEDIAN AGE WAS 21 AND THE OTHER THREE AFRICAN SITES IT WAS LATER 20s, MID TO LATE 20s AND IN THAILAND IT WAS SOMEWHAT OLDER. WE REACHED A RELATIVELY YOUNGER GROUP OF CLIENTS. THERE WAS GENDER EQUITY IN THE UPTAKE. ONE OF THE PROBLEMS IN ANY KIND OF INTERVENTION, HIV INTERVENTION OR OTHERWISE IN SUB SAHARAN AFRICA IS BRINGING THE MEN IN. WE HAVE A NATURAL WAY OF BRINGING WOMEN IN PARTICULARLY WITH THE USE OF ANTINATAL CLINICS BUT WE DID WELL IN ATTRACTING MEN. WE FOUND REPEAT TESTING GREW OVER TIME. IT IS IMPORTANT NOT ONLY TOW GET TESTED ONCE BUT IF ONE TURNS OUT TO BE HIV-NEGATIVE, TO GET TESTED AGAIN. NOW THIS IS IMPORTANT TO NOTE. THESE PREVALENCE NUMBERS ARE NOT BASED ON THE COMMUNITY PREVALENCE. I'LL TALK ABOUT HOW WE ARE GOING TO GET THAT NUMBER IN A MINUTE. THESE PREVALENCE NUMBERS PERCENTAGES ARE BASED ON THE PREVALENCE OF PEOPLE COMING FOR TESTING WHICH IS A SELF-SELECTED SAMPLE. AS YOU CAN SEE, IN THE SVCT SITES THE PREVALENCE WAS HIGHER THAN IN THE OTHER TESTING SITES. NONETHELESS, EVEN WITH LOWER PREVALENCE, WE IDENTIFIED MANY MORE HIV INFECTED PEOPLE. THIS IS A VERY IMPORTANT OUTCOME. AND AS YOU CAN SEE, VCT AND POST TEST SUPPORT SERVICES GREW OVER TIME AND IN FACT, IT TOOK A WHILE FOR THE SERVICE TO GET STARTED AND IN SUPPORT SERVICES REALLY TOOK OFF. I WANT TO TALK ABOUT SOME OF THE DIFFICULTIES. NOW I TOLD YOU WE HAD A QUALITATIVE COHORT AND I WANT TO TALK ABOUT ONE FINDING FROM THE QUALITATIVE COHORT AND THIS IS TALKING ABOUT TESTING AND EXPERIENCE WITH FRIENDS. SO THE QUESTION IS HOW WOULD SOMEONE FROM THE COMMUNITY LEARN ABOUT HIV STAT US? THEY WOULD GO FOR TESTS AND ARE THERE OPPORTUNITIES? YES THERE ARE PEOPLE WHO TEST. CVBCT, YES. DID YOU HAVE A DISCUSSION WITH ANYONE? YES I DISCUSSED WITH MY WIFE. I ALSO SPOKE WITH A FRIEND WOWENT FOR TESTS. I TOLD THEM I GOT TESTED BUT EARLIER ON I WAS AFRAID OF HIV TESTING BECAUSE I DIDN'T KNOW WHAT I WOULD DO IF I TESTED POSITIVE. I SHOWED THEM MY RESULTS AND ENCOURAGED THEM TO GO AND GET TESTED. DID YOU DISCUSS THAT BEFORE YOU WENT FOR THE TEST? NO WE DISCUSSED THAT WHEN WE MET TO THE SHOPS. GROUPS OF FRIENDS WOULD GO TOGETHER. I WAS THE FIRST ONE WHO CAME UP WITH THE IDEA OF GOING TO TEST BECAUSE I TESTED FIRSTLY. AND THEN HE ASKED ME HOW IT FELT. AT FIRST HE DIDN'T TAKE IT SERIOUSLY UNTIL I INTRODUCED HIM TO THE SESSIONS, THE POST TEST SUPPORT SESSIONS WHICH WERE ALSO PRETEST SESSIONS WHERE HE REALIZED THE IMPORTANCE OF TESTING. YES HE TESTED AT THE CARAVAN. PEOPLE WERE MOTIVATED TO DISCLOSE AND WE THAN DISCLOSURE IS AN IMPORTANT ISSUE TO FAMILY BECAUSE THEY WOULD BE THE ONES TAKING CARE OF THEM, TO PARTNERS AND FAMILIES, TO PROVE ONE'S TRUSTWORTHINESS, TO PARTNERS BECAUSE THEY HAD THE RIGHT TO KNOW, TO FRIENDS TO MOTIVATE THEM TO TEST. NOT MUCH DISCLOSURE TO MOTIVATE BEHAVIOR CHANGE. IT WAS REAL BELETTING PEOPLE KNOW AND GETTING PEOPLE TO TREATMENT. MOTHER EVERYWHERE ARE IMPORTANT. MY MOM WAS CALLING ME ABOUT THE RESULTS. I WAS SICK. SHE WAS PANICKING. BECAUSE I WAS SICK AND I WAS NEVER THAT SICK IN MY LIFE. AND SHE ENCOURAGED HER SON TO GET TESTED. PRIMARY PARTNERS, WE ARE LESS SALIENT IN SOUTH AFRICAN NARRATIVES BECAUSE OF A PARTICULAR NATURE OF PARTNER RELATIONSHIPS IN SOUTH AFRICA AND THAT IS A WHOLE OTHER STORY. OTHER FEMALE RELATIVES WERE IMPORTANT TARGETS FOR WOMEN AND MENDIC CLOSED TO MALE FRIENDS. DISCLOSURE DID MOTIVATE OTHERS TO TEST FOR HIV AND THIS IS ONE OF THE PROCESSES WE WANTED TO INSTIGATE. I TOLD MY SISTER AND SHE ALSO GOT TESTED. I WANTED TO SHARE THEM WITH MY SISTER AND FRIEND FROM CHURCH WHO ENCOURAGED ME TO GET TESTED AND SHARED HER OWN TESTING EXPERIENCE WITH ME. I DID BECAUSE I WAS EXCITED ABOUT MY RESULTS. I WAS NOW ENCOURAGING OTHERS TO DO THE SAME. I DISCUSSED WITH MY WORK MATES AT WORK. SOME ACCEPTED IT AND SOMEWHERE HESITANT SUCH THAT THEY TOOK TIME TO GO FOR THE TEST. NOT A ONE SHOT THING. THINGS DON'T HAPPEN IMMEDIATELY. I TALKED WITH VILLAGERS. THEY SAY IT'S TIME TO GET TESTED A SECOND TIME AND THEY WOULD ASK ME. AFTER THE TEST, I HAVEN'T GOTTEN INFECTED SO I TALK WITH A LOT OF VILLAGERS. I SAID, YES I GOT TESTED TWO TIMES AND I WASN'T INFECTED. WE TOLD THEM WHETHER THE BLOOD TESTS. YES, I SAID I PASSED. NOTHING SERIOUS. TIME TO TEST I SAID. SO THIS IS ONE OF THE PROCESSES WE WANTED TO INSTIGATE. NOW THESE PROCESSES ARE IMPORTANT. AND AS DR. DIEFFENBACH MENTIONED, IT'S NOT ONLY THE PRO VENTION OF THE STRATEGY, BUT IT'S ALLOWING THE SOCIAL PROCESS TO WORK. AND I'LL TELL YOU AN ANECDOTAL STORY. ONE OF THE TRUE SUCCESSES OF HIV PREVENTION IS PREVENTION OF MOTHER TO CHILD TRANSMISSION. WE HAVE AY PEP VAR PROJECT IN MALAWI. MALAWI HAS CHANGED ITS NATIONAL PLAN SUCH THAT EVERY PREGNANT WOMAN WHO COMES TO THE ANTINATAL CENTRES WOULD BE TESTED FOR HIV AND IF FOUND POSITIVE WOULD BE PUT ON TREATMENT FOR LIFE. AND WE WERE JUST, WHICH IS GREAT. WE WERE JUST LOOK TEG RESULTS AND MANY WOMEN ARE REFUSING. THIS IS ANECDOTAL RESULT AND THE THEY ARE REFUSING BECAUSE IT'S TOO MUCH. TOO MUCH AT ONCE. GUESS WHAT? YOU'RE PREGNANT, YOU GOT HIV AND NOW YOU HAVE TO TAKE TREATMENT FOR LIFE. NO OPPORTUNITY TO TALK WITH ANYONE. NO OPPORTUNITY TO GO HOME AND THINK ABOUT T NO OPPORTUNITY TO THINK ABOUT HOW AM I GOING TO TELL MY PARTNER. IT IS COMPLICATED. AND I THINK ANY OF THE INTRODUCTION OF ANY OF THE THESE KINDS OF INTERVENTIONS NEED TO TAKE INTO ACCOUNT THE KINDS OF SOCIAL PROCESSES. TESTING TOGETHER AND DISCLOSING TOGETHER, PEOPLE DID THIS AS WELL. WE AGREED TO GO THERE TOGETHER. THERE WERE THREE OF US. YES, I WOULD HAVE TOLD THEM AS IT IS BETTER TO TELL THEM THAN TO KEEP QUIET, THEY WOULD HAVE HAD TO COME TO KNOW ABOUT IT THAT I WANTED AEST AND WHY I WASN'T SHARING MY RESULTS WITH THEM. NONDISCLOSURE IS NOT SURPRISINGLY BASED ON FEAR OF STIGMA. AND SOME THEN EXPERIENCED RELIEF AND AGAIN, TALKED ABOUT THAT RELIEF. AFTER I TOLD THEM I LIVED A NORMAL LIFE, NOW I WAS FREE. I DIDN'T HAVE ANYTHING TO HIDE. AFTER THEY KNEW THAT I WAS POSITIVE, THAT IS WHEN I LIVED MY LIFE, MY POSITIVE LIFE AS TO HOW THEY LOOK AT ME, I DIDN'T CARE, AS LONG AS THIS THING IS OUT IN THE OPEN. THEN AFTER THAT I WAS FINE. THAT'S THE INTERVENTION. WE ARE NOW IN THE PROCESS OF֜ COMPLETING THE POST INTERVENTION ASSESSMENT, A POPULATION RANDOM SAMPLE OF 18-30 YEARS IN THE INTERVENTION CONTROL COMMUNITIES. 55,993 INDIVIDUALS AND SAMPLES WERE PREPARED AND FROZEN. SAMPLES KEPT IN COUNTRY AND SHIP TO THE CORE LAB IN HOPKINS AND I'LL TALK ABOUT THE ATTEMPT TO ESTIMATE INCIDENTS. THE FIELDWORK WAS COMPLETED IN 2011. THE DATA WILL BE READY FOR ANALYSIS SOON IN THE NEXT WEEK OR SO AND THE SAMPLES WILL BE SHIPPED BY THE END OF THE YEAR. THE PILOT DATA WERE JUST PUBLISHED. WE DID A PILOT IN EACH OF THE FIVE SITES IN A SORT OF RESERVE COMMUNITY. AND WE USED RAPID TESTING AND HIV INFECTION WAS CORRECTLY DETERMINED IN 99.5% OF THE PARTICIPANTS AND WE ARE GLAD FOR THIS ASSESSMENT OF QUALITY CONTROL. THE ASSESSMENT ITSELF INVOLVED AS YOU SEE OVER 11,000 PERSONS WITH ACCRUED PREVALENCE OF 31%, WITH ACCRUED PREVALENCE OF 15%, SIM BAB WAY ACCRUED 13%, TANZANIA 8% AND THAILAND 1.5%. SO, IN TERMS OF THE FIRST PAPER, WE BELIEVE THAT THE COMPLETE PACKAGE IS ESSENTIAL, THAT INCLUDES OUTREACH VCT AND POST-TEST SUPPORT SERVICES. THE NEXT END POINT PAPER TO COME OUT WILL ALSO BE A SECONDARY END POINT PAPER AND WE WILL BE ASKING THE QUESTION. THESE WILL BE TWO COMPANION PAPERS, EQUAL TASTIVE AND QUANTITATIVE AND COMPARISONS BETWEEN THE INTERVENTION AND CONTROL COMMUNITIES, INCREASE HIV TESTING, DISCLOSURE AND REDUCED STIGMA AND REDUCED BEHAVIOR AND INCREASE SOCIAL NORMS, DISCUSSES ABOUT HIV AND HIV-RELATED NEGATIVE LIFE EVENTS. THE FINAL QUESTION, IS DID THE COMMUNITY BASED CVT REDUCE HIV INCIDENTS WE ANTICIPATE THAT BEING AVAILABLE IN 18 MONTHS AND HOPKINS IS COORDINATING THESE ASSAYS. WHEN WE STARTED THIS STUDY THERE WAS CONFIDENCE IN THE BED ASSAY TO DETECT INFECTIONS. CONFIDENCE HAS WANED OVER THE YEARS. THE CORE LAB HAS BEEN WORKING HARD ON DEVELOPING THE MULTIASSAY ALGORITHM THAT MAY INCLUDE THE BED AND AVIDITY INDEX, CD4, VIRAL LOAD AND A NEW APPROACH ALSO LOOKING NOT ONLY AT IMMUNOLOGY BUT ALSO VIROLOGY, HIGH RESOLUTION MELTY DIVERSITY ASSAY TO LOOK AT THE DIVERSITY OF THE VIRUS AS AN INDICATOR OF RECENT VERSES LATER INFECTION. THAT IS PROJECT ACCEPT. I WANT TO THANK THE SPONSORS AND THE PEOPLE WHO BELIEVED IN US AND THE CORE LAB AT HOPKINS, STATISTICAL CENTRES AT SCHARP AND THE CHARS UNIVERSITY FOR THE OPPORTUNITY TO DO WHAT HAS BEEN A VERY INTERESTING, IMPORTANT AND HOPEFULLY USEFUL PIECE OF WORK. THANK YOU. [APPLAUSE] -- FREE ADDICTED REPEAT TESTING -- PREDICTED. WHAT HAVE YOU LEARNED FROM THE BEHAVIORAL SURVEYS AND WHAT KIND OF PARAMETERS DID YOU COLLECT. >> WE COLLECTED IN A SAMPLE OF 13,000, WE DID LONG FORM SURVEY THAT IS COLLECTED A LOT OF INFORMATION ABOUT BEHAVIOR, ATTITUDES, KNOWLEDGE, PRACTICES AND SO ON AND SO FORTH. WE COLLECTED SHORTER SURVEYS IN THE REST OF THE SAMPLE BECAUSE WE DIDN'T NEED TO DO THE LONG SURVEYS WITH THE ENTIRE SAMPLE. THAT DATASET, THE COLLECTION OF THOSE DATA WAS JUST COMPLETED IN JUNE OF 2011.,EI WEEK AND LOCKED. AND WE WILL START THE SECONDARY ANALYSIS AND IT WILL BE SUBMITTED FOR PUBLICATION EARLY IN 2012. ALONG WITH THE QUALITATIVE PAPER. THE ANSWERS TO YOUR QUESTIONS ARE YET UNKNOWN BUT WE HOPE TO ANSWER THEM SOON. >> THANK YOU. >> WE'LL TAKE ONE MORE. >> [OFF MIC] >> THEY ARE INVOLVED IN THE WHOLE PROCESS. IT COULD NOT BE DONE WITHOUT THE COMMUNITY. THEY ARE NOT CO-AUTHORING PAPERS BUT THEY ARE INVOLVED IN THE INTERPRETATION OF ANALYSIS. BUT THE ACADEMIC PARTNERS ARE. THE SCIENTIFIC PARTNERS ARE COLLABORATING SUINGS ARE. BUT NOT COMMUNITY MEMBERS. >> THANK YOU. NOW PLEASE JOIN ME IN WELCOMING DR. WAFAA EL-SADR FROM COLUMBIA UNIVERSITY. [APPLAUSE] >> GOOD AFTERNOON, EVERYONE. I HAD ANOTHER ADVENTURE TRYING TO GET HERE FROM NEW YORK CITY. IT'S ONLY 36 MINUTE LIGHTS BUT LOTS OF DRAMA CAN HAPPEN. I HAVE TO SAY THAT NOW AFTER LISTENING TO DR. DIEFFENBACH, I PROBABLY AM NOT NECESSARY HERE BUT I THINK ESPECIALLY HE SAID WHAT WOULD TAKE ME MUCH LONGER TO SAY. SO THANK YOU FOR THE INVITATION AND THIS HAS BEEN A WONDERFUL OPPORTUNITY TO BRING TOGETHER A LOT OF DIFFERENT SCIENTISTS AND PEOPLE WHO COME FROM REALLY DIVERSE DISCIPLINES TO TACKLE SOME OF THE ISSUES WE ARE ALL FACING. JUST AN OVERVIEW OF MY PRESENTATION, WHAT I CAME TO DO BRIEFLY IS TO JUST VERY TOUCH ON SOME OF THE GLOBAL ACHIEVEMENTS WE ACCOMPLISHED OVER THE PAST 30 YEARS SO WE FOCUSED ON THE LAST 5-10 YEARS. TALK ABOUT GLOBAL CHALLENGES AND SOME OF THE PREVENTION BREAKTHROUGHS AND MORE DETAILS AND MAYBE HIGHLIGHTING SOME OF THE PARTICULAR AREAS THAT I THINK ARE VERY RELEVANT TO THE EVENT TODAY. AND THEN DISCUSS A BIT ABOUT HOW TO MOVE FROM EFFICACY TO EFFECTIVENESS AND THEN TO SCALE UP BEYOND THAT AND THE NEED FOR ENGAGEMENT AND SOCIAL AND BEHAVIORAL SCIENCES TO ACCOMPLISH THOSE STEPS AND COME TO CONCLUSIONS. AS ALL YOU'RE AWARE OVER THE PAST SEVERAL YEARS, REMARKABLE ACHIEVEMENTS IN TERMS OF HIV CARE AND TREATMENT PARTICULARLY IN SUB SAHARAN AFRICA. FOR SOMEONE LIKE MYSELF INVOLVED IN THIS EFFORT FROM THE BEGINNING AND THE END OF 2002 THERE WERE NOT THAT -- MAYBE 30,000 PEOPLE IN SUB SAHARAN AFRICA WHO HAD ACCESS TO TREATMENT AND THEN THE HISTORIC ACCOMPLISHMENT OVER THE PAST FEW YEARS WERE NOW CLOSE TO OR NOW MORE, ALMOST 5 MILLION PEOPLE WHO ARE RECEIVING ACCESS TO VIRAL THERAPY AND CLEARLY THIS WAS ACHIEVED THROUGH A LOT OF HARD WORK, PARTICULARLY WITH THE PEOPLE ON THE GROUND THEMSELVES AS WELL AS THE FUNDING SUPPORT FROM THE U.S. AND OTHER INTERNATIONAL GROUPS AS WELL. IN ADDITION, I THINK WE OFTEN FORGET THAT WE ALSO MADE TREATMENTS IN TERMS OF PREVENTION AND IN THIS, YOU CAN SEE THAT THE, IN THE GREEN COUNTRIES THAT HAVE BEEN CLEARER THAN 25% THE HIVINS DISPENSE ESTIMATED. IN GRAY IT'S COUNTRIES WHERE INCIDENCE IS STABLE AND IN RED INCREASE IN INCIDENCE. AND AS CAN SEE, A PORTION OF THE COUNTRIES IN SAAB SAHARAN AFRICA THERE HAVE BEEN INCREASING HIV INCIDENCE. WHENEVER I SHOW A MAP LIKE THIS I LIKE TO REFLECT ON THE U.S. AND AS YOU KNOW, WE HAVE NOT HAD DECREASED IN INCIDENCE OR NEW INFECTIONS IN THE U.S. FOR A DECADE OR SO. I THINK WE HAVE A LONG WAY TO GO IN TERMS OF HIV TREATMENT, YOU CAN SEE HERE THE COVERAGE IN LOWER AND MIDDLE-INCOME COUNTRIES IS STILL WAY BEYOND OPTIMAL COVERAGE AND THIS IS THE LOWER CD4 THRESHOLD ONLY ABOUT A THIRD OF PEOPLE WHO NEED TREATMENT EVER LOWER THE THRESHOLD IN SUB SAHARAN AFRICA HAVE ACCESS AND SOME OF THE OTHER COUNTRIES AGAIN SUB OPT MAT ACCESS TO HIV TREATMENT. NOW IN TERMS OF ALTHOUGH WE HAD SUCCESS IN PREVENTION, AS YOU CAN SEE FROM THIS SLIDE, AT THE SAME TIME, ONGOING INFECTIONS ARE BEING TRANSMITTED AND HIV IS CONTINUING TO BE TRANSMITTED WITH 2.6 MILLION NEW INFECTIONS IN 2009. AND THAT TELLS US WE HAVE A LOT OF WORK AHEAD OF US TO TRY TO SEND THESE TRANSMISSIONS. WHAT IS IMPORTANT TO KEEP IN MIND IS SO MAYBE SOMETHING WE WON'T TOUCH ON TODAY, BUT I THINK THE CONTRIBUTIONS OF THE NEGLECTED POPULATION TO THE HIV EPIDEMIC EVEN IN GENERALIZE EPIDEMICS FOR EXAMPLE, SEVERAL COUNTRIES IN SUB SAHARAN AFRICA AND YOU CAN SEE THE PORTION OF NEW INFECTIONS IN THIS GROUP AND OF COURSE IT APPEARS HERE HAVE YOU IN PURPLE, HETEROSECTSUAL COUPLES BUT NONETHELESS, YOU CAN SEE A SUBSTANTIAL TRANSMISSION FROM SEX WORKERS AND DRUG USERS AS WELL AS INCREASINGLY RECOGNIZED MEN WHO HAVE SEX WITH MEN. SO THE CHALLENGE IN TERMS OF EFFICACY, EFFECTIVENESS AND HOW TO REACH AND ENGAGE IN SPECIAL KEY POPULATIONS. IN TERMS OF HIV PREVENTION COVERAGE, SIMILAR TO TREATMENT COVERAGE, WE HAVE A LONG WAY TO GO. THIS IS UNMET PREVENTION NEEDS AND YOU CAN SEE AGAIN, HUGE UNMET NEEDS IN TERMS OF PREVENTION IN THE COUNTRIES. HOWEVER, WE HAD TREMENDOUS SUCCESS SYSTEM OVER THE PAST SEVERAL YEARS AND OF COURSE IT STARTED BY–r THE THREE LANDMARKS IN THE PRECISION STUDIES PUBLISHED 5 OR 6 YEARS AGO 4-6 YEARS AGO AS AN EGYPTIAN I HAVE TO OF COURSE DEMONSTRATE THAT WE WERE FIRST THERE. WAY BEFORE LIBYA, 4-6000 YEARS AGO. ALSO I THINK WHAT IS MORE ADDED TO THE EXCITEMENT IS THE WHOLE AREA OF ARV, AREN'T RETROVIRAL BASED BREAKTHROUGHS AND I THINK NOW PREVENTION IS IN A VAGUE WAY OF NON-TARGETED PREVENTION, THINKING OF THE POPULATION AS A WHOLE WITH MASS MEDIA AND PREVENTION MESSAGES AND SO ON WE HAVE BECOME MUCH MORE SOPHISTICATED AND THINKING ABOUT PREVENTION AND THINK OF IT IN THE CONTEXT OF PARTICULARLY ARV-BASED PREVENTION FOR HIV-NEGATIVE INDIVIDUALS WITH THE DATA I'LL SHOW IN TERMSzV OF PRE-EXPOSURE PROPHYLAXIS AND OTHERS AND THEN FOR HIV POSITIVE, ART FOR PREVENTION. WE WE NEED TO LEARN IN THE FUTURE IN ORDER TO GO FROM EFFICACY TO EFFECTIVENESS AND TO SCALE UP. NOW IN TERMS OF THE STUDIES THAT HAVE BEEN DEMONSTRATED THESE EFFICACY IN HIV-NEGATIVE INDIVIDUALS SO THAT THE STUDIES THAT WERE MENTIONED BRIEFLY AS WELL AS OF COURSE TO REMIND THAT YOU TWO PREP STUDIES DID NOT CONFIRM THESE FINDINGS EVEN THOUGH USING THE SAME MEDICATIONS, WHICH I THINK IS A WHOLE TOPIC OF DISCUSSION THAT COULD TAKE AS MANY HOURS BUT OBVIOUSLY AN AREA OF IMPORTANCE TO STUDY IN TERMS OF SOME OF THE BIOMEDICAL OR BIOLOGICAL REASONS AS WELL AS SOCIAL AND BEHAVIORAL REASONS FOR THE DISCREPANCY. I'M GOING TO GO TO A STUDY BECAUSE EACH OF THEM HIGHLIGHTS A PARTICULAR AREA THAT I THINK ARE IMPORTANT. SO THIS IS A STUDY WHICH DEMONSTRATES 39% AFFECTS USING VAGINAL GEL AMONG WOMEN IN SOUTH AFRICA COMPARED TO PLACEBO. THE CONSTANT INTERVALS WERE WIDE FOR THIS PROTECTIVE EFFECT. NOW IN TERMS OF ORAL, THIS STUDY FOCUSING ON MSM AND TRANSGENDERED WOMEN WAS CONDUCTED IN SIX COUNTRIES AND IT'S IMPORTANT TO SHOW HERE THAT ALSO THAT STUDY WITH SIMILAR EFFICACY IS HIGHER AND 42% AGAIN QUITE WIDE CONFRANCE ENTER VAL BY COMPARING TO PLACEBO. IN AN IMPORTANT STUDY THAT WAS DESCRIBED AT THE INTERNATIONAL AIDS CONFERENCE IN ROME THIS SUMMER INCLUDED DISCORDANT COUPLES. THE LAST TWO STUDIES WERE IN INDIVIDUALS OR MSN AND THIS WAS IN DISCORDANT COUPLES AND I'LL FOCUS A BIT ON THAT IN A SECOND N THAT STUDY IN BOTH THESE THEY WERE HIGHLY EFFECTIVE WHEN TAKEN BY HIV-NEGATIVE PARTNER WITHIN THIS PARTNERSHIP. YOU CAN SEE THE PROTECTIVE EFFECTS SUBSTANTIAL 62 AND 73%. AND WHEN I THINK FINALLY AGAIN A STUDY OF DISCORDANT COUPLES KEEP THAT IN MIND WITH A POSITIVE PARTNER AND OF COURSE WE ALL KNOW THE REMARKABLE 96% WITH A PRETTY TIGHT CONFIDENCE INTERVAL. AGAIN DISCORDANT COUPLES. IT SHOWS HERE THE EFFECTIVENESS OF ALL OF THESE BIOMEDICAL INTERVENTIONS AND I THINK ALL OF YOU SITTING IN THE ROOM WILL SAY ALL OF THESE ARE BIOMEDICAL INTERVENTIONS. SO WHY AM I PRESENTING THIS TODAY? I THINK YOU WILL NOTICE THAT NONE OF THESE ARE 100% EFFICACIOUS WHICH IS INTERESTING ACTUALLY AND KIND OF INTRIGUING EVEN MAY HAVE -- MALE CIRCUMSTANCIZATION WITH ABOUT 50% EFFICACIOUS. SO IT MEANS THAT WE HAVE WORK AHEAD OF US IN TERMS OF HOW DO WE ENHANCE THE EFFICACIOUS OR EFFECTIVENESS OF THESE INTERVENTIONS AND ALSO ANOTHER IMPORTANT PART OF THE CONVERSATION IS HOW TO COMBINE THESE INTERVENTIONS. SO WHAT ABOUT THIS WHOLE ISSUE OF THE LIMITED EFFICACY WITH THESE POWERFUL INTERVENTIONS AND WHAT ARE SOME OF THE REASONS PEOPLE THINK THAT MIGHT BE THE REASON FOR THAT? I THINK IT'S IMPORTANT TO SIT BACK AND THINK ABOUT THESE PARTICIPANTS IN THESE CLINICAL TRIALS AS WE THINK OF MUTUALING ON TO EFFECTIVENESS AND SCALE UP. IT'S UNIQUE. THESE ARE CLINICAL TRIALS. PARTICIPANTS ARE SELECTED FOR PEOPLE WHO ARE DEVOTED TO THE STUDY WHO ARE GOING TO BE LIKELY TO BE ADHERENT. AND KEEP IN MIND, IN ADDITION TO THE BIOMEDICAL INTERVENTION THEY RECEIVE, THEY ALSO ALL OF THEM, WHETHER THEY MET PLACEBO OR ACTIVE R, THIS IS QUITE THE COMPREHENSIVE PACKAGE PREVENTION PACKAGE AND INCLUDES A LOT OF WHAT WE CALL BEHAVIORAL OR OTHER BIOMEDICAL INTERVENTION, INCLUDING RISK REDUCTION COUNSELING, FREE CONDOMS, AND CONDOM COUNSELING, SCREENING TREATMENT FOR STIs. COUNSELING REFERRAL TO OTHER PREVENTION SERVICES AND ET CETERA. NOT ONLY THAT, THESE ARE NOT JUST DECIDED THESE WERE RECEIVED BECAUSE THEY WERE FOLLOWED QUITE AGGRESSIVELY ON A MONTHLY BASIS WITH REPEAT TESTING AT THESE VISITS. SO AGAIN, THIS IS SOMETHING TO KEEP IN MIND AS WE ARE THINKING ABOUT WHAT IS THE PACKAGE. WHAT ARE WE DOING WITHIN THESE CLINICAL TRIALS AND WHAT IS THE INTERVENTION OF INTEREST? SO BEHAVIORAL ASPECTS OF EFFICACY, YOU CAN SEE THIS STUDY WHICH DEMONSTRATED THAT WHEN YOU LOOK AT THE EFFECT, YOU CAN SEE A GRADIENT BASED ON ADHERENCE LEVELS AMONG THE WOMEN. AND WITH THE HIGHEST ADHERENCE HAVING THE HIGHEST EFFICACY. SIMILARLY, FROM THE IPREX STUDY WHERE THEY DID INTRACELLULAR LEVELS OF THE DRUG, BOTH THE DRUGS THAT WERE HERE, YOU CAN SEE AGAIN CORRELATION BETWEEN PROTECTION AND THE RISK OR THE LEVELS AND THE RISK OF INFECTION DEMONSTRATING THAT CLEARLY ADHERENCE WITH TAKING MEDICATION WAS ASSOCIATED WITH THE EFFICACY OF THE INTERVENTION ITSELF. ANOTHER ASPECTS OF THINKING ABOUT THE INTERVENTIONS IS WHAT HAPPENS TO SEXUAL BEHAVIOR. THAT'S IMPORTANT TO THINK ABOUT WHEN WE ARE DOING PREVENTION STUDIES. IN THIS STUDY WHICH IS THE ONE THAT I MENTIONED TO YOU BEFORE IN DISCORDANCE COUPLES, ESSENTIALLY THE PART AT THE BEGINNING OF THE INTERVENTION WHEN THEY ASKED HIV-NEGATIVE INDIVIDUAL ABOUT 27% OR SO REPORTED ANY UNPROTECTED SEX. IT WAS INTERESTING OVER TIME DURING PARTICIPATION OF THE STUDY DECREASE IN THE PORTION OF SUCH AN ACT AND IT WAS SIMILAR IN BOTH ARMS. THIS PLACEBO-CONTROLLED STUDY. THAT'S ENCOURAGING IN TERMS OF THE FEAR OF THIS INHIBITION. BY TAKING THESE INTERVENTIONS. WHAT IS VERY IMPORTANT IS THAT ALSO IN THESE COUPLES, STUDIES, THE RISK OF ACQUIRING SEX FROM OUTSIDE THE PARTNERSHIPS AND ONE REPORTED DURING THIS STUDY, AND DID NOT FAIRY -- VARY BY ARM WHICH IS NOT AS CRITICAL IN THE INTERVENTION BUT OBVIOUSLY IT'S A MUCH MORE IMPORTANT IF YOU'RE PARTNER IS TAKING THE TREATMENT I THINK IT'S INTERESTING WE HAVE SELF REPORTED BEHAVIORS SO THE ADHERENCE TO MEDICATION OR SEXUAL BEHAVIORS THAT WE ESSENTIALLY HAVE NO, ART PART FROM THE BLOOD, DEPENDENT ON SELF REPORTED BEHAVIOR REPORTS. THERE OFTEN ARE NONCONSISTENT WITH BIOMEDICAL OUTCOMES OR BIOMEDICAL MEASURE LIKE BLOOD LEVELS. IMPORTANT ASPECT OF DISCORDANT COUPLES STUDIES IS THE ISSUE OF4}"T) TRANSMISSION STUDIES WHICH MEANS THE HIV INDIVIDUALS GOT INFECTED NOT FROM THE PARTNERS. YOU CAN SEE FROM THESE TWO STUDIES, ABOUT 20% OF THE TRANSMISSIONS IN THIS WERE UNLINKED AND 27% OF TRANSMISSIONS IN OTHER PARTNER PREVENTION STUDIES WERE UNLINKED. THE IMPORTANCE OF TRYING TO DO SOME OF THE VERY IMPORTANT BEHAVIORS WITHIN THESE STABLE PARTNERSHIPS AND HOW THAT CAN IMPACT ON THE EFFECTIVENESS OF AN INTERVENTION. KEEP IN MIND THE DISCORDANT COUPLES IN THE PARTNER STUDY, 95% OF THEM WERE MARRIED IN BOTH OF THESE STUDIES SO THESE WERE STABLE PARTNERSHIPS AND NONETHELESS ALMOST A THIRD OR A QUARTER TO A THIRD ACTUALLY GOT INFECTED OUTSIDE THE PARTNERSHIP. SO MOST THE CONVERSATION HAD FOCUSED ON ISSUES AROUND ADHERENCE ON SEXUAL BEHAVIOR, ISSUES AROUND PARTNERSHIPS AND MULTIPLE PARTNERSHIPS AND SO ON. BUT I THINK LESS HAD FOCUSED ON THE STRUCTURAL ISSUES THAT REALLY CAN MAKE IT OR BREAK IT IN TERMS OF HOLDING TO EFFECTIVENESS AND SCALING UP. SO NOW WE HAVE GONE THROUGH THE FOUNDATION OF PREVENTION AND DR. DIEFFENBACH MENTIONED HIV TESTING AND KNOWLEDGE OF STATUS. HERE IS THE DATA FROM THE KENYA AIDS SURVEY WHICH IS RANDOM SAMPLE OF THE POPULATION LOOKING AT THE KNOWLEDGE OF HIV STATUS AMONG THOSE FOUND TO BE POSITIVE. YOU CAN SEE THAT 84% OF HIV INFECTED DID NOT KNOW THEIR STATUS. THIS IS REMARKABLE. IT IS VERY IMPORTANT ISSUE THAT WE NEED TO WORK ON IN ORDER TO EXTEND KNOWLEDGE OF STATUS. KEEP IN MIND IN THE U.S., WE ALSO KNOW THAT ABOUT 25% OF PEOPLE WHO ARE INFECTED DON'T KNOW THEIR STATUS. DR. COATES COVERED THESE, INCLUDING HIS REMARKABLE STUDY, PROJECT ACCEPT. A LOT OF THE EXCITEMENT ABOUT HOME-BASED TESTING IDENTIFIED HOUSEHOLD MEMBERS OF HIV INFECTED INDIVIDUALS AND THIS IS ANOTHER STRATEGY THAT WILL BE FRUITFUL IN TERMS OF IDENTIFYING DISCORDANT PARTNERSHIPS BY GOING TO THE HOUSEHOLD OF HIV INFECTED INDIVIDUALS. I THINK IT IS ALSO VERY EXCITING NEWS ABOUT THE POTENTIAL FOR TESTING WHERE MOST STUDIES IN MALAWI TRYING TO DO SOMETHING SIMILAR HERE IN THE U.S. IN THE CONTEXT OF ANOTHER STUDY AND IN THIS SMALL STUDY OF THOSE WHO ARE VERY HIGH ACCURACY RATE AND A LOT OF THEM WERE HIGHLY ACCEPTED AND RECOMMENDED TO THEIR FRIENDS. SO CLEARLY A NEED TO EXPAND HIV TESTING AND WHAT IS VERY IMPORTANT IS THAT WITH ALL OF THE INTERVENTIONS, THE NEED FOR NOT JUST THIS TESTING BUT REPEATED TESTING AND HOW WE MAKE THIS REPEAT TESTING HOW WE ACCOMPLISH IT AND OFFER IT IN A CONVENIENT MANNER WITHOUT THE NEED FOR COMING TO A CLINIC OR COMING TO A FAR AWAY FACILITY. SO WHEN I THINK ABOUT STARTING OUT NOW WITH OUR PREVENTION INTERVENTIONS, WE THOUGHT WE HAD TO START WITH KNOWLEDGE OF STATUS AS MOST OF OUR INTERVENTIONS ARE BASED ON THE STATUS OF THE INDIVIDUAL THAT IS IN FRONT OF US. AND I THINK THE PREVENTION CONTINUES FOR HIV POSITIVE INDIVIDUALS WHEN WE THINK OF PREVENTION AS WELL AS THE PREVENTION CONTINUING FOR HIV NEGATIVE INDIVIDUALS. OF COURSE WE NEED TO START WITH SOMEBODY IF THIS IS FOR THE POSITIVE INDIVIDUAL, SOMEONE IDENTIFIED TO BE POSITIVE QUICKLY THROUGH EFFECTIVE HIV TESTING, THAT INDIVIDUAL MUST BE LINKED AND THIS IS VERY IMPORTANT TO HIV CARE AND THAT PERSON NEEDS TO BE COUNSELED AND MONITORED AND ON AN ONGOING BASIS AND ONCE THEY ARE ELIGIBLE FOR ANTIRETROVIRAL THERAPY FOR WHATEVER REASONS AND FOR PREVENTION, IT NEEDS TO BE INITIATED IN ADVANCE OF VIRAL SUPPRESSION SHOULD BE ACHIEVED OR NEEDS TO BE ACHIEVED FOR THE PREVENTION BENEFIT WITH VIRAL SUPPRESSION. NOW THIS IS A VERY IMPORTANT -- THESE ARROWS ARE IMPORTANT AND I ALWAYS FIND WE FOCUS ON WHAT IS IN THE BOXES RATHER THAN WHAT IS ON THE ARROWS IN TRYING TO ACCOMPLISH ANYTHING IN LIFE. SO, I THINK WE NEED TO SORT OF FOCUS ON REALLY THE ARROWS RATHER THAN THE BOXES IN ADDITION TO OF COURSE THE ISSUES IN THE BOXES. I THINK THIS IS THE IMPORTANCE OF LINKING OR ENGAGING PEOPLE FOR THE LONG TERM OR COUNSELING AND SUPPORT AND SO ON AND MAINTAINING THEM IN THE SYSTEM AND THEN ONCE OF COURSE THEY START ARC COUNSELING, MAINTAINING AND SUPPORTING THEM TO BE ABLE TO MAINTAIN AND ACHIEVE VIRAL SUPPRESSION. SIMILARLY, THERE IS ALSO A PREVENTION CONTINUUM FOR HIV-NEGATIVE INDIVIDUALS AND FOR HIV-NEGATIVE INDIVIDUALS, WE THINK ABOUT THE BIOMEDICAL AFFECT OF INTERVENTIONS THAT WERE DESCRIBED IN A PRIOR SLIDE, I WANTED TO REFER THE DECISION FOR DISCORDANT COUPLES OR WOMEN FOR ARV FOR PREP, THERE IS -- IT DIDN'T ACTUALLY INITIATE THE INTERVENTION OF THE THE IMPORTANCE OF ONGOING COUNSELING CANNOT BE UNDERESTIMATED IN TERMS OF ADHERENCE AS WELL AS REMAINING IN PROGRAMS THEY CAN RECEIVE COUNSELING NEEDING TESTING. THESE ARROWS ARE VERY IMPORTANT AND YOU CAN IMAGINE THAT IN ORDER TO ACHIEVE THE OUTCOME WE NEED, WE HAVE TO OPTIMIZE THESE. AND OF COURSE ONCE SOMEBODY WHO ACTUALLY BECOMES HIV POSITIVE, THE IMPORTANCE OF GUIDING INTO HIV CARE AND TREATMENT SO THEY CAN RECEIVE THE OWN BENEFIT AS WELL AS FOR THE PARTNER IN TERMS OF PREVENTION ART FOR PREVENTION. NOW HOW ARE WE DOING IN TERMS OF THIS. WE SHOWED ONE CASCADE FROM THE U.S. AND THIS IS ANOTHER CASCADE VERY INFORMATIVE. IF YOU THINK ABOUT IT FROM THE HIV POSITIVE, THIS IS IN CARE AND NOT FOR PRO VENTION. THESE ARE PEOPLE WHO ARE GETTING TESTED OFTEN LATE IN HIV DISEASE. YOU CAN SEE IN THIS PART OF MOW ZAM BEAK THEY STARTED WITH 23,000 INDIVIDUALS WHO WERE TESTED AND 7000 OR 30% WERE FOUND TO BE HIV POSITIVE AND 40% OF THEM WERE NEVER OR DID NOT INVOLVE IN HIV CARE. SO THAT MEANS THE MAJORITY WERE LOST. AND THEN THAT'S EVEN IF YOU FOLLOW THE CASCADE FURTHER, YOU CAN SEE THAT MANY OF THEM DID NOT HAVE ABOUT 23% NO CD4 TEST WAS DRAWN. SO YOU ARE LOSING A WHOLE LOT OF PEOPLE WHO COULD BENEFIT FROM ART FOR TREATMENT AND POTENTIALLY FOR PREVENTION. AND EVEN THOUGH THEY HAD 1500 WHO WERE ELIGIBLE FOR ART INITIATION, ABOUT 70% DID NOT INITIATE ART AND A LARGE PERCENT WERE TO FOLLOW. YOU CAN SEE AGAIN THAT IT'S VERY IMPORTANT TO EXPAND THE TESTING BUT IT'S THE WHOLE CASCADE THAT IS VERY IMPORTANT. AND NOW, FOR NEGATIVE AS WELL AND UNTIL RECENTLY WE FOCUSED LARGELY ON THE POSITIVES AND HOW TO LINK THEM. NOW WE HAVE TO DOUBLE THE EFFORT TO FOCUS ON THE NEGATIVE AND KEEP IN MIND IN ALL COUNTRIES THE MAJORITY OF TESTS WILL BE NEGATIVE. NOW IN ADDITION, THERE IS ANOTHER HURDLE WHICH IS INITIATION OF ANTIRETROVIRAL THERAPY. THESE ARE INTERESTING DATA. RECENTLY PUBLISHED WOULD SHOW THAT INITIATION OF ART WOULD FEEL IF WE KNOW SOMETHING WORKS THAT PEOPLE WILL TAKE IT BECAUSE IT'S FOR THEIR OWN GOOD AND WE CAN MAKEzV COMPELLING ARGT]ENTS FOR IT. IN THIS STUD THEY LOOKED AT ABOUT 7000 INDIVIDUALS WHO WERE TESTED, 25% WERE HIV INFECTED AND ABOUT 743 OR 30% WERE ELIGIBLE FOR ANTIRETROVIRAL THERAPY AND THIS IS FOR THEIR OWN HEALTH. NOT FOR PREVENTION. 20% REFUSED REFERRAL TO INITIATE ANTIRETROVIRAL THERAPY AND DESPITE COUNSELING IN THE REPEATED COUNSELING ABOUT THE IMPORTANCE OF REFERRAL AND TREATMENT OF ART, MOST OF THEM AGAIN REFUSED TWO MONTHS LATER. AND THE MAIN REASON FOR REFUSAL, INTERESTING IN CONSIDERING ART FOR PREVENTION, AND ARGUMENTS IN THE REASONS AND ALL THE BEHAVIORAL AND SOCIAL PARAMETERS THAT MAKE SOMEBODY TAKE MEDICATIONS WHEN THEY ARE HEALTHY, IT IS GOING TO BE VERY INTERESTING WHETHER FOR PREP OR ART FOR PREVENTION BECAUSE WE ARE SEEKING TO PROVIDE TREATMENT FOR MANY MORE HEALTHY PEOPLE. THIS IS IMPORTANT AS WE NEED TO ADDRESS THAT WE HAVE A FOCUS ON UNTIL NOW. WE ARE GOING TO TOUCH A BIT ON DISCORDANT COUPLES BECAUSE THAT'S ANOTHER YEAR WHERE THE EVIDENCE IS IN TERMS OF EFFICACY AND INTERVENTIONS FOCUSING ON STABLE DISCORDANT COUPLES. SO FOR STARTERS, WHAT THE DEFINITION IS, WE CAN SPEND HOURS OF TALKING ABOUT IT, WHAT IS THE DEFINITION OF STABLE DISCORDANT COUPLES. I THINK IT'S IMPORTANT TO THINK ABOUT IT IN THE STUDIES THAT I CITED THEY APPEARED THE DEFINITIONS OF SOME OF THEM WERE DATING FOR A MINIMUM THREE MONTHS. BUT AS YOU CAN SEE FROM THE DATA ON THE BASED OF CHARACTERISTICS OF THESE COUPLES, 95% OF THEM IN BOTH OF THE STUDIES WERE MARRIED COUPLES. IN OTHER CHALLENGES, THE PREVALENCE OF COUPLE DISCORDANCY, HOW TO FIND RICH INTERVENTION AND OFFER IT TO THEM. THERE IS A NEW CONCEPTION THAT DISCORDANT IS QUITE COMMON AND BUT THE DATA DEMONSTRATES OTHERWISE. IF YOU LOOK AT THE PREVALENCE OF HIV DISCORDENTS BASED ON DHS DATA FROM SUBSAHARAN AFRICA AND YOU GET A COUNTRY WHICH HAS PRETTY HIGH OR VERY LIE HIV PREVALENCE, YOU WILL SEE THE MAJORITY OF COUPLES, CONCORDE ENT NEGATIVE, 67%, ABOUT 20% OF CONCORDE ENT POSITIVE AND YOU HAVE ABOUT FINE% DISCORDANT MALE AND 10% FEMALE. SO EVEN IN A COUNTRY WHERE IT'S HIGH PREVALENCE, THE PREVALENCE OF DISCORDINENCE THOSE COUPLES IS QUITE LOW. HOW DO YOU -- AMONG ALL THE COUPLES IN THE COUNTRY, ESPECIALLY A COUNTRY WITH VERY LARGE POPULATIONS LIKE GHANA OR SOME OTHER OF THE COUPLES, IT'S VERY IMPORTANT CHALLENGE, -- RUEANDA HAS MUCH LOWER. MANY WILL BE CONCORDE ENT NEGATIVE. HOW DO WE FIND DISCORDANT COUPLES, IT REQUIRES US TO THINK ABOUT THIS AS WE ARE CONCEPTUALIZING WITH DISCORDANT COUPLES. THERE ARE STRATEGIES THAT HAVE BEEN OFFERED AS A WAY TO FIND DISCORDANT COUPLES BECAUSE WE KNOW SOME INTERVENTION THAT IS WORK FOR THEM. HIV HAS BEEN ADVOCATED FOR THIS LIKE I MENTIONED. VERY IMPORTANTLY, HIV TESTING FOR THOSE WHO ARE ALREADY INVOLVE IN HIV CARE, IT'S֜ IMPORTANT TO KEEP IN MIND, VERY LOW PREVALENT OF DISCORDANT COUPLES WITHIN A COUNTRY, AS YOU START OUT WITH AN HIV POSITIVE INDIVIDUAL, 50% OF THE TIME THEY HAVE A NEGATIVE PARTNER. SO IT'S VERY EFFICIENT TO THINK OR TO GO TO HIV POSITIVE AND TRY TO GET THE PARTNER TESTED BECAUSE YOU YIELD OF DISCORDANT COUPLES IS HIGHER THAN TRYING TO LOOK FOR DISCORDANT COUPLES. SO THERE IS INTERESTING WORK THAT HAS BEEN DONE. IT'S ALSO IMPORTANT TO THINK ABOUT THE YIELD FROM COUPLES VERSUS INDIVIDUAL COUNSELING. THIS IS ONE STUDY OF 1,500 WOMEN IN TANZANIA WHO RANDOMIZED. WHAT IS INTERESTING, YOU SEE THE PORTION WHO RECEIVED THEIR RESULTS IT'S LOWER FOR THE COUPLES TESTING AND HIGHER IN INDIVIDUAL COUPLING AND WHO WERE TESTED. AMONG THE POSITIVE WOMEN, THEN THERE WAS A HIGHER PORTION WHO RECEIVED THE PMTCT FOR THE WOMEN OR INFANTS. SO AGAIN, IT MEANS THAT COUPLES TESTING WAS NOT THE WOMEN MORE WOMEN DID NOT RECEIVE THE RESULTS BUT ON THE OTHER HAND, THE WOMEN WERE PART OF THOSE WHO GOT THE RESULTS YOU HAVE A HIGHER PORTION WHO WILL TAKE THE INTERVENTION. IT'S IMPORTANT TO THINK ABOUT THE NUANCES OF COUPLES TESTING. IT'S NOT VERY SIMPLE. AND ACQUIRES A LOT OF WORK TO BEEN HOW TO UTILIZE IT EFFECTIVELY. SO WE HAVE BEEN INVOLVED SINCE THE BEGINNING MANY YEARS, 10 YEARS, IN THE SCALE UP OF HIV CARE AND TREATMENT. THIS IS JUST TO SHOW YOU THAT THE POTENTIAL, LIKE JUST IN THE SUPPORT IN SUB SAHARAN AFRICA SINCE 2004, NOW MORE THAN A MILLION INDIVIDUALS HIV INFECTED INDIVIDUALS HAVE BEEN INVOLVED IN CARE AND ABOUT 500,000 HAVE INITIATED ANTIRETROVIRAL THERAPY. SO THE DIFFERENCE HERE ARE ALL THE PEOPLE WHO ARE IN CARE WHO ARE POSITIVE WHERE THE OPPORTUNITY NOT ONLY TOW TAKE CARE OF THEM AND PROVIDE HIV CARE, BUT ALSO TO TRY TO GET THEIR PARTNERS TESTED AND IF THE PARTNER IS NEGATIVE, THEN THEY IDENTIFY A LARGE NUMBER OF DISCORDANT COUPLES. IT'S A VERY IMPORTANT WAY OF GETTING DISCORDANCY. SO I'M GOING TO END BY ONE OF OUR FIGURES FROM ONE OF THE WONDERFUL PAPERS. WE TALKED ABOUT HIGHLY ACTIVE HIV PREVENTION AND I THINK REPORTED THE IDEA THAT DR. DIEFFENBACH MENTIONED AS WELL THIS IDEA OF COMBINATION PREVENTION AND WHEN WE THINK USUAL BECOMBINATION PREVENTION, WE ARE THINKING OF TWO SEPARATE INTERVENTIONS BIOMEDICAL STRATEGY, BEHAVIORAL STRATEGIES AND ANTIRETROVIRAL STRATEGIES OR STRUCTURAL INTERVENTION. AND I THINK THERE IS ALSO ANOTHER WAY OF THINKING OF COMBINATION PREVENTION WHICH IS WHAT I THINK TRIED TO SAY IN THIS TALK, WHICH IS ACTUALLY WITHIN EACH OF THE OR WITHIN A STRATEGY, WITHIN ARV FOR EXAMPLE, FOR PREVENTION AS A STRATEGY, WITHIN THAT ARE MULTIPLE COMPONENTS. SO FOR EXAMPLE, WHEN YOU THINK OF ARV, ART AS A PREVENTION INTERVENTION, YOU KNOW YOU HAVE TO DO EXPANDED TESTING. YOU KNOW YOU HAVE TO LINK TO THE INTERVENTION AND YOU HAVE TO INITIATE ARV IF IT'S PREP. YOU KNOW YOU HAVE TO HAVE MECHANISMS TO INCREASE YOUR TENSION AND ADHERENCE AND YOU KNOW HAVE YOU HAVE TO DO PREVENTION COUNSELING AS WELL. SO ALL OF THESE COMPONENTS, IT'S A MOSTLY COMPONENT -- MULTICOMPONENT WITHIN ONE INTERVENTION RATHER THAN THINKING OF DIFFERENT INTERVENTIONS AS PART OF COMBINATIONS PREVENTION INTERVENTIONS. SO IN CONCLUSION, I BELIEVE THAT THE SUBSTANTIAL ACHIEVEMENTS IN SCALING UP OF HIV TREATMENTS PROBABLY ONE OF THE MOST UNIQUE AND HISTORIC PUBLIC HEALTH ACHIEVEMENTS EVER. AND WE SHOULD ALL OF US BE VERY PROUD OF THESE ACHIEVEMENTS AND BE VERY PROUD OF THE RESEARCH THAT IS ENABLED THESE ACHIEVEMENTS. ALSO BEEN IN THE PAST SEVERAL YEARS REMARKABLE BREAKTHROUGHS IN PREVENTION RESEARCH AGAIN A REMARKABLE ACHIEVEMENT IN SUCH A YOUNG EPIDEMIC. ON THE OTHER HAND WHILE BREAKTHROUGHS ARE LARGELY BIOMEDICAL IN NATURE, EACH OF THE NEW DISCOVERIES, EACH OF THE NEW BREAKTHROUGHS REQUIRES SUBSTANTIAL BEHAVIORAL AND STRUCTURAL COMPONENTS AND IN ORDER TO ACLEAVE HIGH EFFICACY AND MOST IMPORTANTLY TO HAVE ACHIEVE EFFECTIVENESS AND TO ACHIEVE SUBSTANTIAL SCALE-UP BECAUSE THAT'S THE WAY TO CONTROL THE EPIDEMIC. AND LASTLY, MOVING FROM EFFICACY TO EFFECTIVENESS AND TOWARDS IMPACT WILL REQUIRE EXTENSIVE EFFORTS BY INDIVIDUALS FROM ALL DISCIPLINES AND PARTICULARLY THE BEHAVIORAL AND SOCIAL SCIENCES WHO ARE CRITICAL FOR GETTING US TO WHERE WE WANT TO GET TO. SO THANK YOU VERY MUCH FOR YOUR ATTENTION AND I'D LIKE TO ALSO ACKNOWLEDGE THE SUPPORT OF NIH AND NIAID AND NIMH AND NIDA AND OTHER FUNDERS FOR ALL THE WORK AND IN PARTICULAR, THE HPTN FOR ALL THE SUPPORT OF PREVENTION RESEARCH. THANK YOU. [APPLAUSE] >>> PLEASE JOIN ME NOW IN WELCOMING HARVARD UNIVERSITY'S'S DR. BANGSBERG. >> THANK YOU. IT'S AN HONOR TO BE HERE TO DISCUSS WHAT I THINK IS A VERY EXCITING TIME FOR BOTH HIV TREATMENT AND PREVENTION. FIRST TIME IN THE 30-YEAR HISTORY OF H-VIV, WE ARE HAVING INCREDIBLE DISCUSSIONS ABOUT TOOLS THAT CAN COME TOGETHER TO END THE HIV EPIDEMIC. IN THE DISCUSSIONS, ADHERENCE BECOMES A CENTRAL FACTOR AS TO WHETHER THESE TOOLS CAN BE PUT TOGETHER TO ACHIEVE THE ALL THE MAT GOAL OF ENDING THE EPIDEMIC. AND THESE ARE DISCUSSIONS AROUND ADHERENCE TO BOTH ANTIRETROVIRAL TREATMENT AS WELL AS ANTIVET ROW VIRAL-BASED PREVENTION. I'D LIKE TO START THIS STORY IN 1997, THE YEAR AFTER THE ADVENT OF THE EFFECTIVE ANTIRATE ROW VIRAL THERAPY. THERE WAS GREAT CONCERN THAT IF WE PROVIDE THIS LIFE-SAVING HIV TREATMENT THAT TURNED HIV FROM A TERMINAL DISEASE TO A CHRONIC DISEASE TO PEOPLE WITH MENTAL ILLNESS, DRUG USE, THE HOMELESS, THAT THAT POPULATION WOULD MISS THEIR DOSES, LEAD TO DRUG RESISTANT HIV, WHICH COULD THEN SPREADED TO A LARGER POPULATION AND AS THE "NEW YORK TIMES" ARTICLE SAYS, DOCTORS WITHHOLD THEY WERE FRESOME. SO THERE WAS A PUBLIC HEALTH ARGUMENT THAT ADVOCATED WITHHOLDING TREATMENTS FROM SUCH AT RISK POPULATIONS THE SAME ARGUMENT OCCURRED IN THE LATE 90s AND EARL TWO THOUSANDS WHEN WE RECOGNIZED THAT OVER 90% OF PEOPLE LIVING WITH HIV WERE IN THE POOR REGIONS OF THE WORLD AND THE CONCERN WAS IF WE ROLLOUT ANTIRETROVIRAL THERAPY TO ALL PEOPLE LIVING WITH HIV, THAT THOSE LIVING IN EXTREME POVERTY WITHOUT EDUCATION, WOULD SIMILARLY MISS THEIR DOSES AND LEAD TO GENERATION AND SPREAD DRUG RESISTANCE AND THAT WE SHOULD WITHHOLD TREATMENT UNTIL WE CAN MAKE SURE THAT EVERY PATIENT TAKES EVERY DOSE. THESE ARGUMENTS WERE BASED ON A CONCEPTUAL RELATIONSHIP BETWEEN ADHERENCE TO HIV TREATMENT AND THE RISK OF DRUG RESISTENCE. THIS CONCEPTUAL RELATIONSHIP POSITIVE THAT IF YOU HAVE IMPROVED ADHERENCE ON THE X AXIS AND THE PROBLEM LIBERTY OF RESISTENCE ON THE Y AXIS THAT A PATIENT WITH PERFECT ADHERENCE WOULD FULLY SHUT DOWN REPLICATION AND THIS WOULD GIVE A LOW PROBABILITY OF RESISTENCE. ON THE OTHER END OF THE EXTREME, PATIENT TAKES NONE OF THEIR DOSES, THERE IS NO DRUG PRESSURE TO SELECT FOR RESISTENCE AND AT THE PEEK RISK, IT WOULD OCCUR AT SOME LEVEL OF INCOMPLETE ADHERENCE WHERE THERE IS VIRAL REPLICATION AND SELECTED DRUG PRESSURE TO SELECT FOR RESISTANT VIRUS. WE SPENT ROUGHLY A DECADE MEASURING ADHERENCE IN AN URBAN POOR POPULATION, SAN FRANCISCO WITH ELECTRONIC PILL CAPS AND RANDOM PILL COUNTS TO FIND THAT EACH ANTIRETROVIRAL REGIMEN HAS A DIFFERENT ADHERENCE RESISTENCE RELATIONSHIP. THE FIRST ANTIRELATE ROW VIRAL THERAPY EFFECTIVE AT PREVENTING DISEASE PROGRESSION IS SHOWN HERE IN YELLOW. WE FOUND THAT THE PEEK RISK OF RESISTENCE FOR UNBOOSTED PI THERAPY WAS ABOUT 70-80% ADHERENCE AND THAT PERFECT ADHERENCE DECREASED THE RISK OF RESISTENCE BUT DECREASED THE RISK MODESTLY. THE PROBLEM WITH THIS EARLY THERAPY THAT WAS SAVING LIVES WASN'T SO MUCH THAT THE PEOPLE WEREN'T TAKING THE MEDICATION, THE PROBLEM WAS THIS REGIMEN WASN'T POTENT ENOUGH TO SUPPRESS THE VIRUS IN PATIENTS FOR MOST OR ALL MEDICATIONS. HIV TREATMENT HAS IMPROVED. AND BECOME MORE POT SCENT WITH MORE POTENT THERAPY WORKS WE HAVE BETTER VIRAL SUPPRESSION. ONE WAY TO IMPROVE POTENCY IS TO ADD BOOSTING AND WE GO FROM THIS YELLOW CURVE TO THIS BLUE CURVE WHERE MODERATE TO HIGH LEVELS OF ADHERENCE ARE CAPABLE OF FULLY EXPRESSING THE VIRUS YOU SEE VERY LITTLE RISK OF DRUG RESISTENCE. THE OTHER POTENT THERAPY ARE THE NONNUKE BASED REGIMENS WE SEE HERE IN GRAY. THESE ARE POTENT THERAPIES AND AT MODERATE TO HIGH LEVELS, WE SEE HIGH LEVELS OF VIRAL SUPPRESSION AND VERY LITTLE DRUG RESISTENCE. THERE IS A KEY DIFFERENCE BETWEEN THE PROTEASE-BASED THERAPY AND THE NONNUKE BASED THERAPY AT THE LOW END. FOR PROTEASED BASED THERAPY YOU SEE LOW DRUG RESISTENCE OR FOR NONNUKE, YOU SEE THE BURDEN OF DRUG RESISTENCE IS OCCURRING AT THE LOW END OF ADHERENCE. NOW IS THERE ALSO BEEN IN ADDITION IMPROVING POTENCY TO ANTIRETROVIRAL THERAPY, THERE IS IMPROVEMENT IN REGIMEN IN TOLLABILITY AND SIMPLICITY AND WE CAN TREAT HIV WITH ONE PILL DELIVERED ONCE A DAY IN A SINGLE TABLET REGIMEN. WE COMPARED ADHERENCE WITH RANDOM UNANNOUNCED PILL COUNTS IN A HOMELESS POPULATION WITH A HIGH PREVALENCE OF DRUG USE, MENTAL ILLNESS AND UNSTABLE HOUSING. AND COMPARED ADHERENCE TO A SINGLE TABLET REGIMEN IN LAVINDER TO OTHER MORE COMPLICATED REGIMENS AND SAW THAT ADHERENCE TO MORE COMPLICATED REGIMENS IS BETWEEN 60 SHORT OF 70% ON AVERAGE WHEREAS ADHERENCE TO THE SIMPLE SINGLE TABLET REGIMENS APPROACHES 90sY% EVEN IN A POPULATION WITH VERY INTENSE ADHERENCE CHALLENGES. AND THAT COMBINING THE HIGH LEVELS OF ADHERENCE WITH A VERY POTENT DRUG, YOU ACHIEVE VIRAL SUPPRESSION OVER A WIDE RANGE OF ADHERENCE. HERE WE ARE COMPARING VIRAL SUPPRESSION TO SINGLE TABLET SUPPRESSION NO, SIR LAVINDER COMPARED TO OTHERS. WHEN WU STARTED ROLLING OUT ANTIRETROVIRAL THERAPY TO POOR REGION, PARTICULARLY SUB SAHARAN AFRICA, WE WERE PLEASANTLY SURPRISED IN THAT EARLY REPORTS OF ADHERENCE WERE HIGHER THAN EXPECTED. AS MILLS COMBINED THE INDIVIDUAL REPORTS IN A METANALYSIS LOOKING AT 28,000 PATIENTS, AND ASKED THE QUESTION WAPORTION OF PATIENTS ARE CLASSIFIED AS ADHERENCE IN RICH VERSUS POOR REGIONS OF THE WORLD AND FOUND THAT ROUGHLY 55% OF PATIENTS IN RICH REGION ARE CLASSIFIED AS ADHERENCE COMPARED TO 75% IN THE POOREST REGION. SUGGESTING ADHERENCE IS GOOD OR BETTER IN THE POOREST REGIONS OF THE WORLDCOM PAIRED TO THE RICHEST REGIONS. THIS WAS ENCOURAGING AND I THINK SUMMED UP IN THE JOURNAL THAT MATTERS IN THE "NEW YORK TIMES" THAT SAID AFRICANS OUT DO U.S. PATIENTS IN FOLLOWING AIDS THERAPY. BUT ALL -- BUT EXPLAINING THIS, THESE HIGH LEVELS OF ADHERENCE IS IMPORTANT. AND IT'S IMPORTANT TO UNDERSTAND HOW TO KEEP THESE HIGH LEVELS OF ADHERENCE SUSTAINED BOTH AS TREATMENT EXPANDS TO A LARGER POPULATION AS WELL AS PATIENTS GO DEEPER INTO YEARS IF NOT DECADES OF TREATMENT. IN ORDER TO UNDERSTAND THESE HIGH LEVELS OF ADHERENCE, I TURNED TO THE WORK OF NORMA WEAR WHO INTERVIEWED OVER 200 PATIENTS IN DETAIL QUALITATIVE INTERVIEWS IN TANZANIA, UGANDA TO, ASK PATIENTS TO TELL THEIR STORIES OF ADHERING TO HIV TREATMENT. WHEN THESE STORIES ARE COMBINED AND THEMES EMERGE, NORMAL FINDINGS THAT THE FIRST AND FOREMOST REASON PATIENTS TAKE THEIR TREATMENT THE SAME THROUGHOUT THE WORLD AND THAT'S FIRST AND FOREMOST TO IMPROVE HEALTH. BUT WHEN LISTENING TO STORIES IN MORE DETAIL, YOU FIND THAT THESE STORIES ARE ALL TOLD IN A SETTING OF THE EXTREME RESOURCE SCARCITY. YOU HEAR STORIES OF INDIVIDUALS HAVING TO SPEND 50% OF THEIR MONTHLY INCOME SIMPLY TO GO TO CLINIC TO PICK UP THEIR MEDICATIONS. OR STORIES OF HAVING TO SPEND A DAY AWAY FROM THE SHOP OR THE FARM TO PRODUCE FOOD FOR THE FAMILY IN ORDER TO GO TO CLINIC TO PICK UP THEIR MEDICATIONS. AND SO THAT THESE HIGH LEVELS OF ADHERENCE ARE EVEN MORE SURPRISING WHEN YOU UNDERSTAND THE STRUCTURAL ECONOMIC BARRIERS THAT PATIENTS IN EXTREME RESOURCE SCARCITY HAVE TO OVERCOME TO ACHIEVE THESE EXCEPTIONAL RATES OF ADHERES. HOW DO PEOPLE DO THIS? THEY ASK THEIR FRIENDS AND FAMILY FOR HELP. THEY STARTED TREATMENT WITH ADVANCED AIDS, EXTREMELY ILL, OFTEN BED BOUND. THEIR FAMILY HAS WATCHED THEM RETURN TO HEALTH AND RETURN TO ECONOMIC ACTIVITY TO SUPPORT THE FAMILY, THERE IS A STRONG PERSONAL AS WELL AS ECONOMIC INCENTIVE TO KEEP THAT PERSON ON TREATMENT. SO WHEN THAT INDIVIDUAL ASKED TO GO TO CLINIC, THEY HAVE TRAN POA–r TRANSPORTATION, THE FAMILY IS MOTIVATED. ONCE THAT LOAN IS RECEIVED, THE HELP IS RECEIVED, PATIENTS DESCRIBE ATTEMPTED RESPONSIBILITY EVEN OBLIGATIONS TO HONOR THAT HELP BY TAKING THEIR MEDICATIONS TO STAY HEALTHY AND TO GIVE BACK TO THAT RELATIONSHIP BY GIVING BACK TO THAT RELATIONSHIP, YOU STRENGTHEN THAT RELATIONSHIP SUCH AS THE NEXT TIME YOU NEED HELP WITH THE SHOP OR ATTENDING THE FARM OR COST OF TRANSPORTATION, YOU'RE MORE LIKELY TO RECEIVE HELP. SO WE GET POSITIVE FEEDBACK LOOP OF PEOPLE ASKING FOR HELP, RECEIVING HELP, HONORING THAT HELP, REINFORCING THAT RELATIONSHIP. AND THE ECONOMIC VALUE OF THESE RELATIONSHIPS CAN BE DESCRIBED AS SOCIAL CAPITAL. THERE ARE ALSO OTHER IMPORTANT FACTORS OF ADHERENCE WE SEE THROUGHOUT THE WORLD, JUST AS FORGETTING, DEPRESSION AND SUBSTANCE ABUSE. WE FIND THAT THIS INTERDEPENDENT, ECON?M SOCIAL TIES ARE THE ONE FACTOR THAT MAY EXPLAIN HIGH LEVELS OF ADHERENCE DESPITE ECONOMIC OBSTACLES TO ADHERE. HOWEVER, NOT ALL IS ROSIE. THERE ARE IMPORTANT GAPS IN ADHERENCE THAT ARE EMERGING. WE FOLLOWED 177 PATIENTS WITH ELECTRONIC PILL CAPS FOR UP TO 42 MONTHS AND FOUND HIGH ADHERENCE, 98.3% ADHERENCE BUT THAT BEE LEVELED THE HERENCE KICKED DOWN JUST A LITTLE BIT EACH MONTH AND THAT ADHERENCE WILL APPEAR TO BE DECLINING OVER TIME. SIMILAR TO WHAT WE SEE IN NORTH AMERICAN WESTERN EUROPEAN STUDIES, WE ALSO SEE VERY STRONG CHALLENGES TO ADHERENCE IN POOR REGIONS OF THE WORLD. THE FIRST AND FOREMOST IS TRANSPORTATION. THE ECONOMIC CHALLENGES TO JUST CONTINUE TO SUSTAIN ACCESS TO TREATMENT ARE QUITE PROFOUND. THE OTHER DIFFERENT PROFOUND BARRIER IS FOOD IN SECURITIY. NOT ONLY ARE THERE ECONOMIC CHALLENGES WHERE YOU HAVE TO DECIDE WITH THE LIMITED AMOUNT OF CASH AVAILABLE, DO YOU FEED YOUR CHILDREN OR SPEND THAT MONEY TO GO TO CLINIC? YOU ALSO HEAR STORIES OF PATIENTS WHO WITH ADVANCED AIDS PRESUMABLY MALNOURISHED, WHO REPORT SEVERE HUNGER PAINS ON STARTING ANTIRETROVIRAL THERAPY. PRESUMING THE PATIENTS HIGH LEVEL OF STEMMATIC ANTIOR APPETITE SUPRESSANT CYTOKINES WHEN THEY STOP, STARTING ANTIRETROVIRAL THERAPY, THE INFLAMMATION GOES DOWN AND THEY REALIZE FOR THE FIRST TIME THEY WERE STARVING AND FALSELY ATTRIBUTE THE HUNGER PAINS TO THE SIDE EFFECT OF HIV TREATMENT. AND SOMETIMES DISCONTINUE TREATMENT. WE ALSO SEE THE PATTERN OF ADHERENCE IS DIFFERENT IF POOR REGIONS OF THE WORLD. WE FOLLOWED PATIENTS AND FOUND THAT USING ELECTRONIC PILL CAPS, PATIENTS HAVE ON AVERAGE TWO INTERRUPTIONS OVER A COURSE OF 6 MONTHS AND THESE INTERRUPTIONS WILL LAST 11 DAYS. THESE INTERRUPTIONS ACCOUNT FOR 90% OF ALL MISSED DOSES AND AGAIN THESE INTERRUPTIONS ARE LARGELY DUE TO NOT BEING ABLE TO OVERCOME THE STRUCTURAL ECONOMIC BARRIERS TO TREATMENT ACCESS. WE THINK THAT THESE INTERRUPTIONS ARE IMPORTANT AND ARE LIKELY TO DRIVE DRUG RESISTENCE IN THIS POPULATION, ESPECIALLY ON NONNEW THERAPY AND TO SUPPORT OR REFER TO THIS WORK WHO LOOKED AT PATIENTS ON NONBASED THERAPY WHO WERE ON ELECTRONIC PILL CAP MONITORING AND ASKED WHAT IS THE RELATIONSHIP BETWEEN INTERRUPTION AND THE RISK OF -- AND THE PROBABILITY OF SUSTAINING VIRAL SUPPRESSION. SO ON THE X AXIS, YOU HAVE THE LENGTH OF THE SPONTANEOUS UNSTRUCTURED INTERRUPTION AND YOU ON THE Y AXIS YOU HAVE VIRAL SUPPRESSION. SO SOMEONE INTERRUPT HER TREATMENT HERE. THEY DON'T HAVE ENOUGH MONEY TO PICK UP THE MEDICATION. YOU HAVE A TWO OR 3 DAY WINDOW WHERE THE PROBABILITY OF VIRAL SUPPRESSION REMAINS HIGH. AS THAT INCREASES THE PROBABILITY OF DRUG RESISTENCE DECLINES AND THE PROBABILITY OF RESISTENCE INCREASES SUCH THAT AT 14 DAY INTERRUPTION, YOU HAVE A 50% CHANCE OF VIRALOGGIC REBOUND. SO HOW DO WE USE THIS INFORMATION TO IMPROVE ADHERENCE, PREVENT SUPPRESSION AND DRUG RESISTENCE? WORK BY JESSICA IS LOOKING AT REALTIME ADHERENCE MONITORING USING THIS PILL BOX THAT CONTAINS ABOUT A MONTH'S WORTH OF MEDICATION. EVERY TIME THIS PILL BOX OPENED UP IT TRANSMITTS THAT EVENT THROUGH THE CELL PHONE NETWORK TO A CENTRAL SERVER THAT MONITORS ADHERENCE. AND THEN THAT INFORMATION CAN BE USED TO PROMOTE INTERVENTIONS TO THE PATIENT. HERE IS THE PATIENT WHO SHOWS HER PICTURE WITH HER PERMISSION AND LIVES IN RURAL SOUTHWEST UGANDA ABOUTyM 20 KILOMETERS OUTSIDE OF -- HOLDING HER WISE PILL DEVICE. HERE IS HER ADHERENCE RECORD. A DOT EVERY TIME SHE OPENS AND CLOSES HER PILL BOX. SHE'S ON A TWICE DAILY REGIMEN TAKING MEDICATIONS ABOUT AFTER 8 A.M. AND ABOUT 8:00 P.M. I'D LIKE TO POINT OUT THE DATES HERE. HERE IS NOVEMBER 9 AT 8 A.M. LOCAL UGANDAN TIME THIS MORNING. WE THAN SHE TOOK THIS MORNING'S DOSE. IT'S ABOUT TIME FOR UGANDA. WE COULD GO ON THE WEB AND SEE IF SHE TOOK HER EVENING DOSE. IF SHE MISSED HER DOSE, WE COULD THEN SEND A TEXT. IF SHE MISSED A COUPLE DAYS OF DOSES, WE COULD CALL HER ON THE PHONE OR SEND SOMEBODY OUT ON A MOTORCYCLE TO GET HER BACK ON TREATMENT TO PREVENT VIRALOGGIC REBOUND. THIS CREATES AN OPPORTUNITY NOT ONLY TO RATHER THAN REACT TO VIRALOGGIC FAILURE BUT FOR THE FIRST TIME PROACTIVELY PREVENT THE FAILURE BEFORE IT HAPPENS. ALSO, IF A PATIENT COMES IN TO CLINIC LIKE THIS, ONE OF THE MAJOR CHALLENGES IN POOR REGIONS, HOW TO MONITOR THESE PEOPLE VINYLICALLY. IF WE HAVE THIS RECORD, WE COULD CALCULATE THE VIRAL CONNECTION. MAYBE A 98% CHANCE OF VIRALOGGIC EXPRESSION. DOES SHE NEED A VIRAL LOAD? WHEREAS IF SHE MISSED 3-4 DAYS IN A ROW, THAT'S A PATIENT WHO SHOULD HAVE MONITORING AND THAT'S VERY FEW PATIENTS. IN LINKING THIS TO SIMPLE INTERVENTIONS, CAN WE LIFE TO IMPROVED ADHERENCE. >> THESE LOOKED AT WEEKLY SMS REMINDERS OR COUNSELING PROVIDED THROUGH A CELL PHONE AND FOUND THAT IN WESTERN KENYA, FOUND THAT BOTH OF THESE WEEKLY STRATEGIES CAN EITHER IMPROVE ELECTRONICALLY MONITORED ADHERENCE OR VIRALLIC SUPPRESSION. SO WE DON'T HAVE TO DO THAT MUCH TO SUPPORT ADHERES ESPECIALLY WHEN YOU KNOW WHEN PATIENTS ARE MISSING THEIR DOSES. SO LET'S TURN, WE TALKED ABOUT ANTIRETT VO VIRAL TREATMENT. NOW LET'S TURN TO PREVENT PROGRESSION AND AIDS AND DEATH AND NOW LET'S TALK ABOUT TREATMENT AS PREVENTION. I THINK THIS HAS BEEN NICELY SUMMARIZED. A SERIES OF STUDIES THAT STARTING WITH TOM KWINN STUDY TA FINDS A DOSE RESPONSE RELATIONSHIP BETWEEN VIRAL SUPPRESSION AND RISK OF TRANSMISSION TO REALLY MODEL THE WORK TO FIND IF WE'RE TO TEST AND TREAT EVERYBODY, WE MAY SLOW THE EPIDEMIC IN SOUTH AFRICA. AND OBSERVATIONAL STUDIES AND NOW RANDOMIZED CONTROL TRIALS SHOWS THAT ANTIRETROVIRAL THERAPY IS POWERFULLY EFFECTIVE IN REDUCING TRANSMISSION. BUT THERE ARE TREATMENT AS PREVENTION CHALLENGES BOTH DR. DIEFFENBACH AND EL-SADR TALKED ABOUT CASCADE AND GETTING PEOPLE ON TESTED, TREATED CARE IS NO SMALL FT. THERE ARE ADDITIONAL CHALLENGES. THE FIRST IS, WILL HEALTHY PEOPLE ADHERE AS WELL AS ILL PEOPLE AND THE SOCIAL FABRIC THAT SUPPORTS ADHERENCE SUPPORTING SUCCESSFUL ADHERENCE SO FAR IS BASED ON ILL PEOPLE. WE HOPE TO PRESENT RESULTS AT THE UPCOMING -- TO SEE THE HIGH LEVELS OF ADHERENCE IN ASYMPTOMATIC INDIVIDUALS. I DISCUSSED THE WORK BY JANE THAT SUGGESTS THERE IS A MODEST DECLINE IN ADHERENCE OVER TIME WHICH WILL BECOME IMPORTANT AS WE TALK ABOUT DECADES OF ANTIRETROVIRAL TREATMENT. BUT I THINK THAT THE MOST IMPORTANT CONCERN THIS SUSTAINING ANTIRETROVIRAL TREATMENT AS PREVENTION IS WHETHER OUR HEALTH SYSTEMS WILL BE ABLE TO EXPAND TO MEET THE GROWING DEMANDS OF TREATMENT UNDER CURRENT FISCAL CONSTRAINTS. LIKE TO HAVEzV FOCUS ON THESE WORDS TO ADDRESS THIS ISSUE. IN MAY OF LAST YEAR, WE SAW A REPORT IN NEW YORK TIMES OF INDIVIDUALS IN UGANDA WITH ADVANCED AIDS GOING TO CLINIC AND BEING TURNED AWAY BECAUSE THERE WAS NO TREATMENT AVAILABLE. THIS PROMPTED US TO LOOK AT THE NUMBER OF NEW TREATMENT STARTS AT A UNIVERSITY-BASED CLINIC IN UGANDA. HERE WE SEE THE NUMBER OF NEW TREATMENT STARTS PER WEEK AND EACH COLOR IS A DIFFERENT FUNDING SOURCE. THIS CLIN SICK PUTTING 15-20 PATIENTS ON TREATMENT EVERY WEEK. INITIALLY THIS IS LARGELY SPONSORED BY PEP FAR IN RED. AND THEN IN OCTOBER OF 2009, PEP FAR STOPS PUTTING PEOPLE ON TREATMENT AND THE MINISTRY OF HEALTH IN GREEN PICKS UP AND CONTINUES TO PUT PEOPLE ON TREATMENT. THEN YOU SEE IN MAY OF 2010 WHEN THE NEW YORK TIMES ARTICLE WAS REPORTED THAT THE MINISTRY OF HEALTH STOPS PUTTING PEOPLE ON TREATMENT. THERE IS A SMALL FOUNDATION CALLED THE FAMILY TREATMENT FUND THAT STRUGGLED TO PICK UP WHERE THE MINISTRY MINISTRY OF HEALTH LEFT OFF CONTINUING TO PUT PEOPLE ON ANTIRETROVIRAL TREATMENT. SINCE THEN, PEP FAR AND MINISTRY OF HEALTH HAS COME BACK AND IS NOW PUTTING PEOPLE ON TREATMENT AGAIN BUT THERE WAS A VERY SIGNIFICANT GAP DURING THIS PERIOD WHERE THEY WERE NOT PROVIDING TREATMENT. WHEN WE LOOK AT THE TIME THAT SOMEBODY HAD LESS THAN 250CD4 CELLS AND HOW LONG THEY HAD TO WAIT TO GET PUT ON TREATMENT, WE DID A PLOT OF THAT WAIT TIME, OVER THESE CALENDAR OR THIS CALENDAR PERIOD, WE SEE A SIGNIFICANT INCREASE IN WAIT TIME SUCH THAT THESE SYSTEMS WERE UNABLE TO PUT PEOPLE ON TREATMENT WITH ADVANCED AIDS IN A TIMELY MANNER. I'D LIKE TO TURN TO ANTIRETROVIRAL PRE-EXPOSURE PROPHYLAXIS AS A WAY TO PREVENT TRANSMISSION IN THE HIV-NEGATIVE. DR. DIEFFENBACH DESCRIBED THE DIFFERENT RANGE OF EFFICACY RESULTS IN A DIFFERENT PRETTY RULES AND WE SEE A LOT OF HETEROGENEITY. DR. EL-SADR TALKED ABOUT ADHERENCE TO PREP AND WE SEE THE CAPRICA 10 OP VEER STUDY. ADHERENCE IS THE LINCHPIN THAT EXPLAINS ADHERENCE SUCCESS IN THESE STUDIES. SO, HOW DO WE BEGIN TO UNWRAP THIS HETEROGENEITY IN TREATMENT EFFICACY AS WELL AS ADHERENCE? SO HERE IS A NUMBER OF BIOMEDICAL PREVENTION STUDIES. NOT ALL STUDIES WERE FOUND TO BE BIOLOGICALLY EFFICACIOUS BUT I THINK THE ADHERENCE INFORMATION IS IMPORTANT. WE SEE A WIDE RANGE OF STUDIES, NOT EFFICACIOUS, HAD 49% ADHERENCE BY SELF REPORT AND ADHERENCE WAS PROBABLY MUCH LESS. SEE A WIDE RANGE OF ADHERENCE. WE ARE LOOKING FOR DETAILED ADHERENCE DETAIL FROM THE VOICE STUDIES BUT THEN WE GET TO THESE TWO STUDIES AT THE END AND THE PARTNERS IN PREVENTION STUDIES USING ACYCLOVIR WHICH IS NOT BIOLOGICALLY EFFICACIOUS IN PREVENTING HIV TRANSMISSION BUT HAD A HIGH LEVEL OF ADHERENCE. 80% REPORTED MORE THAN 90% ADHERENCE AND THE PARTNER'S PREP STUDY LOOKING AT THIS FOUND 95 TO 100% ADHERENCE BOTH WITH ELECTRONIC PILL CAP MONITORING AND HOME-BASED UNANNOUNCED PILL COUNTS. NEAR PERFECT ADHERENCE. WELL, EITHER CONNIE HAS A SPECIAL SOFTWARE ADHERENCE BY RUNNING BOTH THESE STUDES AND HAS MAGIC WHICH IS DIFFERENT FROM THESE STUDIES OR A DIFFERENCE IN POPULATION OR BEHAVIOR OR ALL THE ABOVE. ONE OF THE KEY FACTORS IS THEY ARE BOTH STUDYING STABLE DISCORDANT PARTNERSHIPS WHERE THE BIOMEDICAL STRATEGY֜ IS APPROPRIATED TO THE COUPLE TOGETHER AND THE ADHERENCE COUNSELING IS DELIVERED TO BOTH THE NEGATIVE AND POSITIVE PARTNERS. ALL THE OTHER STUDIES ARE LOOKING AT HIGH RISK INDIVIDUALS IN THE COUNSELING PRIMARILY DRIVEN TO THEINDIVIDUAL AT RISK. HOW DOE WE EXPLAIN THE POWER OF THE ROLE OF THE RELATIONSHIP IN SUPPORTING ADHERENCE? THEN I TURN TO THE WORK OF NORMAN WEAR WHO DID IN-DEPTH QUALITATIVE INTERVIEWS AND PARTICIPATES IN CONNIE AND JARROD'S PARTNERS STUDIES TO TRY TO EXPLAIN THESE EXCEPTIONALLY HIGH RATES OF ADHERENCE. WE FIND THAT RELATIONSHIPS ARE QUITE IMPORTANT. WHEN YOU LISTEN TO THESE STORIES, YOU HEAR PATIENTS DESCRIBING WHAT WE DESCRIBE AS A DISCORDANCE DILEMMA. THE TENSION BETWEEN A POSITIVE AND MEGGATIVE PERSON IN A COMMITTEE RELATIONSHIP AND THIS DISCORDANCE DILEMMA THREATENS THE RELATIONSHIP. PREP OFFERS THE WAY OF HOPE TO RESOLVE THAT DILEMMA AND COUPLES DESCRIBE THAT PREP STRENGTHENS THE RELATIONSHIP. BY STRENGTHENING THE RELATIONSHIP, THE PARTNER, THE POSITIVE PARTNER BECOMES VERY INVOLVED IN THE NEGATIVE PARTNER'S ADHERENCE. AND WHEN WE ASK THE PARTNERS HOW DO YOU ADHERE TO THERAPY AND HOW DOES THE POSITIVE PERSON, WHY DOES THE POSITIVE PERSON HELP NEGATIVE PERSON STAY ON TREATMENT? THEY SAY IN VERY SIMPLE TERMS, I LOVE MY PARTNER. I WANT TO PROTECT HIM. I WORK HARD TO SUSTAIN HIS OR HER ADHERENCE. THIS CAN GO THE OTHER WAY TOO. AND IN THESE RELATIONSHIPS, WE KNOW DISCORDANT RELATIONSHIPS THERE IS OUTSIDE PARTNERSHIPS. AND WHEN THERE IS AN OUTSIDE PARTNERSHIP, THERE IS DISTRUST OR DISCORDINANT RELATIONSHIP. PREP CAN BE A REMINDER OF INFIDELY, DISTRUST. AND CAN ACTUALLY FUEL AN ARGUMENT IN THAT RELATIONSHIP AND LEAD TO THE NEGATIVE PERSON, WHY AM I TAKING THIS MEDICATION EVERY DAY WHEN THIS PERSON IS NOT WORTH STAYING WITH? AND THEN ACTUALLY DAMAGES THE RELATIONSHIP IN THE PA AND THE PARTNER IS NO LONGER ENGAGED IN THE SUPPORT AND PREP ADHERENCE CEASES ALL TOGETHER. AND THIS RELATIONSHIP DISCORD AND DISTRUST CAN WORK IN THE OCHES OF DIRECTION. I WOULD LIKE TO END IN TWO CASES TWO, PATIENT STORIES THAT ILLUSTRATES THESE POINTS. THE FIRST THING THE PATIENT THAT WAS FOLLOWED IN THIS STUDY LOOKING AT INTERMITTENT PREP ADHERENCE. THIS WAS THE HIV-NEGATIVE WOMAN WHO HAD EXCELLENT ADHERENCE BY ELECTRONIC PILL CAP AND FOUND OUT HER PARTNER HAD OUTSIDE SEXUAL RELATIONSHIP. SHE GOT ANGRY AND SHE THREW HER CAP AT THE WALL, BROKE THE CAP AND EVEN BROKE THE TABLETS. THAT DISCORD AND DISTRUST DAMAGED THE RELATIONSHIP AND DAMAGED PREP ADHERENCE. THE SECOND STORY IS INSPIRED BY ONE WHO SAID, YOU PROBABLY HEARD THIS QUOTE: THIS INSPIRED US TO PUBLISH A STORY OF JOHN WHO LIVES IN RURAL UGANDA AND NEVER BEEN TO SCHOOL A DAY IN HIS LIFE. HE WORKS AS A FARMER WITH HIS EXTENDED FAMILY IN A THREE-ROOM MUD-WALLED HOUSE. IF YOU DO INVENTORY OF WHAT HE HAS, HE HAS A LANTERN, A BED, SOFA, BIKE AND RADIO. NO WATCH. HOW IS THIS PERSON WITHOUT EDUCATION WITHOUT A WATCH GOING TO ADHEREzV TO ANTIRETROVIRAL THERAPY? WE MONITORED WITH THIS ELECTRONIC PILL CAP AND HERE IS HIS ADHERENCE RECORD. A DOT IS EVERY TIME HE OPENS HIS PILL BOTTLE AND THEY ARE AROUND 7:20 A.M. AND ALSO AROUND 7:20 P.M. IF YOU SUMMARIZE THESE DOTS HE IS TAKING 90% OF HIS DOSES WITHIN 10 MINUTES OF 7:20 A.M. IN THE EVENING, HE IS A LITTLE BIT LOOSER, TAKES THEM A TOTAL OF 17 MINUTES TO GET 90% OF HIS DOSES. OVER ALL ADHERENCE IS 98.9%. THE ONE PENALTY 1% IS A MIMES CAP FAILURE. THIS IS NOT JUST GOOD ADHERENCE. THIS IS NOT JUST MINUTE BY MINUTE. THIS IS SECOND BY SECOND ADHERENCE AND HO HAS NO WATCH. HOW DOES HE DO IT? HE LIVES IN UGANDA. THE SUNRISES AT 7 A.M. AND SETS AT 7:00 P.M. IT'S ON THE EQUATOR. SO THAT HELPS. SO THE SUN IS NOT GOOD ENOUGH TO GET SECOND BY SECOND ADHERENCE. I HEARD THE RIGHT ANSWER. THE RADIO. SO THE SUNRISES AT 7 A.M. IN UGANDA. AT 7 A.M. HE TURNS ON THE RADIO. THIS IS A SHOW CALLED RADIO WEST LIKE PUBLIC RADIO, BBC, WITHOUT THE PLEDGE COMMERCIALS. RADIO WEPT COMES TO GOOD MORNING THIS IS RADIO WEST IN THE LOCAL LANGUAGE, GUESS WHAT TIME IT STARTS? 7:20 A.M. HE KNOWS IT'S TIME TO TAKE HIS DOSE. HE TURNS OFF THE RADIO TO SAVE THE BATTERY AND GOES OFF AND DOES HIS WORK AND COMES BACK IN THE EVENING AND THE SUN SETS AT 7:00 P.M. HE TURNS ON THE RADIO. RADIO WEST PLACE IN THE EVENINGS. GUESS WHAT TIME? 7:20. TAKES HIS DOSE, SHUTS DOWN THE RADIO AND HAS ANOTHER DAY. THIS IS NOT THE END OF THE STORY. SO HERE IS JOHN'S ADHERENCE DURING THE FIRST 90 DAYS AND HIS ADHERENCE DURING THE SUBSEQUENT 9 MONTHS. DOLLAR GABS EVER SEVERAL DAYS. THIS IS THE RECIPE FOR DRUG RESISTANCE AND REBOUND. WHAT IS HAPPENING TO JOHN EXPLAINS THESE ADHERENCE GAPS? RADIO STILL WORKING. HE'S NOT TRAVELING BUT THAT'S A COMMON REASON. HE'S NOT SICK. SOMETHING HAPPENED TO JOHN THAT HAPPENED TO EVERYONE IN THIS ROOM. HE FALLS IN LOVE. HE FALLS IN LOVE WITH AN HIV POSITIVE PARTNER. SHE GOES TO A DIFFERENT CLINIC. HER CLINIC HAS A STOCK OUT. HE STARTS SHARING HIS MEDS WITH HER TO KEEP HER ON TREATMENT. I THINK THESE STORIES ARE ILLUSTRATIVE IN POWERFUL WAYS. FIRST RELATIONSHIPS MATTER, BOTH FOR TREATMENT AND PREVENTION. IT'S NOT JUST ABOUT THE INDIVIDUAL. IT'S ABOUT THE RELATIONSHIP. AND IT'S NOT JUST ABOUT FORGETTING TO TAKE YOUR DOSES IT'S ABOUT SEVERE STRUCTURAL AND ECONOMIC BARRIERS TO CARE. THAT CAN HAVE PROFOUND IMPACT ON TREATMENT AND PREVENTION SUCCESS. SO IN CONCLUSION, I THINK ADHERENCE RESISTENCE RELATIONSHIPS ARE REGIMEN SPECIFIC. EACH HAS DIFFERENT RELATIONSHIPS. WE DON'T KNOW WHAT THIS WILL BE FOR PREP BUT IT'S PATTERNS OF ADHERENCE AND THEY MATTER ESPECIALLY ON NONNUKE BASED THERAPY WHICH IS THE MAINSTAY OF TREATMENT IN POOR REGIONS OF THE WORLD. WE ARE BLESSED WITH SIMPLER MORE POTENT REGIMENS THAT LEADS TO FAVORABLE OUTCOMES IN THE VAST MAJORITY OF HIV POSITIVE PEOPLE ON TREATMENT. ADHERENCE IN SUB SAHARAN AFRICA IS EXCELLENT BUT IT IS ALSO A FRAGILE BALANCE BETWEEN SOCIAL FORCES THAT HELP PEOPLE OVERCOME ECONOMIC BARRIERS TO CARE AND THE NEED TO CONTINUE EXPAND TREATMENT ACCESS. AND I THINK IF WE BEGIN TO SEE THE TREATMENT WAIT LIST AGAIN, WE MAY SEE A VERY UNPREDICTABLE IMPACT ON BOTH ADHERENCE FOR TREATMENT AND ADHERENCE TO PREVENT HIV TRANSMISSION. THE SAME SOCIAL FORCE THAT IS SUPPORTED ADHERENCE WHEN TREATMENT IS AVAILABLE MAY ALSO MOTIVATE INDIVIDUALS TO BEGIN TO SHARE TREATMENT AS THEY WATCH THEIR FAMILY, THEIR FRIENDS, GET SICK WHILE WAITING ON TREATMENT WAIT LIST. THAT'S COMPROMISING TREATMENT FOR BOTH THE PEOPLE WHO SUCCEEDED WITH HIGH ADHERENCE AND GOOD VIRAL EXPRESSION AS WELL AS PEOPLE WAITING. AND ENGTHAT ANTIRETROVIRAL PREVENTION WILL DEPEND ON HOW WELL PEOPLE ADHERE AND WE ARE JUST BEGINNING TO UNDERSTAND WAT FORCES ARE THAT EXPLAIN ADHERENCE TO PREVENTION. I'D LIKE TO THANK SEVERAL INDIVIDUALS. ANDREW MOSS, TOM COATS, MY MENTORS. THIS WORK IS CO-LED BY UCSF, JEFF AND PETER. JESSICA LEADS THE WIRELESS ADHERENCE MONITORING WORK. AND HELP US UNDERSTAND THE FITNESSES AND RELATIONSHIPS. CONRAD IN UGANDA AND NORMA WEAR HAS DONE THE ANTHROPOLOGY I DISCUSSED. I'D LIKE TO THANK MARK AND MRS. SWARTZ FOR SUPPLEMENTAL FUNDING AND THE NATIONAL INSTITUTE OF MENTAL HEALTH, PARTICULARLY MICHAEL AND CHRIS, OUR PROJECT OFFICERS. THANK YOU VERY MUCH. [APPLAUSE] >> AND NOW WE WILL VEY WRAP UP PROVIDED BY MY FEARLESS LEADER, OBSSR DIRECTOR AND THE NIH ASSOCIATE DIRECTOR FOR BEHAVIORAL AND SOCIAL SCIENCES, DR. ROBERT KAPLAN [APPLAUSE] >> THANK YOU DANA. AND THANKS FOR HAVING ME. WHAT A WONDERFUL AFTERNOON. I DO WANT TO SAY THAT WHEN AN EVENT GOES OFF WELL LIKE THIS, WE ALL WANT TO TAKE CREDIT FOR IT. BUT I DO HAVE TO SAY THAT DANA CAME TO US AND SAID THAT SHE WANTED TO PUT ON THIS EVENT TODAY. AND SHE PRETTY MUCH DID THIS ON HER OWN. SO DANA, IT'S REALLY A GREAT ACCOMPLISHMENT. THANK YOU. [APPLAUSE] AND TO THE SPEAKERS. CARL DIEFFENBACH, TOM COATS, WAFAA EL-SADR. IT WAS A TERRIFIC PRESENTATION. WE WILL BE BACK TO SPEAK WITH YOU IN JUST A MINUTE. I WANT TO SAY A LITTLE BIT ABOUT THE OFFICE OF BEHAVIORAL AND SOCIAL SCIENCES RESEARCH AND HOW IT CONNECTS WITH THIS. I THINK MANY OF YOU KNOW THAT I CAME FROM THE OTHER SIDE RELATIVELY RECENTLY. I WAS A PROFESSOR AT UCLA AND HAVE BEEN ACTIVE IN OTHER AREAS. I HAVEN'T BEEN IN HIV RESEARCH MYSELF, BUT WE LEARNED SUCH A TREMENDOUS AMOUNT FROM INVESTIGATIONS AROUND HIV AND HIV DISEASE SO IN SOME RESPECTS, THE EMERGING EPIDEMIC OF HIV TAUGHT US SO MUCH ABOUT ALL THESE OTHER AREAS THAT WE STUDY AT OBSSR AND IN GENERAL. IT IS WORTH SAYING THAT THE RESPONSIBILITY OF THE OFFICE OF THE BEHAVIORAL AND SOCIAL SCIENCES RESEARCH IS QUITE BROAD AND I DIDN'T HAVE A FULL APPRECIATION OF THIS UNTIL I CAME. SO FOR EXAMPLE, WE REPRESENT ALL OF THE SOCIAL AND BEHAVIORAL SCIENCES AND THERE ARE A LOT OF THEM. SOCIOLOGY, PSYCHOLOGY, APTPOLOGIY, POLITICAL SCIENCE, AND LOTS OF OTHER ONES I HAVEN'T BEEN CONSIDERING, COMMUNICATION SCIENCES ANDzV GEOGRAPHY AN ARE AT THE POINT OF CONTACT AT THE NIH FOR ALL SORTS OF ORGANIZATIONS AND ALL SORTS OF PROFESSIONAL SCHOOLS SO PROFESSIONAL SCHOOLS OF PSYCHOLOGY, PROFESSIONAL SCHOOLS OF MEDICINE AND PUBLIC HEALTH AND SO FORTH. SO WHAT WE DO IS REMARKABLY BROAD-BASED. IN ADDITION TO THAT, WE ATTEMPT TO COORDINATE ACTIVITIES ACROSS 27 STATUTES AND CENTRES AT THE NIH AND ALSO AT THE POINT OF CONTACT WITH ALL KINDS OF PROFESSIONAL ORGANIZATIONS AND STAKEHOLDER GROUPS AS WELL AS OTHER GOVERNMENT AGENCIES LIKE CDC AND AHRQ AND SO FORTH. SO WE HAVE A LOT ON OUR PLATE. BUT IT IS WORTH SAYING THAT WHAT WE HAVE LEARNED FROM OUR COLLEAGUES THAT HAVE BEEN ENGAGED IN THE HIV EPIDEMIC, IT'S BEEN QUITE REMARKABLE. AND IT TEACHES US A LOT ABOUT ALL THE DIFFERENT THINGS THAT WE DO AT OBSSR SO FOR EXAMPLE, IF WE ARE INVOLVED IN BOTH BASIC AND TRANSLATIONAL RESEARCH, A LOT OF WHAT WE BECOME INTERESTED IN IS THE STUDY OF BASIC MECHANISMS OF BEHAVIOR CHANGE. WE HEAR AN ACTIVE PROGRAM AND I THINK MANY OF YOU ARE AWARE OF THAT HAS SOLICITATIONS TO GRANTS AROUND THESE AREAS. WE SEE OUR FLOW TRANSLATIONAL RESEARCH ACCELERATING IN THE NEXT FEW YEARS AND BECAUSE THE NIH IS MAKING A UNIQUE COMMITMENT TO TRANSLATIONAL SCIENCE WITH OUR NEW N CAPS. NATIONAL CENTER FOR ADVANCING TRANSLATIONAL SCIENCE ACTIVITY AND IT IS PRIMARILY FOCUSED ON THE FIRST PHASE OF TRANSLATION. IT IS FROM THE DISCOVERY OF NEW MOLECULES TO GETTING THE MOLECULES LICENSED FOR USE AND HAS LESS INVOLVEMENT IN DISTRIBUTION OF THE NEW MOLECULES OUT IN THE COMMUNITY AND WE ARE PARTICULARLY INTERESTED IN HELPING TO LEAD THE CHARGE TO ADVANCE THOSE SCIENCES. SO LET ME SAY A LITTLE BIT ABOUT WHY WE THINK THAT WHAT WE LEARNED TODAY IS SO RELEVANT TO JUST ABOUT ALL THE THINGS THAT WE DO. IF YOU LOOK AT SOME OF THE MAJOR CHALLENGES WE HAVE IN HEALTH CARE, THE INSTITUTE OF MEDICINE HAD THEIR ANNUAL MEETING THIS YEAR FOCUSED ON VACCINES AND A BIG PART OF THAT PRESENTATION, A BIG PART OF THE DAY, EMPHASIZED THAT THERE HAVE BEEN REMARKABLE ADVANCES IN VACCINE TECHNOLOGY IN THE LAST DECADE AND THESE ADVANCES ARE ACCELERATING SO THAT WE HAVE WITHIN OUR REACH TODAY, THE PROBABILITY OF HAVING A PROFOUND IMPACT ON THE HEALTH OF OUR POPULATION TO BETTER USE OF VACCINES. THE REAL CHALLENGE IS NOT SO MUCH IN DEVELOPMENT OF THESE VACCINES, THEY TELL US, BUT IN GETTING THESE VACCINES IMPLEMENTED AND USED IN THE COMMUNITY. SO FOR EXAMPLE, EVEN CHILDREN WHO HAVE OPPORTUNITIES TO REQUIRE VACCINES FOR ENROLLMENT IN SCHOOL WERE DOWN AT 85% AND THEY ARE CLUSTERS IN THE UNITED STATES WHERE THERE IS FEAR OF VACCINES FOR A VARIETY OF DIFFERENT REASONS. AND WE FOUND PATTERNS WITHIN COMMUNITIES WHERE PEOPLE JUST AREN'T WILLING TO USE THEM. IN THE ELDERLY, MANY VACCINES ARE AVAILABLE THAT AREN'T USED AND IN FACT THE UTILIZATION RATE FOR SOME EFFECTIVE VACCINES IS DOWN AROUND 30%. WE HAVE ANOTHER EXAMPLES AND I'LL INTRODUCE THIS BY SAYING, PROUD OF SAYING THIS BUT I DON'T FINISH THIS STORY IS TRUE BUT IT MAY BE THAT TOM COATS HAS BEEN OR BECOME A MAJOR INTERNATIONAL LEADER IN GLOBAL HEALTH. BUT I THINK I MAY HAVE BEEN RESPONSIBLE FOR INVITING TOM TO HIS FIRST INTERNATIONAL MEETING. IT WASN'T IN THE DEVELOPMENT WORLD. IT WAS IN ITALY. BUT AT THE TIME -- [INAUDIBLE] THAT'S RIGHT. AT THE TIME, BECAUSE -- WE ARE GETTING TO BE, AS THEY SAY, MORE MATURE, AT THE TIME TOM AND I WERE BOTH A FAIR AMOUNT YOUNGER AND TOM AT THE TIME, WAS ACTUALLY AN INTERNATIONALLY RDSOGNIZED SCHOLAR FOCUSING ON THE STUDY OF HYPERTENSION. I BET THIS IS BEFORE HE DEVELOPED THERE WAS AN HIV EPIDEMIC. THEY THINK ONE OF THE REASONS THAT HE HAS BECOME SUCH A POWERFUL FIGURE IS BECAUSE THE LESSONS HE LEARNED IN STUDYING HYPERTENSION ARE LARGELY TRANSFERABLE TO THE STUDY OF HIV EPIDEMIC. WE HAVE AGAIN WITHIN OUR REACH THE OPPORTUNITY TO HAVE A PROFOUND IMPACT ON DEATH FROM MYOCARDIAL INFARCTION AND STROKE IF WE JUST USE WHAT WE KNOW. SO FOR EXAMPLE, WE SPEND ENORMOUS AMOUNT OF MONEY DEVELOPING NEXT GENERATION MOLECULES NOT TO MENTION CHOLESTEROL AND PLOP. AT THE SAME TIME, WE HAVE FAIRLY EFFECTIVE MEDICINES THAT IF USED AND USED PROPERLY, COULD SUBSTANCUALY REDUCE CARDIOVASCULAR DISEASE AND STROKE IN OUR COUNTRY. AGAIN, I THINK THAT THE LESSONS WE LEARNED TODAY ARE REALLY QUITE RELEVANT NOT ONLY FOR THE CONTROL OF THE HIV EPIDEMIC BUT ALSO FOR THE MANAGEMENT OF ALL OF THESE OTHER CONDITIONS. BUT IN ORDER TO DO THAT, WE HAVE TO LEARN A LOT MORE ABOUT A LOT OF THESE PROBLEMS. POPULATION SCIENCE AND OBSSR AND STEPHAN IS EXPERTS IN THAT AREA. WE NEED TO LEARN MORE ABOUT POPULATION AND POPULATION RESIST TONES THESE THINGS. WE ARE LEARNING A LOT MORE IN DAVID'S PRESENTATION, YOU MENTIONED THE M HEALTH OPPORTUNITIES. WE ARE DEVOTING A FAIR AMOUNT OF OUR ATTENTION NOW TO THE STUDY OF ELECTRONIC DEVICES AND GETTING INVOLVED WITH ENGINEERS WHICH I THINK IS A VERY INTERESTING RESEARCH COMMUNITY TO LEARN MORE ABOUT THIS WONDERFUL NEW GENERATION OF NEW DEVICES THAT WILL HELP US RETHINK THE WAY WE HAVE APPROACHED THESE PROBLEMS. SO FOR EXAMPLE, WE HAVE ALWAYS THOUGHT THAT THE WAY WE STUDY THINGS IS WE TAKE PEOPLE TO THE LABORATORY. NOW WE CAN TAKE THE LABORATORY TO PEOPLE AND I THINK THAT THE EXAMPLE OF THE PILL DISPENSER IN AFRICA IS A GREAT EXAMPLE OF NOT ONLY AN OPPORTUNITY TO REPORT INFORMATION BUT AN OPPORTUNITY TO PROMPT A PERSON AND SO FORTH. AND WE HAVE MIKE SCOPES THAT ARE APPS FOR iPHONES, A VARIETY OF DIFFERENT THINGS THAT WILL ALLOW US TO COLLECT DATA ON A CONTINUOUS BASIS AND ALL KINDS OF ENVIRONMENTS THAT WERE POSSIBLE JUST A SHORT TIME AGO. SO THIS IS AN AREA THAT WE THINK HAS TREMENDOUS OPPORTUNITY AND ONE OF THE INTERESTING SIDE EFFECTS OF THIS IS PEOPLE ALWAYS SAY, YOU CAN'T CHANGE BEHAVIOR. ACTUALLY, WE KNOW A LOT ABOUT CHANGING BEHAVIOR. IF WE GO BACK TO YOUR INTRODUCTORY PSYCHOLOGY COURSE AND LOOK AT ANIMAL STUDIES IN THE LABORATORY, ACTUALLY PSYCHOLOGISTS HAVE DONE A GREAT JOB OF MODIFYING BEHAVIOR IN LABORATORIES, THE PROBLEM IS WHEN YOU GET OUTSIDE THE LABORATORY OR A SHAKE AWAY FROM THE CONTINGENCIES IT'S HARD. BUT THESE ELECTRONIC DEVICES AS YOU SHOWED VERY WELL PROVIDE THE OPPORTUNITY TO TAKE THAT LABORATORY TO THE PERSON AND SO TO CREATE THESE CONTINGENCIES IN PEOPLE'S LIVES WHEN THEY AGREE TO THEM AND HAVE A VERY PROFOUND AFFECT ON WHAT HAPPENS. WE THINK THAT THIS HAS A LOT OF POTENTIAL. WE THINK WE ARE LEARNING A TREMENDOUS AMOUNT. I JUST WANT TO CONCLUDE BY -- BECAUSE I'M SO INTRIGUED BY YOUR EXAMPLE OF THE CASE OF JOHN AT THE END AND HOW IS IT THAT JOHN IN A REMOTE AREA IN THE DEVELOPING WORLD DOES SO WELL ON HIS ADHERENCE AND THEN CONTRAST THAT WITH CASES I LEARNED ABOUT WHILE LIVING IN LOS ANGELES. JOHN HAS A FAIRLY SIMPLE LIFE. IN THAT ALTHOUGH IT'S A CHALLENGING LIFE IN MANY WAYS, HE HAS A RECOGNIZABLE SCHEDULE. AND LET ME JUST MENTION THE CASE THAT I DISCUSSED WITH MY FRIEND, A GENERAL INTERNIST AT UCLA TELLING ME ABOUT THEzV CASE OF ONE OF HIS PATIENTS WHO HAD DIABETES. AND THIS WAS A SINGLE MOM IN EAST L.A. WHO HAD TWO KIDS. SHE HAD THREE JOBS. AND THESE THREE JOBS HAD IRREGULAR SCHEDULES SO SHE HAD NO TWO DAYS AND SHE WORKED SEVEN DAYS A WEEK. SHE HAD NO TWO DAYS DURING THE WEEK WHERE HER SCHEDULE WAS THE SAME. SO SOME DAYS SHE GOT UP AT 6 IN THE MORNING AND WORKED THREE HOURS AND CAME BACK AND WAITED AROUND THE HOUSE AND WENT BACK TO WORK AN EVENING JOB. SOME OF THE DAYS SHE HAD A JOB THAT STARTED MIDDAY AND WENT TO MID AFTERNOON. SO FORTH. AND ADDED TO THAT WAS HER COMPLEX REGIMEN FOR HER DIABETES AND OTHER CHRONIC DISEASES SHE HAD. SO CHAOS, I THINK, TELLS US A LOT. THE CHAOS IN PEOPLE'S LIVES CREATES DIFFICULTIES IN ADHERING TO THESE REGIMEN THAT IS CHALLENGE ALL OF THE THING THAT WE TALKED ABOUT. ANY WAY, WOB OF THE THINGS I DID PROMISE DANA IS I WOULDN'T TALK FOR VERY LONG AND SO, I JUST WANT TO SAY THAT THANK YOU DANA AND THANK YOU TO THE SPEAKERS AND THANK ALL OF YOU FOR COMING. IT'S BEEN A WONDERFUL AFTERNOON. AND I THINK WE NOW BRANCH OFF INTO THE QUESTION AND ANSWER PERIOD. SO DO YOU WANT MOO ME TO STAND HERE AND FIELD QUESTIONS. >> AND THEN AGAIN THIS IS YOUR OPPORTUNITY TO QUERY THE SPEAKERS. THANK YOU VERY MUCH FOR EVERYONE'S PROMPT DELIVERY AND CONCLUSION AND PRESENTATIONS. AND WE ARE OPEN TO YOUR QUESTIONS AND THIS WILL BE MODERATED BY DR. DIEFFENBACH. >> SO DANA, AS BOB SAID, THIS IS YOUR OPPORTUNITY FOR QUESTIONS. WE ARE GOING TO TAKE THE WIRELESS MICS AND PASS THEM AROUND. WE ARE BEING RECORDED AND BROADCAST LIVE. SO WE'LL RUN THE MICROPHONES UP AND DOWN THE STAIRS IF THAT'S POSSIBLE. SO WE HAVE A COUPLE OF HANDS UP-STARTING IN THE BACK AND THEN GOING TO MY COLLEAGUE HERE. >> MY QUESTION IS FOR DAVID, I THINK, MOST PERTINENT. WHAT LESSONS IF ANY, HAVE BEEN LEARNED OR OUGHT TO BE LEARNED OR NOT LEARNED FROM TB IN TERMS OF ADHERENCE AND OTHER THINGS. I REALIZE IT'S A DIFFERENT INFECTIOUS AGENT BUT A LOT OF YEARS DEALING WITH THAT, OBVIOUSLY, AND THE FACT THAT IT PERSISTS AND IT'S NOW A MULTI-DRUG, EXTREMELY DRUG RESISTANT AND ALL THE OTHER FACTORS. THAT'S MY GENERAL QUESTION IN TERMS OF IDEAS ABOUT ADHERENCE EITHER DO IT OR DREAMS OF ERADICATION AND THE HIKE AND THE MOST IMPORTANT QUESTION IS WHAT HAPPENED TO YOUR PILL COUNT GRAPH WITH SHE THREW THE MEMES CAP AT THE WALL? >> I WISHEY WE MADE THE SAME INVESTMENT IN HEARING ABOUT THE TB ADHERENCE WE HAVE IN HIV. IT'S DEFINED ADDS NONCOMPLETERS WHICH MEANS PEOPLE NOT FINISHING THE COURSE OF TREATMENT AND THERE IS A RICH LITERATURE TALKING ABOUT PREDICTORS OF NONCOMPLETION. BUT THAT REALLY DOES UNDERSTAND LEVELS AND PATTERNS OF ADHERENCE AND MOST IMPORTANTLY WE DON'T KNOW MUCH ABOUT HOW DO YOU OR WHAT IS THE RESPEE OR PATTERNS OF NONADHERENCE THAT LEADS TO EXTREMELY DRUG RESISTANT TB? WE WANT TO KNOW THAT TO PREVENT THAT PATTERN. THAT WORK IS UNDERWAY. BUT WE ARE GOING TAT A BIT TOO LATE. WHAT WE DO KNOW IS THAT I THINK DIRECTLY OBSERVED THERAPY HAS HELPED ADHERENCE AND I THINK IT'S UNDERAPPRECIATED WHAT MECHANISMS, DOT OR DOT STRATEGY HELPS. I THINK FIRST AND FOREMOST, DMt& HELPS BECAUSE IT ENSURES DRUG SUPPLY AND DISTRIBUTION. YOU CAN'T HAVE A PHARMACY STOCK OUT AND HAVE A SUCCESSFUL DOTS PROGRAM. YOU GET MEDICATIONS TO PEOPLE. AND THAT IS UNDER APPRECIATED. AND THEN THERE IS IMPORTANT FACTORS OF SOCIAL SUPPORT WHICH ALSO ADVANCED ADHERENCE. IN TERMS OF WHETHER -- I THINK THAT WAS IN TERMS OF THE WOMAN WHO -- OR IN TERMS OF THE PATIENT WHO THREW THE MEMES CAP, I THINK IT WAS HISTORY. >> I THINK JUST TO ADD A COUPLE OF THINGS TO TB, I DO REMEMBER DURING THE UPSURGE OF TB IN NEW YORK IN THE EARLY 90s AT THE SAME TIME HIV INCREASING NUMBERS OF HIV. ONE OF THE THINGS I REMEMBER IS THE DANGER PERIOD OF PATIENTS WHO ARE REALLY SICK AND BE THEY TAKE TB AND THEY DOT THEIR MEDICINE IN THE HOSPITAL USUALLY AND THEN THEY FEEL BETTER AND THEN -- IN A RELATIVELY SHORT. IT'S THE SENSE OF FEELING WELL AND WHY DO I NEED TO CONTINUE TO TAKE THIS MEDICINE IF I'M FEELING WELL, WHICH ARE SOME OF THE ISSUES DAVID WAS TRYING TO ADDRESS IN TERMS OF HIV AND THE FEELING OF WELLNESS VERSUS ILLNESS. AND OTHER ISSUE IS THE DANGER PERIODS AND AFTER A WHILE, WE RECOGNIZED THERE WERE PERIODS THAT WE COULD DEFINE WHAT PEOPLE WOULD START THINKING ABOUT STOPPING TAKING THEIR MEDICINE. AND I THINK IT'S BEEN HELPFUL IN 81 TEXT OF HIV WHERE WE HAVE TO KEEP ENFORCING OTHERWISE IT WAYNES OVER TIME. I DO THINK THERE ARE IMPORTANT LESSONS THAT WE HEARD FROM TB BUT I THINK THEY ARE ALSOh IMPORTANT LESSONS FROM H. I -- HIV AND THE TB COMMUNITY CAN INCORPORATE AS WELL. >> THANK YOU FOR ALL THE PRESENTATIONS. THEY WERE WONDERFUL. THE AMOUNT OF WORK IS REALLY IMPRESSIVE AND THERE IS SO NICE TO SEE THE RESULTS COMING TO THAT SO NICELY AS WELL. I HAD A QUICK COMMENT AND A LITTLE LONGER QUESTION. BOTH INSPIRED BY BY DR. BANGSBERG PRESENTATION. FIRST REGARDING THE PATIENT, JOHN. I THINK THE ARGUMENT IS VERY WELL TAKEN. THE POINT ABOUT SOME OTHER PATIENTS HAVING MUCH MORE CHAOTIC LIVES AND BEING A STRUCTURAL -- BUT TING IS ALSO EXTREMELY IMPORTANT TO RECOGNIZE THAT THERE ARE PEOPLE WHO HAVE BOTH RADIO AND A WATCH AND AN iPHONE AND ALL THESE OTHER DEVICES DEVICES AND SUPPORT AND THEY STILL DON'T TAKE THE MEDICATION. IT'S IMPORTANT TO RECOGNIZE THAT THE PATIENT RELATED FACTOR AND NOT JUST AS AN ACADEMIC COUNTER POINT BUT REALLY AS AN ISSUE OR A DIMENSION THAT SHOULDN'T BE FORGOTTEN IN THE BEHAVIORAL AND MENTAL HEALTH RESEARCH. SO, THERE ARE SO MANY PATIENT RELATED FACTORS BUT IN TERMS OF EFFICACY OR DEPRESSION OR OTHER PSYCHIATRIC BEHAVIORAL FACTORS DRIVE BEHAVIOR ON PATIENTS AND NO MATTER HOW MUCH WE DO IN THE STRUCTURAL END. SO THAT THE INTERACTION BETWEEN THE INDIVIDUAL AND THE STRUCTURAL FACTORS THAT IS IMPORTANT. SO ARE FOR SUCH A BRIEF COMMENT. MY QUESTION IS, REGARDING THE ISSUE OF SOCIAL CAPITAL BROUGHT UP EARLY IN YOUR PRESENTATION, DAVID. I THINK IT'S A BRILLIANT CONCEPT, SOCIAL CAPITAL AS A VEHICLE TO IMPLEMENT THE STRATEGIES IN THE COMMUNITY AND I WAS WONDERING IN MY EXPERIENCE IN PSYCHIATRY WORKING WITH HIV INSPECTED PATIENTS IN NORTH AMERICA MAINLY HERE IN L.A. AND DC. IT SEEMS TO ME THAT NO MATTER HOW HUGE THE SUPPORT SYSTEM THE PATIENT HAS, IN ORDER TO BE ABLE TO ASK YOUR NEIGHBOR, FOR֜ EXAMPLE TO TAKE OVER THE JOB FOR THE DAY SO YOU CAN TAKE YOUR MEDICINE, HE HAS TO KNOW ABOUT YOUR HIV. THAT'S ANOTHER STEP. THE DISCLOSURE. I WONDERED HOW IT PLAYED OUT IN YOUR AFRICAN POPULATIONS. >> BINGO. BECAUSE OF TIME, I DIDN'T HAVE A CHANCE TO TALK ABOUT THE RELATIONSHIP BETWEEN STIGMA AND SOCIAL SUPPORT BUT YOU HIT THE NAIL ON THE HEAD. STIGMA IS WON'T MOST POWERFUL PREDICTORS OF INCOMPLETE ADHERENCE AND IN ALL REGIONS OF THE WORLD. AND THE QUESTION IS, ESPECIALLY POOR REGIONS, AND I USED TO VIEW -- BEFORE WE UNDERSTOOD THE ROLE OF SOCIAL SUPPORT AND SUPPORTING PEOPLE OR HELPING PEOPLE OVERCOME STRUCTURAL BARRIERS, I SAW IT AS A COGNITIVE EMOTIONAL CONCEPT. IT WAS DEPRESSING, ISOLATING AND MADE PEOPLE FEEL BAD. WHICH IS ALL TRUE. BUT WHEN YOU SEE ADHERENCE THROUGH THE LENSE OF SOCIAL SUPPORT YOU REALIZE IT HAS MUCH MORE FUNCTIONAL ASPECT WHICH YOU JUST DESCRIBED AS IF YOU CAN'T DISCLOSE YOUR HIV STATUS. YOU CAN'T ASK YOUR NEIGHBOR FOR 1000 OR FOR 5000 SHILLINGS TO COVER THE COST OF TRANSPORTATION. AND THAT IT'S UNDERSTANDING THROUGH BOTH COGNITIVE EMOTIONAL REALM AND FUNCTIONAL REALM THAT HELPS ME UNDERSTAND HOW STIGMA IS SO POWERFUL AT IMPACTING ADHERENCE. >> I THINK THIS QUESTION IS FOR ANYBODY WHO HAS DATA. AS WE HEARD THE TERM, ELDERLY, BY DR. KAPLAN, THE ONLY TIME I HEARD ABOUT THE SUBGROUP THAT IS AGING AS YOU'RE ALL AWARE PROBABLY BY 2015 ABOUT 500,000 OF US WILL BE OVER 50 IF WE ARE HIV POSITIVE HERE, BUT I WONDERED IF THERE ARE DATA INTERNATIONALLY THAT CAN SPEAK TO THIS BECAUSE WHEN I SEE SOME PLACES I SAW AN ARTICLE THE ABSOLUTE NUMBER OF WHATEVER YOU WANT TO CALL IT, SAY OVER 50 INTERNATIONALLY IF YOU'RE COUNTING INDIAN, SUCH AS MUCH LARGER THAN THAT. SO YOU'RE GOING TO BE DEALING WITH THE SAME ISSUES OF CO-MORBIDITY, PREVENTION, TARGETING, NOT TO GO ON BUT THE DISTRICT OF COLUMBIA, AT A HAVE GOT A BIG TESTING AND TREATMENT PROGRAM BUT THEY ARE ONLY NOW STARTING A SOCIAL MEDIA APPROACH BECAUSE PROBABLY 20 OR 25% OF THE NEW CASES INCIDENT CASES ARE IN THOSE OVER 50. SO I'M JUST CURIOUS WHETHER YOU HAVE DATA THAT IS BROKEN DOWN BY AGE AND YOU CAN JUST QUICKLY GIVE ME AN IDEA WHETHER INTERNATIONALLY WE CAN LEARN SOMETHING. >> I THINK IT'S VERY IMPORTANT ISSUE AND I THINK THERE ARE VERY FEW HERE. I DO KNOW THAT IN THE PROGRAM THEY SUPPORT, WE DO HAVE SOME DATA ON SUBSET OF THE HUGE NUMBERS THAT YOU SAW ON THE SLIDE THAT I SHOWED EARLIER WHERE WE DO HAVE PATIENT LEVELS AND IT'S ABOUT 7% OR SO IN THE GOLDEN AGE ABOVE THE AGE OF 50. THE REAL ISSUE IS OF COURSE HOW DO THEY DO? DO THEY DO AS WELL AS PEOPLE WHO ARE YOUNGER AND WHAT ARE THE SPECIFIC CHALLENGES THEY FACE IN ADDITION TO HIV? AND THAT WHOLE FIELD IS COMPLETELY NEW AND IS NOW JUST BEING OR SCRATCHING THE SURFACE ON IT. WE HAVE HOSTED OR SPONSORED A COUPLE OF CONFERENCES TO TALK ABOUT THE WHOLE QUESTION OF NONCOMMUNICABLE DISEASES AND HIV. REALIZING THAT OF COURSE HIV IS ASSOCIATED WITH NONCOMMUNICABLE DISEASE COMPLICATIONS LIKE DIABETES AND HYPERTENSION AND HEART DISEASE BUT ALSO REALIZING THAT BY THE FACT THAT AGING, IT'S LIKELY THAT ALL THE PEOPLE WITH HIV WILL ALSO HAVE CO-MORBIDITIES. WE ARE TRYING TO BRING TOGETHER A COMMUNITY OF PEOPLE WHO DO HIV WORK IN SUB SAHARAN AFRICA WITH INDIVIDUALS WHO DO CHRONIC DISEASE WORK TO TALK ABOUT AND TRY TO BRIDGE THAT DIVIDE AND LEARN FROM EACH OTHER AND TRY TO GET SOME DATA. WE ARE PLANNING JUST THE END OF THIS MONTH A WORKSHOP IN RWANDA THAT WILL LOOK AT STDs AND HIV AND ANSWER OF THIS THESE QUESTIONS. >> THANK YOU FOR YOUR TALKS. THEY WERE WONDERFUL. MY QUESTION IS TOWARDS THE OTHER END OF THE SPECTRUM OF AGE AND THINKING ABOUT YOUTH AS GROWING UP IN AN ERA WHERE HIV HEADS BECOME A TREATABLE DISEASE AND A CHRONIC CONDITION. WHERE YOU THINK THAT BEHAVIORAL INTERVENTIONS FOR PREVENTION MIGHT GO INTO THIS POPULATION. >> IN FACT, IT CERTAINLY IS QUITE RELATIVE TO THE UNITED STATES. WE KNOW THAT AFRICAN-AMERICAN MEN WHO HAVE SEX WITH MEN ARE OVER REPRESENTED IN CASES OF HIV IN THE USE AND A PORTION OF THOSE MEN ARE UNDER THE AGE OF 25. I THINK THE COMMON KNOWLEDGE IS THAT, AND IT'S WELL DOCUMENTED, IS BECAUSE IT'S A CHRONIC DISEASE, AND BECAUSE 1982 WHEN I FIRST WENT TO UCSF, PEOPLE WERE DROPPING LIKE FLIES AND THERE WAS DEATH EVERYWHERE, THAT IT PROBABLY MOTIVATED QUITE A BIT OF BEHAVIOR CHANGE. AND SO, I THINK THE CHALLENGES ARE DIFFERENT. AND THE CHALLENGES DO BECOME MORE CHRONIC DISEASE-LIKE. AND IN L.A., WE THINK WE HAVE ABOUT 65,000 HIV IN EFFECTED CASES. THE CASCADE IS VERY MUCH AS DR. DIEFFENBACH DESCRIBED. 20% DON'T KNOW THEY HAVE HIV. BUT 40% OF THOSE WHO DO KNOW THEY HAD, HAVE NOT HAD A VIRAL LOAD OR CD4 COUNT IN THE LAST YEAR. THAT'S MADE POSSIBLE BASED ON TEST RESULTS. SO I FULLY EXPECT THERE IS NO REASON TO EXPECT -- WHEN DAVID OR WHEN WAFAA WAS PRESENTING THE DATA THAT FLASHED UP ON THE SCREEN, I ASKED DAVID WHERE IS THAT FROM? HE SAID SOWETO. I SAID IT LOOKS EYE LOT LIKE L.A. TO ME. IT'S PROBABLY GOING TO BE THE CASE AS TREATMENT IS INTRODUCED AND BECOMES MORE WIDESPREAD, AS HIV BECOMES FEARFUL, IT WILL BE LIKE EVERY OTHER CHRONIC DISEASE AND THAT IS YOUTH WILL BE LESS AFRAID OF IT. WE KNOW IN THIS COUNTRY YOUTH TEND TO HAVE LESS FEES HEALTH CARE AND TEND NOT TO HAVE JOBS THAT PROVIDE HEALTH CARE. MAYBE THINGS WILL CHANGE IN 2014, WE DON'T KNOW. AND IN CERTAINLY NEDEVELOPPING COUNTRIES, IT'S THE SAME CASE. SO I THINK WE CAN EXPECT AND WE SHOULD PLAN FOR THINKING OF IT LIKE OTHER CHRONIC DISEASES. >> I'D LIKE TO KNOW WHAT ASPECTS OF YOUR RESEARCH FINDING DO YOU SHARE OR HAVE YOU SHARED WITH YOUR LOCAL LEVEL COMMUNITY RESEARCH PARTICIPANTS? AND WHEN YOU SHARE THAT INFORMATION, WHAT TYPE OF RESPONSE DO YOU GET? WHEN I SEE YOUR RESEARCH, I'M AMAZED. I'M WOWED BY IT. THAT'S ME. AS A RESEARCHER. SO I WONDERED IF YOUR LOCAL-LEVEL COMMUNITY PARTNERS WHO ARE A PART OF YOUR RESEARCH, WHEN YOU GO BACK AND IF YOU GO BACK AND SHARE WITH THEM, WHAT TYPE OF RESULTS AND COMMENTS DO YOU GET FROM THEM? >> I WOULD LIKE TO INVITE YOU TO UGANDA ON FEBRUARY 13 OF 2012 WHERE WE ARE HAVING A FESTIVAL. WE ARE INSIGHTING ALL OF OUR RESEARCH PARTICIPANTS WHO CHOOSE COME TO JOIN A WEDDING-STYLE FEAST WHERE WE WILL DISCUSS THE RESULTS OF OUR PROGRAM. I HAVE TO SAY, WE HAVE DONE THIS A BIT TOO SLOW. WE SHOULD HAVE DONE THIS A LONG TIME AGO. AS WE PLANNED THIS, WE FIGURED OQ IT'S COMPLICA TED. HOW DO YOU TRANSLATE, LITERALLY, THE INFORMATION IN LOCAL LANGUAGE AND MAKE IT APPROACHABLE. BUT WE ARE WORKING HARD TO TRY TO DO THAT. IT WILL LAST TWO DAYS. UGANDA WEDDING LASTS ABOUT 12-14 HOURS. SO WE'LL MODEL IT AFTER A WEDDING. >> YOU RAISE A VERY IMPORTANT ISSUE AND THIS IS ANOTHER AREA WHERE I THINK HI HAVE IS AHEAD OF THE CURVE IN TERMS OF THE PARTNERSHIP WITH THE COMMUNITY AND THE PARTNERSHIP WITH THE PEOPLE LIVING WITH HIV WHICH IS UNIQUE AND PARTICULARLY INDIVIDUALS FROM THE COMMUNITY AND PEOPLE LIVING WITH HIV AT THE TABLE, DESIGNING OR HELPING TO DESIGN RESEARCH, HELPING TO DESIGN PROGRAMS AND HELPING WITH PARTNERS IN INTERPRETING AND IN SEMINATING INFORMATION. I HAVE TO SAY I HAVE BEEN VERY IMPRESSED WITH HOW MY COLLEAGUES HERE AND INCLUDING THE PEOPLE OR THE STUDIES THAT SHOWED THEY HAVE COMMUNITYEE FORUMS AND THEY SHARE THE RESULTS OF THE COMMUNITY BEFORE THE WORLD AND WITH THE PARTICIPANTS BEFORE ANNOUNCED TO ANYONE ELSE AND GARNER IDEAS ABOUT HOW TO DISSEMINATE THE RESULTS BETTER AND I THINK HONESTLY IT'S REALLY A MODEL OF HOW TO TRANSFORM RESEARCH AND THE PARTNERSHIPS WE CREATE WITH COMMUNITIES AND PARTICIPANTS AND RESEARCH WORK. >> MY FAVORITE PARTICIPATORY RESEARCH STORY, WE ARE MEETING WITH ONE OF THE COMMUNITIES AND WE HAD A LARGE COMMUNITY MEETING AND IN THIS AREA OF SOWETO, MOST OF THE PEOPLE WERE IN THE FREEDOM PARTY AS OPPOSED TO ANC MECHANICS. SO THE AREA WASN'T AS WELL ATTENDED AS SOME OF THE OTHER NEIGHBORHOODS. SO THE QUESTION CAME UM UP, HOW DO WE ENSURE WE ARE RANDOMIZED TO THE INTERVENTION CONDITION. I SAID LET ME TALK ABOUT THIS CONCEPT. THEY SAID NO. WE UNDERSTAND. HOW DO WE ENSURE WE ARE RANDOMIZED TO THE INTERVENTION CONDITION? [LAUGHTER] FORTUNATELY THEY WERE. BUT THROUGH NO MANIPULATION OF RANDOMIZATION. BUT SO YES, THERE IS ALSO SOME SOPHISTICATED COMMUNITY PARTNERS OUT THERE AS WELL. >> I HAVE A QUESTION FOR THE GROUP. LET'S SAY SYMPOSIUM WAS FOCUSED ON INTERNATIONAL WORK AND WE TALKED A LITTLE BIT LESS ABOUT THE HIV EPIDEMIC HERE IN THE U.S. AND WE STILL HAVE THIS PROBLEM OF ABOUT 50,000 INCIDENT CASES, 5000 SOMETHING CASES IN THE U.S. WHICH SEEMS TO BE SOMETHING THAT OCCURS YEAR AFTER YEAR. WHAT ARE WE LEARNING FROM THE INTERNATIONAL STUDIES THAT MIGHT HELP US AND HOW DO WE TACKLE THAT PROBLEM? >> I'M GOING ASK WAFAA IF SHE'D LIKE TO TALK ABOUT A STUDY CALLED HPTN065, COMMUNITY RANDOMIZED TRIAL GOING ON IN WASHINGTON, D.C. AND THE BRONX AS A STARTER. >> YES, I THINK THAT IT'S CLEARLY A CHALLENGE AND I THINK WITH WORKING WITHIN THE HPTN, WE TOOK A VERY DEEP LOOK AT THE DOMESTIC EPIDEMIC AND TRIED TO REALLY UNDERSTAND THE DOMESTIC EPIDEMIC AND TRIED TO UNDERSTAND THE GAPS IN KNOWLEDGE AND ALSO WHAT ARE THE OPPORTUNITIES FOR DOING SOMETHING ABOUT TRANSMISSION OF HIV? CLEARLY THE POPULATIONS ARE AFFECTED MEN WHO HAVE SEX WITH MEN AS A WHOLE AND AFRICAN-AMERICAN OR WOMEN OF COLOR IN THE COUNTRY. THE NIH BOTH NIAID AND NIMH ARE SUPPORTING THE LARGE STUDY IN COLLABORATION WITH THE CDC WHERE WE ARE TRYING TO LOOK AT NEW EFFORT WHICH IS TRYING TO GET AT THIS CASCADE. HOW CAN WE EXPAND IN THE BRONX AND WASHINGTON,zV D.C., HOW CAN WE EXPAND TESTING IN PARTICULAR REPEATED TESTING BY POPULATIONS AT RISK. HOW CAN WE TEST INTERVENTION FOR IMPROVEMENT LINKAGE AND TESTING TO TAKE CARE OF SITES AND THE HOW CAN WE IMPROVE ADHERENCE AND VIRAL SUPPRESSION FOR PEOPLE WHO ARE POSITIVE AND ALSO ENABLE ACQUISITION OF SAFE SEXUAL BEHAVIORS? THE INTRIGUING THING ABOUT THE STUDY IN ADDITION TO IT BEING COMMUNITY FOCUSED ARE A COUPLE OF THINGS. ONE TRULY AT THE IS A COMBINATION INTERVENTION STUDY TO INCLUDE BOTH THE BIOMEDICAL INTERVENTION, BEHAVIORAL INTERVENTION WHICH INCLUDES PREVENTION AND LINKAGE AND STRUCTURAL INTERVENTION AND LOOKING AT FINANCIAL INCENTIVES AS AN INTERVENTION FOR ENHANCING LINKAGE AND ENHANCING VIRAL SUPPRESSION. SO REALLY LOOKING AT ALL THE DIFFERENT TYPES OF POTENTIAL INNER VENTION AND TRYING TO LOOK AT THE FEASIBILITY AND EFFECTIVENESS WITHIN TWO OF THE MOST SERIOUSLY AFFECTED COMMUNITIES IN THIS COUNTRY. SO THAT'S AN EXAMPLE OF TRYING TO LOOK AT THIS THE LEVEL. THERE ARE OTHER EFFORTS THERE THAT ARE ONGOING TO TRY TO ALSO IDENTIFY EFFECTIVE INTERVENTIONS FOR MEN WHO HAVE SEX WITH MEN AND OTHER GROUPS. IN THE END, I THINK IT IS TACKLING THE EPIDEMIC IN THE U.S. IS GOING TO REQUIRE ENGAGEMENT IN THE COMMUNITIES AFFECTED AND ALSO WORKING VERY CLOSELY WITH PUBLIC HEALTH SERVICE WITH THE DEPARTMENT OF HEALTH LIKE WE ARE DOING WITH THE CDC AND SO THAT FROM THE BEGINNING THESE STUDIES ARE DESIGNED IN SUCH A WAY THAT THEY CAN BE OR WE CAN TAKE LESSONS LEARNED AND THE STUDY CAN OFFER THE RESULTS HOPEFULLY QUICKLY SCALABLE AND IMPLEMENTED. >> NEXT QUESTION OVER HERE. >> GOOD AFTERNOON. THANK YOU ALL FOR YOUR PRESENTATIONS. I WAS HOPING YOU WERE GOING TO COMMENT ON SOME THEORIES AND GUESSES ABOUT THE DIFFERENCES WE ARE SEEING IN THE OUTCOMES WE SEE IN THE PREP RESEARCH AND YOU MENTIONED THE STABILITY OF HETEROSEXUAL COUPLES BUT THERE SEEMS TO BE COMPLEXITY OR A LOT OF UNKNOWNS AROUND WHY WE ARE SEEING SO MANY DIFFERENT OUTCOMES. SO IF YOU COULD COMMENT ON THAT AND WHETHER THE IMPLICATIONS OF THOSE GUESSES ON PREP RESEARCH HERE IN THE UNITED STATES. >> DR. DIEFFENBACH CAN DISCUSS THIS MORE ELOQUENTLY THAN I BUT THE BEST BIOLOGICAL EXPLANATION I HAVE HEARD TO EXPLAIN THE DIFFERENCES IN PREP EFFICACY IS MANY OF THE MOST SUCCESSFUL STUDIES HAVE BEEN IN EITHER WEST OR -- EAST AFRICA OR NORTH AMERICA AND SOME OF THE ONES OF THE LOWEST ARE SOUTH AFRICA. VERY DIFFERENT EPIDEMICS WITH MUCH HIGHER SERUM INCIDENTSMENT OF THE THE QUESTION IS PREP MOST EFFECTIVE WHEN SOMEONE HAS HIGH RATES OF VIRAL LOAD AND MAYBE THERE IS MORE BREAKTHROUGH IN THE SOUTHERN SETTINGS THAN IN THE EAST AFRICA OR NORTH AMERICA OR SOUTH AMERICA. >> TO JUST EXPAND ON THAT THOUGHT A MOMENT. THERE ARE TWO CONSIDERATIONS HERE AND AS WITH HIV'S CASE IT'S NEVER A -- MOST LIKELY NEVER A SINGLE DEFINING RESULT OR EFFECT THAT LEADS TO WHAT WE SEE CLINICALLY AND BIOLOGICALLY. SO IT MAY VERY WELL BE A COMBINATION OF FACTORS SUCH AS ADHERENCE. SUCH AS THE VIRAL LOAD OF THE PARTNER AT THE TIME OF THE EXPOSURE AS DR. BANGSBERG JUST SAID. IT MAY BE DUE TO THINGS LIKE LOW-LEVEL STDs SUCH AS BACTERIAL ADVANTAGE NOSEIS OR OTHER FACTORS THAT PROMOTE INFLAMMATION IN THE VAGINA LEADING TO A MORE NATURAL LEVEL OF OR IN A WORD, INFECTIVITY OF THE WOMAN. SO IT'S PROBABLY MULTIDIMENSIONAL AND MULTIFACTORIAL AND I THINK THE STUDIES THAT ARE GOING ON RIGHT NOW ARE DESIGNED TO TAKE THIS APART PIECE BY PIECE TO LOOK AT THE ADHERENCE QUESTION BY LOOKING AT INDIVIDUALS USING OBSERVED DOSES AND HOW THE DRUG ACCUMULATES IN TISSUE. AND THOSE STUDIES ARE JUST NOW BEING COMPLETED AND THE DATA IS FASCINATING. THOSE WILL BE PRESENTED AT CROIX. I DON'T HAVE THE DATA SO I THINK THIS IS A COMMERCIAL ANNOUNCEMENT FROM CROIX. AT THE SAME TIME, I THINK AS WE LOOK AND GET INTO ANALYZING WHAT HAPPENED WITHIN THE VOICE PROTOCOL AND WITHIN PREP, LOOKING AT CD AND STIs, EVEN THOUGH WE TREATED PEOPLE WHEN WE SAW THE WOMEN ON A MONTHLY BASE AND TREATED, THERE IS STILL AN ISSUE OF THESE OTHER CONDITIONS AND THEN ULTIMATELY WHAT WAS THE LEVEL OF COMMUNITY VIRAL LOAD. IT IS COMPLEX. BUT WE WILL GET TO THE BOTTOM OF IT. IN TERMS OF WHAT THIS MEANS FOR THE FUTURE, I THINK THAT BECAUSE WE HAVE THE DIFFERENCE BETWEEN WHAT WE SAW WITH CONNIE KELLUM'S STUDY AND WHAT WE SAW WITH BOYS, THERE IS STILL BIOLOGICAL PROBABILITY IF IT FOR PREP BUT IT HAS TO BE DONE VERY CAREFULLY. >> ALSO I THINK IT'S THE ISSUE OF DISCORDANT COUPLES VERSUS INDIVIDUALS IS ALSO IMPORTANT AND PREP WITHIN DISCORDANT COUPLES AND FEM PREP ON THE OTHER HAND ITEXT WAS INDIVIDUAL MEN. I DO THINK THAT WE HAVE TO REMIND OURSELVES IT'S IMPORTANT TO DO MULTIPLE STUDIES. THE IMPORTANCE OF DOING THESE LARGE COMPLEX STUDIES CANNOT BE UNDERESTIMATED. I THINK THEY ARE VERY IMPORTANT AND IT'S VERY IMPORTANT TO REPLICATE THEM IN THESE POPULATIONS UNDER THESE CONDITIONS. BECAUSE OFTEN THEY VERY IMPORTANT POPULATIONS. 72 JUST A SORT OF AMUSING REMARK ABOUT 8 MONTHS AGO, WE CAME UNDER PRETTY HEAVY FIRE FOR THE AMOUNT OF STUDIES WE WERE DOING. THAT ALL SEIZED FAIRLY QUICKLY. >> [OFF MIC] >> THAT'S A GOOD QUESTION. THE QUESTION IS WILL THERE EVER BE ANOTHER ART FOR PREVENTION? WE ARE JUST INITIATING AN ACTG STUDY LOOKING AT ADDING THIS IN A PHASE II TO LOOK AT SAFETY AND TOLERABILITY. WHERE THAT GOES FROM THERE TO EFFICACY REMAINS TO BE SEEN. BUT WE WILL CONTINUE TO INNOVATE AND CONTINUE TO EXPLORE NEW ONESES AND IN THE AREA OF CHEMO PREVENTION. >> QUESTIONS? I'D LIKE TO JUST THANK YOU ALL FOR JOINING US TODAY AND FOR REMAINING FOR THE DURATION OF THIS EVENT. THANK YOU VERY MUCH. AND I HOPE THERE IS A GREATER APPRECIATION FOR THE ROLE OF BEHAVIORAL AND SOCIAL SCIENCE AND HIV RESEARCH AND AN APPRECIATION FOR THE FACT THAT WE NEED TO COLLABORATE IF THIS WILL BE THE FINAL GENERATION OF HIV/AIDS RESEARCH THAT WE ARE ENTERING. THANK YOU AND HAVE A GREAT EVENING. [APPLAUSE]