combination prevention. the four priority components that you mentioned in your slide, where arv treatment as prevention, pmtct, voluntary male scircumcision and correct and consistent use of condoms. different times i've heard eric, the global aids coordinator, talk about the importance of behavior change as a component of combination prevention and i presume by that, he meant various aspects of sexual behavior. so, i'm wondering whether there's a difference -- a different perspective of priority between the office of the aids coordinator about cdc or why behavior change didn't appear on your list of priority components of combination prevention. >> thank you. >> in the rear? >> hi, donna berry from partners in health.

so, it's world tb work and i did miss the beginning of your talk so i apologize if you mentioned it, but clearly we're not going to address some of the mortality levels without addressing and building up better tb treatment programs, as well as prevention and i see a lot of tb friends in the audience, too, so i imagine we'll all have a few questions for you, but if you could speak to that a little bit. we are incredibly disappointed with the lack of funding and cdc's played a huge role in the international rollout mdr-tb treatment. love to hear more about that. >> thank you. up front here? thank you, sir. >> thanks. carl this myschmitt with the ai institute. you mentioned in the united states, you are focusing the money and the programs on the communities most impacted, just wanted to say thank you for that. my question is, the affordable

care ability and it's in the news lately and how is that going to impact hiv prevention in the united states? >> shall we take one more? right here. sir? we'll come back for a second round in a moment. >> thank you. my name is david jamison, from the partnership for supply chain management. i wanted to thank you very much for a very clear and encouraging presentati presentation. i wanted to come back to your comments on the unique cost of care. we've been very involved in driving down the unit cost of a number of the xhod tips, particularly the drugs. and an area where we work very closely with many of your folks in the field and successfully, is in the laboratory area. we found it much harder to drive down unit costs of equipment, reagents, diagnostic tests in that area.

work is being done on standardization that reduces the overall cost, but i wonder if you had any thoughts about whether you feel there is scope for economy in the cost of that, of the commodities themselves, in laboratory work and how one would set about driving those costs down. >> thank you. >> thanks. these are all wonderful questions, and all critically important issues. in terms of behavior change, this is and remains and will remain an important part of response to the epidemic. delay of sexual debut has been documented in a number of countries and has a very important role and we would see those programs continuing. similarly, efforts to reduce the number of partners, which have been not as well documented to be effective, but if they were effective would have a major role, need to continue.

what we are looking at are the addition of these combinations to make huge difference. in terms of tuberculosis, tuberculosis remains a major killer and a major challenge. i think the -- as i -- as some of you know, i spent many years working on tuberculosis, so i have to be careful to try to keep my comments short in this topic. i think we need to ensure in tuberculosis that we never lose sight of the basics. i reviewed yesterday a country program where they're treating mdr-tb and they have run out of first line drugs. that should never happen. that should never, never happen. and yet, that is the case in different parts of the world. we have to keep the core programs functioning and functioning effectively. we also have to ensure that the patient always remains the vip of the program.

and there are programs which have been attempting to do that more or less effectively. but that is a crucial concept that needs to infuse all of our tuberculosis care programs, if we're going to be effective. and the third point i'd make is that tb is a disease that takes a long time to treat. it's curable. but it takes a long time to treat. in the same way, we don't know certain, for certain yet, but my read of the data is that in many countries, with current technologie technologies, we can do a lot. we can make huge progress. we can drive down deaths from tb enormo enormously. we can drive down prevalence very rapidly. we can drive down new infections from tb significantly. but the number of tb cases, which arise from people who are infected months, years or

decades ago, likely to continue at significant numbers for a long time. so, with tb, we're are going to need persist ents, not only for individual patients but for programs, to continue a long time in effective treatment. and that's something that we need to do and ensure infection control is also something we need to do a much better job at. we know that infections in health care facilities can account for a significant proportion of new tb cases, especially among people living with hiv. and there are simple low cost ways, separating people with cough, not hospitalizing people in the first place, using simple ventilation methods, that can be used and probably haven't scaled up to the extent they should be. we've seen a lot of progress in tb. i think other programs have a lot to learn from tb in terms, for example, for accountability of outcomes for individual patients. but we need to keep it at for a

long time. the affordable care act will bring health coverage to millions of americans who don't have it today. the result of that may be some what reduced pressures on some of the treatment programs such as ryan white. but that is years from now. and until then, we continue to have a challenge to make sure that people living with hiv get the services they need and have access to care. but the affordable care ability should -- as it will for society generally, increase access to affordable health care, it will do that for hiv-positive people, as well. but it won't eliminate the need for effective prevention programs. and that's something that we need to continue to do from the public health field. the issue of efficiencies in laboratory networks and commodities is an important one, we're looking at it in this country. in this united states, we've

seen a tremendous fiscal pressure on public health departments throughout the u.s. compared to three years ago, there are 50,000 fewer people working in health departments in the u.s. than there were just three years ago. one of the things that we're doing at cdc is a laboratory efficiency initiative to try to identify shared services, maintenance of reagents, to drive costs down. in different parents of the world, we've seen that from a variety of trans port or ere issues, it is harder than we might wish to drive costs down. i think we need to continue to work in that area. we also need to continue to look at new technologies. for example, cdc scientists have developed in another field, a rapid blood test, point of care test for plague, which remains a terrible threat with a very high fatality rate in africa. that test costs about a dollar and is highly a lly accurate.

so, i think new technologies have the potential to either drive costs up because they are complicated or drive costs down because they are simple and appropriate and accurate. i think that was the four. >> that's it. let's take another round. sir? >> hi, david grilli. i'm going to follow up on the tb question and while acknowledging that there's a lot more that can be done better for existing programs and treatments, what about -- what is your perspective on new tools, new diagnostics, new drugs, new vaccines, to invest in that for tb for the long haul? >> do we have some other -- >> and i'm sorry, one other thing related to that, will we see hiv-tb coinfection more prominently at the international aids conference, given the fact

that there is such an extraordinarily high co-infection rate between tb and hiv-aids. >> thank you. back in the rear? shannon, did you? okay. come back. >> hi, greg smiley from u.n. aids. mill question is about the domestic response. you said of the four priorities, 7 75% of the dollars are going to be, the fourth one was around accountability, viral load, i don't know if that was community oral individual. do those programs target the medical provider, the service provider, the community, maybe you can tell me a little bit more about what they look like. >> thank you. alic alicia, can we -- >> hi, shannon from futures group. very diffuse question, i think. so, thank you for your presentation. it was great and it's really wonderful to be seeing the attention to cost and cost effectiveness. we haven't had the numbers and

been able to show the improvements in increments. but with an eye to aids 2012 coming in and realizing a lot of times we usually talk to ourselves, this committed room of people who are well versed in public health and realizing this great opportunity we have where the american public and come and people who haven't been following either hiv-aids or the invisible successes of public health are going to be exposed. are going to be exposed potentially to what we would hope could be reaffirming, exciting and new ideas. sometimes when we limit the discussions to cost and cost effectiveness we forget to make the next jump to value and sometimes surprising value. sort of a difference of, in difficult budgetary times, what is the value of continued funding or increased funding, what's -- and that can be different from perceptional little from non-experts, what's

the incremental cost effectiveness of doing more and incremental little reducing transmissions versus the value of eliminating hiv-amds for a whole generation. on a normal person level, those are very different arguments and those are very different justifications for, you know, budgetary improvement, even. higher bar, maybe. along those lines, when i came back from overseas and came back into the domestic epidemic i found that there was a real range of people being engaged. people who thought hiv-aids, you still couldn't do anything about it, particularly in the developing world, it was just futile. so, every dollar spent is futile. or people who thought, we've done it all, everybody's great, there's not a problem. so why bother to spend more. similarly, i think, we get caught in, right now, it's either money going to foreign

assistance and the international response or it's money being spent here at home. yet a lot of these creative solutions and really value-added leaps, can come from that space in between those extremes. and defining it and it seems to me when i came to work in d.c., a lot of the improvements, we were able to make in testing, skachling up coverage and reducing mortality from hiv here in the city, came from some of the systems approaches we had been doing in pepfar abroad. cdc is uniquely paced to tell some of these value-added stories because of your role, not just with pepfar, but also here with state and jurisdictional health suspects, so, i guess my long winded question is, what are some of the value-added stories, you think, people are unaware of and that are compelling and are the difference between driving incidence down a little bit and

creating motivation for an aids free generation. >> thank you, shannon. one more? >> thank you for the presentation is. i've worked in both africa and here and so when we work in hiv, you mentioned before, workers, the one who provides services, so, we are looking through the increasing quantity, quality and retention of health workers in their own countries. and so we have been working in different areas so, how -- you mentioned cdc cannot do it alone. as u.s. agencies, how is your plan to work together with other agencies so that we can really provide both prevention and treatment and care services to the people in an expanded and

sustainable way. >> thank you. come back to you, tom. >> first, on tuberculosis, i think we've seen significant progress on new diagnostics. in terms of development in the laboratory, laboratory developments in the laboratory. we now have to define the role of those new diagnostics. for example, we have rapid test for gene expert for tb resistance. that could be done in a high volume district hospital to rapidly rule out tb and get people out of the hospital if they have tb to reduce spread. i don't know if that's the best place to do it, but that's something to figure out. one technology that i'm quite excited about is l.e.d. flores sense. when i worked in india, my biggest piece of unfinished business that i was so frustr e

frustrated with was the areas without electrical supply. it oo educational nos a small problem. in many countries, maybe a third of health centers don't have any or very little electrical supply and maybe another third have poor quality electrical supply. so, we tried everything. and solar didn't quite work and batteries can get used for home uses and not work well and may not last long. but l.e.d. resulted in -- it's a great technology. you don't need a big battery, can last a long time and flourless sense increases your through-put. i don't know if this is an area that will be highly effective or scaleable, but let's figure it out. we'll have new technologies that we have to use them. we've got some inklings of new drug combinations in tb that may get treatment down from six months to five or four. i said in 2000, i predicted that it would be at least a decade

before we had a significant reduction in the length of anti-tb treatment. i'm sorry that i was right. i don't know if it will be another decade before we do, but the tb bacteria grows slowly and it is tough to treat it. it's important we develop a wider arment. and there are benefits to reducing the treatment regimens. a tb vaccine would undoubtedly be a nobel prize. we've made progress in the basic science there. we're a long way from where we need to be to make it happen. but it's a very important area. and i do hope to see more, i'm sure there will be a lot on hiv-aids at the international aids conference. talking about tb-hiv, just mention in passing men anyone

gji gis -- meningitis. it's a fungal disease, often fatal and it is preventable, with inexpensive medications. and pfizer and cdc are doing studies in south africa and elsewhere, where cdc scientists have developed a rapid test for the infection and then we think just as we give to prevent pcp, we may be able to identify which people would benefit and make a big difference in aids-related tb. so, i think there's a lot of development in new diagnostics, new treatments and then figures out, what's the role of those treatments? how can they best be used? the question about how we're going to priority treatment in, or prevention funds in this country, 75% on four core

interventions and scaling those interventions up to get population impact, i think we're still figuring out how to use viral load. we would like to see a convergence of the use of viral load to monitor clinical qualify and the use of community viral load to hold the entire community accountable for how are we doing at stopping the hiv up 'epidemic? and that has tremendous potential for both improving the care of individual patients and individual patient health, because someone whose viral load is not suppressed is experiencing a ravaging of their immune system and of other parts of their body, by the hiv virus. at the same time, they are increasing the risk to partners. i think we hope to see a convergence of accountability through viral load monitoring. already half of states get vira the best way to monitor it?

the volume of viral load testing is high and so, ensuring that we are able to get ensuring that we are able to get the information through laboratory systems, duplicated, not simple, but i think this is a critical area to learn about ensuring we have complete confidentiality and by saying we want viral low suppression on a community level, we say at all times that nobody is suggesting mandatory treatment for hiv, but we are suggesting that the treatment facilities use that information and accountable for whether they're reaching out effectively to make sure people are being given every opportunity to come into and continue treatment for h hiv. in terms of the value proposition, i would make a few

comments. it is important we not over promise. hiv is with us, and it is going to be with us until we have a vaccine. it can be with us in a much less burden some way. we can drive down incidents. we can prevent maternal to child transmission. we can make it no longer the major public the major public health crisis it is today. in terms of economic benefits i think we can document significant impacts on the health of communities globally and in the u.s. ultimately, one of the wonderful thinkers in public health is jeffrey rose, whose book says basically that the best case for prevention is that it is better to be healthy than sick and it is better to be alive than dead. that is the real value proposition for public health but there is a lot of value to

not only the hiv care we're doing but also strengthening of systems we're seeing around the world, whether that is systems for accountability in clinical care, systems for linkage between community organizations and advocates and clinical providers, and there there is a lot of value in that and we need everyone thinking of what are the best ways to communicate that to different audiences. there is no one best way and there is no one best message but to different audiences there are different effective messages and i think we need to continue to show what works and to show the reality because that's the best case for our preventive efforts. in terms of helts care workers we have done development and training in healthcare workers in nursing and residencies and public health programs and we need to continue to build on that success. we need to support healthcare workers in developing countries and in this country where we are

seeing real shortages in the areas where there is the greatest need and that's another strong case for team-based care, getting people from within communities trained and empowered and able to provide life saving interventions going to be critically important going forward. >> thank you. we're getting towards the end of the time. i would like to close with leadership. as we look foward to aids 2012, about having the value proposition put forward and consistent messaging and making the case clear and science and evidence-based way, clearly leadership remains very fundamental. we have seen this with the impact president bush has had, president obama, secretary

clinton, yourself, mayor bloomburg, in the polo case in india in the last phase, very much at the level of indian leadership, and maybe you can say a few words about what we expect going into july and what we should expect or should be calling for with respect to the contribution leadership will play in that and sometimes in these conferences in the past there has been dramatic expressions of leadership and other times there has been less than adequate or optimal leadership. >> we have seen u.s. leadership in this issue globally for much of the past decade, starting with president bush and continuing in the current administration. we have seen over the past few months tremendous leadership from secretary clinton and president obama calling for an aids-free generation with ambitious targets that are achievable, real-world, real lives.

around the world we see leadership as the leading single predictor for whether a program will succeed or fail. to be blunt, look at south africa. what a dramatic turn around from denial to acceptance and leadership in addressing the hiv epidemic. i think we need to hold countries throughout the world accountable for continuing and achieving that leadership and in the u.s. we need to ensure there is not only the leadership that we have at the federal level but also at the state and local level where we are seeing states not treat people with hiv, seen localities step back from commitments they had prosecute and leadership at every level is the strongest predictor of success or failure of hiv and other public health programs. >> thank you.

thank you so much for spending this time with us. please join me in thanking him. thank you very much. >>

if you missed any of this event it is available in the video library at c-span.org. coming up this evening, the top commander in afghanistan, general john allen, says the united states will still need, quote, significant combat power in the country in 2013 despite the call for reducing force and in siz second this week before the senate armed services committee today and you will see that in its entirety on c-span. the supreme court will hear oral argument in a series of cases about the healthcare law and they will provide same day audio monday through wednesday. you can hear the oral argument each day as they're released in the afternoon about 1 p.m. eastern with coverage on c-span 3 and also c-span radio and c-span.org.

they are building something for the centuries and want to get it right. >> with the eisenhower memorial designed by frank gary and opposed by the family, a house subcommittee discussed the memorial. watch sunday at 7:30 p.m. eastern and pacific, part of american history tv this weekend on c-span 3. the genetic scientist who nailed down a rough date for when the hiv epidemic starts describes tinderboxes and wet moss. in post parts of the world there is not that much hiv and in some places there is a ton, and it is incredibly destructive.

understanding that the two categories exist and allows you to think, okay, what are those factor that is keep this virus moving and what can we do as a world to end it? >> afterwards author craig timber tracks the history of aids sunday night at 9, part of a book tv weekend on c-span 2. education secretary arne duncan next on school improvement grants and efforts being made to increase high school graduation rates. he spoke earlier this week at the america's promise alliance for 45 minutes. >> thank you so much for the kind introduction. target has been a fantastic partner. they absolutely walk the walk. i appreciate everything you are doing to change children's lives around the country. i want to give a quick shoutout to bob bellfans and john bridge land for groundbreaking work over the years to promote solutions to the high school dropout crisis. please give bob and john a big round of ala