Let me welcome you to the school of Public Health, im Alan Mckenzie i am privileged to be the dean of the school. Thank you for joining us today. Today for what will be a compelling conversation. One that will provide great hope that we can make a difference in the fight against aids. But also it will remind us there is still much, much to be done. Importantly, we will need to double down on our efforts if we need to set out in the bold tenure federal initiative championed by the nh and cdc and by our special guest doctor Anthony Fauci and doctor john brooks. Here at the Bloomberg School of Public Health we have talked about the power of Public Health health, the power that comes from doing the fundamental research and translating the research into programs and policies that make a difference. The power that comes from strong partnerships across disciplines, public and private sectors and across community. In the power that comes from advocating solutions of the state, local and national levels. The fight against hivaids exemplifies how sustained commitment to these powers can make a true difference. Todays conversation will be facilitated by our own chris buyer, the professor of Public Health and human rights. Doctor breyer in my humble opinion is a true publichealth hero. A researcher and practitioner who is committed to solutions to some of the worlds most challenging Public Health problems. He is a longtime hivaids researcher with extensive experience with Collaborative Research and Training Programs and hivaids with key populations. He is also wellknown for his overriding commitment to securing health and human rights for all. As director of the john hopkins, the program, doctor breyer provided fellowships for 1400 International Scholars in hiv aids Prevention Research and treatment. Chris is one of the bloombergs most remarkable graduates in his success in research and practice with the continuing ongoing commitment from the policy leaders at the cdc and nih make for a powerful combination and have helped bring us to where we are today and on the cusp of ending hiv epidemic in america and across the world. Todays event is cosponsored by the center for aids research and it is a collaboration across the three john hopkin schools in the schools of Public Health, medicine and nursing. With support from university for the office of provost. Founded seven years ago it is committed to ending the epidemic through the promotion of Disciplinary Research and importantly by training the next generation of hivaids research here in the u. S. And abroad. The return on investment is quite clear, one example, hiv funding for junior investigators has risen from 7 of nih funds to 25 of all nih Research Funding now. This has created a larger welltrained and powered hiv experts who in the past decade have accelerated the work to get us nearer to the Necessary Solutions for this epidemic and getting us to the goal were striving towards. While hiv impacts the health of populations worldwide i am particularly pleased that it is been on the forefront of supporting hiv research and programs here in our own city of baltimore. The Bloomberg School faculty is making a difference in participating in so many of the hiv epidemic by collaborating with leaders and state policy makers. This is a remarkable example of us working together for policy solutions that work across all levels of government to save lives millions at a time. I would like to close by offering a special thanks to our director dick chasen of the school of medicine and again, to chris buyer the associate director. Thank you both for all you have done and you continue to do and thank you to all of you for being here, your determination and commitment to hiv is so critically important because of your work our dreams to end hiv is now on the horizon and we hope coming true by 2030. With that i will turn the program over to doctor chris breyer who will introduce todays guest. applause thank you so much ellen and on behalf of chase and i want to thank you for your support. It has made a difference. So we are delighted on behalf and to welcome all of you to the special session and with our special guest doctor Anthony Fauci and john brooks the head of the hiv Prevention Program at the cdc and just before i introduce them i want to make a few comments about why we think its so important that Academic Research institutions like Johns Hopkins engage in the initiative and take on the roles that we think we comply in helping to finally achieve the end of hiv epidemic. I think before we do that we have to acknowledge two or three fundamental truths that you will hear about from our speakers today and theyre very essential to thinking about the tasks ahead in the first of those we have to acknowledge the hiv epidemic and the new infections in the u. S. Has been stubbornly persistent, we had declined over a number of years and basically been in a plateau with around 38000 or so infections for a number of years. So the first enormous goal that has been top of the initiative is 75 reduction in new infections over the next five years. That is on a very different trajectory from where we are and where we have been. We have an enormous task ahead in primary prevention of hiv infection and delivering new science and technology that you will hear from our guests that could achieve reductions in new infections but we will have to engage the folks who are at risk for hiv acquisition if we will achieve those goals. The second challenge hiv has always been marked by Health Disparities but as we have done better as a country and over the last decade the Health Disparities are getting all the more stark. Hiv is now very much geographically concentrated in the south and southeast and basically it goes from baltimore down to texas and across the south and southeast. There is a geographic disparity. There is a concentration in africanamericans and native americans and that is particularly stark for africanamerican women and for africanamerican and latino men who have sex with men. We have a concentration with race and ethnicity in a concentration of vulnerable groups and people at risk. We also have to deal with the emerging and quite different demography of the Opioid Epidemic and its impact on what we see with new clusters and quite a different map with the south and the midwest. Finally the third area that i think we have been surprised about after 30 years of effort and the tremendous advances in treatment and prevention is that hiv remains a stigmatized condition and the people who are living with the virus or at risk are in a very highly stigmatized groups and there is intersectional sigma stigma which relates to ethnic minorities in sexual gender minorities to substance users and of course also the stigma around hiv infection itself in persistence about that stigma remains very important barrier to achieving the goals that we want to achieve. So we have to do is stigma and Health Disparities and reducing new infections and that means both getting the new Prevention Technology to people and getting the american living with this virus successfully linked to care and finally suppressed. The exciting thing and you hear a lot about this from her guest is that we do have the scientific and technical capacity to do this and now the question will we be able to achieve that as a Public Health effort as a country. I think particularly for the young folks in the audience and younger investigators this is really going to be for the next decade or two decades the enormous implementation science and technical challenge for your careers and i think its enormously exciting. You will hear it does not mean the end of aids research. There is a long way to go to achieving these goals. Let me turn to a delightful honor who is to introduce our first guest doctor Anthony Fauci, the National Institute of Infectious Diseases and he is one of the architects of ending hiv initiative and this is often called as some of you wouldve heard, that is not surprising because dr. Fauci he is also one of the architectural. Which of course has been a world changing Global Health intervention and the largest commitment to disease by a government in human history. And really something that is enormously important. Doctor fauci, always say that he needs no introduction but i think Everybody Needs an introduction. To let me go on for a moment and say he is one of the most sided scientist in any field and a recipient of the president ial medal of freedom which is the highest honor that the president can give and hes playing an extraordinary role in maintaining over decades the research and funding support for the hivaids epidemic. And for that, all of us as investigators are deeply in his debt, but more importantly everybody allied with hiv it took a hundred Clinical Trials to reach therapy to be effective as it is not proved without the sustained decadelong support of the nih in funding that research we would not be where hiv is a manageable chronic condition in an extraordinary and saved millions of lives. I will add one more thing that some of you may know im a past president of the International Aid society and when you take on that task you have to give an award. It is called the is president s award and when that fell to me too make that decision i had a short list of one person. I would like to thank you dr fauci for accepting and coming all the way to south africa to accept the award is a great honor giving it to you and without further ado, dr fauci. applause thank you very much chris, for the very kind introduction. Its a real pleasure to be with you this afternoon to talk about the subject at hand in ending hiv pandemic and all talk about it from the standpoint of science to implementation. This is a paper that we put together and were describing right after we submitted it before the president made the announcement on february 5 but it came online the next morning and it was the print version describing the plan which was a 75 reduction in new infections in five years and 90 reduction in ten years to diagnose and prevent and respond to outbreaks. You will hear a little bit more about that from doctor brooks in a moment. What i would like to do is talk more and flush out what i refer to as the hiv vulnerability profile. Why did we feel that we could actually end the epidemic given what we have. It starts off with the population that we have as a vulnerable population. Both demographically and geographically. Lets look demographically, its very prevalent in baltimore, 13 of the population of the United States is africanamerican and of the new infections 43 are among africanamericans and 60 are among men who have with men and 75 are young men who have sex with men. So we have a concentration of a vulnerable population and we also have a geographic concentration and when john brooks and his colleagues at the cdc put together this map it was stunning, there was 3007 counties in the United States and if you look at 38 of the counties plus the district of columbia plus san juan, that account for more than 50 of all the inspections in the United States, that is extraordinary, 40 units out of 3007 units. They had 50 of the population. So we had this plan, a number of agencies involved and ill focus just for a few minutes on what the nih role. We were discussing the stocks a little while ago and we call the implementation science. The cdc and others will be responsible for going out and engaging in the community and whether they are doing that correctly which im sure they will but how you make it even better from yeartoyear will depend on implementation science. That will be done through the center for aids research which is right here in baltimore. If one looks at the map of the country and the red ribbons are for the aids research and the blue ribbons are the aids Research Center which is mostly Mental Health, you can see an important overlap with some exceptions like in texas which unfortunately does not have that but we will be dealing with that by extending other cfars there. We rose to the occasion of trying to get them for doing a good job in other aspects of hivaids, a critical part of what we do. But we needed to supplement them to do the extra mile of getting involved in the extraordinary effort to end the epidemic. So we did 65 supplements to 17 cfars. 36 of the 48 counties were involved with the cfars, we collaborated with Health Officials and we studied the optimum of delivery of evidencebased intervention. I just had the pleasure of listening to two hopkins people present Work Associated with the hopkins cfars and the baltimore collaborative project with joyce jones and the linkage and retention and repair upon release from the maryland state prison. If everything is done here is as good as what i saw this morning you guys are in really good shape. So, lets get on to the scientific basis. Beside the implementation, i think we should not forget how we got to where we are now, it really is a science that got us there. Mainly the scientific bases for even older ability to implement the program. Let me talk about that for a few minutes. We have hiv treatment and prevention toolkits that have accumulated as chris said, over decades of research with basic research and Clinical Trials including the drugs on the lefthand toolbox in the prevention on the right hand. Where has that brought us . I began taking care of hivinfected individuals in the fall and winter of 1981. Before it was called aids, before we knew what it was. At that time, the patients i admitted to my unit at the nih in a meeting in the expectancy of about a year which means 50 of your patients are dead and one year end following them about 95 were dead in two to three years. If you look back today and if patients come in to the same clinic which i should have been having rounds today but im here with you in baltimore. But if a patient came in who is reasonably newly infected and i put them on a combination, i could look them in the eye and tell them they would live an additional 50 plus years which would give them almost, not quite but almost a normal life expectancy. What are the returns of that, in the 20 years from 1995 to 2015, over 10 Million Deaths with almost 8 million infections were inverted and we save 1. 05 trillion dollars. For every dollar spent, 3. 5 in benefits were realized. What about deaths, of 55 reduction in death from 2005 to 2018. We had Game Changing scientific advances. The one that is linked them is the concept of simple as it may seem but we did not realize it is treatment equals prevention. In two ways, treatment has prevention, the iconic hpp and 052 trial which showed different couples if you saw therapy early in individual who is infected as opposed to waiting to the guidelines triggered at the time and guidelines did not say everyone should be treated, you decreased by more than 95 and the likely it you would transmit to your sexual partner. We followed up five years later and we started to look at the relationship between viral load and the chance of transmitting and it was a strong suggestion that if you were below the level that you would not transmit, very few people believe that so we had to prove it. We did three studies, two opposites attract into our amazement and very positive amazement out of more than 150,000. Sex acts not one single linked transmission which allowed us to say about scientific basis that we were hesitant to say before that actually treatment does equal prevention and undetectable does mean an transmittable, a very important concept. The next was prophylaxis. One pill containing two drugs if taken optimally and consistently was more than 99 effective in preventing sexual transmission and acquisition of hiv. If you put those two things together, treatment is prevention and take a deep breath and think about that for a minute, theoretically if you put everybody on treatment, almost everyone and put all at risk people on prep, theoretically, you could in the epidemic tomorrow. But we dont live in a theoretical world we live in a realworld in the way that you make the bridge of the gap is by implementation. Thats what it is about and thats what you guys will be doing. In order to do that, we have also got to optimize this toolkits in two ways. Maximal implementation, why do we need maximum implementation. Lets look globally not just the United States, 23 Million People are receiving antiretroviral therapy. Great news prechallenging news almost 15 Million People who should be on therapy are not on therapy. That has led to a very modest and even less the modest reduction in incidence globally and in fact, there has been less than 2 annual decrease of incidents since 2010. So as chris said, although were going down, we have plateaued a bit which is why we put the plan together. Retention in therapy is also challenging, if 100 is the day you go on therapy, 48 months later only 60 of people are still on therapy, you will not end the epidemic that way, utilization of the 2020 un target says that 3 Million People