to export gas we have to build expensive expensive liquefied facilities, at least, to get them underway. one of the things we can do, i suppose, and we are doing, is take less of the world's gas, although, we are heavily relint on canada and mexico, and maybe less of the world's liquids. so, in fact, we push that surplus in the direction of people who need it. my own feel suggest that the most effective sanctions on mr. putin in the long run will be to take advantage of his strategic era, of not using his oil income over the last 15 years to diversify and strengthen russ russia's economy outside of the area of hydrokargon. he is vulnerable to market

changes. interestingly enough, the present drop in the price of oil has an impact on russia, they have balanced the budget at $100, and it is now down an $80. russia's political fast and hoos activities have had a serious effect on the russian economy, more than anybody expected to see at this stage. a serious infleet in flight. many billions of dollars have left. almost no foreign investment. a rubble exchange rate that is going 10% against the ruble. no growth in the russian economy. oil prices down, income is down. they may account for at least mr. putin's temporary paying attention to the minsk

agreement, over how to deal with the problem in ukraine. not beautifully, not perfectly, not without exception, some of that is happening. if we could get the europeans, four 40 and 50% on russia's hydrocarbons, get off that, giving them the opportunity to say to the russians, our off take is so low, we request suspend it, find other sources to. do that, we have to find other sources for the europeans. iraqi oil is undisturbed and growing, gone from a million barrels a day to almost three and a half. that if we have an agreement with iran, iranl can get up to 3 million barrels a day, it is down on to a million because of

sanctions, that can fill in the losses, in other places in the world, they are beginning to look at exploitation of shale. not all of it is as good as ours, that will begin to change some of the oil availability that we can see. so, maybe we can convince the europeans germany has to lead, germany so far is not readies to move. germany is getting rid of the nuclear, not until 2021, 2022. we as well a chance with germany to bridge the grap. all of these kinds of things, and new technologies, interestingly enough, solar is coming down in price. wind has been less productive. it has been expanded in many places, in this cases, china, one of the greatest wind farm production capacities, of

anybody. even if in fact, it is not a particularly big piece of china's production. >> yes, the young woman with her hand up here. >> ambassador, i wanted to know what your favorite part of your career was? >> well, gosh, interestingly enough i was in a lot of strange and sometimes difficult places. i liked them. for me, the most satisfying was the opportunity that i had in new york in 1990, when iraq invaded kuwait, to work with the security council for three very intensive months of bringing it together. prushing on resolutions for sanctions for increasingly tightening the strings on hahn.

it didn't produce what we wanted, but it produced a coalition that stuck together, even the shy members of the democratic members voted enough to cemetery u.s. military involvement, in itself did produce a result, in large measure, because we had a political goal in mind and stuck to it. >> this it will have to be our last question. thank you very much. i was wondering, tying off of russia and china, you mentioned the problems with member of the relations, how they are often defined by negative factors, disputes, territory, like in ukraine, and/or the south china sea. we have talked about solutions

regarding sanctions and pressures, you mentioned, what kind of positive aspects can we utilize to improve our situations with these characters, whose importance is clearly not going to diminish any time soon? >> i think for people who are particularly hard to deal with, they only have to turn to leverage. clearly, what leverage we have has to be articulated and operated in ways that are effective. sanksings, if broadly applied, have the disadvantage of punishing the population for the sins of the leader. i used to say, back when we were dealing with hahn, that he owns the last chicken sandwich in iraq. but he makes all the decisions. targeted sanctionses have interest suggest possibilities. it is also true that over the years, the u.s. treasury was to

impose financial sanctions because they feared it would destroy the world banking system. they have been the most effective, they say to the international banking system, if you want to do business in iran, you won't do business in the united states. it is a harsh judgment. it means that we try up the country's ability to trade and export which is very important and that is a draconian sanctions with a lot of effect. one of the drivers in the iranian input, because the president wants to be able to demstralt to his population that he can change the economic

equati equation, and bring inducement, sometimes. we seem to be interested in spending trillions in war, rather than billions to buy off somebody. that is not a happy circumstance. some cases it works, some cases, we have found financial solutions, some big, some wall. i had the opportunity to go to china, to explain how we bombed their embassy in belgrade. there it was a lot of chinese encouragement of put it this way, demonstrations. each of us paid for the damage that was done to the other. that is a way to settling international disputes.

courts have been pretty good about it. they take into is on the leg regimes, and it would make sense if we do so, in my view, not the right answer. >> i would like to thank mr. pickering, for his his career and his enormous contribution to this country. >> thank you.

>> the center for international

studies, annests to develop an hiv vaccine. the head of the aids vaccine coalition, this is an hour and 40 minutes. >> i am steve morrison, the senior vice president here at csi, and global policy center. welcome to csis today. we are thrilled with the lineup that we have, and thrilled to be able to do what we hope will be a recurrent series of meetings of this sessions of this kind, focused on technologies, and central importance, and the evolution of new opportunities, and new tools that can be quite important in a number of different areas of global health. this is a terrific way to kick this effort off. and it is really the brain child of my close friend and cleek,

todd summers, thank you, todd for getting this rolling. and i want to thank sap hill anello who worked hard to pull all the pieces together over several months, welcome, i will turn the floor over to todd. we will get on our way. >> thanks, steve, welcome, for many of the new digs at csis. up scale, nice new building for dr. fachi. many us in the room have been working on hiv for some time. for me, past my third decade. many of us would like to move on and we see an hiv vaccines, the hope for an end to the epidemic. to start the series that steve mentioned, we wanted to focus on

hiv vaccines, and give you a sense of where we are in the research pipeline. what you are like lito see, what it will look like. potential impacts on the epidemic. we are thrilled to stauf it off with dr. tony facuhi, he has been head of the hin, nid, since 1984. which is quite an accomplishment. and has been a stalward champion of vaccine research, among many of the responsibilities he has leading the hiv agenda. thank you very much for coming here. we have joining us, mitchell warren, who runs a vac, now, avac, i am on the board. a big conflict of interest there. mitchell will talk about some of the perspectives where the research is from the organization, focused on hiv

prevention. and margie runs the hiv initiative. product development partnerships, focused on bringing together a multiple sets of actors to it will be a great opportunity to hear from her, where the partners are, and the leading pdp in this area. for format, about 30 minutes for dr. fauchi, to give a presentation, and then, we move to mitchell warren, eight or ten minutes of comments, margie mcglenn, and then, open it up for the panel for you to engage them in questions and answers, i will moderate that. that is a good chance for you to see where we are with hiv research, dr. fauchi, over to

you. thank you for coming. it is a pleasure to be here with you today. i am going to talk a bit about the issue of the role of an hiv vaccine. i want to start off by putting into perspective the concept of why we really do need an hiv hax vine, despite the spectacular successes, that we have had over the last several years, in the arenas of both treatment and prevention. take a look thea the background, then i will get into the nitty-gritty about where we are with the vaccine. we are all aware of the most recent numbers from un aids, that again, keep hiv aids, historically, among the short list, less than a handful of

devastating pandemics that our civilization has to face, with stunning numberers, 75 million total tass, 39 million deaths, 35 million still living with hiv, as of the last count, 1.5 million deaths last year, 2.one million new infections, in the united states, we are a developed nation. we have drugs, health care, that is getting better. and it is really very difficult to accept one million living with hiv, 16 to 18 percent of them don't know fay are infected. 600,000 deaths, the number that keeps bothering me for decades, is that there are approximately 50,000 new infeces every year for decades.

why go we say we are doing so well, it is based on decades of extraordinary accomplishments in science. i could spend a half hour on each of these here, but the ones that really come to mind are the extraordinary advances in treatment which started off, if you think of the history, todd was mentioning he was involved from the beginning, i began in miff, after the mmwr came out on june 5th, i have been doing it ever since. it was a time when we didn't

know not even what the virus was, over the years, to developing treatment. we have 30 fda approved drugs, right now, we can say, without exaggeration, a lot of times people when they talk about results, exaggerate. if you can put anyone on retrovifrales and they stay on their drugs, 25-year-old infeblthed man or woman, look them in the eye, when i see them in my clinic three times a week and tell them, if they stay on their drug, you can project they will live an additional 50 years, one of the most, now, low and middle income countries, to

the point not the first time, but when i was sent to africa by president bush, for the program, there was less than 50,000, now, 13 million, that leads to 7.6 million deaths that are averted globally since 1995. you super impose that on prevention, condom use, needle exchange, sir rinchlg exchange, behavior modification, we have medically related, circ cision, mother to child transmission, treatment as prevention, that not only saves the lives of the infected person, in a high percentage, 95%, to transmit it to another individual.

that has allowed us to talk starting from a couple of years ago, at the international aids conference in washington, d.c., when hillary clinton came to the nih a few months before, and used an aids-free generation. we can talk about a world without aids. why do we need a vaccine? i will tell you why. so, take a look at the current status, whether it is essential, what the path way is. the current status. the projection in the absence of an hiv vaccine, you canny do mathematical models, i am in the middle of an ebola mathematical model, that is another story, steve will think of another session to discuss that the

projection is that when you look at the new injections, it is a 30% decrease since 2001. the current projections is good. if you get to that mathematical model, it depends on how much you implement what we already have. say we don't have a vaccine, take all the things that i put on the prevention slide, and everything that i have told you about treatment, the red to blue to green really means how you increase the implementation of these modalities, if you put a full-court press on, you can see that emplimt egg. then you can say, is the hiv

vexine essential for the pandemic. i wrote an article about this, and i will talk about some of the things i mentioned in that new england journal of medicine article. the reason i believe it is necessary, if you look at some sufficient the challenge that is we face, about ending the hiv despite all of the great results, there is a thing called a care continuum. i don't want to spend time, i spoke to similar audiences about that it we don't do well, access into the system, retention in the system, and adherrence to therapy, and look at as a country, we are doing really, really badly about the number of people infected, and the percent of those who are in a health care system, stay in a system, get on therapy, stay on therapy, and drop their viral load to the point where they don't infect

anybody else. we have a long way to go, even though we are doing well. one example is, circ cision, circ cision now, if you look at the numbers, started off 55 to 60% effective. in long term follow up. 73% effective. i can't imagine if i had a vaccine 73% effective. we would be celebrating it, and the front page of the new york time-o times. there is stigma. there is the homo sexuality being illegal in a large number of countries which is mind boggling, when you think about that. there is a lot of things that are impeding our ability to get to ending the hiv aids. the other one that is, i think

apparent to everybody, that is the idea of human nature, and recidivism. i have shown this before, it is a great example, when you are interested in other infectious diseases that seem to go away, then they don't go,a way. malaria is one of them. this is an example of measurement of paraside prevalence, in zans bar, 1987-to 1993. there it was indoor spraying and reduce the parasite prevalence, 76% to less than 5%, the officials involved in the great wisdom decided they were done with malaria in zanzabar, then stopped, look what happened to the kurveg. it went back. the mathematical model that we talk about, i am afraid that

even in the best of circumstances, if you just take that green line that goes down, and i say, 2000? i have no idea how long it will take to get there. given human nature, when we start seeing there is such a low level of infection, and the numbers look good, that we will have a rebound. my conclusion then is that it really is essential to durably control and end the aids epidemic, it is like the nail in the coughin of hiv. i think we can do an incredible amount without it if you want to nail it, then i think you need to get a vaccine. pathway to an effective vaccine. break it up, years of disappointments, the unexpected success, and the way forward. the years of disappointment, i can relate to, cliff lane in my group did it first vaccine trial

in 19 kwechbl with a gp 1 subunit candidate. it was the time of naive tee, hiv was smarter than that, we went years and years, and the history of it is truly one of frustrations. first, we started off with the b-cell, the natural thing that vaxinologists do, give a unit, well, we were wrong, the body doesn't like to make neutralizing antibodies against hiv, less than 20% or so make it, and usually do it after one, two years of infection, when it is too late. unique micro, unique virus, no

other virus acts this way. even the worst of the ones, ebola is easy. it is a terrible disease. you make a good immune experience, and it clears the virus, then you are good to go forever. we went through a bunch of trials, with vectors, with proteins, 2003, we said, do a face three -- phase three trial. we can't prevent infection, at least try to suppress reputation, switched to a it-cell, nobody imagines will prevent infection, it may suppress viral load. that didn't work either. one of the studies showed that it made individuals more

susceptible to infection, once they were vaccinated. which i use as the example of why we shouldn't be distributing an ebola vaccine before we prove it works, we may -- then again that is another story. okay, what was the unexpected six? y success? you have to get lucky sometimes, we did a pox virus vector with an insert of viral components followed by a protein boost. that is what we now refer to as rv 144, or the now famous, thailand trial, showing a 31% efficacy. that is not ready for prime time, but it was an important study. at least it proved that it son sept, as marginal as it is, you can actually prevent infection

with a vaccine. enormous proof of concept. what will we do, for those not foll followed it was an interesting fundamental philosophy, how you pressure a vaccine. the way forward. think about what we are doing over the never several buckets, one is the rv approach, the other, structure based, trying to develop a broadly neutralizing antibody. we found something interest with the rv 144. this is a fwloe up. look at the bottom of the slide. i blew it up. that is the key you want to use.

we now know that as a matter of fact, if you want to get neutralizing antibodies. having no idea at all to what the immune experience would be against. let's see what happens. and we injected into people, blowing it up, and found out among the 31% infected, they had an immune response in the v-1, very-2, it was one of the two of the envelope, it changes from

mutation to mutation. we identified an antibody. only by extrapolating backwards did we say that that is the sight that you really want to make an antibody against. we threw it in, said, okay that is the immune. now, what do you do. you have something that 31% effective. you say, let's amplify it you amplify it, increasing the strength of the response, namely, how much antibody you make, you increase the breath of the response, can it be broadly against multiple strains, and increase the durability. does it last for a year, two, three, four? the response in the rv 144 kept on going down as you get further from the vaccination. you do that by sticking with the product, but now, doing multiple boost, modifying the vectors,

and abdullah akadiing, so you are not changing any concept. you want to do better in the same concept that you did before. in fact, right now, we are doing it in africa, and trying to find out, is there anything in africa, between the ties and the afric afric african -- we are planning a large study, using the same concept at rv 144 in africa to see if it works in a high risk heterosexual population, which leads us, the title of the slide is alternative strategies and parallel tracks, that is a

structure base. let me repeat, the first time, we took an envelope, had no idea what the response we were looking for, we found out what immune experience was, said let's armify that immune experience. when you look at that it is the obviously, you go to hiv-infected individuallies, are they making antibodies, if so, to what opposed to throwing it in and finding out? if you talk the 20% of individuals who make the neutralizing antibodies, and closed do frustrating immunology, you can identify

five parts of the trimerthat are actually the targets of neutralizing antibody. we know what we want to induce, look at where the antibodies, those skrigly things, something we immuneologists like to confuse people by giving them pg-3, and things like that the recognized epitoeps, now, the challenge is to take those epitoeps, on the and present it to the body in a way that makes the antibodies, we are saying, here is what i want you to make a response to. who knows what we will make a experience to.

that is when you do that, you have to on the other hand, what is called, b-cell lineage. can you coax them to do what it is you want them to do? why am i throwing it up for you? >> in how do we know that? 20 percent of people do it, it takes them two years to do it. we have to maybe fool the immune system. how do you do that? well, there it was a seminal study reported by a college, a fellow named bart haynes, who

followed someone that was infected and they knew they were infected really early. what he did was, he followed the evolution of the antibody mutation with the evolution of the virus mutation. if you had a pointer, i could go through that t look at my talking with my happened italian background and i will tell you. what happens is that virus comes in, and the b-sell mutates and makes a response, and again, until it goes, and the antibesides keeps following that mutation to the point that it is such a great antibody it is neutralizing, it is too late for the patient, they have so much virus, that neutralizing antibody is not going to do anything. if you selectively present to the b-cell, a changing evolving

immune gen, you can coax it to make a broadly neutral icing antibody. to mimic, this is to get an you see, that is the chimer i am showing, and vaccinate somebody, two, three beasts to get a neutralizing capitalize on the hv 144. the result of pure impureicism, and in parlevel, it is totally structural based and planned. that is where we tend to go.

the t-cell approach, t-cells are important, not only in suppressing virus, it is a complicated slides. the cd provides help and it can induce cells. today with the b-set responses. inform summary, by scaling up the current prevent, and treatment, i can tell you, we are decreasing in the absence of a vaccine. a save for achieving a timely, suddened end to the hiv, if we

integrate naup axine with vaccine sthen and only then do i think we can ensure the end of the hiv aids pandemic, as i said, in the article that we pushlish, the only sgrnt is to get where we want to go, to a world without aids, thank you. >> i think if we give laser pointers on the end of your fingers, we will be in great shape. mitchell warren runs avac. one of their job system to bring

the community into these discussions, he needs to translate some of the b-cell, envelopes, into languages people like me understand. we asked mitchell to do, to how do you generate the advocates to make sure they have adequate -- former secretary of health, and a former president gave us ten years, we keep running on. one of the thing that is mitchell has to do is to get people excited to keep the money flowing and so they don't get ahead of progress. >> mitchell. >> the magic is being introduced by a board member, the hard part is following mr. translating

complex science to a range of people, and issues back, someone working in the field, we often see people compart mentalized. i am i think dr. fauchi is a translator as much as as of us, when when they come together, it is try for hip, and i was thinking bl what to say after dr. voucher, i went back seven years ago, we did a bit of a sound track. three different. my favorite is that is "we are

on a road to no where" by the talking heads. i don't think we are. if you go back, there it was a sense that we were investing and working hard not making progress're gress. somewhat on a road to no where. as we had it seemed that if they didn't know where you were going, they any can we weren't clear where we would take it all. what i am struck on, what an remarkably exciting time we are in now. i don't know when we will have a decade, i would urge you not to start counting too soon. one of the most exciting moments, in terms of where we

are in a -- cape town, for research for pro -- google does a how important they are, how transformative. his no disease will be fully eliminated without one. all of the presentations that give you the latest on aids vaccine, research and development, as well as conversations about

prefoalation, the they are on the website there. it it was an invigorating meeting. the dproup had had. we have been engaged globally in the 90/90 presented by mel worn, this one is 90, 90, 90 all people infeblthed this be tested, 90% should be on treatment, and they will long lives, don't transmit the virus.

there is a huge challenge, getting that many tested, and that one. i want to highlight that is critical. whether talking in the u.s. epidemic, or gloepally, we should be moving as we tauds when a the idea is that we will only finish that when we complete the circle there. at the heart, is human rights. this emepidemic doesn't get with biomedicine. >> this is really where i want there was a lot of i won't tell

you with your eyes. basically, whether you see are a range of different approaches, the reason i do challenge you to come to terms with it, as advocates, policy makers to know the issues at heart in terms of what is happening in the field. what results are being generated. to upon what they are rv 144 was five years ago. very exciting result five years ago, for many advoit cas and communities, generally, who desperately want an aids vaccine, they say, what happened? five years ago, snoo where is it? it is a challenge do do all that needs to be done to boost it

well beyond a range of other vaccine candidates. we hope all or some of them will work, some in combination, the challenge is, how do we articulate that and invest in it. if there was a single, definitive act we could get the result and move on, it would be an easy equation. it is not that at all. i wanted to spend a few minutes talking about money. as e, sighting as this wedding is, with the united nations aids program, to track not only in you don't have to read the numbers we saw an incredible

increase, then it began to decline. it won't surprise you, the u.s. major investor in the $820 million invested. that is a number i do these presentations and they are people who say, we invest in all this and the other side -- >> back to the franklin baslo.

they were invested n at most, 10% of it in polio vaccine r and d. the other 90% was invested in public education, and in care and support. and i would argue as you think about $820 million is it too much or not enough to put that in the context of the global aids response. as we spend 15, 16, 17 billion dollars, money that needs spent and increased to meet the ambitious targets for delivery and treatment we can't invest in aids vaccine. 820 million would go back into the 900 range and be invested well and wisely because it really is the long term investment as you heard earlier to finally sustain the end of the epidemic. again, just to show you again the nih at the top, not

surprising, the bill and melanie gates foundation. and all the other investments, important, in european funding declined over the past several years. it made little difference in the overall, and when those big numbers stayed big, stay significant, do we have a robust pipeline of ideas and activities that get funded. so what do we do new? you heard it from the lead scientists in policy perspective, and the p 5 strategy and high vaccine resulting in southern africa and thailand, up and 31%, we can't not explore that. we have to look at a range of the other ideas on that slide previously that begin to highlight there are other ideas. will they work? we don't know. that is why we do the clinical trial. clinical research needs investment.

all of the work around that structure based design, all of these exciting neutralizing antibodies that have their clever code names for what they are, each of those needs to be pursued and they need to be pursued in a different way than we worked before. how do you translate that novel idea into a clinical trial? when you walk the halls of a scientific meeting today in cape town last week or any other vaccine we go to the scientists are beyond excited but how do you capture that into communities where the crowds are -- the trials are still a number of years off. we need to invest in that and delivering what we have today, we continue to develop the tools we need tomorrow. that is a consistent theme from what you heard before and will hear after me. i want to highlight one other piece of information that i think from keeping hope alive, so to speak in aids vaccine is so very important. we have to be honest and convey the credible scientific promise

we have, better promise, better excitement that we have had in decades in aids vaccine science but we have to be honest about the time line. they will take longer and there is no benefit in falsely promising a vaccine will be licensed any time soon. we don't actually know. i am always a believer in under promising and over delivering. i think that's really important as we think about these timelines. we have to prepare policymakers, funders for the long haul. we need to prepare them for incredibly challenging trials to come but also to be sure they are there to invest on the fruits of the research when we get it and we can act on positive results as we saw after rv 144. as we do this work to deliver what we have today, and think about what is tomorrow the one other piece that is important is the clinical trials of tomorrow will undoubtedly be more challenging than they were in

the past. as hard as the science has been, and as frustrating the results have been the future trials will be more complex because we will be running the next wave of trials in south africa where we are scaling up male circumcision and providing oral pre-exposure prophylactics and providing a microbeiside for south africa and if they are positive, women will need access to those. when we are ready to embark on the next large efficacy trial in late 2016, roughly 2017 i hope it is at a time when incidents are going down and the trial will be larger. it may take longer and cost more money but it is absolutely essential that we do the right thing in designing those trials, providing everything we know they can use but still recognizing their contribution in a vaccine trial is to get what is clearly the ultimate prevention option.

thanks very much. [applause] >> we're now going to hear from margie mcglynn, she spent 26 years at merck. one of her jobs is to lead their efforts on the step trial and other vaccine products. she was instrumental in getting merck to reduce their prices for delivering ain't viral components into the developing world. better strategy than pursuing nelson mandela. it is a great opportunity for someone involved in the industry and take a moment of her life in an aids vaccine, thank you for coming. >> thank you, todd. to mitchell's point, it is very difficult to first follow such

an esteemed scientific colleague. so the organization that i lead, if i have the right slides up here. here we go. the organization that i lead, the international aids vaccine initiative, many of you are familiar with the concept of product development partnerships. anywhere from 13 to 15, depending upon how you define that term, these types of organizations that were started primarily from the mid-'90s to early 2000s, started because of market failures, and some diseases affecting the poorest countries of the world where there are not enough incentives for commercial organizations to step forward to develop a vaccine or a treatment or

diagnostic test. hiv isn't a market failure. i really believe there will be a commercial market for an hiv vaccine although it has been difficult and different companies have invested in different times along the road. i will tell you when you get burned by a significant investment as merck was with a step trial, it causes companies to take a step back and say i want to wait until there's proof of concept. a good way to think about the role of an organization like this, how can we help to facilitate advancement of science to get us to proof of concept? i will talk more about that in a moment. let me get more commentary on the modeling work and i am bolder than anthony fauci. i put years down on my graph. the model is only as good as the assumptions that go into it. the one thing we say for certain about this model is that it is wrong, that is demonstrative.

the few things i would like to point out about this model. this model begins with -- look at the purple line, that is the enhanced investment framework. you may remember in 2011, a publication where unaids and investing in pools that are available today, if we get 100% roll out of these programs wherever they are and we get adherence targets get achieved what can we achieve? it was aspirational. it was the best we could do with what we had then. it's been updated to go down to 2017. we may get down to half a million new infections a year and that is extremely optimistic for many of the reasons anthony fauci went through but that is the best we can do about a vaccine. then you add a vaccine and

assumptions. i assumed a launch date of 2027 because i always answer the question when we have a vaccine, i can give you a pretty good sense, once we have proof of concept, we should have a vaccine on the market in ten years. the proof of concept means you have a candidate that has shown the ability to prevent infection or significantly control viral loads. i don't believe we are there yet. we have a hint of that with the rv 144 trial but once we get that all the industry metrics will tell you we can get there in a ten year period. since we don't know if we will achieve those optimistic assumptions we worked with unaids and others and we looked at alternative scenarios. what if the green light happened, we stayed at the current trend, fund it as we are

now $19 billion a year and continue to have problems with acceptance of these programs. if that were to happen, this line shows even more significant impact. chances are we will be somewhere in between because we can do better than we are doing today and there is strong funding support, strong moral support throughout the world so we showed a 50% scale up scenario, to show what this looks like. and the cumulative number of new infections that will be averted over this time period for those different scenarios, whether it is 16 million or 42 million, that is a lot of lives being saved and a huge burden of illness and cost being avoided so clearly all of us should maintain the commitment and excitement we have for what a world without aids could look like. as dr. fauci said, a vaccine making that happen quicker, but

very importantly sustainably. one other modeling slide would like to show you look the other prevention technologies and the purple line shows enhanced investment framework. we then show the next line down which i think is red, if you wish to add free exposure prophylaxis, take an uninfected individual who has a relationship with an infected person and you prophylax them with anti-virals you can prevent a significant percentage of infections by doing that. there are problems that i won't go into today but if you were able to overcome the objections to adopting that i think we heard a lot of enthusiasm for approaches to do that at the cape town meeting last week. you could see additionally decline. if you independently took the

investment framework and added on treatment as prevention, treating early to significantly decrease the likelihood that person will infect a partner, you could then go down to the green line under 400,000 new infections a year. if you independently took enhanced investment framework, i showed you the purple line but if you do all of those in combination with the approaches that were available and the investment framework developed in 2011 you can get under 50,000 new infections a year and you can seriously say we will bring about the end of aids and have an aids free generation. what does it take to do that? it takes the result you heard so much about already in this program and takes the sustained funding and just a comment on funding. looking at the chart that mitchell's showed a miss thinking back to my days at

merck. once you move through the development cycle, once you start to get some promising results which i think is where we are right now with broadly neutralizing antibodies, you are spending usually escalates dramatically. it may go up two or three fold. the fact the we are down 10%, 15% is worsened by the fact the we should be increasing exponentially and so we all have to work hard to make sure that story is heard and when we are ready to move forward with large-scale trials and manufacturing costs that the funding is there to support that. the organization was developed because global experts came together and said we need an organization that is solely dedicated to the development of an aids vaccine that can work with all the parties out there and be sure that happened. were it not for profit organizations funded to u.s. government or unaids and usaid

and the gates foundation, our largest foundation donor the gates foundation and smaller foundation donors as well. so the role we try to play is what i call the translation off space. we do not have t research expertise that y will see in het public sector such as niaid but when those discoveries are there, what we have in house are some laboratory capabilities and a lot of external partners including biotech companies caught contract manufacturers, a lot of product development expertise. we have conducted 20 days 1 trials in africa, one in india, 12 vaccine candidates. so we have in house individuals primarily from industry who have joined us that are able to help advance candidates coming from

other researchers, help to turn those promising discoveries into actual vaccine candidates. we also have a clinical trial network, primarily in africa, a little bit in india, primary funding for that is usaid and product development work as well. through that network we have been able to make a lot of contributions in the epidemiology of hiv and as anthony fauci talked-about the broadly neutralizing antibodies, we utilize those centers to help us to gather the samples of the hiv-positive patients to contribute to the design of the ultimate vaccine products and we have an expansion program of our activity, we are not adding more sites, we have nine clinical trial centers in five african countries but an expansion program that helps build to an even greater extent, the scientific leadership coming from africa to help build that infrastructure that will help with the next major global health threat that emerges and

certainly has a lot of ancillary benefits within africa. so our real goal is to get to that proof of concept. we are not equipped to bring vaccine to market. as an organization we are not equipped to undo that. we need a major vaccine company and/or emerging market manufacturer talking about delivering the vaccine to the developing world and there are other examples where that has been done without a major company involved. i do believe pharma companies will be there. some are already making investments in earlier stages of research, at this point primarily santa fe, j and j and i believe as we get to the proof of concept, that we will have motivated partners who will help us with the massive building of manufacturing capacity that will be needed and a massive undertaking of launching a

vaccine like this in over 100 countries of the world that will need it. i am optimistic about where we are. it has been a long winding road, but there are other vaccines that have taken longer. a chart i often show, there are several vaccines that took 40, 50, 60 years to get to market and i would like to point to the number for polio, 40 or 50 years and ask a question, what have we given up on a polio vaccine. imagine what the world would be like today and let's all move together with the resolve that we are not going to give up on an hiv vaccine. we are absolutely committed that it is going to happen. it is going to happen within our lifetime, it will happen while phil is the director of niaid and still out jogging every day. any support you can provide to make sure that resolve continues

will be for a good cause that we can one day be proud of, leading the generation down the road free of the aids virus. thank you. thanks to our donors as well. can't forget that. >> hopefully the microphones are on. this is a chance for you to have questions and answers for the panelists. i will pick up with one and open up, we have microphones around the room to take those questions. when you ask a question if you could give us your name and if you are with an organization tell us which organization before you ask question. one of the things that came out of the discussion around polio

is the stick to it intention. it took awhile to get the vaccine but now we are seeing some dilution of commitments to seeing through the final eradication of the polio virus. overs the years, you have seen spurts of energy, so there is a doubling of the nih budget, if you pay for that later buying spotlighting the budget and certainly that results in the flat lining of the hiv but along with the nih overall budget. what do we do to keep the energy going? financing and political energy, once you start, dr. fauci you spent a lot of time with congress, would you think? >> to hear the answer, part of

it is capturing the successes. we do have this challenge we had a successful 2009. an enormous amount of work has happened since then. it is hard to describe, and we are different at articulating promising things that have been happening and what we need to do. as hard as the science is we should never assume the delivery part, i would argue as hard as the science is delivery will be harder and we need to be prepared for that with the aids vaccine and aids prevention options already. the science brings us excitement and delivery brings us more challenges. on the vaccine side we are articulating the specific things

we should be expecting in the foreseeable future. >> this is a very unusual time. there is no new money on anything. make the argument, you can make all the arguments you want, the budgets are flat, it likely under these circumstances will stay fat. that doesn't mean you should continue to advocate for important things. vaccine, hiv, important, you could argue global funds in some respects, it is as important. we have a scientific challenge with a vaccine that is still in the discovery phase as opposed to the implementation phase. what i would say not to avoid your question is that we always

can use more money. i'm always arguing for more money. i get in trouble sometimes, i am always arguing for more money. it will increase the pace of where we are going but there is no guarantee so right now we still have scientific challenges. we want to do the best we can with the scientific challenge and when we get to the implementation, then we have to put the full court press on the implementation but polio, polio vaccine is a really easy vaccine -- i'm sorry. jonas salk was a good friend of mine. it's easy. you just needed to do it. why is it easy? 90% of people who get infected with polio, a small response

does poorly. everyone who recovers makes it that in response, a beautiful indian response. the implementation is the problem. why haven't we eradicated polio after all of these years. very much in implementation issue. we are dealing with hiv as a scientific problem, not an implementation problem. it isn't direct. we are putting a lot of money in. people say why do you put so much? you haven't put enough. we need to continue to push hard to make a vaccine a hard priority. >> i hear you say the rate limiting factor here is as much as science -- >> it is. >> and the other challenge we are going to get through with all the other prevention nodalities we talked about is the human part of it which is getting people to use them and keep using them. you convince donors to continue to support iavi and you have been engage with merck to convince your board to put money on the table. how do you make this case in the ever-changing world of washington d.c.?

>> you need data. first of all need a show modeling slides like we show here today, especially when a lot of lay people think we have an hiv vaccine. treatment and prevention, it is interesting how we had to go back and re-educate our audiences about what the vaccine is and what we do differently. you need to talk about what will the impact be? how will it affect funding? i didn't have time to go into that but starting the model if you look at the total treatment costs today for hiv at $19 million globally, as you see the implications of the vaccine how did that come down? we showed a little of that data in cape town last week, the lines started to cross so donors that contributing hundreds of millions, national governments contributing hundreds of

millions to organizations like the global fund which is great to treat hiv, they have to have a long-term view and realize they also can invest in millions of dollars that is what we are asking for here. if we had 1/20th of what they're giving to the global front, you can see that treatment line come down over time so it is all about the data and all about telling the story and all about getting them to realize what the implications will be if we are successful. >> it is election day and you had to worry about shareholders focused on quarterly profits. the timeline of attention in this city is shorter than a quarter. the fact is this is an argument you need to keep making over and over again, so retention of message is a challenge here.

why don't we open it up for questions? i have lots in my head. let's go to the back of the room. >> i'm with the american college of medicine and the center for analysis working at the surgeon general of the navy. i was fascinated by the introduction of a new kind of vaccine by dr. fauci's presentation of the approach. what does it look like for the individual that is challenging enough to have a few doses to deliver? do you envision a vaccine where there would be multiple boosts? how do we prepare to approach that social challenge of behavior change. people are rather poorly trained. >> that is a very good question. i hope it is up multiple multiple. if you look at the science of it, you really want to trigger a

b-cell that is one that recognizes an epitop eme that i actually going to get to the affinity maturation you want without having to mutate multiple times. i will try to explain simply for non-immunologists. the higher the affinity or more power the antibody has to bind on to the hiv, the more you evolve and mutated genes of the cell mutate and mutate and mutate until they build up a really tight infinity so we know the really good antibodies are highly mutational and the reason they are is that hiv when you get infected just keeps regulating for -- replicating and bombarding your immune system. bad for you but ultimately leads

to this antibody that is a really good one. how do you do that with a vaccine? that is the challenge. you need to give it in a form that doesn't take as you are suggesting seven boosts to get there. if it does, scientifically interesting that is the nonstarter when it comes to a vaccine. you try to fashion it in a way that you need one or two to get there. you need to capture the b-cells thsy only required a couple of iterations. i would say two would be good. you get to six or seven is not practical. you are not on target with your question. >> with other vaccines that require redosing the nutrition rate which affect the overall effectiveness. any other responses? in the middle? why don't we do a couple, we will do a couple in a row and we can answer it.

>> dr. ted bailey with johns happen kins division -- hopkins division of infectious diseases. question for mitchell and margaret you, point out he match the scientific path way and i

which either individually or together start to result in a pretty high level of preventive benefits. how do you find 50% or 60% effective vaccine? does it get hidden behind these interventions? >> i would love to see the search for a silver bullet or magic bullet stopped. if we are searching for a silver bullet we should focus on something else. i don't think there will be one. that's not a defeatist attitude it's a realistic attitude. i don't get to decide levels of efficacy the regulators do but we do know the 31% efficacy, regulators in thailand where the trial took place were clear that wasn't good enough. the number often bandied about is 50% but every regulatory agency would make a decision based on risk and benefit but we use that some what as the lowest level and i think this issue of combination plays out in two ways. the future clinical trials will be complicated, we hope are complicated by the fact that this other background and

prevention would reduce the level of incidence of new infections so we have to work harder but doesn't have to be perfect because the number of infectious cause to prevent it is lower. the other interesting thing, there was a presentation in cape town about all trial looking at a combination of microbe vaccine, there were two injections, from a couple of monkeys. we are not here to prevent an infection in monkeys. we are here to stop infection in humans but in this small monkey trial a combination of microbicides shows to be much more effective than the vaccine alone. it doesn't tell us -- we have assumed just as a combination treatment being the most effective treatment, combination prevention is what we will look

for. whether that is licensed by the combination or whether it is 50% effective vaccine when the rest of the prevention package has risen up. we do not have to be perfect to be good enough. that is the take home from my perspective. >> 31 is not good enough. we will never get 95, it will be somewhere between the two. i agree with mitchell. i will take 50. i would like to see 60. i don't think there will be any trouble in proving a vaccine because even though we know we have combination prevention, the issue of human nature and lack of adherence to that so we have to pick out a highly at-risk population. you have the ethical obligations who offers them things like

microbicides, et cetera, et cetera. at the end of the day human nature can win over and people will get infected and hopefully you will get enough people to show that a vaccine works. >> i'll be a little controversial from my background introducing other vaccines and looking at the barriers to vaccine adoptions. so i introduced hpv vaccine, 100% efficacy against four strains that were included but most commonly the common strains out there and i was able with in the united states and insured population, was covered for insurance programs to only get uptake of the three dose regimen in less than 40% of teenage girls. a lot of barriers, we know about anti-vaccine groups, more an issue in developing countries but we will see some of it in

developed countries as well. i really think we need to strive for 65%, 70%. i would hate to go to the market with a vaccine that is 50% effective. we will have all sorts of barriers put up not the least of which is cost-effectiveness. we have scenarios on that when i talk about hitting that cost-effective barrier or target that you need to reach. if you lower the efficacy, anything below 60%, you lost cost-effectiveness so your policymakers and payers there might be exceptions or a high risk population that when you immunize that population maybe 50% is good enough and combined with other approaches but to really get global uptick of a vaccine, widespread acceptance of a vaccine we need to push the envelope. maybe we come out with something, we keep working at it to get to that 75% barrier. >> let me tell you a population

of 50% vaccine i would vaccinate them all. if you go to south africa and look at pregnant women between the ages of 23 and 25, they have a 44% prevalence of hiv infection. i will take that 50% vaccine and give it so fast your eyes will turn. >> i will agree with you. >> heidi you have bento south africa. we were there together. one of the questions that will come out of this is who pays for all this? the global fund went for replenishment not long ago and got 12 billion. they have not seen the increase of factors and increases recently and if you start secreting these things, or do we do what marty says which is focus on at least in in the

interim waiting for the money to go back up. and these kinds of interventions that make more sense at the same time. >> i disagree. if we get a vaccine i agree with margy that 50% is good for south africa but not vaccinating everybody who tests. but if we get a vaccine, 60% effective. i don't think we will have a problem in getting that paid for to be quite honest with you because the cost-effectiveness of preventing an infection versus lifelong anti-retroviral therapies huge. you get world bank, gates foundation and aids foundation, u.s. government, a lot of groups that will pay for that. a lot of things keep me up at night.

that isn't one of them. >> we use the term combination prevention which is a lovely term, like many terms in public health. it is not throwing this everybody all the time. what we are looking at is your point, a lot of talk about hot spots and go where the epidemic is and we are getting hopeful and smarter in the community to figure out where we need to be with interventions and it will be different. we need to be clear about that because we are going to see flat lines and that is the new normal. let's hope it doesn't go the other way. and the delivery expenditure. even in the coming years how do we take the tools we have and ensure they are reaching the right people at the right time and not throwing things? that is not an efficient combination of prevention. >> this may be a sneak preview

for your next talk, dr. fauci, but how has the re-emergence of ebola and its attendant hysteria in this country if i may characterize it, how does it compare with the early hiv scare in haiti, san francisco, and central africa when there wasn't even a name for it. how are you competing with ebola on funding? talk about the funding levels. and economies of scale in the field for public awareness campaigns. or conditions. >> i will take the first one. if you go back to the early '80s, you have the evolution of what turned out to be an incredibly historic epidemic, pandemic, and relatively few people paid attention to it. now you have two americans have

been infected with ebola, both of whom directly and deliberately in a self-sacrificing way cared for an ebola patient. those str the only two people who have gotten infected in the united states and we have this overwhelming attention and fear to it. it would have been nice retrospectively if back in the 1980s when i was saying we have a real problem here, probably more infections than you can imagine. we would have had as much concern in the 1980s for hiv as we are having for ebola. [applause] >> there's an article in the "new york times" by larry altman who is semiretired and has done a lot of reporting on hiv, an

epidemic of misinformation. can you get ebola from a sneeze, if someone has something in their hands and picks up a plate it has a little bit of deja vu all over again, even if to hiv in the early days. information is powerful. is there an opportunity to take the attention being paid to ebola and leverage that to try to regain the attention on the investments the need to be made. we did some work on the global security agenda and we got a limp response, why don't we have a global health emergency response? is there a leveraging? >> i try to leverage. i throw some interesting numbers out. so there have been now, they say 4900, 51, it stayed there for a while. but say 5,000 people have died

from ebola. since the beginning. probably more. a month or so it was 3,000 or 4,000. when i explain the magnitude of the problem yesterday 4100 people died of aids, yesterday 5,700 people were infected with aids. compare that to what is going on right now with ebola and the amount of attention and concern. i am not downplay or denigrating at all the concern you have about a serious disease. ebola is a serious disease but when you think of the magnitude and how the public gets immune to that every single day, 4100 people dive aids, every single day. you get kind of numb to that and it's not the thing that is getting people excited. you try when you want to put

attention on minsk that really need more attention you could say, folks, take a look at this. we have this ongoing problem. take a look at malaria, at tuberculosis. i use the attention we're getting with ebola, get all this attention, the same sustained attention for other great killers. >> there was another part to the question which is the ability to sort of do public information campaigns, economies of scale were able to lead some terms of basic capacity building, state practices and hospitals, and to leverage what we're doing on information around ebola to help with hiv risk. >> it's a different ball game. >> geographically remember where ebola or hiv, countries affected by ebola -- i was struck and you

know better than i the nigerian response that described the building on platforms. aids investments in nigeria and gates foundation allowed nigeria to quickly get on the of the aids epidemic and an ebola epidemic who have made things more dramatic in terms of numbers. it tells me something separate from the vaccine, we know that, functioning health systems work and i'm from omaha, nebraska, prouder now than over the last couple of months to watch the clinic in omaha. health systems matter and we have underinvested and will make a big difference when we have a vaccine. a health system that can deliver what is critical and one of the reasons why the leveraging for me is don't say we're not going to invest in pharma because we

have an ebola outbreak. we should double down. it's the single best investment. so we need to be seen in that regard. >> paul? >> you give voice to an important comment that the defense against ebola in nigeria could have been explosive. are funded labs and some of this. so we've -- the president said that in response to a question and answer period in boston, which is rather unfortunate. members of congress are talking

a whole lot about an emergency supplemental which we haven't seen for global public health for years. department of defense freed up millions of dollars to construct clinics. but there's not exactly a shortage of funding at the moment. nonetheless members of congress are talking about doing emergency supplemental putting their stamp on. same members of congress that we're doing a year long grind for $300 million for pharma. >> that's a washington question. >> to say there's a lot of momentum around health systems and ebola and other viruses and that's important and we need to capture. >> let's put our shoulder to that grindstone. >> we're hoping margie is right.

as confident as you are, certainly, around here enough you see this is a place where it's easy to start trading one thing off another. what i hear you saying we need to add on top of what we're already doing, the cost of potentially getting hiv vaccine out and incorrectmen more in terms ever financing. that case has to be made. that's a hard argument to make in this city particularly when it comes to foreign aid. final question and then we'll close out for the day. great. so i want to thank our panelists for coming here. dr. fauci thanks for leading off the series. thrilled to have you here as

always. thanks for your work on this. get back to the other virus. mitchell, thank you very much for coming and sharing your views of civil society. mar margy. we're looking for future ideas. we're happy to hear from you. thank you all for coming. have a good afternoon and don't forget to vote. [ applause ] .

chuck hagel, secretary of defense app at a time when our world is facing a multitude of challenges the council seeks to enkbaj americans in a better understanding of these issues. and to better prepare ourselves and our children for the 21 t century environment. general perkins graduated from the united states military academy at west point and was

commissioned second lieutenant in armor in 1980. he completed ranger and airborne schools and then served in armor assignments from platoon leader to battalion and brigade staff commission. command of the 4th infantry from 2011 to 2014 general perkins was commander of the combined armed center at fort lef an worth, kansas. general perkins is featured prom ne ne neptly in the book. he received the silver star for his part in that invasion. on march 14, 2014, general perki perkins assumed command. along wait in 1988 he received a masters of science degree in

mechanical engineering from the university of michigan and in 1999, he received a masters degree from the naval war college. he is well positioned to take on tonight's topic, the future of the u.s. army, we are in a complex world. his title, taken from the army concept in 2020, 2040, that paper published just weeks ago. our discussion this evening is jason campbell. associate policy analyst at rand corporation where he focuses on issues of international security counter insurgency, security force development and measuring progress in a post conflict reconstruction. he has an m.a. degree and is working on his ph.d from my alma mater in london. he will take questions after his presentation and discussion. just a reminder, please silence

your electronic devices at this time as a courtesy to all of our audience here and at home. please join me in welcoming general david perkins. [ applause ] >> thanks so much. make sure the right microphone is turned on and right one turned off. technological challenge this evening. i appreciate coming here to speak with you all and have a discussion about how the united states army is viewing the future and our role in it and we will look forward to have much the discussion following this as well as the ability to get questions from the audience and it is very helpful for me to sort of get your insights about aspects of this that may not be clear or things that you think we may have overlooked or oversimplified. one of the things that training a doctrine command does for the army, we sort of have one of our

bumper stickers is we are the architect of the army. we design the army of the future and in the process of doing that, we describe what the future operating environment is like and then we try to come to grips with what role the army has and then determine what capability the army has to have to fulfill its role in the future that we describe. so at this point in time, our history is very exciting to be doing this. as we are coming out over a decade of war. and being intro spective in the army and saying we want to be informed. but a recent multiple years of war but not captive to them. we want to be informed by them as to what insight they can give us as we look to the future and therefore, try to innovate and get out in front of our head lights so to speak, so we are always maintaining that advantage that quite honestly our nation expects of the united states army. the way that training indoctrine command does that is we write

our operating concepts for the army. and that's really our first attempt with regards to all of the products that we produced to say what is it that the army is going to have to do as we try to describe the future i tell folks, not predict it, but describe the future. and then describe the role of the army in that and that will lead us to what capabilities. and from this operating concept, drives another series of documents, what we call our war-fighting concepts and specifically our capabilities documents. so this is really the broad initial process of coming sort of to an intellectual visualization of what it is that the future's going to look like and what it is the army does about it. so this is not the end-all be-all document. people say i read through the whole document and it doesn't discuss what color the new bayonet is going to be. eventually we will get to the color of the new bayonet.

that is not the role of this document here. so we need to con tech touralize that. the chief of staff of the army met with me and said we need to start putting emphasis in the future and we need a new operating concept because it will drive really the rest of the army for a number of decades. so you sort of need to get after this. as i always tell folks, life is really all about metrics. you have to be able to measure what it is you're doing and know if you're going in the right direction and where you want to go. and in my previous assignment before i was here as the host kindly mentioned, i was at fort lefian worth, which is where we write doctrine. and they said we need to update our counter insurgence manual. the manual that a great warrior, general petraeus did when he had that job and was new york times