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announcer: now, the director of the group right on time discuss the decline on the use of the death penalty and the potential for the supreme court to in the practice. this is from the aspen ideas festival in colorado. it is about an hour. >> thank you for being here. one of the greatest decisions a society makes outside of going to war is to whom apply the death penalty to. we are here to talk about the death penalty, where it is going. i can't imagine a better group of panelists. steve is the president for the center for human rights. in my mind, the leading death penalty litigant in the country and has been for a number of years.

traveling throughout the country to bring these cases to fight. he had a big win in the supreme court a few weeks ago. he has been teaching at yell law school since 1993. mark does really interesting work and is making the case for -- a conservative case for limits on things like mandatory minimums or the over criminalization -- not on a defendant perspective of individual rights but on the return on investment idea.

politico named him one of the top thinkers of 2013. he graduated from the university of texas with all sorts of honors. i'd like to start off by just asking you what going on with the death penalty right now in terms of numbers. if we talk about the number of sentences imposed, not carried out, just imposed, in the 1990's, it was like 314. if you look at last year, it was 73. fewer people are getting sentenced to the death penalty. much fewer people are getting sentenced to the death penalty. in terms of executions carried out, the numbers are even more striking. last year, there were 20 executions carried out. that's three times less than

1999, when there were 98. you will see a similar drop from other years. a striking drop. so far, 14 executions in 2016. and it's not just a number of executions carried out, but the fact that it's only occurring in a few places. a few counties are doing the sentencing and actually carrying out those executions. 35 states have had no executions in the last five years at all. this year, five states have carried out executions, texas, florida, missouri, georgia alabama. and take states like nebraska. they have outlawed the death penalty. when you think about human rights focused states, no offense to nebraska, but you don't think of it as being the vanguard of criminal justice reform. that's a lot to think about. steve, when that you start. tell me what you think is going

on and how these numbers can be explained. >> the death penalty since 2000 has been an marked decline. we went from around 310, as neil said, to the 200s, 100s, 70's. the numbers have dropped like a rock every year significantly. what interesting is that today many people who would never get the death penalty are people who by today's standard -- george on july 14 will execute a fellow who was one of two drunks in a fight who hit the other guy on the head with a whiskey bottle and it turned out he died.

that would never be a death case today, the prosecutor wouldn't even think to propose it, but we're going to kill this guy. that's one of the ironies. a number of states have repealed the death penalty. illinois is one of the largest states, as well as new york and new jersey, by judicial decision. of the executions that of taken place, 80% have been in the south. one of the most interesting points is that 2% of the counties in the country account for over half of the death sentences and executions. 62 counties account for 10 of the death sentences imposed.

and some, like harris county texas, has executed 121 people more than any other state except texas itself. texas has executed a bit lower than that. virginia and oklahoma have executed over 100 people, but neither have executed as much as harris county. in a handful of counties across the country, people don't get executed but they get sentenced to death. l.a. county, in california, they don't get executed, but they do get sentenced to death. in harris county, they get executed quite quickly. it also depends on pretty much to the prosecutor is in the quality of lawyers appointed to the defendant. if you have very aggressive prosecutors who seek the death

penalty in virtually every case, and you find lawyers who are so incompetent that in three cases in harrison county, the lawyers fell asleep while they were defending a death penalty case you put those two together, and you can sentence a lot of people to death. if you have a really bad lawyer in the appellate process, you can execute people just like that. >> my mom is here who lives in houston. harris county is where i went to high school. but things are changing. you are right about that. texas isn't the leader of people on death row. california has 743 people on

death row, but their last execution was in 2006. one man waited 23 years before being executed. that is one of the lines of argument, is just waiting all this time. these individuals are almost all waiting in solitary confinement. they are automatically placed there because they got a death sentence. the texas prison guard association said we want to end this practice because it is endangering us. for the one hour a day people can leave the 36 square feet -- which is smaller than our bathrooms, by the way -- for the one hour they take them to get something to it or for their minimal recreation, that when hours dangerous to them because of the other 23 hours. and freedom is another word for nothing left to lose, according to janis joplin. once you have somebody sentenced to death, what do you have to hold over them? nothing. so this is a challenge for the guards tried to protect them and

the other inmates. >> it sounds like one thing you are isolating his representation. in harris county, the representation isn't so good. is it getting better elsewhere or our defense lawyers blocking executions that would otherwise happen? what is going on? >> i think one of the guest factors is exonerations. we've had 156 people sentenced to death who were later found to be innocent. that's a sobering number when you think about it. last week in texas, robert robertson was literally on the verge of being executed for being convicted of shaking his baby to death, and they now believe he is completely innocent.

it appears he will not be executed. this is about as close as you get. in the arson case -- there is a great book called the wrong carlos about a man who was most certainly wrongfully executed by the state of texas. and so that's one. the improvement in the lawyers -- georgia and virginia set up capital defender offices so the people facing the death penalty were not just represented by anybody with a bar card and a pulse, which is pretty much standard, and still is in texas, sorry to say. as a result -- well, there had not been a death sentence imposed in georgia since march of 2014. this is remarkable for a state

that used to sentence 10 to 15 people to death every year. virginia has a five-year stretch of nobody being executed. this is remarkable. lawyers who were just doing it for the money, to having people specialize in -- this is all they do. they actually know what they are doing. and in the legal profession, the idea that any lawyer can represent somebody in a death penalty case is like saying i go to the airport and the pilot is not there, so i just buy the 747 back and land it. it's preposterous. >> in texas, in many cases, you get something like $200 to argue a capital case. the defense lawyer has to get

permission from the judge for experts for testimony. we have signatories on both sides of the issue. conservatives concerned about the death penalty, which are a sickly conservatives against the death penalty, but even if you like the death penalty, we're sort of in this trap. speeded up and we have the potential for executing more innocent people. it's not practical, if anything else. >> so we have representation exoneration, costs. as i understand it, several states and counties have a limit on how much they will pay in a capital case.

is that right? >> in mississippi, until recently, it was $1000. >> $1000 total. most lawyers make more than that in an hour. >> and anybody who is a member of the bar -- this was for all types of cases, not just death penalty, if you are a member of the bar, what are your duties? so if they say, if i have a case for you, it might be a burglary case, you would be surprised how many people tell me that their very first trial was a death penalty case.

the courts later threw it out. when the case came back, the judge appointed the same lawyer. he said, 15 years later, maybe here has learned something in the meantime. that is the attitude you often have about the lawyers appointed to represent these cases. cork steve, you wrote an article of the death penalty, not for the worse crime above for the worst lawyer. let's assume that the death penalty cases in the last 10 years have excellent lawyers. i know it is a hard thing, but give us a sense of what percentage of death sentences would not have been imposed if you had excellent representation.

stephen: look at georgia. zero. you have lawyers that know what they are doing. most of those cases were absolved by plea bargain because the prosecutor's new that if they -- the prosecutors knew that if they went to trial -- one other factor in the decline is life imprisonment without the possibility of parole. so draconian sense but when i started practicing in georgia, the judge would say, if we don't give the guy the debt talty -- death penalty, when will we get out and the judge would say, can't tell you. and then, impose the death penalty now, death penalty now they tell you have three choices with the death penalty. you have life without parole life imprisonment, and life with parole. of course they have a tendency to go for that middle compromise. both in the plea-bargaining and jury, so today a prosecutor calculating the political advantage of going for the death penalty takes into account that if you are up against a good lawyer you may not get the death penalty. they spent a huge amount of time, money and resources in the -- resources, and the jury may not impose the death penalty but i think the capital offender has learned to do is create the moment ahead of time and resolve these cases with plea bargains and not risk the client being sentenced to death.

neal: ok, so we talked about effective representation. we mentioned exoneration. 106 people have been exonerated. i know your centers then one of their leaders calling for better dna testing. as i understand it the dna testing is a small number of these exonerations, something like 20 of 156 have been through dna testing. is that right? and if so, how do we -- what are the mechanisms we want as a society to try to make sure that we are getting the right people, not just for representation, but for the cases that are in the system. what should we be doing? marc: one of the things is witness lineup identification. a lot of people's memories are not perfect by any means and police don't follow us -- don't

follow those practices. they do this line up in a suggestive way to get the answer would want. we have had a problem of crime labs. they are independent comeau but we have had -- they are independent, but we have had those run by the police department. and i think the other issue is you can speak to this, but the certain procedural barriers to getting these in front of appeals courts even with new evidence. for example, we had the michael morton case. he was convicted for murdering his wife and for 26 years he was in a texas prison and he had to jump through all these hopes, -- all of these hoops. the district attorney obstructed the dna testing and finally they had actions taken against them by the state bar which is great. one of them had to leave the country to find work.

the second guy the curse me out -- who cursed me on the legislature, but anyway, the bottom line is they put michael morton before the senate committee chairman. and he asked, about being bitter in prison. and he said i've had a long time to get over it. he's become an activist and we passed the michael moore to which prosecutors have to turn over all the exculpatory evidence as soon as they happen to the defense and so it's even a broader issue beyond the death penalty of in fact, in many instances prosecutors withhold the evidence. there was a scandal orange county reporter and is withholding evidence from the defense and the grand jury process, not giving the grand jury the full information, including the exculpatory information. neal: mark, you had talked about cost as well and i hear all sorts of different things about how the death penalty is more expensive compared to incarcerated somebody for life because of the appeals process. so what is the truth about these competing studies and claims?

stephen: i think it is more expensive. marc: it cost maryland $3 million to do a death penalty and because they are part and -- in solitary confinement, you are getting an additional cost of $90,000 a year if they weren't in solitary confinement. i do not think that cost is the main reason that people come down where they do on the death penalty. for many people, it's a moral issue. certainly you can look at specific examples. you can look at the theory. for example, the strongest argument would be you have someone serving a life sentence in prison and killed another inmate, what other sanction could you deliver? you can talk about serial killers and things like that. once you look at the numbers, if you look at them now, and you further circumscribed it to narrow the cases, you could get to even more expected of a death penalty. it is this kind of, i think the debate is almost being forced into practical terms in november of 2016 that the ballot measure in california to get rid of it.

and reed hastings of netflix is one of the people pushing that. it narrowly failed last time in california but certainly could go the other direction. neal: you do not really think that it is the moral claims that are driving the debate, because i do not think the morality in society is changed a lot from the 1990's to today. we are looking at a strikingly different set of numbers, so something beyond morality, maybe you should start. i do not think it could be morality. it must be something about concerns for the way that it has been carried out. marc: that is a great question. stephen: i think a loss of confidence in the government, as a whole. including for prosecutors. we have seen many cases of prosecutorial abuse. i'm sure there were probably some african-american people a

decade or two ago who supported the death penalty but it struck -- but perhaps do not because of the racial implications they have seen. the interesting thing is, you do not even have to get to 50/50 to have a huge effect on juries. they ask you could you impose the death penalty but in reality, not everybody will be perfectly candid. so you will get people on more juries that say, ultimately they are not willing to impose it. neal: you have been very patient. marc: that is fine. i think new jersey was the first state to repeal. they had a commission that had everybody with a law enforcement, the victims, the rights groups, everybody and they cannot unanimously that it takes too long, it re-victimizes the victims because they go through an appellate process oftentimes a retrial like a case ahead of the supreme court, this

case that is 28-years-old. now we are going to go back and retry a 28-year-old case which is not good for the victim's family, but cost was a factor that went into it. and the risk of executing innocent people. the latest cost figures i have hot off the press, the reading eagle, a very highly regarded newspaper in pennsylvania, they actually do excellent work. they looked at pennsylvania and since 1978 they found they have only executed three people in pennsylvania and all this time. all this time it cost $272 million for each execution, so the three of them together cost $816 million. that's three people over time period of 1978 to today. now, a lot of people, no matter how they feel about the death penalty will look at that and to say that is not a great expenditure of government money, when we have schools that need funding and when we have so many

other things that we could be spending that money on and quite frankly, just the criminal justice system i see people in all kinds of cases getting the same kind of representation i described in a capital case. we could move a lot of that money. we have spent a huge amount of money at least in the state of pennsylvania, in those states that take it seriously, a lot of money that could be spent to make sure that we are not convicting innocent people in other kinds of cases as opposed to really devoting a huge amount of money -- and that there is california studies that said between 1978-2011, california spent $4 billion on the death penalty and it doesn't execute hardly anyone. neal: the last one in 2006. stephen: that is why i thought it would pass last time. marc: even when you are for the death penalty, it is hard to comprehend. stephen: and you look at it and say, what are the other things

we could be spending money on rather than these cases? neal: do these figures offer a false comparison, because as you said, every state that now has the death penalty, also has a life without parole statute so it's not as if we are talking about the death penalty are -- penalty where the people are out on the street, we are talking about the death penalty versus a very extreme sentence of being imprisoned for the rest of someone's life. so i suspect that some of those costs that we are currently incurring with the death penalty would be transferred over for a life without parole costs. is that not right? stephen: nowhere near the enormity of the capital cases. when you talk about life and death, you are doing it right. you have a number of lawyers on the case and you are doing a complete life history the -- of the client. you are going to do some of those things. in georgia today, the prosecutor

does not have to seek the death penalty. they just seek life without parole and those cases are pretty much like other criminal cases. they may go to trial, but there is no penalty phase which is a big part of capital cases. neal: this might be counterintuitive, but there -- but is it there an argument then that we, because we spend a lot of resources of a death penalty cases and trying to get everywhere like harris county, except that if we got rid of the death penalty we'd have less justice rather than more because society will allocate those resources currently to the tough cases and not really fight the likes of those cases as much? stephen: that's a tough question because one of the ironies that i see with those states that have ponied up, money that goes to the capital cases right, if someone does a terrible crime and faces the death penalty and they get all these lawyers and social workers and investigators, and then you have somebody charged with, an 18-year-old kid may not be

guilty of armed robbery that they may have a lawyer were one single public defender is carrying 150 cases and there's no question people facing the death penalty in some places are getting much better representation. i believe we could take those resources and put them into the armed robbery case so that lawyer has cocounsel and an investigator and we can do a better job of the most fundamental responsibilities that the system has with separating the guilty from the innocent. we are failing at that. neal: it is an interesting question. when you have more prosecutors more state prosecutors are freed up. marc: you could argue that there would be more people sent to prison, but on the other hand, when you have the prosecutors -- with mediation and property cases, they say they do not have enough manpower. likewise, they would not have

enough manpower to identify the cases where someone has substance abuse or mental illness should be devoted. so they even plea out before the screen the person before they see they should be in the federal justice system or diverted entirely. the district attorney in milwaukee has established neighborhood prosecutor's offices that handle these cases in the neighborhood. and so he argues that have a more prosecutors, he could divert more people on the criminal justice system. neal: what about the pharmaceutical industry as we read a front-page nerc times -- front page new york times article, pfizer has announced it's going to block access for its drugs for the injection protocol, following what other big pharma companies have done. as i understand, five states right now have the death penalty on hold for their lethal injection protocol. do we expect that to be a significant strain on the death penalty in the future?

marc: utah devised a solution, they brought back the firing squad. which i do not think they had since 1977. maybe john lennon would be a good place to start but you know a person can choose which method they want. but i think the other issue that's related to this is state attorney generals are issuing opinions and legislation saying that they are exempting all of this from open records, for public transparency, so you cannot get a freedom of information request and find out the details of the drugs and how they are administered. and everybody saw in oklahoma, what happened where this man was withering on the vine from this, in pain, so i do not blame the european drug companies. they could be sued in europe for providing something that would kill someone in united states it would be used that way. it is creating a strain and now the reaction is to shield that from public view.

stephen: that's a tactic which we see a lot of. the government -- there are all these problems, problems with the people that carry it out that do not know what they are doing. all of this and so the answer, instead of fixing it, make it all secrets and nobody knows what is going on. and so we cannot bring a lawsuit to say, wait a minute, the drugs they are using are not reliable for bringing about a person's death. and the people that are doing this really shouldn't be doing it. we do not know that anymore. it is all secret. and the federal court and state courts have allowed it to remain secret so they are all in the dark now. the other thing, on the firing squad, i agree with one of the judges, we are kidding ourselves by trying to pretend that killing human beings is like a medical procedure. he said that medical procedures

are about healing people, they use these drugs to heal people not kill people. in a notion, we are sanitizing the execution by having lethal injection. it is doomed to failure. he said, bring back the firing squad. we have people that are trained as sharpshooters, you put him in a chair and you have people shoot at him at the same time and it is like, it is -- quick painless, and you have no problems like the problems we are having. we have had a lot of problems with lethal injection. we have able flopping around forever before they die. things like that. go back to the drug companies, because i think if we went to the firing squad it would be the end of the death penalty. gary gilmour, 1977 from the firing squad.

but no other state doesn't and even when utah does it people get upset. let's pony up to what we are doing, let's face what we are doing. we are killing people. we are trying to put them to sleep for whatever. but back to the drugs, no drug company right now will give the department of corrections the drugs to carry out lethal injections. so what everybody has gone to, not everybody is there yet, but eventually they will go to these other compounds, which the judge on the eighth circuit said maybe nothing more than a high school chemistry class with how well they are run, these compound pharmacies that makes it for you and you get the amt's, the ones carrying out the executions, they inject it into people and they are able to kill them without too many problems. that is pretty much what we are going to do.

and you have problems there. in georgia, we were getting ready to execute a person when suddenly somebody noticed that the drugs were cloudy. there was something in the drug. maybe we should not execute her, because the drugs appear contaminated. and in oklahoma, they had the right drug and they literally discovered before the execution that they had the wrong drug. instead of having the drug they thought they had, they were supplied with a different drug which would have been a disaster if they inducted the guy because it would not have killed him. remember, on the ground where this is happening, we are not dealing with, you know, the best medical people doing these.

many doctors will not have anything to do with it. it violates the hippocratic oath. so, we end up using emts, people like that. and it is all done in secret. and eventually it is bad in my opinion. we will have more of these executions, probably not enough to do anything about. in georgia, that will be the 12th person killed in the last years. all of those have been able to be pulled off. but one of them will go terribly wrong, just like in oklahoma. he did not die, he just kept flopping around. it will happen every now and then. neal: what is going on with the secrecy with the punishment?

a book i never thought i would praise, but "discipline and punish." it is not crazy, the construction of stuff, but it is about how the executions were in the town square and they were spectacles for everybody to come see. prisons where in the center of the city. and it was kind of a warning to people. but now we have these executions at midnight local time generally, and access to what is happening is not classified, but somehow made secret or like classified information. what is accounting for that trend, the fear of government, or is this the government embarrassed? marc: there is fear, whether it is on the part of the state or the attorney general, the corrections officials, who ever is with a drug company that is selling the formula, they could be the target of vigilantes. the bottom line, it is a

corporate double, whether you -- core principles, whether you are conservative or liberal, whether we should have transparency in government. and i think it becomes worrisome when you see the law passing exempting this area alone from freedom of information. so, it is a broader issue with the presence being out of sight --- prisons mean out of sight and out of mind. and in texas, we have a number of heat related deaths, because it is so hot. and things go to the wayside. we need to focus on the solitary confinement, 30 square feet and no daylight. some of the horrendous conditions that these individuals are confined to and obviously would like them -- life in prison without parole, we will be struggling with the public saying, you got rid of the death penalty, but we want this person to be miserable.

stephen: i would say a couple of things. when we adopted the death penalty, the supreme court said in 1976, they declared it unconstitutional in 1972, saying it was discriminatory credit they were all these problems -- saying it was discriminatory and there were all these problems with it. they wanted to make it fair, it is remarkable arrogance to think that, because the problem was racism, poverty, all these things. the death penalty is the same today as it was back in the old days, except there are some crimes that they have the death penalty for. but they said, we want the death penalty molecular clinton says for those like timothy mcveigh. and that is what everybody was saying. at the time, ted bundy, that is what they had a four.

but if you look at it, who it is for, you see a tremendous racial disparity and you have african-americans who are well over 50% of the murderers in georgia, the 80% of people on death wrote who were killing white people. so many of those our kids that went into -- our kids that went to 7-eleven and tried to hold it up and somebody was killed. that is terrible. locking people up. these are not death penalty cases, these are not the most heinous crimes that are committed. most of the people, and i learned the other day, we both have clients that are mentally ill. profoundly mentally ill come out of touch with reality and cannot carry on a conversation. these people are not going to take a clean. -- a plea. they cannot make decisions and judgments, because they are so limited.

it is a combination of intellectually disabled and schizophrenic. so everybody is conspiring against them. these are the people getting the death penalty, not because of the crimes they committed, but because they do not understand to take the plea. where the eric rudolphs of the world who blew up buildings, he can say, i know where a lot of dynamite is in north carolina and you give me a life sends -- life sentence. and the green river killer in washington who basically traded the locations for 78 bodies for a life sentence. he killed around 100 people. but the families want to know where their loved ones were. and he plea bargains.

he is smart enough to do that, so he avoids the death penalty and so many that commit these -- we had a guy come in and issued -- and shoot in does, and court reporter, and he did not get the death penalty. marc: there are people in georgia under the federal rules. a getaway driver at a convenience store and they rob the store, and they are not necessarily charge with murder but they could be executed under the federal felony rule. in the course of the felony, somebody dies, even if you have nothing to do with it. neal: and it is now murder and he can be tagged with it as the getaway driver. marc: one thing we are working on is that there should be a criminal intent element.

so there is a push back for those folks as they relate to the environmental crimes. some of them do not get discussed and this comes up in the sentencing phase, for whether it is murder or other crimes. but still, it ought to be that you cannot get the death penalty for felony murder, even if we have the death penalty, because you did not have the intent to kill somebody. stephen: and take it one step further, very often the person that was at the center of the action wins the race to the courthouse and gets a plea bargain for a life sentence to testify against the others that are not nearly as centrally involved in the but there is not strong evidence on them. as i mentioned, there was a lovers trying to. you would think, it is not eligible by death -- untouchable by death. she and her boyfriend decided to

kill her husband. the boyfriend stabbed him, had blood all over him, they had a case against him. but to make the case against her, they needed to give him the plea deal. he is out on parole. she did not take the deal. she was involved, no question. she certainly should go to prison for the involvement that she had to bring about the death of her husband but she is the one -- has been. but she is the one that is put down by the state of georgia. not long ago. so that is another example of plea bargaining, 95% of all cases that go around the plea bargain. and the two most important decisions, one of them by the prosecutor, do we seek the death penalty? most prosecutors do not. they never once thought the

death penalty. but then johnny holmes, seeking every opportunity he gets. because the overwhelming majority of these cases will be resolved with the plea bargain. so who we sentence to death ends up being very much a random matter of geography, race, poverty. all of those things. to say, this is the person that has offended us most previously and this is the person that gets it. neal: let's make this less abstract. these are systematic concerns, but i'm sure that you had cases in your life, and it may not be a john wayne gacy, but for the victims of the crime, it is. for those people. they feel that way. and obviously, there are cap --

concerns with those who have mental disabilities, and some who do not. so what about the families of the victims asking them a what are you doing -- asking you, what are you doing? stephen: a lot of prosecutors tell me that they tell the families, look, this is your son, get this case over with so you can go on with your life. there is no closure. there is no such thing as closure. if you have lost a nephew, there is no closure. you think about it every christmas, every thanksgiving. and watching an execution will not help. the other thing is -- .01% of cases end up with the death penalty. so it is like a fraud, to tell the family that they will get this guy executed in the next few years, but the probability of that happening is slim to

none. even in texas. but there are families of victims that are in cases that are not going to be seeking the death penalty, which understandably, they feel like if they could strangle that guy they would do it, because he killed your loved one. but it is up to the society to decide if we need to eliminate them from the human community. that is an enormous decision and probably not a good one to be made by people. people who are directly affected by it, the families, they are not terribly objective when it comes to making that decision. you would be surprised how many people i have gotten to know and liked and had dinner at their houses who were victims of somebody that my client killed.

marc: it does draw things out in terms of appeal, going on for many years. neal: we could ask questions for a long time. but we only have 10 minutes for questions. and we have a microphone. i see you have a question. >> what an extraordinary panel. my question is, is it possible that the death penalty goes the way of marriage equality where there is huge opposition, but the conventional wisdom now is that it is something even john mccain who is supporting marriage equality, especially where we have places like illinois were the governor put a stay on all executions, in new jersey, california could go this way, is it possible?

if it is, will be the route -- what would be the route of the supreme court to actually strike down the death penalty? [laughter] marc: you can go ahead and i will do any cleanup necessary. stephen: i do not want to throw cold water on that. a lot of people talk about marriage equality and how this could be like that, but there is a difference. everybody learned over time that their nephew or own children people that they knew, that they were gay and they were like everybody else. very few people have somebody on death-row in their family. i tell my students, the cases we are going to study our cases that we will all be crying because this is going to be some of the most god-awful stuff you have ever seen.

i cannot believe human beings can do things like this. so it makes it very hard politically to bear. and i think support is still around 70%. so it is an abstract. when you actually sit down with 12 jurors and decide whether or not to put somebody to death that is what is incredible, the number declining, because it shows that those 12 people -- you know, radio would say that they pulled the arms and legs off the teddy bear and it is ridiculous, but you go into a parent's house and you start pulling the arms and legs off it, you will not be there for very long. so with jurors, they understand with a person went through, so it did not really explain it other than what we are measuring is that this person is so beyond redemption that we will

eliminate them from the human community. you can say that this person is responsible, we are not going to forgive them. when it comes to punishment, we have an array of death penalty is -- of punishments, death penalty, life without parole and as the number goes down, we will have the death penalty only in the old confederacy. where we have it pretty much now. and those estates will eventually -- state will eventually just be the five states that have it. -- eventually, they are going to be pariah states. states will eventually just be the five states that have it. and of course the supreme court, nobody knows, because nobody knows who will be on it in a few years. once we find out, they could come back and say, that if it is used this rare, it is cruel and

unusual. marc: another way to look at it is the groundswell to bring it back. so with magic quality, they said it was the genie out of the bottle, they do not find that the marriage was less valuable. so i think, i agree with what you said, it does not touch people in the same way, because of a host of reasons. on the other hand, maybe there is a similarity, with once it is abolished, people will not be saying we miss the death penalty so much. i think that the supreme court's, obviously it will be the issue of what is cruel and unusual punishment and you have the usual that take the side that what is cruel and unusual is cruel and unusual when it was written. so this is a narrow set of practices that could be cruel and unusual based on that.

and the others involved in evolving standards of decency, where the majority is they look -- majority is these days. and they look to the state and that the executions. a lot of originalists complain because -- the list of valuation. neal: it does look at the marriage equality with death penalties to get rid of the prohibitions, and the political route there, there has been recent successes and no backsliding from the success when they abolished the death penalty, but it is harder to imagine. so i think that the courts are

in a place where we will see action. and i believe that the current view of the supreme court, you do not need judge kennedy to go, but they will get rid of the death penalty. justice kennedy has a heartfelt view on decency and on marriage, in which they do not have special expertise. they know how the system is being implemented in this area. they do have expertise. and how sentencing does wind up in the supreme court. and even a few hours before the execution, last minute. they see this day in and day out. that is why many consider this important in their lives, to come out against the death penalty or have misgivings. there are 4 justices for those democratic presidents and i think justice kennedy and one of the prosecutors in the oklahoma city bombing case, one of the very few, one of the few federal

executions carried out in the last years, timothy mcveigh was one of them. but these should be brought to the court under the eighth amendment strategy. stephen: i would say this, the death penalty is a very damaged brand. and a lot of people realize that. and i also think there is a general acceptance, even in the south, everybody thinks it should be gone in a few years. everybody thinks the abandonment of it is inevitable. nobody says, we are going to expand the death penalty. it is, how do we get there? as the committees look at it

with the cost and the time, they will abolish it like the other states that have. it is not that there is a lot of opposition, like the 1990's. you would have been gone. today, i think that seeing -- scene is cleaning up the government. neal: other questions? all the way in the back. >> what are the thoughts about putting money into rehabilitation? like, in europe. in removing death sentences? and life sentences completely? marc: i took a tour of prisons in germany, and those who commit the most serious crimes, the most you would get is about 15 years. but they do have a special detention that is similar to

what we do. it is for violent offenders. in reality, they use it sparingly. the concern among all of us is if we had a here, would it be used sparingly? but they do have psychologists who are screening them after 15 years. and the prisons themselves were like dormitories. and the detention center on the same premises, it was like an apartment. you had tremendous freedoms. and it was every way like it was an apartment, except you stay on the premises. that is the restriction. and i just, that is how they chose to approach it. on the juvenile side in this country, we have seen great progress with the life without parole and provides an example of what we can do by addressing the unnecessary extreme practices.

neal: one last question. >> do you see in the future, maybe changing direction abolishing life in prison without parole and everybody having the possibility of parole? and everybody having the possibility of parole? stephen: i was saying, many of the fights in life without parole, prosecutors often fight over life without parole because without it, you would get the death penalty. i would say until the death penalty gone, we will not see life without parole. terrible, because now we are

giving all these people life without parole -- no hope whatsoever. my friends that are wardens, do not send me a kid with life without parole. he has no incentive to behave himself, no incentive to make himself better or do anything. this is not good correctional policy. there needs to be hope, because many of these folks are so young. they are 18, 19 years old. to say to them, you have no chance you will die in this , institution. it is incredibly cruel. but i do not see do anything. the way in which we will get rid of the death penalty is from -- sadly, but true. neal: thank you. [applause] [captions copyright national cable satellite corp. 2016] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. visit ncicap.org] >> our road to the white house coverage continues with the green party national clinical convention in houston.

saturday the green party chose jail's their presidential nominee, and ajamu baraka as their vice presidential nominee. watch their acceptance speeches tonight at 9:00. this weekend c-span's city tour will explore the history and literary life of port huron michigan. we talk about the role of railroads played. >> the container movement, particularly the connection of shipping containers moving from places like china and indonesia and elsewhere -- railroads are very much a part of that route. so when you go to long beach california, where there is large shipping facilities, the railroads are right along the container ships that help them

to write route. >> then michael connell talks about the rich history of port huron, its importance to michigan's economy. >> in the 1990's, we were a thriving economy, not only statewide but also locally. it collapsed around the year 2000. in 2000, if you go by household income this was one of the 15 wealthiest states. by 2008, we were one of the 15 poorest states. >> and we visit the train depot where thomas edison worked as a young boy and stop at the thomas edison museum. we also talk with the manager of the museum. >> we had a recreation about the chemical laboratory, where he was the first person to print a

newspaper on a moving train. he had access to the latest news through the telegraph agent at the train offices and would get that news hot off the presses. >> and we tour the fort gratiot lighthouse, the first lighthouse in michigan. watch today at 2:00 p.m. eastern. this c-span cities tour. working with cable affiliates and visiting cities across the country. the c-span radio app makes it easy to follow the 2016 election wherever you are. it is free to download from the apple app store and google player. get up-to-the-minute information and broadcast times for our popular programs. stay up-to-date on all of the election coverage. c-span's radio at means you always have c-span on the go.

now, global aids experts discuss the results of the 20 16th international aids conference. panelists talk about the advances in research, new vaccines, and funding and health care challenges. this is almost two hours. steve: good afternoon and welcome to the center for strategic international studies. i'm steve morrison, i'm a senior vice president here, and i direct our global health work. today is the sixth occasion over 12 years in which we've joined together with jen kates and the kaiser family foundation to jointly host this debrief on an international aids conference.

proud to do that. we've found year-in and year-out, when we've done these, very strong interest. thank you all for coming. we're going to work to hear from you. many of you who are here were present in durbin or many of you tracked and followed closely what happened. a warm welcome also to our audience online and the audience tuning into c-span. special thanks to colleagues from csis. joe jordan and sara allender were together with me in durbin -- special thanks to them. special thanks to lily dattilo who here in washington was tracking the responses in the media carefully and took charge getting us organized today along with joe. we're here -- we have to begin with a special heartfelt congratulations to the three leaders who we will be hearing from momentarily, chris beyrer deborah birx, and jennifer

kates. and to the other people i'll mention momentarily, who were so responsible for the success at durban. chris, deborah, jennifer all brought science, rigor, human compassion, commitment and pragmatism to the table in durban. all had dramatic and lasting impacts. and all are inspiring leaders to whom we owe a great debt. their influence over time is so substantial, and we're so fortunate to have them in that role, playing that leadership role. professor chris beyrer, he's the immediate past president of the ias. i think he stepped down around 5:30 p.m. on friday afternoon, whatever date that was -- july 22nd. so he's clean and free now. and he's also, in his routine job, he's the desmond tutu professor of public health and human rights at the johns hopkins university bloomberg school of public health.

he partnered at durban with south african co-chair, olive shisana. chris brought extraordinary grace, wit, and savvy in organizing this. on opening night, many of you may have seen the duet that he did with olive shisana. it is his appeal to unity of purpose across the multiple populations and communities that matters so much on hiv/aids, but who oftentimes operate in somewhat exclusion from one another. it was an appeal for unity across sexual identity for an end to homophobia. it was an appeal for unity across gender, across racial lines, across economic class. it was a powerful, genuine timely, and much-needed stroke and it was quintessentially chris. so thank you, chris, for doing that. he and olive were ubiquitous throughout durban.

their personalities permeated the assembly and set the tone of seriousness, of joy, of inquisitiveness and humanity. i want to pause for a moment to give a special shout out to owen ryan, executive director of the international aids society, and his remarkable team in geneva. they did an exceptional job under oftentimes not the easiest of circumstances. they did it with grit and a lot of grace. and we're all in their debt. and of course, special note of gratitude to our south african hosts, most importantly minister of health aaron motsoaledi, also ubiquitous throughout the events, also inspiring in the multiple initiatives that he has pioneered, often in partnership with the united states and others. i also want to acknowledge special thanks to nomonde nolutshungu, health attache in south african embassy here in washington, who's been very supportive in assisting us in the events that we did in durban.

ambassador deborah birx, u.s. global aids coordinator and u.s. special rep for global health diplomacy. she has been in that role for over two years, and in that short space of time had dramatic and profound impacts. she carried to durban -- no surprise to any of us -- her signature relentless drive to force a focus on young women and adolescent girls, the special threats they face, their centrality, the future of prevention efforts, the demographic wave that lies on the horizon, and the need for integration looking forward, bringing in all sorts of other sectors. she also carried to durban her signature relentless drive to carry forward the transformation of pepfar's approach to apply greater rigor, to insist on better data, to concentrate investments of scarce dollars in the right place and the right time on priority micro-epidemics, and to measure impacts much more carefully, assiduously in this process. just prior to the opening of the

conference was the two-day pepfar implementers meeting. we'll hear, i hope, from deborah what that revealed about progress in moving forward with that agenda. deborah, like chris, was ubiquitous and indefatigable. it seemed like there were two or three versions of her at durban. i would walk from one hall to the next, and she would be speaking on panels that were happening simultaneously, it seemed. she embodied, more than anyone in durban, the remarkable leadership of the united states, our continued indispensable role globally in battling hiv/aids. she embodied the way the u.s. has moved ahead in close partnership with the south african government and others. i do urge you to watch the video of her conversation with minister motsoaledi, which we brokered. it's a very illuminating and affirmative and honest discussion of the relationship. i also cannot fail to mention dr. tony fauci of nih, who brought enormous gravitas and interest to durban, a very active and visible presence,

particularly on the scientific panels. our third speaker is jennifer kates, vice president, kaiser family foundation, a close friend and colleague. kaiser, over the past decade-plus, has been our single most-important institutional partner in washington. it does invaluable analyses of budgets and programs like no other organization does and has an exceptional reputation for objectivity, rigor, quality and reliability. they're the gold standard, and we've been delighted to be able to benefit from that in our partnerships. jennifer released the kaiser-u.n. aids study on finances just prior to durban that documented more than a billion dollar decline in resources in 2015, a 13% decline in aggregate, 8% if you factor in special circumstances. either way you interpret it, it's a disturbing and precipitous shift. we'll hear more from her on what that means. at durban, jennifer's analysis became a central pivot.

it became a common reference point. it was the loudest wake-up call of the week. we'll hear more detail from her. these iacs, these international aids conferences, are daunting. they're huge, they're complex they're exhausting. i always get very anxious throughout them, trying to figure out how are we in hell going to make sense of all of this, because there's just so much going on. and so that's why we're here. i begin to be less anxious when i realize that we can get chris, deborah, and jen to come in here and tell us what happened and what we're going to remember about this particular one. these gatherings are always inspiring, and they're innately inspiring. how can you not be moved by a community of 15,000, 16,000, 17,000 individuals who constitute a determined army of advocates, implementers, civil society leaders, industry, scientists, ministerial officials, elected leaders. it's really a grand mosh pit. and it's unlike anything that we see in global health.

it's all sorts of oddball partnerships, and it's really quite lovely, i think, and quite dynamic. and it's an ever-evolving base of knowledge and experience. every international aids conference is a sobering occasion. it forces us to pause and reflect. and this year was especially the case, particularly when so many geopolitical forces were threatening to erode high-level political and financial commitments essential to sustain global efforts on hiv/aids into the future. we know what some of those are we'll talk more about them. austerity -- while hiv infections have remained flat for five years, not declining, and rising in eastern europe the former soviet union, funding , as we've seen in the kaiser report, has had a significant decline. these are two key axes we cannot ignore in trying to judge progress looking ahead and wonder what the structural drivers are likely to look like. we know the refugee crisis is taking a heavy toll politically,

financially. it has a huge geostrategic dimension, mixed with stability and counterterror. we know there's a spread of populist nationalism isolationism, and chaotic political times. and that turbulence threatens the consensus, particularly in europe and north america, around hiv/aids. we here in the united states, of course, face the prospect of a republican party in disarray and, frankly, we cannot afford for purposes of hiv/aids and global leadership, we cannot afford a damaged or incoherent republican party. sdgs are creating a new reality and a more competitive flattened playing field. one thing that we'll talk about is the pronounced absence of state leaders at durban. 16 years after the 2000 durban conference, after tens of billions of dollars invested in that region and in eastern africa, there was a stony

absence of state leadership and only few ministers who showed up. i'm worried that hiv has diminished in significance. i worry that the world that's assembled in durban, which is so dynamic and so lively and so committed, is a bit divorced from the broader world of geostrategic deliberation and decision power. and that's a vulnerability. a billion dollars leaked out of the system quietly in the past year with insufficient alarm and no apparent strategy for reversing or staunching this trend. we can talk about that. ok, enough of that for now. let's get to our speakers. i'd like to invite our speakers to come up. the flow is going to be as follows -- we're going to hear from chris, deborah, jen, then we're going to have a bit of a conversation across all of us, and then we're going to open the floor to you. when we get to you, put your hand up. we'll bundle speakers, we'll run microphones over to you. please identify yourself, be very succinct, one single

intervention per speaker, and we'll bundle them together and we'll get to you quickly, i promise you. so if i could invite chris, jen, and deborah to come on up and join me. thank you all. [applause] steve: i don't know how many of you were with us at kaiser after melbourne two years ago when deborah, chris, jennifer, and i were on the stage at kaiser, talking about the outcome at melbourne. and chris led off, and it was a tour de force. eight minutes, nine minutes, he didn't take a breath in that entire period, and he illuminated every corner of the conference. so we've asked him to reenact and update. so, chris, the floor is yours. thank you.

chris: well, thanks so much, steve. and good afternoon, everyone. wonderful to be here. i hope we can bring, for those who weren't with us in durban, some of the spirit and the energy and the scientific excitement of this conference. it really was a very extraordinary experience. it was amazing to all share it together. i just want to begin by reiterating steve's thanks to my co-chair, professor olive shisana. you can't really put on a show this big and this size without a trusted, solid partner in-country. and she also happens to be an outstanding scientist, a social scientist. and we are now foxhole friends we've been in the trenches. i don't want to go through all the thanks, there are so many. i have to, of course acknowledge the south african government and south african people for hosting us and being so splendidly welcoming. i'll get to other thank yous as i go through. a but what i really want to do for you is go through the scientific highlights of aids 2016.

and let me just say -- it's often said, you know, that this is a global convening, and it's more of a political event or a social event -- there's a huge amount of science, and it's really very critical. so, a couple of things to say. the most competitive scientific meeting we've ever had. a little under 4% of abstracts accepted for oral presentation so that's extraordinarily competitive. first time ever that the majority of first-author abstracts were led by women. and of the 735 or so presenters, the majority women. so, really, a very important change. 37% or so of the accepted abstract lead authors were africans. that's also very important. 15,180 participants, not including the global village. if you add that in, about 18,000 people participated on-site from over 150 countries.

and interestingly, in order of the countries, it was south africans first, the u.s. second, then zimbabwe, kenya, and the u.k. so an enormous african representation, and that is because we tripled the scholarship size for this conference. we knew that we were going to offer an enormous number of scholarships to get africans able to participate. and we're pretty proud of that. and we, of course, want to thank everybody who contributed scholarships. there were 16 pre-conferences, including the pepfar implementation meeting that debbie alluded to, tb 2016 enormously successful, hiv viral hepatitis co-infection meeting, the msm global forum. and so really, an enormous number of preconferences. will i think -- i think, out of the conference, if one real message emerged, it has to be that it is too soon to declare victory.

we are not done yet with global aids or tuberculosis. we understand that we have an enormous challenge to scientific political challenge to end aids is a public health threat. i think there is a consensus that it is doable, but we really have to be realistic about the obstacles ahead of us. what i am most encouraged about and what i want to share with you now is the fact that there is so much science that it is -- there is so much science that is helping to address those obstacles. so we break the science down for better and for worse, into five tracks. and those are basic science, clinical, epidemiology, and prevention. a big track that includes economics, law, policy, and human rights. and then implementation science, which is track e. that actually now is the , largest of where we get abstracts from, and a lot of that is because, of course,

the pepfar meeting, we worked closely with ambassador birx. it was a pre-meeting, where people were co-registered. so track a, basic science, i think what we really are learning more about than anything is two issues. cure and vaccines. in terms of the hiv care, in a way, the good news is we now have a clear understanding of what the fundamental challenge is. and that is the latent reservoir of hiv in the tissues. we still don't really understand that reservoir. we need biomarkers to be able to tease it out and understand it but we understand that's the , problem. for really a wonderful review of where cure science is, the pediatrician at hopkins that did the mississippi baby work, gave an absolutely brilliant plenary on cure, focusing on the pediatric aspects of cure.

if you have time, that 20 minutes will give you your cure briefing. i will only say that this also was the first time that we had a clinical trial on cure. this was the first time to use this approach -- you probably heard of -- shock and kill where you try to get the virus out of the reservoir and hit it with high dose, high intensity anti-viral therapy. 100% of patients relapsed as soon as the anti-viral therapy was stopped. it did not work. but nevertheless, that is how science is. we learn from our mistakes. so a long way to go on cure. but there is a lot of work and excitement. better news on the vaccine front. the big vaccine news was the hvtn100, which was the immuneogenicity, the immune responses in africans to the next generation of hiv vaccines. that vaccine is basically adapted and built upon the

platform that debbie led rb-144, when she was head of the walter reed program. that's the only successful hiv vaccine we have. but this one is fit to the virus circulating in africa. so the big question, would it be a immunogenic? the answer is yes, the immune responses were vigorous. and impressive. it is a go. and that is going into a phase three trial. hvtn702. and the person who has taken on my role as president of the ias is going to be the in-country lead for that trial in south africa, so it is in good hands , and that israeli very exciting. i would just say that ias put out a new cure strategy, and i think it is a very important document outcome. the lead author is steve deeks. that was out in "nature medicine" the week of the conference. track b is clinical care and clinical science. and this is enormous. i am not going to be able to do justice to it. there were a huge amount of

clinical trials, more than 25 trial results, but i will give try to give you the highlights. the first thing to say is a challenge has clearly emerged that is about longer-term retention and care and adherence. it's one thing to start people on therapy. it's another to look at how they're doing in a year and two years. but in a number of populations what we're seeing is longer term retention and care is a real problem. people go off their meds. we saw that, unfortunately, with data from south africa. one of the things about this conference -- and i think everybody will share you that's so amazing -- this really was a the emergence of those children were born hiv-infected and have survived. they are the first cohort who had really survived. they are adolescents and young adults. they are impressive leaders. they are a magnificent generation of those who will help us and keep the energy going, but unfortunately, they

are not doing so well with adherence. so, for example, the very important south african study, 5 to 9-year-olds, 74% virally suppressed. the older allison's, 15 to 19-year-olds, only 62% viral virally suppressed. so there's a drop-off there. that's a real problem. the promise study, a large important nih- funded trial of early initiation with higher force of hiv pregnant women living with hiv, spectacular outcomes for women who started therapy and stayed on it, but unfortunately, the same issue. postpartum and post-nursing, a drop-off -- only 23% having virologic breakthrough at one year. that is not good. 20% at one year, by two years, you're getting close to half. that was looked at very carefully, and 86% of the time it was because they stopped taking their meds. so that is a big issue for us. there are, however, some really

important new treatment advances. the aria trial, women in the audience will be happy to know. one of the first big trials that specifically looked at hiv treatment outcomes in women, with the new dulutegabir-based regimen, and it had better efficacy, much lower likelihood of resistance, and fewer side effects. that is a real advance. the paddle trial was a "back to the future" idea of taking the medication in combination with one other drug, because it has such a great resistance profile, and going back to two dose antiviral therapy instead of the three drug cocktail. that was very much an experimental study. only 100 carefully selected patients, but 90% viral suppression a year and was well tolerated and looked very good. so some hope there. long acting injectables, also very impressive. ripovorin, it turns out, has a very long half-life in the body that may be an issue with people

who don't tolerate it well. but really, the first trial of injectables -- and this is intramuscular injection of long acting antivirals -- a basically looked at four-week injection versus eight. the four weeks was better. again very well tolerated, and , this is going to go forward into larger scale trials. so imagine being able to offer people daily oral therapy or a monthly injection. that is really something to look forward to. in terms of co-infections, tb and hepatitis c were our two big areas of focus for this conference. and in terms of tb, i would send you to anton pozniak's terrific plenary on tb co-infection to say there's a great deal of data there. and hep-b, dealing with the austral trial.

this was basically dealing with one all the subtypes. we are only doing really well with the one circulating in the u.s., but this looks really great. a 95% cure across all subtypes except subtype c. track c. so we really wanted to focus on prevention because of the data that has emerged. many of you saw the u.n.-aids report right before the conference that we are seeing sustained new infections in adults globally. that is a real problem. and an increase in some regions -- eastern europe and central asia. what is the big news there? lots of different kinds of prevention approaches. we saw more data from the vaginal rings that underscore that adherence is a hugely important issue for efficacy. women that were adherent, more than two thirds protected against hiv. so again more of an option.

, good news from hptno69, a prep trial in women. all of the prep studies are either tonopoveer alone or in combination. this is another drug, very favorable-looking and well tolerated, safe, and no new infections in women over the course of that study. there is a very large trial in a key population. this was the sapphire trial in zimbabwe, almost 3000 women sex workers. unfortunately, the design was a community-randomized design that was going to see a difference in offering services to sex workers who didn't show a difference. but in both arms, what it showed very clearly, is that sex workers living with hiv will accept treatment if it's provided in a friendly and supportive environment, and they're also interested in prep and prep uptake was very good. so that is encouraging. there was data on prep in a very important population, which is adolescent men who have sex with men.

this is 15 to 17-year-old boys in the u.s. the data in htn13. very high incidence in that population, 6% per year. just frighteningly high. it was interesting that adherence was very much associated with kids being concerned that others, if they saw their prep, would think that they had hiv and were on drugs. but the good news is it is safe, it is well tolerated, and there was no increase of evidence of sexual risks or increasing sti's. they were high and stayed high but still. we have the first data on prep prescribing in the u.s. from gilead. now 60,000 to 70,000 americans are on it. pre-prophylaxis, so that is encouraging. four states account for 85% of those prescriptions. that is california, texas, florida, and new york. somewhat of a surprise. and a majority of the relatively older and predominately white population.

so not necessarily addressing where we are most concerned about the epidemic. good news there is that there was a terrific hptn study on prep uptake and use by african-americans that have sex with men, 0-7-3. that is the first of the trials that was led by black, gay investigators in the u.s. and what it showed very clearly is that if there is cultural confidence and an appropriate approach to providing prep that black men want it, they will use it, and they were adhering. there was incredible data on the integration of prep and antiviral therapy for discordant couples. the partner study that showed that prep -- basically the way they did it was to offer treatment to the partner who was infected and to offer prep to the uninfected partner as a bridge until the infected partner could achieve viral suppression. virtual eradication of heterosexual transmission in an african population. it should be said in those

discordant couples, 73% of the time the infected partner was the woman. so this really has an important role to play, i think, in how we manage transitions and prevention. there was very important data on the tonofofir gel study. folks probably know that the phase 2b trial the famous outcome worked and efficacy trial did not work and left us all in a state of confusion, what are we going to do with 1% gel? it turns out the group did an analysis of women looking and trying in a post session to understand why it did not work. women with healthy vaginal flora had wonderful protection and woman with bacterial vaginal stenosis got no benefit. that tells us it is not just adherence for women, there are biological factors that we can do things about. we can treat it. that was encouraging.

then there was great data from the french trial of on-demand prep. this is different. this is not daily oral. this is two doses around the time of sex and two doses after, and you use it when you are sexually active. you don't use it when you're not. in the trial, it showed very good efficacy. but this was the first open label data. so now everyone knows it works and everyone who wants to be on it is on it, and it has spectacular efficacy. so that brings us one infection and that person may not have been entirely adherent. that brings us to a new era which is to say, how would you like your prep? intermittent, daily? that's a new question for us. but then cautionary data, as well. a very large trial looking at the question of treatment as prevention, the 90/90/90 targets and their impact on incident infection in the communities and the outcome, unfortunately there was it's hard to reach the 90/90 targets. it didn't do well with men.

this was a recurring theme of getting men into care. they did well with the people who were on treatment, and they did not have an impact on incidents at all. so that is a cautionary note and we are just going have to pay attention to it. track d, our policy, law, legal, economics had a lot of data on behavioral economics and incentives. this is a very important area. i think the biggest news was data from south africa that providing social protection -- which people don't like to call welfare but developing countries called social protection -- had a big impact on improving adherence with adolescents living with hiv. that was a very important announcement. there was the announcement of the fund for lgbt populations. that critically important stop going forward there. there was the presentation of

the johns hopkins commission on drug policy and the implications of drug policy reform. which was terrific. there was data from the first really successful methadone rollout in kenya. because kenya, tanzania, east africa has now an injection drug use epidemic. they are stirring the lead in that -- hptno75 shows you can enroll a cohort of african men who have sex with men safely so that was a real advance. and there was a great presentation on new york city's plan to fast-track the end of aids. finally, track e -- are you all still breathing? implementation science. very important area. and a huge one. i have said repeatedly that we have big problems with engaging men in care, so we had a great piece of science. the first result of the search trial from kenya and uganda, they reached the 90/90/90 targets in a huge population the

, east african population. and they got great engagement. almost equal engagement of men and women in care. how do they do it? by providing other services to men and convenient, work-hour related times that actually work for men and providing screening for hypertension and diabetes. non-stigmatized diseases that men actually care about. -- showed importantly in a study looking at transmission dynamics in the most affected region in the world, that there's about an eight-year age gap in sexual mixing between adolescent girls and older men. and there is a huge gap in those men in their 20's and 30's getting tested and getting linked into care. this is a challenge for all of us. the big issue for dreams, if we can't do better with that age group of men, we're not going to make real advances.

there's a lot of information on self testing, self testing getting out of the clinic, now rolling out. great outcomes in zambia, with high acceptability, doubling the regular hiv testing rate in gay men in australia with self-testing. there was a lot of data on social media. very encouraging social media platform engaging msm and india in hiv testing and care. a lot of science emerging on differentiated models of care. so trying to get out of the model that everybody has to come every month and sit in a clinic all day and get their meds. unforgettable photo of an african rural woman standing outside with a sign that says "simplify the way i get hiv/aids, i'm tired of walking." i think those are really marching orders for all of us. finally, i want to say something about a real change happening in the field. that relates to pepfar. we are deeply grateful for ambassador birx's engagement. and having so many pepfar

leaders there. what has changed is pepfar has always been a key implementer and played a pivotal role in access, but with the focus on data and on evaluating outcomes and using data to drive decisions, pepfar is a change agent, and that is a huge difference. that really means we'll be able to -- one minute remaining and i'm done, amazing -- we're going to be able to take this incredible science and use it to sharpen and focus and tailor the response. and in an era of what we thought was flat funding but now with the kaiser report, may be declining funding, that's critical. can't waste a dollar. we've got to focus, and the way to focus is using all the science to drive a better evidence-based approach. and, by the way, that supports the human rights approach. because you're actually providing services to the people who need it the most. that includes key populations. that was a fundamental goal at durban, with getting the key populations on the african

agenda. i'll leave it to others to say whether we succeeded or failed, but we certainly tried. thank you. [applause] steve: thanks chris. ,>> that was amazing. steve: they are impressive tour de raison. deborah, ambassador birx. deborah: thank you, chris. that was amazing. jen and i were smart enough to say "have him go first." that sounds like a great idea. really, the ias for this meeting really worked with us. i am just going to give three personal reflections. which are flexed my take-home from the meeting. upfront they really worked with , us to ensure that our individuals, who work for the u.s. government all around the world, had an opportunity to share in this experience, to really learn from each other and from others. and for the first time, we were able to get almost 300 plus u.s. government people working on pepfar to the meeting by having

the dual meeting, which was a lot of work for them, because all of us were in their space for all the days preceding the conference. so there was a lot of trust there, to let everybody in but i think it really created that space for us to really share in that global community. and for many -- remember, most of our staff, over 85% of our staff, are host country nationals in-country working for the u.s. embassy, so real change agents in those countries, and it is really quite extraordinary to have them there, see them in the hallway and as part of this. so we started from the beginning in the opening ceremony. i think there was really -- there was a lot of subtle messages that chris and olive were getting across to us. and the subtle message i took home is they had four brilliant, accomplished women singers. that were all soloists in their own right. all independent soloists, who came together to sing together.

allowing each other to lead while they sang backup. and isn't that what we all should be doing? so really looking at that through the whole conference when should we be the ones singing in the lead and when should we be supporting each other and singing backup? and i think that really has been quite extraordinary in talks about the hiv epidemic from the beginning. my second reflection is we spent a lot of time creating a u.s. government booth, which really shows that all of the u.s. government was willing to come together with one voice and one message. and the message we had in the u.s. government booth was one yes, of u.s. government leadership and how important that was, both at the presidential level, secretary of state level, secretary of hhs level. but it also had the timeline that we created since 1981 showing that in different colors. so green was scientific

breakthroughs. red was advocacy. and the blue was the political leadership. and showing that all of those sections together is what has created our success, to date. and really understanding those three components -- advocacy science, political leadership -- is the real core of the hiv/aids response. which is different from other diseases. i think that is what is celebrated at ias, with the global village, and it was a privilege to spend almost as much time in the global village as in the main conference. because there was a lot happening in the global village. i think my third big reflection is the fact that adult infections are flat is actually saying that things are working. because we've, over this last 30 years, in sub-saharan africa, where the highest burden of

disease is, are having now 85% , and by 2020, a 100% increase in the 15 to 24-year-olds at risk. so if you are not going up in that age group, that is the most at-risk by that number of infections, that means we have made some progress. but it also points out the groups that we have left behind in the public health response. i think we have to be very honest with ourselves where we have succeeded. we've succeeded in pmcc -- pmct, prevention in mother to child transmission. we have succeeded there because of the work that came before us. the work that really built a maternal child health block platform to take care of pregnant women and under 5. so building on that, we could be wildly successful. that's why those rates in country after country are down by 85%, because mothers come forward to protect their

children. you can see that they do not always come forward to protect themselves, and that is why we have to work on the retention issues. but i think we have to be honest that there is not integrated healthcare delivery service for adolescents. there isn't an integrated healthcare wellness prevention service for young men that are 25. their interaction at the health center is when they are acutely ill or have had a traumatic event. that really shows us that we have been wildly successful where there was a platform to integrate to, and when there isn't one, we're going to have to build it together. and we can build it right together. we can really make this about wellness and health. and we can make living with hiv something you thrive with and preventing hiv something that we all do together. and i am proud of the work that chip lions and others have done and the program that was announced about start free, stay free, and aids free.

it is that stay free piece in the middle where we have had the least success, whether you are a key population or a young woman. so i think the work that came out on self-testing, the realization of men -- and i want to take one second to applaud ambassador guzby for starting the three combination trials. because he started three combination prevention trials at the same time ais were starting theirs. and they're expensive. there was a time, i looked at the dollar figure and said "oh gosh, if we're going to do them, we'll have to do them really, really right." and we have been working with the investigators all of these years to make sure they were finding men, because in every one of these trials, that was a gap. and now, that data is quite exciting for two reasons. carescha and slim carim had been sharing the information with us of who has been infecting who. and i think that is the other thing that is so extraordinary about aids researchers.

sharing with us long before things are published or talked about. and that is how we created the age band for circumcision and said we have to find 15 to 29-year-old boys and young men get them circumcised, so they don't get infected. we have to launch dreams for 10 to 24-year-old young women to empower and deal with safety on women to really deal with the issue that he had and he showed so clearly. then we have to find the 25 to 35-year-old young man, and i think that's what the combination prevention studies who are all doing it a little bit differently, from diane havaleer to the botswana project to the zambia, south africa project. and i'm glad those are still going, because we will have an answer of what it looks like when you actually try to reach everyone in the community, even though they may not be in the community at that minute. i can tell you, men are never in the community when we are in the community.

we go household to household to household. they are nowhere to be found. they do not want to be tested in the household with everybody around, even if it is a semi-private situation. this has really pointed out where we have failed as implementers. and i think that's the exciting thing about being able to use data. i have always told the staff you can get around a lot of confidence interval problems when you have a million participants. you can have some not-best data. you don't have to have great data. but you can follow trends. you can follow how you are doing very well when you have the volume of program data that we have. this is my shout out to all of the teams, because this is not debbie, this is teams all around. -- this is teams all around the world who have worked with partners to get us data in a timely way, so that we're

analyzing it together. and i mean together. to really shed light and be honest with ourselves about where we are doing well and not doing well and taking everything that chris just summarized to the field immediately and try those things in a key way and look at those outcomes. and that is what we are so excited about being a partner in the scientific endeavors and being a partner in that implementation and utilizing the data in a comprehensive way. so it was exciting to me, but i hope we all learned how -- when is our time for our solo and when we sing backup for each other. because then i think we impact child marriage. we impact first preginancies, we impact hiv for young women, and we have educated, thriving non-pregnant, non-married young women that can have a successful life. so this is really how we can come together in the future. [applause] steve: jennifer kates.

jennifer: i was smartest to go last. first, i have to share my thanks as well, particularly with steve and csis for doing this again. for 6 times. when we first started, i don't think we thought we would be doing this every other year but it has provided such a great opportunity to hear and reflect and share for those who could not go as well as those who could, what we all experienced. i want to congratulate chris and olive and owen ryan for an excellent conference. for those of us who have worked with them over the years and see what goes into it, we know how hard it was, thank you very much. and also congratulations to ambassador birx and the whole pepfar team. i will say more about that but there was incredible leadership and participation throughout the conference. so i have a few reflections to add what they shared and then share reflections about our report on funding and what i think it might mean. obviously, this conference, the

big comparison of this was to durban 2000. this is a very different conference, a different time, a different point in the epidemic. so comparing -- there's a lot of interesting comparisons, but it was quite a different experience. a few additions to what we heard, in terms of the amazing and successful things at the conference. the pre-conferences. i know you mentioned them. these were amazing experiences for two reasons. first of all, there were so many different types of pre-conferences that touched on so many issues. if you look at the names. then the depth that each one , went into. the one thing that was quite different and unique this time that i hope to continue is they were really part of the fabric of the conference. so purposefully, they were made to be part of the experience. so anyone who attended those went to the conference, they were in the same space, and it really created a seamless connection between btb -- between the tb focus, for those who went to the tb preconference or cure. there was a focus on transgender

individuals and hiv for the first time, and incredible, very intense focused effort to bring people together and talk about specific challenges and issues and connect that to the rest of the conference. that was amazing. i went to the pepfar preconference just to see all the country teams come together and talk about their very different challenges opportunities, what they've accomplished was unique. you don't get to see that en masse like we did. the important science that we heard. i'm not going to repeat any of it. chris was the expert. there was incredible civil society engagement. it was really great to see. there was a real emphasis on the role that stigma plays in challenging our efforts on hiv. there was a lot a focus by many speakers on key populations, particularly lgbt populations. that might not expect to see such a strong emphasis. it was there, at least in this speeches, in the talks it in the sessions -- very, very strong. pepfar, i want to say couple of things about that. pepfar was ubiquitous in the

sense of being an incredible leader and participant at the same time. maybe to your point about being the soloist and backup at the same time. pepfar did that well. one thing that i went to a lot of pepfar sessions but the dreams, innovation, challenge fund, the announcement of the recipients of the award of that. just to be there and know those individuals and teams who got the awards just found out that day or maybe even that moment, and came up -- a few were able to come up and share what they were going to do and what they proposed. that actually was awarded. the excitement they expressed, mostly young african women talking about what this meant to be able to go back to their communities and try something different, to reach young women, was really powerful. thank you for doing that and choosing the conference to do it. and the last thing in terms of noticeable things to me, there were a lot of new participants. a lot of people i met had never been to an aids conference, so it was a completely new experience for them.

and that was exciting. that made me feel really good. i had the opportunity, organized in part by pepfar, to meet with several congressional staff were who there, which was also terrific. that congressional staff came, and one, out of all of them, had been to another conference. there were new staff engagement from the hill of people who really wanted to be there and were there the whole week. those were incredibly positive things. at the same time -- sorry about this -- with a little distance i have a little bit more of a cynical or murky perspective on the future. this picks up on something steve said. which i do feel like there was this veneer around the conference of the larger global discussion or uncertainty in the world that's going on, that is just there and sort of loomed out as we were all meeting. and what to make of it. i don't think any of us really know. it was this sort of weight of the global state of affairs was

heavy that i haven't felt at some of these conferences before. this brings me to our report that we released and the pathway forward is. this is something we have been doing for more than a decade and partnership with u.n.-aids. we collect data on donor governments on their spending on hiv, and we go directly to the donors, because it's the best way to get the most comprehensive data. and to work with them, so there's no surprise to donors. we are not trying to expose anybody about their funding to say, what are you spending? we work with them and try to analyze it with them. we have been doing this for a long time. we've had blips over time. we did not expect to find what we found this year, which was $1 billion less provided in 2015 for hiv in low and middle income countries than in 2014. 13% drop. there were many reasons for this. some of the reasons are not necessarily problematic. and some are.

on the problematic -- or challenging side -- or maybe not problematic just the reality but the dollar appreciated significantly. why does that matter? when the dollar appreciates, the currency of other donors goes down. so a donor may be giving the same amount they gave the year before, even more, but because everything is expressed in dollars and that's how the global economy talks about these things, it made it look artificially lower. so we looked at that. we said, ok, how much did that explain it? it explained some of it. it did not explain most of it. that was one reason. the other thing that occurred that was a unique situation for the u.s. government is, and this is about using the data and information to do the right thing -- i don't want to speak for pepfar, but we talked with them a lot about this. there was less made available by the u.s. government in 2015 compared to 2014. about $400 or $500 million less. why was that? the money was there. that money was reprogrammed to be focused on dreams, focused on voluntary male circumcision, and

to take money from some places where there was over funding and put it where it is to be. it takes a little time to do that, for any government. so the u.s. amount is actually going to be there in 2016. we expect to see it. it wasn't an actual decrease, it was a delay. we said, ok, what if we take that out? if you take that out, it's still an 8% decline. we looked. basically, most governments , most of the european donors in particular declined in their currencies of origin, and even more so when you adjust in u.s. dollars. and what was more, i think, of a disturbing trend, is that we have been tracking this over time, and we've seen them decline over time. it was just that, in the past, the u.s. government has been able to make up that difference. so this was a real decline no matter how you looked at it. even accounting for all these factors, most governments went down. and why is this? we did not do a survey to ask everyone what happened, but there are some general lessons or observations that we made and i think others have made

, too. first, we clearly saw shift after the global economic crisis. generally. the world changed. it really shifted. the dialogue shifted. the trajectory shifted the equation for development aid. and many governments put fiscal austerity measures in place. that is a factor. more recently, particularly for the european governments, they are very focused, as they need to be, on the refugee crisis. and that has, for several of them, placed a dilemma, with some countries deciding to shift money and others still in the debate. but that is another factor. that is pulling on budgets. another factor that just emerged is brexit. nobody really knows what that is going to mean. it is not just what the u.k. is going to do, but what it means for europe and what does it mean in general for the future of the development aid community. another factor, is there less of

a focus on hiv? is there aids fatigue that we're seeing among donors? another question to ask, has there been an overly optimistic focus on domestic resource mobilization? we have all talked about the need for domestic resource mobilization, that countries that is receive aid can do more and want to do more and are doing more, but almost to a fault focusing on that as a solution. i think those governments, some of the ones we thought were best able to provide more, are also struggling economically for some of the same reasons. i have one minute left. looking ahead, i think there's a lot of uncertainty. we will have our data before next summer. looking at 2016. but before that, a big moment in time is the global fund replenishment on september 16. the global fund is hoping to reach $13 billion. and there's pressure -- billion, yeah. pressures to get there. the dollar appreciation is one issue.

i think these are uncertain times and what i feel like reflecting back on the conference, ultimately, i hope that is the case, but it could be a year that was a make-it-or-break-it time for when we reach the age of aids regeneration. i will stop there and i look for to everyone's questions and hope we can really turn the corner on this. [applause] >> you hinted at some of the things we need to concentrate on. it does seem like coming out of this that for the next year or two, we need a rethink on what kind of high-level political strategy are we going to pursue. the u.s. is the dominant player today. two-thirds of the dollars are u.s. dollars.

that's a dangerous position for us to be in. we need to get past an e.u. in disarray and the u.k. exiting and losing their capacity to influence, keep capacity. we are in our own transition. we had you in agency to leadership positions turning over. that can be both dangerous and also the opportunity to make the case. i would add to jennifer's notion around, have people become complacent? i think also we have a confusing set of messages to the american public. i think part of it is what we are telling people they should think. and some of that complacency is around a bit too much hubris around the success that lies immediately or soon around the corner and it gets people to think that there are more urgent and pressing things and that we can half off a little from here and a little from there and ease off and the like. i would also add because the conference took place are you currently republican convention,

it got somewhat muted coverage although the coverage was not bad. it might have been more of the broadcast media attention if it had been timed somewhat differently. that is just the way things are. but maybe you could all say a bit about if you're thinking aloud now about what is a strategy that's going to try to renew high-level political interest in this, renew budgetary interest. get people on record technology this which seems to be one of the big missing pieces. my fears we are in a turbulent and transition year and then we get through that and then i continue to be likely considerable turbulence and transition of new governments and new leaders and we might get to amsterdam and have another major setback, continued absence of high-level political leadership interest in this.

what can we do in the next 6-12 month in your view that try to reverse those trends? deborah? deborah: i think two things. one is the work that we have been doing with the global fund has resulted in none of the u.s. government programs now in t.b., h.i.v. or malaria, can be successful without an enormously successful global fund replenishment. we've spent the last two years de-duplicating every single thing to make sure every dollar has the maximum impact. because the issue of the currency, a lot of the real dollars in the country were less. mark and i have really worked country by country, site by site -- and one of the reasons we mapped every single pepfar site down to the site level thousands of sites every single place, is to really made clear where we are, where we are

dependent on the global fund to where we are, which is 100% and most of our sites. so in most of our sites, the global fund is either providing the commodities for testing or the commodities for treatment. all the first-line commodities for treatment. half of the bed naps. many of the mdr treatments, and gen experts and those commodities. so whereas pepfar and pmi in the tb money may be working very closely with countries on service delivery, the majority of our commodities are coming from the global fund. so can't have one without the other. i think we have done an enormous job in de-duplicating and making ourselves dependent on each other but now we are completely dependent on each other so i think that's really an important thing for the american people and the american congress to understand but also every single donor so that they understand when they invest in the global fund, they're investing in the

ability to leverage the 65% of the u.s. investment that we're all making collectively to end these three pandemics. i think the second piece is, sometimes we have to be willing, again, to sing backup. i think we have to be able to show and bring together the groups that are interested in sexual reproductive health for young women, interested in education for young women, interested in combating child marriage early pregnancy, and bring those groups together as well as the groups that are interested in human rights and understand the interface between public health and public health programming for lgbt and human rights and bring their voices back to the table. because we have to have a larger message. we have to be up to use each other's indicators. we are in discussions right now, how do we measure whether we are impacting teen pregnancy, child marriage?

how do we measure lgbt has access to preventive services, to treatment services? so together we can integrate our messages in a way -- we talk about integrating program. we have to integrate our indicators and messages so we can show how we're leveraging and impacting each other's global development goals. sustainable development goals. i'm never going to get that right. there are 17 of them. we have to start utilizing each other's indicators so we can show we are not only having an impact on hiv, we are impacting these other social determinants of health which are really key. i think that's on us to figure out how to do that so the american people and congress sees that what they invested in the global fund and pepfar has made it as able to deal with

maternal child health, immunizations, ebola and now potentially the public health infrastructure to deal with other global health security threats. >> chris? chris: that's a tough question. let me say, first of all, one of the efforts we invested in to try to get back on the global agenda in a way was to have a lot of high level, high profile people be with us. and from different sectors. on that level, we were spectacularly successful. it must be said. we have in the opening, charlize theron, south african actress, who actually gave a great talk. bill gates, very important for the people within the foundation working on hiv to maintain his interest. obviously, the private sector support is huge for specifically the research agenda and many of the things we need to do. he came, he was very engaged. we had an extraordinary moment

where elton john and his husband david furnish were there. they announced this new initiative with pepfar for lgbt people. but in his session, he essentially handed on the advocacy torch to prince harry. and prince harry, you know, who is from u.k., by the way, a country that we absolutely need to stay. when you look at the actual global donor base, the second after us is the u.k. they are a critical partner in this. so his engagement around aids and connecting it to his mother's legacy is very important for us. we had, for the first time really ever, the un's secretary-general ban ki-moon. outgoing but nevertheless he came. he was very engaged. having those kinds of folks be there and participate with us really does help. i will tell you that on the opening of the conference, the single biggest news item was charlize theron.

not my prep science, i don't know why that is. what are you going to do? from that perspective, we were successful. a lot of the success has to do with people's commitment to africa and how engaged they were. also, the legacy of durban i think was meaningful to people and the enormous sense of urgency around the epidemic continuing. my own view in terms of the global fund replenishment, i think that's absolutely right. that that is the central and we are very heartened that it is happening in headed a interested to know -- justin trudeau seems to be committed and engaged. that is great. there are a number of donors who are stepping up. i do think that one of our goals was to change and nuance the messaging around the likelihood of success and the urgency of this moment. there had been, i think, an overemphasis on basically we

have won the fight. well, we haven't won the fight. we have achieved an incredible understanding of what we need to do and we have an amazing number of scientific tools in place and it, but it is very much a make it or break it moment. and that message needs to be out there, that we have not won the fight yet. it is much too early to back away. i think we succeeded in changing that message. >> i do think here at home, we don't need to rely on others. i think we need to be blunt in the appeals to the clinton campaign, to the democratic and republican leadership. there needs to be some kind of reformulation coming out of durban of what's the problem we're facing here in the next two years and fairly concrete appeal as to what they should do. i agree having bill gates there was absolutely invaluable. having charlize theron, prince harry. all those people can be brought in.

i think it is to be a europe strategy and one that gets african leaders reignited and speaking. in the absence of them speaking, it is really hard to make the case. it's really hard to make the case. in the midst of the refugee crisis. right? and half of the refugees that are coming to europe are emanating from broken african states. and they are coming across under the worst and most cruel circumstances and dangerous circumstances. so that is dominating a lot of this. on the american front, jen, you guys have been carefully tracking opinion in the united states. maybe you could say a few words about how do you when you look out on the american opinion environment, we're in the midst of this unprecedented turbulence and we're not sure where it's going to conclude, but on these issues, where does that sit? jennifer: we have been tracking u.s. public opinion on h.i.v., on global health for many years.

i say in general, and there's a lot more nuance in the report, but in general, the public is supportive of u.s. engagement in the world. and we saw that just a few months ago, despite sort of the political rhetoric, a few months ago, that was still the case. we'll still be polling on this. we will report back if that changes because we are still -- the public seems to get that our role in the world of global health, hiv matters. it is morally important. and that is a driver for them. but we have seen two things. one is less attention to hiv among the public. they do not see it as a big problem anymore. they don't see it in the news very much. that is one trend we have observed. we have also observed a growing partisan divide on some of the support. we will report back if that changes because we are still -- the public seems to get that our role in the world of global health, hiv matters. it is morally important. so there still general support but when you look by party identification or ideology there is always been differences, but we are seeing those differences starting to grow more.

maybe not a surprise, but those say to me, the larger climate is spilling into the support for global health and hiv. and also this issue we have all brought up around waning attention. people are not seeing it in the news. people are hearing mixed messages around are we successful, are we not, what do we need? we see that i think in public support. i want to say one thing about, you asked what needs to happen. just a couple of thoughts. i agree that the messaging has been really tough. when i think back, if you think of it this way, the first 15 years of the epidemic, there was really no hope. there wasn't anything that worked. for the most part. i'm exaggerating to make this point. it wasn't until 1996 where there was something that people could hold onto, and it wasn't until 2000 when there began to be achange globally that the epidemic in africa had to be a priority. so for the first half of this epidemic, there was very little

to hope for. then all of a sudden we were in a different place. i think there is a tendency to grasp onto that and hold onto it because it is so important -- but i don't know the best way -- maybe we need to retell the story a little bit. retell it and the dramatic story that there is to tell, i don't think -- we've done it recently in the way people need to hear it. the other thing is, the single most -- there's so many factors that have made the response to h.i.v. what it is and how unique it is. the single factor that is so different is civil society and aids activists. that is the bottom line that is what makes this epidemic different than every other and that's what we need to see. that is going to help change the mood, the trajectory, the importance, is the engagement of aids activists. >> let's open it to the floor. the single factor that is so different is civil society and aids activists. early interventions.

we have two hands here. dean, over in the corner. we're going to bundle together, so hold off. identify yourself. >> my name is anna forbes. i'm an independent consultant based in d.c. i wonder if you could talk a bit more about the significance of abdul kareem data looking at bacterial vaginosis and its effect in heightening h.i.v. risk. we know from u.s. data there is a correlation between bacterial vaginosis and the economic status of given populations of women, especially among black women in the u.s. so doesn't this suggest that improving the economic status and vaginal health among women has a direct or might have a direct effect on reducing hiv risk? >> thank you. and up front. dean? then peter. >> yes, thank you for the illuminating conference.

>> arista. excuse me. yes? >> hi, i'm indy riser, i'm a sociologist and have worked in the developing world. a question about the role of some of the u.n. agencies, the u.n. population fund does a lot of work with reproductive health and maternal health. say a little bit more about w.h.o. ban key moon was there. what about the role of the world bank and the man who's head of it being a physician. what impact has that made? >> thanks for bringing the panel together. it is a real public service to all of us to have this opportunity and thank you to all of the panelists for the great work that you do. a question specifically for ambassador birx but i'm interested in anybody's response. incredibly impressive gains in pepfar and treatment and in circumcision. debbie, you have impressed upon

me about the population growth that's already been mentioned today. that half the population growth by 2050 will be in africa and the population of africa will double in that time. given the great success of pepfar with a focus on targets and data in the rigorous implementation, has there been any discussion or feasibility of bringing reproductive health -- you mentioned this but more close to pepfar in terms of that rigor and focus on data? it seems like such a great challenge and such a great successful model of pepfar. >> there will be another opportunity. we'll get to a second round. we take a fourth one and come back. hear from our speakers and do another round. yes, please. >> my question is, what indicators is pepfar using around gender and hiv? are you using the indicators around gender norms, gender-based violence, age?

and sex disaggregation? how are those playing out? and with the decline that jen talked about with the importance of civil society yet all the groups they talked to in durban from civil society are saying their funding is going down or evaporate. jen, particularly would you comment on that? >> jen, why don't we come to you first. several were directed to you. >> let me integrate them because i think they have a common thread, the four questions. part of the dreams work we're doing is dealing with what you just described, the social determinants of health and meeting the young girl where she is. what does that mean we have to have done? all of our interventions are directed at specific age groups, realizing specific age groups need a different approach. so we have a 10 to 12, 13 to 15,

15 to 19. and for those of you who are pepfar implementing partners, i apologize and don't apologize that we are collecting everything by age and sex and disaggregated so that we really understand who we're reaching and who we're not reaching. it does point out precisely how chris started. we're not reaching the 25 to 35-year-old men who unknowingly are transmitting to the younger women. i mean unknowingly is that no idea what the status is. when you take slim's data any project that across the entire global program, and particularly in africa, 780,000 new infections every year are being driven by that. 25-year-old infecting a 15-year-old who grows up to a 20-year-old who infects her partner in a discordant relationship. that's why 23% of the discordant positives are women.

because they got infected by the age group that is not being measured anymore. now they are 40. this is exactly why you have to bring in the social determinants of health and really meet women where they are. and the first thing young women say to me no matter where i am i want to know how to not to be pregnant. so that is when you really understand that you have to -- you can't approach a young woman if that is her concern. saying, why aren't you worried about hiv? that is how i started it. i asked one in four, you have a high risk. i asked you about how to keep from getting pregnant. that is what i'm worried about. ok, yeah, that's what we have to do, then. we are really working with groups to really make sure that we have all those pieces available to young women. i asked you about how to keep from getting pregnant. that is what i'm worried about.

we have to be honest with young women that try to go to clinics where they are being turned away and told to go to church. we have to understand where we are working and be sure we are dealing with those cultural issues at the same time. all of those pieces in the investments we are making -- this $480 million that has been set aside, it is critical because it is really about prevention. but it is not solely about prevention messages. it is about meeting the young women at their concern level and addressing those but addressing them within the framework of dealing within the community and the families. panel after panel that was there at ias kept coming back to -- we have to work within the cultural framework. yes and no. if girls are being trafficked in their communities and one third of them are being raped, we have

to be berry honest about what is putting young girls at risk and not except that just like we have not accepted gender mutilation as a whole troll acceptable way to go forward. we cannot accept rape in the community as anything but inappropriate. these are the kinds of tough discussions we have to have. young girls are being trafficked within their communities. for many reasons. we are finding those out within dreams. that is what i was talking about when i said the tent has to be bigger. we agree with jen. this is not a given. with the still unrelenting risk to young women and what is putting them at risk and what is putting key populations at risk. this is not a matter of taking the tools and saying they are here, come and get them. it will be a much more difficult road.

that is what we are in together and that is what we have to have solutions for. you said this -- i talk to them and they said this and now we have to fix this. we really are in this together. >> chris, can you speak about the vaginal health. >> it is important to understand that there was a special session put together with three different data sets. if it sounds like we are talking about different things, we are. one was the announcement regarding transmission which showed the age gap. the other was this analysis of the micro biome vaginal flora. it did not show elevated hiv risk. what it showed is a dramatic

increase in the efficacy of the gel. it just did not work for women. they did not get any protection from it. if they did not have a normal healthy vaginal flora. the women who did, the protection was in the 65%-60 8% range. that paper is just about to be released in the new england journal. you can see for those of you who are epidemiological he oriented, the data stays a part. it probably does a -- point to that mechanism. that is partly what we are talking about. the gel, the 1% gel as a topical microbicides remains a tool that we need to understand. the trial was disappointing but this suggests potential he a way

forward. i think that is why it matters. to some extent it is true with the vaginal rings as well. >> thank you. jen on civil society. >> with funding going down -- what about funding for civil society? u.n. a is and some -- u.n. a ids -- the engagement is not there. it has been less than what it has been, it is not an area that has been invested heavily in. how can the global community get a bigger focus on hiv without a strong civil society. there are a lot of ways to engage in civil society. in terms of direct support, that came up at the conference in

durban. it is an ongoing one. going hand in hand with civil society engagement is supporting civil society in a variety of ways. >> while you are getting the next question, let me make a quick comment. we put our dream challenge and it was $85 million. the fact that we got 48% of the new individuals having never received pepfar money. it also caused us to give pause about how we should do the key population investment fund. we will create tiers within that. groups that have never received hiv global fund dollars to compete in their own group. people that have competed for other grants right to the most beautiful proposals. we wanted to be serious in

bringing on additional groups. we are serious about groups doing their application in their native language. >> before we go back to the questions, just one point around who. it is fairly important to think about what the next leadership will look like at durban. i am not sure what public positions he took on any of these matters the fact that he was there was quite important.

he was very engaged. that is promising. there are a lot of decisions that lie ahead on priorities and the way in which it u.n. system is going to be examining its structure and sustainability across multiple agencies in this next time frame. there is a lot of talk about that. i don't know what to make of it. it is beyond me. what that could have an impact on keeping the eye on these issues. why don't we open again for another round. we have two right here. >> good afternoon, my name is anna maria. my question is to the honorable ambassador burks and it is about voluntary counseling and testing. this intervention has been

proven highly effective across sub-saharan africa. two thirds reduced transition -- transmission in hiv infections. also cross deceptiveness and perhaps most significantly cross effectiveness in its appearance to a rt's. my question is -- what is pepfar's -- thank you. >> right here. >> thank you so much for a fantastic discussion. i am very loud that you mentioned the role of collaboration and synergy. when i hear about hiv the one

example that comes to mind is botswana. one of the first places where there be was rolled out. the women they saved they lost to abortion due to lack of family planning or cervical cancer. my question is -- with the changing scenario, do you see of future of the hiv community and advocacy to work with -- to improve health outcomes specifically hiv outcomes? >> thank you. i am particularly proud to learn

from one of the people that attended the conference that they delivered on the objectives of the conference and were able to lend all of these things from those presented here. it seems to me that going forward, we need to think about messaging. we need to demystify the science of this disease. so that it builds confidence in communities about understanding the actual science of the disease. as we do that, i take your point about not talking too much about successes, but at the same time we need to strike a balance that will not instigate fear and therefore lead to stigma. we need to strike a balance. part of that is demystifying the science. there is a conference, the one that comes between this

conference i think if we did a deep reef on that conference, a lot is known it now and a lot still needs to be known. we don't know who may be sitting in the audience. as they get to learn about the science of the disease they may want to fill in the gaps and the science. demystifying the science debriefing from the science like we are doing today would be useful going forward. congratulations to durban for hosting and to you chris for cochairing with us at that conference. >> thank you. [applause]

>> i would love to have a little more information about the postpartum and the retention issues. we have had a lot of success there. >> chris, let us start with you on the science issues. the very important trial data judy courier at ucla is overall the eye. there were several different abstracts and papers presented. you will start to see them coming out. there are several things to say the outcomes were outstanding. there was no question that that worked. the promised concept was a

randomization of a media there be versus the standard of care the critical outcomes were have the challenges that when you're out postpartum, 23% of women were not suppressed. there was a drop off. in an analysis of those women there were several reasons why you would not be virally suppressed. you might have a resistance to the virus. but the most common reason is that you stopped taking your meds it looks as though mostly

women were it here and through breast-feeding and they got the message that they needed to stay on there be through lactation. but there was a big drop-off with weaning. there are a lot of issues there. both debbie and jen alluded to this which is the whole issue of stigma. doing things and through breast-feeding and they got the message that they needed to stay on there be through lactation. for your baby and a healthy outcome is culturally and socially supported. but if the baby is healthy and doing fine and you're not breast-feeding, why are you still on those meds. you get into a different dynamic of disclosure. and those challenges are out there. i think promise points to the power of early initiation therapy and why that is so important. but also the challenges with uptick. this is a change for us. we started in the early days -- we tested everyone, and people will remember that if you had an

aids to finding illness, to get therapy. in burma there were so little treatment sponsor they went down to 150. people had to be advanced immunocompromised before they could start. that turns out to be bad medicine. early initiation of there be, -- therapy, getting rid of the idea that you have to stage people and say if you are living with hiv you should be offered immediate treatment. reduced county. the ultimate endpoint we all care about and reduced morbidity and malignancy and tuberculosis. it really worked. the problem is now you are talking about offering daily lifelong therapy to people who are healthy and asymptomatic and have never had an aids complication and have 800 or thousand cd4 is. it turns out uptake is lower. in promise when women were

offered immediate there be the uptake what changed is while they were well into it and enrolled several thousand women, the data came out. now you have the evidence you really have to offer everyone therapy. what was the uptake? here's the data that you should start there. 66%. one third of women diagnosed with hiv pregnant or recently delivered offered immediate therapy in a setting where there were a lot of services. a lot more than most clinical settings. still a third of people said no. that's a big problem. >> what pulls a couple of the questions together is this, if you think about messaging, imagine what we have done over the last 15 years. we just talked about the index cases in most cases are the their cd4 is lower. the young young women.

men who were more recently diagnosed, their cd4 is higher. for the last 10 years we have been saying, woman, if you are pregnant or you have less than 500 cd fours you need to go on treatment. the site of the man, you are fine. you don't need anything. that is a very confusing public health message particularly when you want couples supporting each other in retention and adherence. now through start and promise we have a new opportunity where we all can say the same thing. if you are hiv-positive it is detrimental to your health and you can transmit the virus to others. that is a single message. it doesn't matter if you are 2-year-old, 15 years old, 85 years old. the message is the same. it is not dependent on a secondary message. that allows us to be much more effective. it could result in what was brought up another question, some gender-based violence in

other pieces, women could not understand they had the same disease but weren't offered any treatment -- when men could not understand they had the same disease but weren't offered any treatment. we are working equally hard on trying to find men and getting them engaged. one place we know men and women are all the time or at least every sunday is the church. going back to churches and saying it's really important for everyone in your congregation to be tested and have access to treatment. we're going back to the faith-based community and saying help us tackle this problem of a lot of men being undiagnosed. we can't start going to every bar for every gathering place for farming convention to find men. we have to find them in a much more effective way. this really gets into how important leadership is. president bush started pepfar but also what i to think ribbon,

red ribbon for cervical cancer. that has been a big investment that pepfar has been supporting and cervical cancer prevention. primary and secondary convention and test treat for women that are positive. i think it also illustrates the importance of secretary clinton bringing in the gender-based violence piece. she started on this violence against children survey. we only got two done while she was just secretary of state. we had not done 11. what is been enormously consistent is -- in their lifetime experience, this is asking 24-year-olds, 40% plus experience sexual violence. this is an issue that we really have to combat if we are going to end this epidemic.

we really do need everybody at the table. thank you for talking to mystify the disease. i got a call on you now to do what those global health diplomacy pieces we talk about let's have this discussion with. the diplomatic corps here about the realities of hiv and help them write the cable's home so they can get the prime minister's and let's do that together. that is on us and we have a thank you that was a perfect mechanism to do that. question. >> thank you. one more round. we will come back and then move towards final thoughts. >> i'm with hhs office of global affairs.

my question is focused on the general decline of donor support. i was piggybacking on the botswana situation. with the increasing role of the private sector in africa, what is the role of the private sector? how was the reception at the conference? what are some issues to look for moving forward? >> right behind you. >> my name is event gonzales -- we see rising epidemics of syphilis and other sti's. in the future, are we looking at changes in education, awareness? is there going to be funding surrounding those changes in behavior?

>> thank you. >> david bratton with results. durbin was an unforgettable experience particularly coming back to what jen was saying about the power of activism on display. absolutely extraordinary to see that motion. one of the things it exciting for me was the recurring theme of the enormous risk that people living with hiv are facing because of tb. i had this experience, i was handing out stickers saying where's my ipt? and i would get again and again people saying, what are you talking about? this is a really important daily antibiotic to help people living with hiv against -- protect against tuberculosis. this is super important.

what can we do to get more tb c? where are we in terms of pepfar tracking the implementation of ipt? >> thank you. any other hands? >> hi, krista johnson from howard university. i wanted to know about and the role traditional healers traditional health systems played in the conference and how that was highlighted. i would have expected perhaps now would be the time that we would see more of a coming together of the scientific community, the western scientific community and traditional health systems. >> could get him the microphone over here. then back to the speakers.

>> i take the point about reaching men and would suggest or perhaps get a response on the possibilities of expanding hiv prevention in the workplace. >> thank you. start with you chris. we will move down the line. >> quickly to respond to that, search has a focus on doing that precisely. trying to get the men where they are. so much of our success was built on the maternal child health platform which just doesn't speak to men. that was something that we really need to rework. i would say that traditional healers have, if they had a voice mostly it was in the global village and the cultural competency context. very are important allies. i will say in south africa there is a bit of a challenge because that is a country that went

a through a long period of denialism. there were a lot of nonscientific herbal remedies put forward that were not remedies. we know they are important cultural allies. you really have to balance that. beetroot doesn't work and antivirals do. that was the reality that we are dealing with. something i think we need to be mindful of in terms of the global fund and beyond africa. a that is that this issue of the funding gap and concerns about the global fund have a particular relevance for middle and higher income countries. it's different because that's where we are even more worried. and what you are seeing is as the global fund has withdrawn from a number of those countries

governments are not picking up a the programs that really are essential for their epidemics. by that i mean harm reduction. methadone. substitution therapy. eastern europe, central asia particularly russia and ukraine is where hiv is expanding most rapidly in the world right now. the withdraw of those resources is playing a very important role. more it's very appropriate that that has been the focus of our conversation today. you should not forget that it is a pandemic and it has hotspots that are really in trouble. i would add that this is a major focus for us for amsterdam 2018. that's where the next conference is going to be. in our first conversations with the dutch when we were making a decision between amsterdam and san francisco, apologies folks here. this is one of the issues they raise.

western europe is doing great in its hiv response. eastern europe is deeply fraught. over they were interested in helping with that problem. you are going to see more of that and you are going to see that focus coming forward in amsterdam. they have already appointed a special envoy. they have people working in the region trying to outreach. they are going to invest in a significant way. >> we have been very privileged in getting a lot of private sector support in our key a initiatives. dreams is taking advantage not only of incredible wisdom the private sector is giving us on how to create a brand around young women that people cherish and value but also their insight into how to sell things to young or into how to sell things to young women because we want to sell a wellness message. we want to sell a message of empowerment and that has been very exciting to us and they in very exciting to us and they have been financial supporters whether it is johnson & johnson

that they get foundation. that has been really central. we have several other public-private partnerships that are really key. an important piece, we just of this great piece. it really put it out some of the issues with that. particularly if they are one-off. how do you convert that into really investment into those programs and countries for that long-term and what should that look like and how do you achieve that upfront? this is exciting. i think dreams gives us the opportunity to do that. ipt, we had a terrible ipt you are indicator which ended up just people ignoring it. we are going back to the drawing board because we think you don't manage what you don't measure. we have to figure out how to measure this in a way that is

relevant so we can really tell where the gaps are. we could not agree more. traditional healers, we have really used traditional healers in the rites of passage and voluntary medical male circumcision. they have been extraordinarily helpful in demystifying why voluntary medical male circumcision is important and understanding how it is not how threatening their right of passage. it is a rite of passage that can still be accomplished but let's get medically correct. they have been really helpful in all of that. we are doing a lot of hiv prevention in the workplace but we still have a lot of men in very informal work situations and we are trying to figure out how we reach them. in many of the countries botswana being one of them obviously people are crossing borders to go to work. in most of the public health programs in the work place they are funded by the government.

governments have been really open to providing cross-border support to those individuals and as a providing art and other things in the workplace. i think that is important. governments have really stepped into that gap and have been very good partners with that. >> i would add one thing on the private sector engagement. the private sector has been engaged and important in the global hiv response for quite a long time. for the majority of the years. especially if you include foundations and companies. pepfar has numerous examples of how the private sector has been able to do innovative things. just being realistic about what that means. what is the private sector realistically going to do? i still think the role in general is to provide innovative pathways that can be taken up by governments, supplement, fill in gaps. i'm not sure it is the answer to

the bigger problem we are facing. >> we are getting towards the close. i'm going to come back to the three speakers to close with just a minute. about what you think, how you think durban will be remembered. what will be the signature terms that people have in their minds when they think about this? you were the maestro, chris, so you have the closest grasp and you have been involved for many years. what do you think is going to be distinct and different? chris: first of all you have to say how transformative the global engagement around hiv say how to informative has been. we cannot escape the narrative that when we were all there in

2000 we were looking at a human moral quandary of available therapy that was unavailable where it was needed most and had an incredible impact on human life. this movement turned that around and it really is extraordinary. in durban we celebrated 17 million people worldwide on antiviral therapy. that is a huge achievement and the scientific achievements have been extraordinary. we all gathered understood that it really is a different world. and we are less than half way there. what we really wanted the messaging to be around this conference and i think we achieved it was to try and regalvanize and re-energize the

movement around saying we're not done. this is not over. we have an extraordinary road to go and we need the world to keep focused on the success and the amazing achievements we have done so far together as a community and don't take your foot off the gas. >> thank you. deborah. deborah: i think it will be remembered for the stock taking reality of knowing where we have been successful and where we have had this huge gap. 50% on treatment but less than 85% of young women reach with prevention. we have only had a 15% decline in new infections in young women. the hopeful thing to me that i think will be remembered and i want to thank everyone who put this together, to have jake glaeser there. to have the elizabeth taylor grandchildren there. to have prince harry the son -- there. together saying we have to address this.

to have nelson mandela's grandchildren there and say, we are willing to step up and carry that torch. i see sandy sermon was the head of the u.s. delegation in 2000 to durban working for president clinton. we are getting older. [laughter] it was encouraging to see the next generation willing to step up because we are not talking about something that is completed in five years. we are talking about something that's going to take us at least 15 years by the model. that means we still have 25 million people who will need treatment for the next 50 years. we are talking about a century to really understand how to end the whole disease. seeing the next wave and seeing their passion like their mothers and grandmothers had was just very thrilling to me because you want that passion carried in the same way. that's why the rest of us get up every day and don't sleep because we know that this has to be done and to see the next

generation, it may have skipped a generation but close to the next generation step up and they we are happy to carry that torch with you gives me great hope. >> you get the last word. >> i would just add, it will be remembered for extraordinary african engagement. maybe it was not always leadership, but a lot of civil society participation and scientific participation at a level i did not ever experienced. that's incredibly powerful. that was one. the wake-up call, the message that this isn't over. this is what durban to be remembered for. the third thing was there's incredible science out there and we need to go back and

retranslate it for people. what do we know, what don't we know, what are the barriers. the last few years since 2011 have been unbelievable. we need to document that in a clear way for people to understand where we are and what the potential is and the risk of not going forward. >> this is been a really rich and invaluable. you're on your debt. i want to thank everyone who has come into my post for the past few hours and joined in this. chris, deborah, jennifer congratulations on these outcomes and the way you shape them. thank you so much for coming and sharing all of this. they join me in thanking the speakers. [applause]

>> next, live, your calls and comments on "washington journal." then "newsmakers" with green party candidate jill stein. then the discussion of the impact of the presidential campaign of vermont senator bernie sanders.

tonight on "q&a," virginia professor james robertson discusses his book "after the civil war: the heroes, villains, soldiers, and civilians who changed america." >> state allegiance was very deep. it went as far back as generations. i think one has to keep that in mind. slavery is without question, the major cause of the civil war. you can explain the actions of good, pious men. they fight because virginia need them, not because they support the confederacy, because they did not. >> tonight on "q&a." this morning former new york lieutenant governor betsy mccaughey talks about donald trumps strategy. eric morath looks at the rising cost of childcare in the u.s.

and karim mezran talks about libya. "washington journal" is next. ♪ host: for those who would like to occupy the oval office, a new poll has hillary clinton leading donald trump by eight percentage points. this also blends in some third candidates. the green and libertarian, so they combined to be 12% of the potential vote in the "washington post" poll. this leads to our question -- are you considering a third-party candidate? who is it, why, what are you not seeing in the other folks?