president obama has said on world aids day, "we will beat this disease." that's an ambitious but achievement goal and challenge to all of us. what we've seen is a goal to reduce mother to child transmission by 90%, but not only to meet the goals of pepfar in hiv, but to meet the goals in pepfar in strengthening systems, reducing mortality by at least half. and ambitious goals. three numbers that we need to keep front and center in everything we do. 6 million on treatment, 1.5 million women treated to prevent mother to child transmission and 4.7 million voluntary medical mail scircumcisions. those three numbers are enorm s enormously ambitious. we have 21 months to achieve them and we're confident that

working together we can. at home, we have, for the first time, a national hiv/aids strategy for this country. with a focus on reducing new infections, increasing access to care and improving health outcomes for people living with hiv. reducing hiv-related disparities in health and equalities and achieving a more coordinated response to the hiv epidemic. and let's not mistake, we have significant challenges in this country. 1.2 million people are living with hiv, approximately. 1 in 5, 200,000 people, don't know that they have hiv. another 450,000 or so know they have hiv but they're not on effective treatment. we're seeing an increase in hiv incidence among young men who have sex with men in african-american communities.

we see that more than 60% of new infections occur among men who have sex with men. and when we look at that key concept of accountability, only 28% of all americans living with hiv have their viral loads pressed. that means that their own health is at risk, and their partners are at risk. so, we have a long way to go. but we also know that significant progress can be made. san francisco, for example, has scaled up treatment as prevention and they're seeing significant reductions in incidence of hiv. and at cdc, we're taking a new approach to our prevention work. we're saying, let's make sure, in this country, for our prevention dollars, that we're sending our resources to the places that need it most, for the programs that work the best for the populations at highest

risk. that means we will shift our fund i funding. and determine our funding based on the number of people living with hiv and support innovation in health departments and communities. and ensure that three-quarters of all resources we send out go for four key activities. scaling up testing and linkage to care, comprehensive prevention with positives, condom distribution and initiatives to promote prevention and accountability, as personally monitoring viral load and helping health care workers ensure that we're controlling it. we won't be able to effectively manage the epidemic and help people be healthy unless we sis maticly track these numbers. in this country, we have seen progress. 11 million more americans know their status than knew it before. three-quarters of those at high risk have been tested.

we've seen 90% decreases in mother to child transmission, in trance mission transmission of drug users. those same levels of effectiveness, 90%, can be seen globally. and what we hope to know in the next few years is whether scaling up treatment as prevention can reach that kind of impact on sexual transmission of hiv. not only is this saving lives but it can save money, as well. we know from a broad variety of public health initiatives that we can drive down health care costs. immunizations save $3 for every $1 we spend for the health care system alone and $10 for society. a single patient living with hiv has a lifetime cost in this country of about $400,000. if we can drive down new infections and reduce the number of people who become infected in the future, we can truly bend

the cost curve for caring for hiv. effective prevention interventions are increasingly understood. we know that pmtct can be highly effective and reduce transmission down to 2% or 4%, but we're at less than 50% coverage globally. this is all on the global scale. we know that treatment as prevention has been documented to reduce transmission by 96%. this is remarkable evidence of progress. we now know that if you are on treatment, not only will you live longer and healthier, but you'll be 96% less likely to spread hiv to others. that's a game-changer, in our understanding of how the epidemic works and how to treat the epidemic. how to manage the epidemic, how to control it and prevent it. but even with a modest level of

cd-4 count, we're still at only 47% coverage. mail circumcision is at least 60% effective in reducing female to male transmission of hiv. our coverage is less than 5% glo globally. but we've seen that it can be scaled up. kenya, for example, has scaled up remarkably. and done nearly 400,000 voluntary medical mail circumcisions. and they will have an enormous benefit from that effort in fewer transmissions, fewer illnesses, more productivity in future years. the vaccine, we're still a long way from where we need to be, but we need to continue to work on it, because it would be without a doubt an enormous contribution. we're trying to see how we can incorporate this and scale it up and eidentify its effectiveness and preeck poe sure is something we need to try to understand

better. this is the data from ewe dan ga on the effectiveness on circumcision. as time went on, it didn't go down, it actually went up in terms of the level of effectiveness. 73% effectiveness over a longer time period. so, there's tremendous potential progress by interventions. what we are able to do is increase our partnering is insure that costs decrease and sustainability increases. we've seen systems established, and when the systems are established, the unit costs fall dramatically. drug costs have fallen, but there have been economies of scale. we've transferred services to local partners and now cdc is providing most of our services through local partners, ministries of health and others. we've helped to expand

team-based care, and team-based care is a very, very important initiative. it's a very important tool that we could learn more from in this country, as well. making sure that every member of the health care system is used to their fullest potential will allow us to do better care for lower cost and ensure that we have people in the health care system who are working in ways that can support communities. we're also seeing south africa and other countries take on a greater proportion of the financial burden of treatment. and that needs to continue. this is a global shared responsibility. the u.s. has done an enormous amount and is committed to continuing to do an enormous amount and more going forward. but other countries, countries that are affected by the epidemic, as well as other low, middle income countries and donor countries also need to do more.

this slide shows a model of different scenarios of what may happen in swaziland as we scale up different interceptions. on the y-axis, you see the number of new infections per 100 person years. the current model, based on the best available modeling that we have is that there are about 2.5 for every 100 person years. and if we do nothing, that will increase. if we expand medical circumcision, that will fall. if we don't do either, it will increase. but if we look at expanding both treatment and circumcision, we can see substantial reductions from 2.5 to 1.5 and if we treat at lower levels of cd-4, we can see those levels going down all

the way below 1 per 100 person years. we think it's possible to drive down incidence of hiv with combination prevention. time will tell how effectively that can be done in the field and what the impact will be. but all of our best estimates and models today tell us, and interesting suggestive evidence indicates that we have tremendous potential for significant progress. at cdc, we're delighted to be part of the efforts to make that progress. at cdc, we do a lot to develop capacity locally. and there are parallels between what we do in this country, to support public health and what we do globally, to support public health. we provide technical guidance, technical assistance, as well as direct funding.

we have technical experts in more than 75 countries, working on hiv and a variety of other issues. we have very close partnerships with ministries of health and local overizations. we work in-country to build capacity. applied 'em deemology is critically important, helping countries look at and act on their own information. the field training programs i told you about earlier have populated ministries of health, as well as non-governmental organizations committed to progress in countries throughout the world. we place staff and imbed them in ministries of health so they can help to set up monitoring systems, implementation systems and ensure those systems can continue for many years to come. we also use a large number of host country national staff whose skills we rely on and who are able to interact effectively with local organizations.

we have agreements with 63 ministries of health, developed carefully over the years with safeguards and technical assistant so we can gradually and steadily improve the capacity of countries to detect and respond to hiv and other health threats. we've established or helped to establish the caafrican societyf medical to improve labs so there are labs throughout africa now that have reliable results for hospitals and others. we improved laboratory networks and quality. and improved health security by helping to build institutions like cdc, which can work assent nalls for health and as the leading edge of response to epidemics and health threats. countries throughout the world are building programs like cdc, most recently, india has created its own cdc and countries in

africa are doing the same. health security reminds us that we are all connected by the air we breathe, the water we drink and the food we eat and a risk somewhere is a risk anywhere. the spread of drug resistance is something that takes only days or weeks to spread from one country to another and can be very costly. now, we're all looking forward conference in july in this city. and i think it will be an exciting time. it's a welcome return to the u.s. and i know that many in the audience worked hard to reverse the travel ban on hiv.oud to ple in that policy change. and we're delighted to welcome back the aids conference after a long pause. and what a world of difference two decades makes. i trained as an internist and

infectious disease physician in the mid-80s. my training experience was seared by caring for hundreds of people dying of aids for whom i could do virtually nothing. when i left the u.s. to go to india for five years in october of 1996, it was just at the point when combination anti-let voe viral treatment was coming into widespread acceptance. i had two friends who were dying from aids and i figured i would never see them again. both of them are working full-time today. so, two decades makes an enormous difference. i think we can expect protelss at the international aids conference. and we also need to recognize that if it weren't for the

advocacy in hiv, we would not be where we are today. not just in hiv, but in many other diseases. the hiv advocacy community, i think, showed the way for people suff suffering, to command better treatment. to demand faster results. to demand access to the latest information. and we celebrate the progress, we celebrate the ability to respond to the needs of a community with an entire partnership of commitment. we have the national hiv-aids strategy in the u.s. and the rolling out of that strategy, despite the enormous fiscal pressures the government faces, we have increased our spending in each budget year. we celebrate the commitment to an aids-free generation. we'll be looking at the scaleup of effective treatment.

we'll be looking forward to the reauthorization of the pepfar program. and we'll be focusing on the translation of science to policy and policy to action. we'll be looking at new technologies, at microbes. we'll be looking at preexposure proflax sis and the impact of treatment or both incidence and death rates. i think there are very exciting possibilities. we know that treatment works as prevention between one individual and another. we're going to focus now on treatment as prevention on a population basis and document the impact of that. and optimize it so that we can do it as effectively as possible. we're also looking at the impact of pepfar and hiv programs on

systems. not only has pepfar achieved its targets, not only has it done that with steadily declining costs, but it's done that at the same time we've been able to strengthen systems. health care systems, public health systems, delivery systems, community efforts to improve health. and that's something to be celebrated an built on moving forward. combination prevention is something that would have been virtually unimaginable ten years ago. no one entity can do this alone. but i think working together, we can achieve a society in which infant infections are rare. progression from hiv to aids is rare. hiv treatment is effective and accountable, helping people live long, productive, healthy lives. and that incidence of hiv is

falling rapidly. and that's the world that we all need to continue fighting for. so, thank you all for the work that you do, all the time, to make that reality. thank you very much. >> thank you. thank you very much. that was really powerful presenpr presentation. let's talk for a few minutes and we'll open to our audience for their comments. let's talk a little bit about budgets, because obviously that's a great unknown at the moment and many of the really most difficult decisions are being postponed until the end of our year and into the next cycle. and the vision that's been laid out, which is a very powerful and compelling vision, does imply that there will be an ability to certainly sustain and

scale up resources looking forward. it always -- also rests on the cost gains that you've outlined in terms of decreasing costs and many of those cost advantages have been captured in this last peer yoond the modeling exercises that have gone forward have steered us towards redirecting those dollars towards the most effective use of them. but we're still going to need to address a very, very difficult budgetary environment, as we look forward and perhaps you could say a few words about that. i mean, much of what you've laid out here is, in fact, the essence of the case, but looking beyond that in a very polarized and conflicted context, and one in which some really hard decisions await us as a country around our budgets. how is your thinking right now? and your advice? >> i think three points to make about this. first, we're not done decreasing unit costs in pepfar.

we think there is still an ability and we can still drive unit costs by transferring services to local entities, by increasing accountability, by achieving economies of scale, by using optimumization. i don't think we're down with that i'm confident within the budget envelope i think we're going to see, we'll be able to reach the target of 6 million, the target of 1.5 million, and the target of 4.7 million. the challenges will be p program and fiscal. the second thing is, we need to see more country skin in the game. we need to see more country commitment to paying. no one wants to see hard-earned hiv or other assistance dollars used to basically supplant existing government investments in health. and secretary clinton has been

very forceful and forthcoming on that issue. and i am confident that an increasing number of countries, not all, but increasing number of countries will increase their domestic commitment, they already have and more will. we're also seeing more commitment from other countries and i think we'll see more responsiveness from many of the multilateral organizations ensuring there is effective accountability and use of funds. the third point i'd make is that i'm encouraged by the bipartisan administration and congress medical community and advocates, there is a commitment to global health and a commitment to hiv. and that's something that is strong, i think it can be brittle at times because we have to ensure that we make optimal use of all the funds entrusted to us. but i'm impressed by what a strong commitment there is to global health, generally and hiv

specifically. >> thank you. what we're hearing now, in talking to different interests on the hill and elsewhere, who are puzzling over the budgetary realities, those who are sympathetic and part of this coalition, but nonetheless, rethinking, what we're hearing is that, yes, indeed, there has to be more skin in the game from partner countries, we're hoping that the multilateral institutions that have been very fragile and bitter themselves, global fund going through its own, that they will return and be stronger. but there's also increased discussion around, how do you -- how do you present to an american public what the end game looks like? the end game may be the wrong term, because that implies an exit at one. but a vision, looking out, four, five years or ten years, that --

that tells a narrative to the american people, that is different than what a few years ago, seemed in the emergency faze, seemed like an open-ended and ill defined narrative looking forward. can you say a few words about that? >> well, i think there are several trends that are going to affect that. the models suggest that within just a few years of scaling up treatment, we can truly bend the cost curve and reduce expenditures down the road. there's going to be a need for more, but the option is, do you let people die from aids or you scale up treatment? and we've decided, as a world, we're not going to do the first, we're going to do the second. the data is clear. the quicker we do that, for the more people, the lower the financial burden will be in the medium term. not even long-term. but in the medium term. so, we have a major impact that we can make on investing now, to drive down costs going forward.

but i think we need to see increased commitment from countries, both host countries as well as donor countries. and i think it's also important that we see pepfar as a platform for other critically important medical functions, laboratory strengthening or reducing health disparities or establishing a health work force. we need to, on the one hand, always keep that accountability for outcomes. and we've got those three numbers to focus on. but also, use that -- use all the precious resources that we have, to build systems that will be more resilient and more able to address a wide variety of health threats. >> let's talk for just a moment, a little more, about what lies ahead in the aids conference, aids 2012. this is coming after a 22-year

gap, which is an interesting proposition, as to, well, what will the opinion environment be like and will this ignite a renewed interest in enthusiasm or will this become aboutive to some of our other more polarized and politically charged debates that may attach themselves to this and ignite tensions, rather than bring about greater unity and renewal of interest. and when you think back, historically, to the relationship that the united states has had to these conferences, it's oftentimes been some what contested and combative. the last conference in san francisco in 1990, was quite a turbulent event. and between then and now, there's been periods in which the u.s. government has found itself at different points, bangkok and other places, in a fairly confrontational position.

and so, there's a little bit of anxiety about what will happen. and i very much enjoyed the fact that you positioned this in saying, we must acknowledge and celebrate the dimension of social mobilization and protest, in driving forward our own leadership and the like. but perhaps you can say a bit more about how you think about getting the best outcomes and getting the best set of messages to an american public. long history of communicating to publics and trying to get publics to understand what the opportunities are and we have an opportunity, as we move towards and through the july conference, to connect with the american people in a very different >> there are areas within the hiv response and the response to the hiv controversial now and will remain controversial.

but i think the u.s. has a great deal to be proud of. pepfar is the largest global health program ever undertaken by any country for any disease. we've built on that success in this administration and we've done more nationally. there are certainly -- there are certainly plenty of unfinished business. and all of us are benefitted when we focus on the unfinished business, honestly, objectively, going to do whatever we can within whatever resource envelope we can achieve to save lives and stop the epidemic. i think what i hope is that we can focus on where are the areas where we need to do more? there are, i think there's an 80-20 rule here. we agree about 80% of what to do, but we may spend 80% of our time arguing about the other 20%.

and i think one of the things that we can do is to figure out ways and use the conference as a catalyst to move further in those areas where we need we need to make more progress and there is widespread consensus. i think a generation of americans have grown up not realizing what a terrible scourge aids is. a generation of men who have sex with men. a generation of gay men, have grown up not seeing their friends die, thankfully, thank goodness. but -- but that means we're seeing an increase in sexual risk behavior. we're seeing very high levels of sexual risk behavior across a wide variety of demographic groups, among men who have sex with men. so, one of the things that it could do is increase awareness of how bad hiv is. it remains an incurable disease. wonderful as treatment is, it remains an incurable disease.

so, one thing we can hope, for our general understanding, item fa sizes that this still is an emergency. and for a general understanding, it could emphasize that this is a bipartisan commitment to stop a terrible epidemic. >> i want to invite our audience members to offer comments and questions. and we have microphones in the back. and what we'll do is take three or four at a time and come back. so, we have a couple of hands up, ray in the back. and up front. and please be patient. we'll do a couple of cycles. yes? please stand up and identify yourself. >> ray martin from christian connections for international health. thank you very much. it's great to hear, considering what we faced not too many years ago, all this talk about combination prevention and the potential of all the tools that we could bring. i have a