Transcripts For CSPAN2 Discussion With Dr. Anthony Fauci And Others On Federal HIV Policy 20240713

That we can make a difference in the fight against aids. But also it will remind us there is still much, much to be done. And partly, we will need to double down on our efforts if we need to set out in the bold tenure federal initiative championed by the nh and cdc and by our special guest doctor anthony and doctor john brooks. Here at the Bloomberg School of Public Health we have talked about the power of public heal health, the power that comes from doing the fundamental research and translating the research into programs and policies that make a difference. The power that comes from strong partnerships across disciplines, public and private sectors and across communities. In the power that comes from advocating solutions of the state, local and national levels. The fight against hivaids exemplifies how sustained commitment to these powers can make a true difference. Todays conversation will be facilitated by our own chris buyer, the professor of Public Health and human rights. Doctor breyer in my humble opinion is a true publichealth hero. A researcher and practitioner who is committed to solution to the worlds most challenging Public Health problems. He is a longtime hivaids researcher with extensive experience with Collaborative Research and Training Programs and hivaids with key populations. He is also wellknown for his overriding commitment to securing health and human rights for all. As director of the john hopkins, the program, doctor breyer provided fellowships for 1400 International Scholars in hiv aids Prevention Research and treatment. Chris is one of the bloomberg remarkable graduates in his success in research and practice with the continuing ongoing commitment from the policy leaders at the cdc and nih make for a powerful combination and have helped bring us to where we are today and on the cusp of ending hiv epidemic in america and across the world. Todays event is cosponsored by the center for age research and it is a collaboration across the three john hopkin schools in the schools of Public Health, medicine and nursing. With support from university for the office of provo. Founded seven years ago it is committed to ending the epidemic through the promotion of Disciplinary Research and importantly by training the next generation of hivaids research here in the u. S. And abroad. The return on investment is quite clear, one example, hiv funding for junior investigators has risen from 7 of nih funds to 25 of all nih Research Funding now. This has created a larger welltrained and powered hiv expert who in the past decade have accelerated the work to get near to the Necessary Solutions for this epidemic and getting us to the goal were striving towards. While hiv impacts the health of population worldwide i am particularly pleased that it is been on the forefront of supporting hiv research and programs here in our own city of baltimore. The School Faculty is making a difference in participating in so many of the hiv epidemic by collaborating with leaders and state pulsing makers. This is a remarkable example of us working together for policy solutions that work across all levels of government to save lives millions at a time. I would like to close by offering a special thanks to our director of the school of medicine and again, to chris buyer the associate director. Thank you both for all you have done and you continue to do and thank you to all of you for being here, your determination and commitment to hiv is so critically important because of your work our dreams to end hiv is now on the horizon and we hope coming through by 2030. With that i will turn the program over to doctor chris buyer who will introduce todays guest. Caugh[applause] thank you so much and on behalf of of chase i want to thank you for your support. It has made a difference. So we are delighted on behalf and to welcome all of you to the special session and with our special guest doctor anthony and john brooks the head of the hiv Prevention Program at the cdc and just before i introduce them i want to make a few comments about why we think its so important the Academic Research institutions like ours engage in the initiative and take on the roles that we think we comply in helping to finally achieve the end of hiv epidemic. I think before we do that we have to acknowledge two or three fundamental truths that you will hear about from our speakers today and theyre very essential to thinking about the task ahead in the first of those we have to acknowledge the hod of the comic and the new infections in the u. S. Has been stubbornly persistent, we had declined over a number of years and basically been in a plateau with around 38000 or so for a number of years. So the first enormous goal that has been top of the initiative is 75 reduction in new infections over the next five years. That is on a very different trajectory from where we are and where we have been. We have an enormous task ahead in primary prevention of hiv infection and delivering new science and technology that you will hear from her guest that could achieve reductions in new infections but we will have to engage the folks who are at risk for hiv acquisition if we will achieve those goals. The second challenge hiv has always been marked by Health Disparities but as we have done better as a country and over the last decade the Health Disparities are getting all the more stark. Hiv is now very much geographically concentrated in the south and southeast and basically it goes from baltimore down to texas and across the south and southeast. There is a geographic disparity. There is a concentration in africanamericans and native americans and that is particularly stark for africanamerican women and for africanamerican and latino men who have with men. We have a concentration with race and ethnicity in a concentration of vulnerable groups and people of risk. We also have to deal with the emerging and quite different demography of the Opioid Epidemic and its impact on what we see with new clusters and quite a different with the south and the midwest. Finally the third area that i think we have been surprised about after 30 years of effort and the tremendous advances in treatment and prevention is that hiv remains a stigmatized condition in the people who are living with the virus or at risk are in a very highly stigmatized group and there is intersectional sigm stigma which relates to ethnic minorities in sexual gender minorities to substance users and of course also the stigma around hiv infection itself in persistence about remains very important barrier to achieving the goals that we want to achieve. So we have to do is stigma and Health Disparities and reducing new infections and that means both getting the new Prevention Technology to people and getting the american living with this virus successfully ends early suppressed. The exciting thing and you hear a lot about this from her guest is that we do have the scientific and technical capacity to do this and now the question will we be able to achieve that as a Public Health effort as a country. I think particularly for the young folks in the audience and younger investigators this is really going to be for the next decade or two decades the enormous implementation of the technical challenge for your careers and i think its enormously exciting. You will hear it does not mean the end of aids research. There is a long way to go to achieving these goals. It may turn to a delightful honor who is to introduce our first guest doctor anthony the National Institute of Infectious Diseases and he is one of the architects of ending hiv initiative and this is often called as some of you wouldve heard, that is not surprising because he is also one of the architectural. Which of course has been a world changing Global Health intervention and the largest commitment to disease by a government in human history. And really something that is enormously important. Doctor always say that he needs no introduction but i think Everybody Needs an introduction. To let me go on for a moment and say he is one of the most scientist in any field and a recipient of the president ial medal of freedom which is the highest honor that the president can give and hes playing an extraordinary role in maintaining over decades the research and funding support for the hivaids epidemic. And for that, all of us as investigators, but more importantly everybody allied with hiv it took a hundred Clinical Trials to reach therapy to be effective as it is not proved without the sustained decadelong support of the intake age and funding that research we would not be where hiv is a manageable chronic condition in an extraordinary and save millions of lives. I will add one more thing that some of you may know im a past president of the International Aid society and when you take on that task you have to give an award. It is called the president s award and when that fell to me too make that decision i had a short list of one person. [laughter] i would like to thank you for accepting and coming all the way to south africa to accept the award is a great honor. [applause] thank you very much for the very kind introduction. Its a real pleasure to be with you this afternoon to talk about the subject at hand in ending hiv pandemic and all talk about it from the standpoint of science to implementation. This is a paper that we put together and were describing right after we submitted it before the president made the announcement on february 5 but it came online the next morning and it was the print version describing the plan which was a 75 reduction in new infection in five years and 90 reduction in ten years to diagnose and prevent and respond to outbreaks. You will hear a little bit more about that from doctor brooks in a moment. What i would like to do is talk more and flush out what i refer to as the hiv vulnerability profile. Why did we feel that we could actually in the epidemic given what we have. It starts off with the population that we have as a vulnerable population. Both demographically and geographically. Lets look demographically, its very prevalent in baltimore, 13 of the population of the United States is africanamerican and of the new infections 43 of among africanamericans and 60 are among men who have with men and 75 are young men who have with men. So we have a concentration of a vulnerable population and we also have a geographic concentration and when john brooks and his colleagues at the cdc put together this map it was stunning, there was 3007 counties in the United States and if you look at 38 of the counties plus the district of columbia plus en one, that account for more than 50 of all the inspections in the United States, that is extraordinary, 40 units out of 3007 units. They had 50 of the population. So we had this plan, a number of agencies involved in all focus just for a few minutes on what the nih role. We were discussing the stocks a little while ago and we call the implementation science. The cdc and others will be responsible for going out and engaging in the community and whether the doing that correctly which im sure they will but how you make it even better from yeartoyear will depend on implementation science. That will be done through the center through age research which is right here in baltimore. If one looks at the map of the country and the red ribbons are for the aids research and the blue ribbons are the aids Research Center which is mostly Mental Health, you can see in important overlap with some exceptions like in texas which unfortunately does not have that but we will be dealing with that by extending other there. We rose to the occasion of trying to get them for doing a good job in other aspects of hivaids, a critical part of what we do. But we needed to supplement them to do the extra mile of getting involved in the extraordinary effort to end the epidemic. So we did 65 supplements to 17. 36 of the 48 counties were involved with the c fires, we collaborated with Health Officials and we studied the optimum of delivery of evidencebased intervention. I just had the pleasure of listening to two hopkins people present Work Associated with the hopkins and the baltimore collaborative project with joyce jones in the linkage and retention and repair upon release from the maryland state prison. If everything is done here is as good as what i saw this morning you guys are in really good shape. So lets get on to the scientific basis. Beside the implementation, i think we should not forget how we got to where we are now, it really is a science that got us there. Mainly the science for even older ability to implement the program. Let me talk about that for a few minutes. We have hiv treatment and prevention toolkits that have accumulated as chris said, over decades of research with basic research and Clinical Trials including the drugs on the lefthand toolbox in the prevention on the right hand. Where has that brought us . I began taking care of hivinfected individuals in the fall and winter of 1981. Before it was called aids, before we knew what it was. At that time, i admitted to my unit at the nih in a meeting in the expectancy of about a year which means 50 of your patients are dead and one year end following them about 95 were dead in two to three years. If you look back today and if patients come in to the same clinic which i should have been having rounds today but im here with you in baltimore. But if a patient came in who is reasonably newly infected and i put them on a combination, i could look them in the eye and tell them they would live an additional 50 plus years which would give them almost, not quite an almost a normal life expectancy. What are the returns of that, and the 20 years from 1995 to 2015, over 10 Million Deaths with almost 8 million infections were inverted and we save 1. 05 trillion. For every dollar spent 3. 5 in benefits were realized. What about deaths, of 55 reduction in death from 2005 to 2018. We had Game Changing scientific advances. The one that is linked them is the concept of simple as it may seem but we did not realize it is treatment equals prevention. In two ways, treatment has prevention, the iconic hpp and 052 trial which showed different couples if you saw therapy early in individual who is infected as opposed to waiting to the guidelines triggered at the time and guidelines did not say everyone should be treated, you decreased by more than 95 and the likely it you would transmit to your sexual partner. We followed up five years later and we started to look at the relationship between viral load and the chance of transmitting and it was a strong suggestion that if you were below the level that you would not transmit, very few people believe that so we had to prove it. We did three studies, two opposites attract into our amazement and very positive amazement out of more than 150,000. Acts not one single linked transmission which allowed us to say about scientific basis that we were hesitant to say before that actually treatment does equal prevention and undetectable does mean an transmittable, a very important concept. The next was prophylaxis. One pill containing two drugs if taken optimally and consistently was more than 99 effective in preventing sexual transmission and acquisition of hiv. If you put those two things together, treatment is prevention and take a deep breath and think about that for a minute, theoretically if you put everybody on treatment, almost everyone and put all at risk people on prep, theoretically, you could in the epidemic tomorrow. But we dont live in a theoretical world we live in a realworld in the way that you make the bridge of the gap is by implementation. Thats what it is about and thats what you guys will be doing. In order to do that, we have also got to optimize this toolkits in two ways. Maximal implementation, why do we need maximum intimal mentation. Lets look globally not just the United States, 23 Million People are receiving antiretroviral therapy. Great news prechallenging news almost 15 Million People who should be on therapy are not on therapy. That has led to a very modest and even less the modest reduction in incidence globally and in fact there has been less than 2 annual decrease of incidents since 2010. So as chris said although were going down we have plateaued a bit which is why we put the plan together. Retention in therapy is also challenging, if 100 is the day you go on therapy, 48 months later only 60 of people are still on therapy, you will not in the epidemic that way, utilization of the 2020 un target says that 3 Million People should be on prep, theres only about 380,000 people as of last month who were on it. Can we overcome implementation gaps . Some groups have been successful and particularly in San Francisco with the rapid and treatable program in which they go into the community identify people, put them on therapy immediately and at that risk putting them on this immediately and followup very closely. Resulting in a dramatic decrease in a new diagnosis of San Francisco. You will probably hear from john berkson about that new york is doing the same thing, the governor decided if San Francisco can do it, new york and representative. [laughter] in fact it has gone down. We in d. C. , in collaboration with the d. C. Program in the d. C. Department of health have tried to mimic what was being done in San Francisco and again, the new diagnosis has gone down dramatically in my city of washington, d. C. In addition to implementation you need to develop new and improved tools, why, we have to make treatment and prevention more userfriendly for people because as much and strange as it seems they dont optimally utilize that. Theres two ways to develop new and improved tools, the arena of treatment. How do you include treatment, there are a couple of ways. The goal is to trying get people oughdaily art, few ways to do t, you can eradicate the virus, i will not spend time talking about that, that is highly aspirational. Not impossible but i want to concentrate on ending the epidemic before i get too concerned about radically the virus. With all due respect at attempts to eradicate in the virus. What we can do to make things userfriendly is retroviral. Its amazing how people are much more to receive an injection every couple months rather than a pill every day. Its a most counterintuitive but its the truth. Theres no doubt about that. These are number of studies starting off with one and going to every other month of injectable. Another way to avoid daily retroviral therapy is neutralizing anybody. There are 200. The have been identified from being. We have used them in humans to replace any retroviral therapy. We did a study from my lab with the university of pennsylvania. With a single antibody give it as a past as a significant delay in the rebound of virus. Michelle and others have done a combination of two antibodies. Where are we going with this, the ultimate goal or end game is about every six months for anybody to get a transfer and never have to take in antiretroviral drug. Youve come into the clinic once every six months with a long acting antibody and that your therapy. What about prevention, how will we prove prevention. We can improve preexposure pro collective, the fun same fundaml principle by long acting prep where we have two good studies, one is about 4500 men who have with men and trans gender women in multiple countries, the same principal testing as an injectable could be as good as or better, another study. So those of you who were there or in mexico city there was a presentation of an implant that gave levels of drugs for one year that would be predictive of being suppresses to. The others getting back to the antibodies as i mentioned there was neutralizing antibodies in their being used in a study both in africa and in the United States and south america as a preventive measure with a long acting one if you can actually prevent hiv by having somebody with an infusion of an antibody. Again in Southern Africa and south america, even the United States people would rather have an injection or an infusion then taking a pill every single day. Finally the issue of vaccine. Were talking about ending the epidemic and i think we could do before we get a vaccine. If we want a durable and to the epidemic i think will have a vaccine together with the things i have been speaking about. Very quickly there are two major pathways, the first was to test a number of vaccines. We did that without success for a number of years and then in 2009 we had a hit, the hit was a crime in a protein boost in the study 144 which give us 31 to c. This is very much a mimic the proteins boost now with and agitate so that we took a little further with a study of two years ago this month to go to the trial and that vector had the protein boost and then the third one that was started a couple months ago is the mosaic oh trial that adds the boost that isnt in Southern Africa and south america and the United States. To be highly aspirational and the assumption being with the antibodies that we need to induce. It makes a lot of them only after a person but only if they had the virus two years or longer. And with those neutralizing episodes for what they enter boat with a combined two so the challenge put some in the form of the interview jetton and a lot of studies are going on right now so what about a vaccine cracks clarity told you 31 percent is not good enough i dont think there is a chance of the world would ever get a 98 percent hiv vaccine like for mesial but i would settle 50 or 60 percent together with the non printable modalities and there was a model that shows the other 50 percent even if you did status quo and nothing else you could dramatically impact. s on my last slide is that we have an enormously to maximally utilize them and to implement them in with new treatment modalities and the Game Changing. And in baltimore in the United States and globally. [applause] antes extraordinary speaker. Please hold your questions. And by the way cspan is recording this. That the medical epidemiologist with the cdc and it is Epidemiology Service training there and other efforts and the response to Hurricane Katrina which was a huge Public Health challenge and humanitarian challenge. And the anthrax challenge. He has a medical degree from the other h, harvard we dont hold that against you. [laughter] now the cdc is one of the key federal agencies with the nih but then the cdc plays easy store nearly important roles as well. And then to be on the frontlines. And now john over to you. [applause] so i have to raise this up to make sure that you can hear me. To thank you for this and for the opportunity to speak today. To do this beautiful job to set up the science what we know will work. And thats where it lies. But i want to walk through with you with details around the planned action. With no affiliations to disclose into the Key Information with that hiv initiative and then to detail a couple of Innovative Solutions for the three pillars above diagnose and treat and prevent we been living with hiv too long over 700,000 have lost their lives since we first started to keep count in 1981. That is an enormous amount of money that we should be having to spend. But as pointed out before we have not seen a substantial decline of infections were a couple of years now and if we did nothing for the next ten years 400,000 will become infected infected with hiv. And then to reduce the impact of new infections and with this incident. But they also have significant threats out there to our success not the least of which is the resurgence of drug use ramping up across the country with those that we didnt consider previously and also complacency. But then somebody elses job and thats it we have to work on. And to end that hiv epidemic that the most powerful tools in history. But leading to the figures a 75 a 90 percent reduction and how will we do it . So first with the person that transmit the infection. So that they cannot pass it on to others the goal is less than 100,000 americans americans with the ongoing epidemic to be able to eradicate it. So over time is that people experience than they exceed new infections from that point forward. So there were four principal means for people who work in any form of Infectious Disease. To treat those effectively and pre one approach those and then keep an eye if those hotspots occur to treat them and eradicate them. Some people say isnt that an ambitious goal for the first five years . But as you are aware the mayor kicked in some extra funding to the state annual budget with an auspicious goal to reduce new infections by 75 percent. In the next number 42018 with that trajectory. And this is a combination of whats possible and ambitious. And thats what they think about cdc with hiv. At the assistant secretary of health. And then television to the plan. So that one of the large ones that happened is to do it they are laying out for applications for cdc Hiv Aids Bureau versus primary care to be deeply engaged with people much more regularly. And then that arc grants. And three cities receive jumpstart funds of 5 million. But you can achieve some early success with infusion of capital in one of those cities is baltimore. You have heard the prep program and then to go online the first few weeks of december and those across the country this is open to anyone looking for prep dad is uninsured and then the Planning Grant and then not to reinvent the wheel many places that are longstanding bodies for those treatment funds. And now those efforts are underway not an entirely new idea. And then to bring it together to refocus those plans to realign them. And with a particular emphasis and now getting the local community involved. People that have hivpositive to be part of these Planning Communities are not previously engaged we need to get the next generation on board to move this forward. To treat and prevent and those opportunities of innovative ideas and the challenges we are facing. So early diagnosis is vital. You cant get treatment unless you have the infection. And of those recently diagnosed seven out of ten in the year of their diagnosis past through the system if work offered hiv testing and thats a tremendous opportunity because first we have to get them diagnosed early for their own health but 20 percent of people today diagnosed present with an opportunistic infection are less than 200 please come down to brady hospital. Second undetectable is an transmittable if they is submitted they have no wish to translate the infection thats another reason why its important to find people that dont know their infection because we estimate 80 percent of new infections of those who dont have the benefit. And those that want to do for a long time. Is a what i really want to push to automatically order a test for a person if they come in with no evidence of prior testing. Its difficult but it can be done and there are many examples of places that have done it successfully. Also with repeat testing strategies and for those that have to be screened on a regular basis. I also want to talk about expanding access to hiv testing asking people to come to us to get tested. Soft testing and bring it to them. And tweaking those approaches for the different populations. And of a study of this monday. Of what you can do for testing. They divided people into two groups. 2600 roughly that were drafted to participate. They were given for self test. So four times over the 12 month period at each point that they could replenish. And they could share those test passages packages of the network they got extra they were not told to share them but they got them if they wanted we said thats fine. Let me show you the results. So that you stamp so the data from all bottomline for those that were firsttime testers so look at a new diagnosis. For those with three or four times the next year. With a new diagnosis. And in the social network with the rates that was almost backwards if you will for testing reaching that level we wanted to reach. Also who double the number of firsttime testers. 17 percent ever tested before. With half of the control. So theres that room at risk of people and they are beginning to do that more so that was a promising opportunity. So this complacency issue that it is an epidemic that has ended i dont have to worry about it that is somebody elses job we have to change that. We also have to really build up to implement screening. And for them to say this is the way to go but we would like to see more working with fda. So that treatment it is an okay job not a great job. And to see expanded rapid engagement of people who possibly disengaged and are using to identify people. But that tcell count takes a long time. Could we move this back. And for a group in detroit it is a means as identifying people earlier. Look at what they found with the standard of care are 92 people versus one person and it took 41 minutes per person standard of care versus 15. s is not intended to be a replacement but an adjunct and i want to note the big barriers with Mental Health Substance Abuse incarceration. And thats hard. So with prevention focusing on preexposure. In less than 20 percent america the large increases in with the nose ethnic disparities. And with those latinos we really need to work on this with those populations and engage primary care and then to increase access the newest number of how to get touch with people straining capacity for primary care. And then the interfaith access. And to be discreet and tele prep they work beautifully in rural areas like louisiana and iowa where programs are in place. And with these new agents and to identify to engage them. How may times and he said the doctor said that my patient is in that type of person. And to understand what consumers want. And with those inservice programs and part of the scott county outbreak. So i we are concerned if its a real threat to push it back looking at the new infections but there are some trends. And then to see some early upticks with People Living in rural areas. And those to be at risk of hiv infection and then it needs to just to be comprehensive care until people of the community benefit. And skip this quickly to integrate with access we could drive down hiv infection in the number of people receiving syringes daily and infections came down but we did not see the way until people were more engaged because thats the blue line going up. And with that anthropologist and social scientist. And then they dont increase crime. And that these are two costly but that is just simply not true. So looking at the costbenefit in baltimore and philadelphia. The return on investment was 234 billion. Thats a lot of money for really good purposes. Money speaks to power. I would just notice the syringe binging machines but now they have those in las vegas thats a great thing to explore. And challenges they will always be resistance to those barriers. And many of those services with Infectious Disease doctors dont know a lot about administrating out with the medication and assisted therapy. And with that hepatitis c can we have to bridge that gap. But then its impossible working together i want people to be disruptively innovative. Thank you very much. [applause] spin i thank you so much. That was just marvelous. Now we have some time for some questions for our speakers we will have double microphones but somebodys ready at the microphone to go ahead. Thank you for that amazing presentation. I want to talk about adolescence with that four pronged approach should be rolled out with young people they are an extraordinarily High Risk Group specifically among the latino. And all of these apply to youth. But the one that i would highlight mostly is we have to help young people recognize they are at risk and you know what a challenge that is dealing with the minority community. With that social stigma. For persons 35 kilograms or less. It is in the age limit. But the challenge is to provide this in a way that does not out them. A lot of parents are on their insurance parents plan and a lot of local jurisdictions are working on ways to work on that. An interesting issue with the implementation science to do things right. What is clear it may not be the same for transgender women. Because adolescence that is distant from the other. And at the best to implement. Thank you for your presentation i have a state Department Health background. We came up time and time again looking at our plan and other states is criminalization with hiv. And then you transition that unknowingly and that it prevents people from getting tested. Is there a plan to address that . First of all let me say im sure john will say the same thing i am completely against any criminalization of hiv at all. Number one. Number two this is a federal plan criminalization is at the local level they think to see criminalization because its all local even though we are clearly very much against that because that is part of the stigma. We have two questions with prep. And with the medical mistrust and then to have participants and with that prolonged treatment and second when it comes to the treatment pillar with this whole initiative what are your thoughts to have better collaborate on collaborations these other competing priorities. And with those initiatives that are outside these initiatives. So you raise that important issue that there is medical mistrust it is a real barrier to what we want to do especially with this initiative. How do you address this . To have a key opinion leader but then to go out. Two peer to explain and with this self test idea. And with regard to that question is more and more collaboration and speaking almost as i do every day as they all start to achieve with the systems that are operating separately. If you can get political leaders to come up this is important for us but this would get them moving in the right adding one more thing to what john said, we saw in a lot of sectors the importance of integrating hiv prevention and treatment and care to other aspects of individual lives because you might often hear you want me to take prep, a lot of things im worried about, i am homeless, i will probably get shot in the next month so you have to have an integrated approach, not just take hiv in isolation, weve got to look at every aspect of a persons life before we focus too much on vacuum on hiv. Thanks for a great talk. I wonder if both of you could comment, ending the hiv epidemic is a huge goal that some of the things we see with prep use is an uptick in other stds and i was wondering is there a plan built into this to treat the other stds we are seeing an uptick in because of prep . Absolutely. I cant speak to what the announcement is going to look like but for any stds nationwide we want to see prep brought out to clinics, it is a point venue for us to access those people, part of prep that we promote as part of our guideline is routine std screening and the beauty of that is once you have a group of people and you begin screening them regularly and treating them you can begin to reduce the prevalence that leads to reduce incidents. Im not sure the final chapter has been written on this but there are the increases in stds, testing all the people who havent been tested before but those who have been routinely tested every 3 or 4 months, rates are going down. Ultimately prep will lead to a decrease in other stds because if prep is implemented correctly, it will not be in the first 2 months to a year but at the end it will start coming down. The misperception that prep is driving std rates of the people who need prep are already engaged in behavior that puts them at risk for stds. If anything it will bring it down i think. I would add we also know there are important stds. Is not just a prep issue. We have to address People Living with the virus. We have another question. Carry from the department of epidemiology. The goal has been clearly defined, we love that in Public Health, what will be the lag between when the goal is met and we know. What data systems are using to monitor . There has been a group of people working on how they, what the data sources are going to be. The main indicators, the big indicators hiv incidents that theres a long lag. We have other indicators we can produce to help people redirect the direction they are going, among them are prep updates with time, linkage to care and time to suppression and those are being drawn mostly from federal data systems, particularly Surveillance Systems but part of the funding we hope will encourage systems to improve and report results. There will be a point that is visible in hhs websites that posts for the nation as a whole, where we are but each of the indicators, and individual jurisdictions will get their own reports as well. So a caveat. If we are successful you will start to see an increase in hiv dagan ocs before you see a decrease in incidents because if we are doing it correctly we will be testing more people already infected and the diagnoses will go up. We are concerned about that because we know the general public will say what is this plan of yours. If we are doing it right it will go up and incidents will go down so. Communicate to people the expected epidemiological profile of ending and epidemic. Thank you for that epidemiological insight. They found the same phenomenon in new york and San Francisco. To that end in terms of theres a problem now where we cannot get centralized samples of all the new diagnostic diagnosed individuals to test for biomarkers or recent infection. Is there anything since this is now a government Wide Initiative to either take all the new blood samples from newly diagnosed people, to have them then tested for other biomarkers or anything to collect that, to give the cdc the ability to better estimate the number of new infections or incidentss of infections in the us . Not much i can say about that in detail because that is being worked on right now, a plan that is in development. We currently use diagnosis on a population level, not individual level to assess where we are. There has been a lot of interest in revisiting incidents and we are working on them now. There are some tough barriers working with Public Health, moving specimens around from people who didnt consent to that kind of testing and what to do with the results that has to do with Clinical Utility but only Public Health. It is something we are looking at. We could clone you and have you go to this. The cloning process we are coming to the end. Thank you for your incredible service. Im going to ask a question about the fact that theres hiv at immigrant communities at a time when immigrant communities might be scared of medical services in part because it may under Administration Proposals keep them from ever becoming citizens or because of the fear of enforcement. How is that factored into your thinking when your maps overlap with areas with a lot of immigrants. Tough to give an answer to that. As Public Health officials we would like to see no one be denied access to or implementation of healthcare based on their immigration status. To me that is a Public Health mandate but unfortunately it is not. It is not within our purview to change that. I will we treat everybody crosses the threshold, we dont care who you are, you are part of the public and we need to take care of you so whatever can be done to facilitate that and reduce the barriers of people coming in. There was an interesting project in houston, they have a very large crossborder community and they have engaged folks who are themselves undocumented to go out into the community and begin to try to explain to folks that is currently stands there is no threat to bring them into care and the here navigator model. It isnt a perfect solution but there are hopefully ways to begin trust to get people into care. We have i am with older people embracing life. When this plan first was put out there were five colors. Workforce development went away, because the thought process is Workforce Development in each of those other pillars is going to happen. Is that going to be funding that is going to allow for Workforce Development . You are absolutely right and linda scrubs, it is good to see you again. I dont know shes here that this is a topic of a lot of conversation. The reason it went away, and by isolating it, all the things we are trying to do. We hear from the field all the time, they dont just focus on hiv, a lot of services for Public Health. And and they already can be used how that is going to be negotiated at the local level depends on what you can help contribute to the people driving your plan to get them to do what you think is needed. They are waiting to hear from you about what the best thing to do is and how to reach people. We are looking at a number of ways to enhance that, not just the Public Health workforce we are worried about on the other side is the colorful workforce, a lot of people who treat hiv are aging out or retiring and we need to find ways to bring into the workforce new folks who work not only interested in this but can be engaged in taking care of people for the rest of their lives living with this affection. That has to be our last comment. Those of us who are longterm survivors or aging, theres really nothing in place because we are the first cohorts of those driving with hiv that are aging. Do you mind if i mention your name, doris baker . And the Baltimore City hpg, we have our coalition for hiv, aging and longterm care where we are trying to tackle how we are going to be treated in rehabilitation, nursing homes, assisted living because we dont want to see what happened in the beginning of the treatment happened for those of us that are aging, okay . So we need folks to support a coalition. I really admire the attitude that you want to make sure other people dont have to go through what you have had to go through. You have a lot to teach in how to help manage folks so they dont face the same kinds of barriers that you face so thank you. I would just add that when we talk about getting control of the epidemic indenting the epidemic what we also mean is everybody in this Country Living with hiv is going to live long lives, so the issues that you raised about aging and longterm survival is a reality regardless of how well we do with ending the Epidemic Initiative and we think we all know that and that is an important part of our work, we have a very active group as you know. With that we have come to the end of what has been a wonderful conversation, two wonderful presentations, we want to thank doctor brooks, doctor fauci for coming, thank the dean for hosting us in this extraordinary place. I want to thank the see farm director for the support and the team who helped so much, and please, everyone join me. [applause] [inaudible conversations] booktv has live weekend coverage of the Miami Book Fair. Starting today and sunday, featuring other discussions and interactive viewer call in segments. Stay at 11 am eastern republican senator tom condon talks about Arlington National cemetery, former Obama Administration National Security adviser and un ambassador susan rice discusses her life and career. Megan phelps roper on the Westboro Baptist church, doctor janine, chair of constitutional studies at the university of notre dame and wired magazines Andy Greenberg discusses russian hackers. On sunday at 10 30 a. M. Eastern, live coverage continues with former under secretary of state in the Obama Administration richard stable on the proliferation of disinformation and international politics. David marinus on the 1950s red scare. Journalist elinor randolph discusses michael bloomberg. Former Deputy Director of the cia counterterrorism ctr. Philip mudd talks about the state of cia Detention Centers and former Football Player John Mcpherson on toxic masculinity. Watch live coverage of the Miami Book Fair today and sunday on cspan2s booktv. Wednesday on the senate floor, but Diane Feinstein and joni ernst presented competing legislation under the violence against women act. Senators john cornyn,