 Today at CSIS we had a conversation with Jeff Crowley, Director of the White House's Office of National AIDS Policy. Jeff came to tell us about the new U.S. government strategy to approaching the HIV AIDS epidemic in the United States. You know, HIV first surfaced in the U.S. more than 30 years ago. Today there are a million people who are HIV positive in the United States and 55,000 new infections every year. Jeff came to tell us about the strategy and specifically its goals of reducing those new infections by 25%, expanding access to care and treatment, and better addressing the needs of those groups that are at highest risk of acquiring HIV. In the course of this afternoon's discussion, we heard from Jeff about both the challenges and the opportunities that the new strategy presents. Good afternoon, everybody, welcome. We're delighted to have you all with us. I'd also like to welcome our audience that's joining us via webcast this afternoon. I think most of you know that here at CSIS we tend to focus mostly on global health and less so on domestic health issues. That's been particularly true in our HIV related work, but it certainly doesn't mean that the issues in our own country are any less compelling. This year marks the 30th anniversary of the diagnosis of the first cases of HIV AIDS in the U.S., and there are now more than a million Americans who are HIV positive. A new infection occurs roughly every nine and a half minutes and HIV prevalence here in the District of Columbia is higher than it is in many African countries. So clearly, even as the U.S. has emerged as a global leader on HIV in other parts of the world, there are critical issues that we also need to address here at home. This past July, President Obama released a new national AIDS strategy that calls for a 25% reduction in new infections over the next five years, commits to expanding access to treatment and care, and resolves to reduce disparities in communities where the need is greatest. The strategy was accompanied by a federal implementation plan which tasks government agencies with developing specific operational plans by the end of the year. The person leading this effort is Jeff Crowley, Director of the Office of National AIDS Policy and the White House's Senior Advisor on Disability Policy, and we are enormously lucky to have him here with us today. Let me say a little bit more about Mr. Crowley from 2000 to 2009, he was a senior research scholar at Georgetown University's Health Policy Institute, where his primary areas of focus were Medicaid and Medicare policy issues as they impact people with disabilities and chronic conditions. Prior to this, he served as the Deputy Executive Director for Programs at the National Association of People with AIDS, and he has also had international experience serving as a Peace Corps volunteer in Swaziland from 1989 to 1991. Mr. Crowley, we're very fortunate to have you here with us today, looking forward to hearing from you. Thank you. Thank you, Lisa. Good afternoon, everyone. So, I was very excited to actually come here today because this is sort of a different audience for me, and we believe that this strategy is an important opportunity for the country, so I'm happy to have this chance to talk to you about it, but I'm also eager for the questions because with your global focus, the direction might be a little different, and so hopefully it'll be a stimulating discussion. So, President Obama made a commitment actually during the campaign to developing a national HIV-AIDS strategy. This is in response to a request or pressure from the HIV-AIDS community that he do so, and when I was appointed, he tasked my office with developing this strategy with three goals, reduce HIV incense, increase access to care for people living with HIV, and optimize their health outcomes, and reduce HIV-related health disparities. Now, we released this strategy in July of this past year, so from the time of the President's inauguration through this past July, it was actually a pretty busy one for our office. We had, I think, a pretty robust process. I started on the job and spent a long time just individually listening to different people in the community, what they thought and recommended, but we also held a series of community discussions across the United States, and I think the AIDS community said initially they wanted us to have two public meetings, and we actually held 14. So, all across the country, east coast, west coast, so the sort of traditional epicenters of the epidemic over sampled the south, because we know there's growing rates of HIV in the south, got to the territories, and really tried as much as possible, listened to Americans from all walks of life about their ideas about what we need to do. We also had an online process, so we allowed people to submit recommendations to us, and we got about a thousand that way. This past April, we actually published a report that told people, not what we thought, but sort of our effort to synthesize what we heard over and over, and I can tell you that it's actually fascinating, having done 14 of these meetings, you get a fairly clear sense of what are the things you heard every single place you went, and every place there's at least one or two ideas that you only heard that one place, and just sort of reflect on why are things different there. It was a very encouraging process because I think there's a lot of people in the community that have remained engaged with us and worked really hard to get good turnout and make sure that these sessions were as productive as possible. Now from there, we also convened a federal interagency working group to really pull together the expertise across the federal government, and as a former advocate sometimes, I think advocates need to reflect on the fact that we have a lot of people in the federal government that have committed their lives to this epidemic and are working really hard and really wanted to get the diversity of their experience. So it wasn't just HHS, but certainly HHS was engaged, but all relevant parts of the government were involved, and we started working with them intensively last December through May or so as we developed the strategy, pulling it together, both synthesizing what the public told us, giving their own recommendations, testing out ideas, and so that was an important part of our process. So the vision of the National HIV-AIDS Strategy is that the United States will become a place where new HIV infections are rare, and when they do occur, every person, regardless of age, gender, race, ethnicity, sexual orientation, gender identity, or socioeconomic circumstance, will have access to high quality, life-extending care, free from stigma and discrimination. And so that's what we hope the strategy provides a roadmap for moving us to the place where this is the reality in the United States. So when we released the strategy, we actually released three things. There is the National Strategy here. Anybody that would like to read it can get it. It's available at the White House website, WhiteHouse.gov forward slash ONAP. But probably the easiest thing to remember is to go to AIDS.gov, which is a website maintained by Health and Human Services, and they've worked with us jointly. There's a lot of information about the strategy there that you can get. So when we released the strategy, we really put out three things. The National HIV-AIDS Strategy itself, which really provides the vision and the roadmap for the country. And again, if there's one thing I can say that I have to keep repeating and I can't say enough, this was not a federal strategy. It was a national strategy. So we think there's an important role for federal leadership, but this is really about what all parts of our country need to do to move us forward. The Federal Implementation Plan gives specific actionable steps that we're gonna have the federal agencies try to accomplish both this year and next year. So FY, excuse me, calendar year 2010 and 2011. And it's really our hope that we can demonstrate a new sense of urgency. It's not business as usual, and these are the specific, some of the specific things that they're gonna try to do. But to ensure that this isn't just a great process that ends when the strategy came out, or once people have sort of looked at it, that that's an ongoing thing, the President also issued a presidential memorandum when we released the strategy that called for a number of things. He said that me and my office needed to be responsible for coordinating policy across the federal government, but he's also tasked me with reporting to him annually in our progress and meeting the goals of the strategy. But he also did a couple of things. He required lead agencies to designate lead individuals. So again, at an agency like HHS, there's one person responsible for recording all the efforts within their department, provide for annual reporting, ongoing reporting and monitoring, but also he directed that within 150 days that they develop detailed operational plans for their department. So the lead agencies are Health and Human Services, Housing and Urban Development, Department of Justice, Department of Labor, Veterans Affairs and the Social Security Administration. So all of those agencies are working on their operational plans and they're due to me and the Office of Management and Budget on December 9th. He also called for specific actions by other federal agencies. So the Department of State is working on a report for us to talk about how they're gonna implement the National HIV-AIDS Strategy in the context of the healthcare programs operated by the military. We've asked the Equal Employment Opportunity Commission to look at issues around HIV-related employment discrimination and come up with recommendations for expanding employment opportunities for people with HIV. And perhaps for this audience, most significantly he directed that the Department of State provide a report on lessons we've learned from the PEPFAR program and how can we apply successful lessons to the domestic AIDS epidemic. So now I'd like to talk to you. I mentioned the President's Strategy had three goals, reducing HIV incidence, increasing access to care and reducing HIV-related health disparities. I should tell you up front that we added a fourth goal. We said to really be successful at meeting these three goals, we needed a fourth goal which is about improving government coordination. So our approach in writing the strategy was that it wasn't a laundry list. We've maintained a strong response going on 30 years. We think that the federal government does a lot of things right and our country does a lot of things right. So we did not try to recapture all of this. What we tried to do is reflect in 2009, 2010 and say what are the small number of steps we need to take as a country to really sharpen our response to the domestic AIDS epidemic. We came up with three steps. We need to intensify our prevention efforts in communities where HIV is most concentrated. We need to prevent HIV infection using a combination of effective evidence-based approaches and we must educate all Americans about the threat of HIV and how to prevent it. So we're really saying that unlike in some countries in Africa where there's a generalized epidemic, we have a series of small number of concentrated epidemics in this country and we need to shift our focus in prevention to focus on those concentrated epidemics. But we also need to really get serious about saying that there's no magic bullet. We're not gonna, condoms aren't a magic bullet. You know, drugs aren't a magic bullet. There's not a vaccine on the horizon but we need to be smart about using all of the tools we have available to us and putting them together in the most effective ways and that's something we're focused on. But again, if we're concentrating effort to high-risk communities, there's a basic question. What do all Americans need and deserve? And that is we think that all Americans need to be educated about the threat of HIV. One of the things that we could reflect on is some basic measures about knowledge of HIV or even fear have remained unchanged. You know, the percentage of people that think they can acquire HIV casually through toilet seats. It's been at the same place for, you know, a couple decades now. You know, so we need to refocus on just some basic education. Now, another thing about this strategy is that we identified a small number of concrete metrics that we're gonna measure progress in. The first of these for prevention is we, within the next five years, we hope to lower the annual number of new HIV infections by 25%. We can talk about this later, but you know, some feedback was is this strong enough, is it not strong enough? I think this is a very aggressive target. I think it's in the realm of reality but it's gonna take very significant, perhaps unprecedented efforts, not only from the federal government from a lot of stakeholders to keep this, to reach the school. And I'll say a little more about this in a second. Also, to really help us get to this 25% target, we set a goal of reducing the HIV transmission rate by 30%. So that's from going from five persons infected with HIV per 100 people living with HIV to 3.5 persons. And then also tied up in all of this and reach areas in schools, is increasing knowledge of serostatus. Because we know that most people living with HIV actively take steps not to transmit HIV. So the more people we have that are living with HIV and don't know their status, the more likely we're to see transmission. So we really want to increase knowledge of serostatus from about 79% to 90%. So just to give you some sense of the challenge we're faced, this graph shows at the bottom is the annual number of new infections. And so it shows that we went up in the mid 80s to about 130, 140,000 infections per year. And we've fallen down to around 56,000. It's remained relatively flat. So you can look at that two ways. It's a great success that we've dropped annual infections from 130,000 to 56,000. It's also a great success that we've maintained this level, even as you see the bar above it, number of people living with HIV. So there's a lot more people living with HIV and potentially able to transmit HIV. But yet we've managed to keep the annual number of infections low. But it's also challenging and it's a problem that HIV incidence has remained flat. And 56,000 is just too high and we need to get serious about lowering that number. Now I recognize when I put together this slide that this would be a challenge to read, but I felt it was important that you see these two figures in relationship to each other. The first one on the top is data from the CDC of the number of annual infections by high risk groups. Now these nine groups together represent 85% of all new infections in the United States. So moving from left to right, white gay men, black gay men, black heterosexual women, Latino gay men, black heterosexual men, white heterosexual women, Latinas, black male IDUs and female IDUs. So to some extent if we're gonna cut HIV infection by 25%, we've gotta go where the numbers are. So you'd really be drawn to those high bars on the left where there's just large numbers of people acquiring HIV each year. The figure below that shows estimated risk for HIV infection and again it's the same numbers but adjusting for the population size. So again if you look at these numbers, white gay men, you can't see it, it's 344 infections per 100,000 people in the population. Elevated risk compared to a lot of these other groups. Next to it off the charts is black gay men. So they're at 1,710 per 100,000 infections. So again if we wanna lower HIV infections, again you go with the top figure because that's where the numbers are. But let's say we wanna focus an initiative on gay men for example. White gay men are at high risk but black gay men are at much higher risk. The figure for Latino gay men is also very high. I think it suggests some areas of relative emphasis. Similarly if you wanna look in the black community, thankfully really focus a lot of effort recently and recognize we have a very concentrated epidemic among black Americans. But if you look at black gay men, the second bar compared to the third bar, black heterosexual women, they're both high risk groups and they both contribute a lot of numbers, new infections you see on the chart at the top but relatively speaking this chart would emphasize that we need to really focus on black gay men. You could also look at the bars that are off the charts. Those are black, male and female injection drug users. So again very high relative risk but they also contribute relatively fewer annual infections. So again all of these groups we would say are high risk groups that merit attention but as we're focusing our efforts we think this is important information to give us some sense of where we should target our efforts. The next key goal relates to increasing access to care and whenever I talk about this obviously the strategy was released after the president signed into law the Affordable Care Act and nothing we do in the strategy is more important than the enactment of the Affordable Care Act as far as expanding access to insurance covers for people living with HIV. That's critically important and so our focus in the strategy was not to replicate that or spend all our time talking about the Affordable Care Act it's really to say okay that's what's happening for everybody, the fact that we're gonna expand Medicaid to all low income people up to 133% of poverty is gonna give a lot of people with HIV access to insurance coverage. So what do we need to do to build upon that? And there's, I should tell you just for the text I have two slides here and I should also make the point that action step one and targets they're not linked. We should just think about, we have three action steps and then three targets. So the first one is that we need to establish a seamless system to immediately link people to continuous and coordinated quality care when they're diagnosed with HIV. So the idea here is that in recent years we've spent a lot of time scaling up access to HIV testing and that's really important but perhaps our weak link now is once we test people and identify people living with HIV we need to strengthen our systems to immediately get them into care and retain them in care. The next key step is that we need to take deliberate steps to increase the number and diversity of available providers of clinical care and related services for people with HIV. So we have a great HIV workforce but it's under stress and in the future we're gonna need more providers or we're gonna need more diversity providers and if we don't take deliberate efforts now we're not gonna produce that workforce we need in the future and we need to focus on that. And then the third key step is that to improve clinical outcomes for people living with HIV we need to recognize that people living with HIV have high rates of other co-occurring health conditions and they're also challenged in meeting basic needs in life such as housing, having enough food on the table and we have to take a more holistic approach to be effective at meeting their clinical care needs. Now the targets we set for increasing access to care are really about increasing the portion of newly diagnosed patients linked to clinical care within three months of their diagnosis. So we wanna go from 65% to 85%. We also wanna increase the proportion of Ryan White HIVAs clients who are in care and that means at least two visits for routine HIV and medical care in 12 months at least three months apart from 73% to 80%. Now I will tell you that we care about all people living with HIV not just people in the Ryan White program but we have some data challenges. The Ryan White program is where we can measure this. So really this is a proxy for what's going on in the broader system. It's not that we're focusing only on those clients. And then our third target for increasing access to care is increase the percentage of Ryan White HIVAs clients with permanent housing from 82 to 86%. And again our goal is to increase access to housing for all people living with HIV but we don't have a good way of measuring it outside the Ryan White program. Now our third key priority or goal for the set by the president is to reduce HIV related health disparities. And we have three recommendations or key action steps there. The first is that we need to reduce HIV related mortality in communities at highest risk for HIV infection. We need to reduce stigma and discrimination against people living with HIV. And I'll tell you, as a season aids advocate this was the thing that struck me most when I traveled the country is just how pervasive stigma and discrimination are for people living with HIV even today. We've made a lot of progress but we still have a ways to go. And perhaps the big idea here is regarding disparities is that we need to adopt community level approaches to reduce HIV in high risk communities. So I think we have a lot of good approaches that work on an individual level but we really need to see community level impact. Instead of reach those action steps we've set some targets. We need to increase the proportion of HIV diagnosed gay and bisexual men with undetectable viral load by 20%. Same thing, increase portion of HIV diagnosed black Americans with undetectable viral load by 20%, increase the portion of HIV diagnosed Latinos with undetectable viral load by 20%. So here, this figure just shows HIV diagnoses by race ethnicity. And there's just a couple takeaways you can take at this. You don't even need to understand all this. You can see on the left the bars are off the charts. Blacks on the left, first blue is black males and red is black females. And then Latino males and females significantly higher than other population groups. So it just shows we have a very significant disparities. And this is on the basis of race ethnicity but you could look at it on the basis of risk factors and other criteria. Now to be successful at these goals that we also said we need to improve our government's response to HIV. And we need to increase coordination of HIV programs across the federal government and between federal agencies, state, territorial, local, and tribal governments. And we also, and I think this is critically important, part of the rationale for a national HIV aid strategy is that we need to refocus attention on the domestic epidemic. We need to develop improved mechanisms to monitor and report on our progress toward achieving national goals. So if we're going to keep the American people engaged, we've got to keep telling them what's going on, what the challenges we face, but also about our successes as we reach them. So this figure here is just important to show that for 30 years, as I said, we've maintained a strong investment in HIV AIDS. I'm not going to explain this, but those in FY 2010 will spend roughly $19.5 billion in response to the domestic AIDS epidemic. About half of it is on the left side, Medicaid at the top, Medicare. So about half of our federal investment are the entitlement programs that provide health care, but significant investments for the Ryan White program, NIH research, comparably smaller investments for CDC, significant investments for Social Security provides income support. But we also have important investments at Department of Veterans Affairs, HUD, Defense, OPM. So now, what's next? We released a strategy in July, and this is just a beginning. It's a roadmap. And so what we really hope is when we look back in five years or more, we can see that the strategy led to some real measurable progress, that we made progress in meeting our goals. How are we going to get there? So as I described with the presidential memorandum, the president directed lead agencies to do things, and they owe us operational plans on December 9. The president's budget for next year is under development. And one of the things in the presidential memorandum is also directed that agencies, when they're developing their budget request, consider their priorities of the strategy and ensure that their agency budget request reflect the strategy's priorities. My office will be working on a process and a template for both collecting data from the different agencies and providing an annual report on how we're doing. The Presidential Advisory Council on HIV and AIDS, or PACHA, has been tasked with supporting implementation, but also to serve as an external monitor. But again, those are what the federal government's gonna do. We also need other entities to do their part. So we've been talking to the private sector about public-private partnerships, and we think there's a lot of exciting things that can happen there. We need to see state and local implementation activities, and we need community stakeholders to support implementation and monitoring. And with that, I will thank you, and I will turn it back over to Lisa. Thanks very much for the overview, and I know we're gonna have a number of questions, but I think maybe just to get us started, I'll put one on the table. And that is, I was fortunate enough to be in Vienna at the International AIDS Conference when you presented the strategy there. And I have to say, I think one could sort of feel the excitement in the room when you laid out the scope of what was being planned and what the aspirations are. And there was great anticipation that when the conference comes here in two years to Washington, D.C., there's gonna be a lot of good news to report. So I'm wondering if you could say a few words as you look ahead over the next two years, which admittedly is a short time frame to discuss some of what you've talked about in your PowerPoint. What are the areas you hope to make the most progress on over the next two years? And what are the areas where you see the greatest risk that you think are gonna be most problematic? Sure. Well, I think the first thing I'd say is, we came up with the strategy that's intended to be and set metrics for five years. And some of these things, it's gonna be hard to see progress in one or two years of time. So I mentioned that the annual infection rates has been relatively changed. So these measures aren't that sensitive. So it's not like we've seen, if we say we have 56,300 infections annually, it's not that we say, oh, in 2008 there's 56,400 and 200. That's not an average. We've just had a, so it's not a real sensitive measure. But if we're gonna see progress, it's gonna take longer term. Hopefully we'll start to see some budging of that. But more than some of these specific metrics, what I hope to see is that we lay out a vision. So we say that we need to focus on the population at greatest risk. I hope that people can start to see some tangible progress there, both in initiatives that have underway, but also looking at funding and how that works out. I hope that if this is a roadmap that's something for the federal government to do, people can also look back and say, oh, because of this strategy, there's new things happening at the state and local level. So it's not all about what my office is doing or even what the federal government is doing, but that we're all moving with a collective vision that we need to focus on these populations at greatest risk. Again, to focus on prevention. If we need effective combinations of effective tools, we do a lot of innovating experimentation. We figure out what are the best combinations and we try to move to scale those up. And those are the types of things that I think we can see some progress on. With access to care, I'm expanding linkages. I'm not saying we can resolve all this, but I think just like we scaled up testing in a relatively short period of time, there's a lot we can do as far as taking steps to immediately link people to care or new initiatives if people fall out of care, how we get them back in and maintain them in care. Great, thanks. I mentioned when we started, we also have a web audience that's joined us and they send in questions ahead of time. So there actually is a question that when I heard you describe the consultation process you all undertook in developing the strategy, I think this question is particularly relevant and it actually goes to how you envision seeing civil society and community groups engaged as the strategy unfolds. And particularly actually the terminology used here was engaged in a way that can help keep the strategy implementers accountable. So maybe a few words on how you envision continuing that type of engagement with community groups. Right, so as I mentioned when we developed the strategy we took input and recommendations from the community. The agencies are developing their own operational plans. They've met with different community groups and had significant engagement. PACHA is an important entity to help monitor progress. And so we will be meeting with them regularly. We've already seen that they've been asking the agencies tough questions just about what the baseline is about how money is spent. And so I think things like that will continue. But you know at the federal level I do think there's a role for we've laid out some specific metrics and people push us and we've said we're gonna do certain things. And I actually think we've put out more specific things that we say we're trying to do than we could realistically achieve. And I'd rather do that than say we're only gonna promise the safe things. But you know if we don't meet every goal and if they're important things I think there's a role for outside groups to keep pushing and say hey you said this is important when are you gonna get to that? So I think that kind of impression is important. But more than anything I think we've demonstrated that it's a new day at the federal level. I don't know what's going on at the state level. I don't control what's going on at the state or local level. So I also hope to see a lot of new energy closer to the ground where people can say okay we have a roadmap from the federal government. How can our state do our part? Let's take some questions from the audience. I'll ask you please to identify yourself. We have some mics that will be coming around and we'll take the questions maybe in groups of two or three. So I think I see, I think we're getting a mic but one question right here. We talked about engaging with PEPFAR, taking account of what lessons they've learned and what you saw as the overlap between an obviously international program and the national strategy you put forth. Sharon, so that, you said that. Well, as I mentioned we had an interagency process of people from across the government and the Office of the Global AIDS Coordinator was very much engaged. I'm interested to see what they come up with. They always this report and it'll be a detailed plan and thinking about that. But I've had my own conversations with Ambassador Goosby and others and some of the things that we think are really relevant is their experience and work in resource poor environments. We may not like to admit it but there are a lot of resource constrained environments. We're challenged in providing services in rural areas and just how they've overcome some of that. To some respects the PEPFAR program had the luxury of sort of scaling up or build whole systems from scratch. How they do things are a little different when we have programs where our prevention programs are funded by one program and even in the care environment. We have the entitlement programs, discretionary programs, but I think looking at how the PEPFAR program navigated that in some ways from scratch, I think will be helpful to see if there's ways that we can overcome some of the challenges. But again, I'm waiting to see what they come up with for us. Other questions, please. Thank you. My name is Lea Idelson. I'm from the Center for Interfaith Action on Global Poverty. And I was just wondering if you could speak to how, if at all, your strategy incorporates the use of faith leaders in this country to speak to prevention and treatment to their communities? Well, you know, faith leaders are very important. You know, we sort of have a litany of all the people that we care about, you know, business, faith, researchers, and so each of those are important. So I don't want to say any one entity is uniquely important, but I can say that as we travel the country at these 14 community meetings, we had faith leaders there. Some places that I went to, quite frankly, were different than others, but certainly in the South, we heard not just that people wanted faith leaders engaged, but really people saying that a preferred way that a lot of some communities want to receive their HIV services. And I think that we, again, learning from PEPFAR, we've seen a lot of leadership on the global side. Now, there are some challenges. We know that, you know, a central recommendation of, you know, if we're gonna focus on populace and greatest serious, I should say that we identified four in our strategy, gay and bisexual men, black Americans, Latino Americans, and substance users. Certainly with gay and bisexual men, but even, I guess, with substance users. Not all faith communities have been as welcoming and some people are at different stages. So I think we need to navigate some tough issues, but I think we've seen both domestically and globally, there's, the faith community has a unique capacity and important role in responding. I think Catherine Bliss here at CSIS. Just a question, you know, as you look forward to the conference in, I guess, July or the summer of 2012, just wondering if you could say a little bit about your office's plans for being engaged at that international conference and highlighting leadership, community involvement and the achievements of the national strategy, you know, in the context of the international conference. Sure. And I think there is another question right there as well. So I just think it's one way. Yeah, go ahead. There was your question, please. Okay, I'm Stephanie Olson and I'm with a company called SAIC. We're an IT developer of the systems that collect the Ryan White program data. And I was curious as to how the target targets in your presentation, as well as the findings and target groups will affect the Minority AIDS Initiative program and if there's any special work that you're doing with them since the findings show that those are the groups that have the highest need right now. Sure. So the first question is about sort of the 2012 conference. I'd say that, you know, I think everybody recognizes that, you know, the conference is coming. It's possible to come to the United States because we eliminated the HIV entry ban. That's something that was a high priority for President Obama, but that process started under President Bush. So it's really a bipartisan thing. But once you get past the decision, so it's possible for the conference to come, I think the Obama administration, we made a conscious decision that we wanted it to come and we see it as an important opportunity. We've, you know, reached out and worked with the IAS. In fact, about a year ago, on November 30th of last year, we announced with the IAS at the White House that the conference would be coming. So it's an important opportunity. Greg Millett, who's my senior policy advisor in ONAP, is a member of the conference coordinating committee, the central group within the International AIDS Society that's planning the International AIDS Conference. But we're also planning to tap into leadership again across the federal government, both domestic and global leadership. I do think that, you know, giving the caution that we came up with a five-year strategy and it's gonna be challenging to see a lot of progress on the specific metrics within two years, I do think that it'll be a good time to sort of step back and assess. You know, a lot of things will have gone on by then hopefully we can start to see a new path. I think also one of the key things that'll come out of it is how our domestic strategy really is in alignment with what we're saying as our PEPFAR strategy and what we think we need to do on the global. You know, I think there's a lot of it coming together and hopefully the conference will be a rare opportunity to feed into and learn from both sides. So again, I think it's an opportunity and I think it'll be an early chance to sort of assess how we're doing. I think that there's been a lot of excitement both within the federal government but also within the community. That doesn't mean I think everything's gonna be perfect. So in two years, hopefully we'll have a lot to show but I think there'll also be things where we're gonna say, oh, we need to focus on this and this, we won't get to everything right away. So I think it'll be a useful time. Now as far as the issue about Ryan White program data and how the targets affect the Minority AIDS Initiative. So clearly, you know, one thing I would say about President Obama, quite frankly, is you know, I don't think he likes to focus on one group of anybody. I think he would say, you know, his inclination in responding to AIDS is that he wants to prevent HIV with all Americans. And you know, his focus is on all Americans but I think he also follows the data. You know, and he does this in every context where there's clear data. There are clear data why we're focused on gay men. 2% of the population, 53% of new infections. For African-American's, 13% of the population, 46% of new infections. You know, I could go on down the line. And so it is appropriate that we focus on these populations. The Minority AIDS Initiative is an important part of our response but it's not the only part. So one of the things that we're trying to do is ensure that in all of our funding, whether it's prevention, care, Minority AIDS Initiative, but broader, that we're appropriately targeting the populations at greatest risk. And so I think it's related to the MAI but again, I would just say that that's just one piece of a broader effort that hopefully collectively will see tangible impacts, not only with gay people but black people, Latinos, substance users and really lots of other high-risk groups as well. Another question? Hi, I'm Jimmy Schneider one from AIDS Action and my question is about, to build upon the earlier question about accountability, the operational plans for the lead agencies, are those going to be made public at any point and where can we look for those? Sure. I think we have a record of being very transparent in everything we've done. I don't know what I'm getting on December 9th. So I have not said, you know, in December 10th, these are gonna be posted on our website. I wanna get what I see, I see what I get. I wanna take a look at it. I may have to have a dialogue or wanna have a dialogue with the agencies about making changes. At some point early next year, I would assume that we'd be communicating to the public about what's in them. Clearly it wouldn't be helpful to have an operational plan that nobody knows the plan we're operating under. But I also know that, you know, we've asked different things of different agencies and I can tell you that HHS has probably a bigger share of this than other agencies. Their plan may look different. I'm not sure we want to just unedited put all of them out. I think we'll have to take a look at what we get. But in some form we'll be communicating to the public what's in these plans early next year. I am Ralph Hargis also with SAIC. During your presentation you mentioned that most of the data you have is through Ryan White. Do you have, what other data would you like to collect and how and from what other organizations? Well, on the care side, a lot of this is about Ryan White. I mean, one of the challenges is most people with HIV, their healthcare needs are served through Ryan White, excuse me, through Medicare and Medicaid. But it's big entitlement programs. We just don't have the HIV specific data we need. We also have a lot of data on prevention from CDC, SAMHSA collects data. One thing that my office has actually recently done is we've commissioned the Institute of Medicine to do a project for us. And it's going to be a two year project looking at HIV data gaps. And for those of you that work with HIV data, you might remember about 15 years ago there was a project called HIXIS, the HIV Costs and Services Utilization Survey. And for a period of time it was a nationally represented sample that could tell us about the healthcare experience with people with HIV. It could tell us how many were enrolled in Medicaid, how many were uninsured. We don't have current data for that. And so one of the things, both as we implement the strategy, but also as we think about implementing health reform, I think we need better baseline data. But we also need to make some decisions about how we can sustain a data monitoring system going forward. And I don't have any illusions that we could come up with a plan and there's like lots of free money to build this perfect system. But we collect a lot of data already. So what we've asked the Institute of Medicine to do is really look at what data we're collecting at the federal level, state and local level, the private sector, how can we put them together better? You know, one thing that I've been told is that we collect a lot of data that isn't really analyzed. So how can we do a better job of analyzing it? But we've also asked them, and we're gonna get two reports, but one is this question of a nationally represented sample. When I first thought about it, I was like, that's what I want. A number of people have said, well, maybe you won't be able to afford that. So one of the questions you're asking is what would it take to give us a nationally represented sample of people with HIV that we can monitor over the long term? And if that's not feasible, what are good alternatives? And so I hope that that will be a really thoughtful review that will help us figure some of these things out over the next few years. Question in the back there. Hi, I'm Matthew Rose with the National Coalition for LGBT Health. My question is around funding, actually. I know this strategy doesn't have any unique funding attached to it in an environment where we're seeing reduced funding for both treatment and prevention dollars. How do we, I guess, continue to fund new and inventive ways to keep the strategy moving in the current environment? Right. Well, you know, I will acknowledge that times are tight, but, you know, at the federal level, we haven't reduced funding for prevention or treatment. Every year of the Obama administration, we've increased funding, our prevention proposals, we're the, you know, prevention basically went flat funded for a decade or more. And every year we've proposed increases. Just this summer, we identified $30 million from the prevention fund to increase funding. So funding's going up. Now, there are some challenges at the state and local level. So that's problematic. But the part I can, you know, we have control over, we have been increasing. But again, you know, I showed that figure and showed $19 billion. We invest a lot of resources. And it's not to say that resources aren't needed and our strategy's been explicit that in some cases we do need to use this to make the case for new investments in some areas. But I also believe that fundamentally, we need a clear sense of what we're trying to get to and what's the best approach. So for example, with prevention. You know, if the idea is that we've acted and so we have a generalized epidemic and our prevention is focused on the general population, maybe we can get more bang for our buck if we really focus on those high-risk populations. You know, the other key goal is we need better combinations of effective interventions. We think there's a lot of room to get better results by really focusing on not just the dollar amount, but what are we trying to achieve and what are the things we're doing and are the things we're investing in things that have been shown to lower HIV incidence? Because I think sometimes we do some things that people feel real good about, but they don't necessarily have been demonstrated to show that they lower HIV incidence. And we've got to take a tough, data-driven look at what works and really focus on that. Now in any environment, we could, you know, the economy could turn around tomorrow. Any environment's going to be resource constrained. So we really need to focus on what's effective in scaling up that. Morrison from CSIS, congratulations to you and Greg and your staff on this plan. And my question is we're entering a rocky period. We have elections tomorrow. There's likely to be a change of power on the hill. We're heading into really confronting the budget deficit and the realities of that. And I think our last question really touched on that subject. And there's also a backlash against the health reform legislation. And so we have a pretty tumultuous environment looking ahead over the next year and beyond. And can you comment a little bit about how do you sustain forward momentum in moving your plan forward in the midst of that? How do you navigate that and keep focus and keep things moving forward? Thank you. Great, thank you. So again, I guess I have several things to respond to. You know, we can't control the environment. We can't control the budget environment. But I think, you know, the President's shown, you know, he's had a lot on his plate but he's prioritized HIV. And I think you can expect that to continue. I also think that, you know, there was a time in the response to the domestic epidemic that was much more contentious. Since I've been in this role, I don't remember of any major partisan fight we've had. You know, the President signed the reauthorization of the Ryan White Program. It was remarkably bipartisan. So I think in some cases it is a different environment than it used to be. But I also, it's not all about what happens at the federal level. You know, that we need to sustain this at the state and local level, too. So I think some of it, if there's accountability, we need federal accountability, but we need to hold other people accountable as well. But I also believe that, you know, if we believe in what we're doing, that if we have opportunities to save lives and have evidence about what works, we can still make a compelling case. You know, there's no point in the AIDS epidemic where it was so easy for us. And people just said, okay, we're gonna give you everything we need. We've had to fight for the resource and attention we've got, but we've done that. Now, I think we're at a unique place where we do have 30 years of experience and we have some evidence about what it works. So I think our challenge is to really refine our arguments so people see a hopeful message that we've done great things with the investments we've been given by Congress in the past. And if they continue them or increase them, they can expect to see tangible improvements in what we get. A question in the back here, please. Thank you. I'm Tim Boyd with AIDS Healthcare Foundation. I was wondering if you can comment about the ADAP crisis and what the administration is going to do to eliminate the over 4,000 people on the waiting list. Obviously, you already produced new funding this year, about 25 million, that's already coming down in an environment of limited resources. New funding may not be possible, but there are also proposals out there to produce drug prices for the program. So I wondered if either funding or drug price reductions, what the administration is gonna do to end the waiting list. Right. So as you framed it, the challenge is real, that there is a crisis in there. There are people living in HIV that need access to HIV medications and in some states, they're on waiting list for drugs. I can say that it's important that the pressure, people pressure us to do more and I think we've shown that we prioritize it, but we can't solve this problem on our own. So one, I think if you're only looking to us at the federal level, I don't think that's the solution. We currently finance this program, it's shared between federal and states. We've long standing had pharmacy assistance programs. We're gonna need all of these entities to do their part. Now at the federal level, as you mentioned, we took some emergency action this summer. So we funded in FY 2010, we spent about $855 million on the AIDS Drug Assistance Program. Now this is just one piece of a broader safety net. We also have other funding for the Ryan White Program. Most people with HIV are the largest sources of healthcare for people with HIV and AIDS are Medicaid and Medicare entitlements. So we need all of these parts to work together. One of the ideas that we talked about in the strategy and facilitated by health reform is the idea that states could do more to cover people with HIV through Medicaid. And I think we intend to work with states to facilitate that for states that choose to do that. Another thing in the Affordable Care Act is there's this technical issue with Medicare where it's called ADAP, spending didn't count towards troop. So if states wanted to step in and help people pay their high out-of-pocket costs for people in a donut hole, even pay cost sharing for the high cost of AIDS drugs, that spending didn't count so people would never get through the donut hole and get the catastrophic coverage. Starting in January of next year, that will happen. So that'll take some relief off ADAP programs. You know, the pre-existing condition insurance program, the PSIP program, which has been called the high-risk pools. For some people, that will be an option. So really until we have full access to health coverage or broader access in 2014, we're gonna need a piece of this together. We need to keep prioritizing ADAP at the federal level. We need to use these other programs. We need to keep states engaged. We mentioned public-private partnerships. We've been talking to our corporate partners, including the pharmaceutical industry. It looks like there's some concern early on with this crisis that they would sort of step back and say, no, we can't do anymore. It seems like appropriately, most of those companies have stepped up and have increased their rebates but also been reassuring about their commitment to sustaining us through these tough times and that's how we're gonna get through it and it's gonna be a rough couple of years but it's all of us coming together is what needs to happen. Follow up on a point that you raised earlier in your presentation, which in some ways, at least for you, is a bit shocking. I know how the rest of the audience felt, but you mentioned that when surveys are done of people's perceptions of how one contracts AIDS, there's still this statistic that 40% of the people surveyed thought you could contract AIDS from contact with a toilet bowl, which sort of goes to the bigger issue of stigma and discrimination, not just in our society but globally and you've been involved in this fight for a very long time. I'd be really interested in hearing why you think that's been such a persistently stubborn issue and how do we ever eventually get ahead of that? How do we ever start to really fundamentally change people's perception so it's a different type of playing field to even start some of these conversations? Well, you know, it's interesting you asked me that because one of the challenges in this position is I've been sort of posed this to other people, that, you know, the president's spoken about stigma a lot and it's a high priority for our office, but I actually believe that more people, we're better at framing the challenge than we are at solving it. And I think that there are some, there's different things that we've done that we need to keep doing. The role of laws really matters. You know, the fact that a lot of discrimination is illegal in this country, that's really important. And now we have a Justice Department, Civil Rights Division that's interested in enforcing the law. That can be really helpful and I think you can see if you talk about what progress we can show by 2012, I can guarantee you that we'll have a number of cases that the Justice Department has settled where they're pursuing illegal discrimination. So that's part of it. You know, the president, I think, personally gets this issue of stigma during the campaign he has tested for HIV in Kenya and he talked about getting tested as a way to reduce stigma. When he announced the rule ending the HIV entry ban, he spoke about the context of reducing stigma. And I think public opinion leaders like the president and others are really important. But one of the most important things that we know are most effective things is when people interact with people in their personal lives. You know, nearly half of Americans report that they know someone living with HIV. That helps us reduce stigma. And when people with HIV are willing to be open about their status and talk about it, that helps us reduce stigma. You know, and sometimes, you know, we know that people might say things. My role, I also work in disability. And I find that there's often an awkwardness around working with some people with disabilities. Not for male intent, but people are inexperienced and they're afraid they'll say the wrong thing or do the same thing applies to HIV. So I think we need to create an environment where people can educate others or say, you know, maybe you didn't intend this, but you know, it would be more respectful if you did this and have this dialogue so people aren't afraid to engage. You know, one of the things in the disability community, we have this concept called people first language. So we don't talk about the disabled. We talk about people with disabilities. We always say people first. But you know, we didn't use that term in AIDS, but the National Association of People with AIDS, our founding document talks about we're not AIDS victims. We're people with AIDS. You know, so I just think personalizing this issue is perhaps the biggest way we're gonna address stigma. But you know, I am open to ideas. I think, you know, my office and I know the federal agencies as well, recognize we need to do more tangible things to make HIV stigma less stigmatized in this country. I wish I had the full array of solutions, but we need more tools in our tool chest for that one. That's a great answer. Thanks. Another question. Yes, please. I'm sorry. Be just speaking to the microphone. Hi, I'm Mindy Reiser. I'm a social scientist. I've worked in many different countries. The education scene in this country is certainly in a bit of turmoil, but I am wondering what you can tell us about how you've worked with the education structure, which is complicated, state, national, local, or teachers' unions or professional associations in terms of education and outreach. Obviously, education will differ by age level, but certainly that's an important foundation for young people to understand what AIDS is and what it isn't. Well, you know, this is a question that's somewhat challenging in this country, that we don't necessarily have a full consensus. And what we've said is that, well, we believe that parents have a primary role in instilling values upon their children. All children have a right to medically accurate age-appropriate information about HIV and other things. So one of the big policy issues that we were presented in when we came in is, you know, there's big controversy over funding of absence-only education. And, you know, the president said he didn't support absence-only because he didn't think it worked. You know, and again, he follows the data. But he also believed that, you know, people that did believe in absence-only, they were coming from a well-intentioned place. And we didn't want this to be an issue that exacerbates the divide. We agree on more than we disagree. We all agree that, well, if we're talking about sex education to young people, that our education needs to be grounded in the benefits of absence and delaying sexual initiation. So I think he's approached it saying, can we bring people together on this? But we have to fund what works. So before our administration, we federally funded about $110 million in absence-only education. The president proposed and Congress enacted $110 million for our Teen Pregnancy Prevention Initiative. So we've moved away. Now, in that pot of funding, 75% is for evidence-based approaches. So HHS funds use an outside entity to do a comprehensive evidence-based review and has compiled these evidence-based practices. 75% of the funding must go for replication of these evidence-based models. The other 25% is to say, we don't believe we have all the models out there and we need more innovation. So it's to fund that innovation in a time-limited way. But since that time, in the Affordable Care Act, Congress enacted two new programs. One is the Personal Responsibility Education Program, which is a comprehensive sex education program that I think is very exciting for a lot of people and I think people, it's sort of a wave of the future. $75 million for that program. Now, Congress also funded absence education at the level of 50 million. We weren't supportive of that. As you know, the way the health reform debate played out, there was never a conference for us to get rid of it. But in implementing the law, we obviously have an obligation to implement the laws enacted by Congress. But we did take steps that we think improve it. We imposed a standard that the absence education should be medically accurate. We said there's, I'm getting way into the weeds here, but there's these technical requirements about what makes a program absence education. They're called the A through H requirements. And some of those, quite frankly, are controversial and some people just think they're wrong. Where it says that you must teach an odd paraphrase and get it wrong somewhat, but that childbirth out of wetlock is likely to lead to lifelong psychological harm or something like that. So as we implemented this program, we reverted to the policy under the Clinton administration that says you can't teach against these elements, but you can give unequal emphasis. So you don't have to emphasize those things are problematic. We also implemented a provision that I don't know why it wasn't implemented under the Clinton administration Bush administration, allowing this program to fund mentoring, counseling or adult supervision. So that's a long answer to say that where we can move to evidence-based approaches and Congress through the Affordable Care Act has now effectively doubled the funding available for this type of education. I actually think though that schools are great settings to reach kids, but they're not the only settings. So I think we need to think of other settings to reach kids and not all kids are gonna be reached in school settings. But specifically, you mentioned teachers' unions and other things. I guess we didn't reference teachers' unions, but we have had conversations with the Department of Education about the role of parent-teacher associations and how we can use them and use the education system to get to parents about to convey medically accurate information. I think there's opportunities there as well. Another question here. Hi, my name is Susie Peale and I've worked mostly with young people and in organizing conferences on HIV-AIDS and delighted it's coming here next. My question is a little different though with innovations being supported with lessons learned from PEPFAR to domestic and all the rest of it. What's the mechanism gonna be? Is there gonna be some sort of platform for sharing what's working, for disseminating the data, for very quickly ensuring things are learned and replicated and disseminated. So there's different ways to answer that. So I could give you an answer about the Team Pregnancy Prevention Program, but for a time limit basis, you need to evaluate it. But a big message I mentioned as far as HIV prevention, is that we think we need better combinations of effective prevention methods. And we also believe that the best combinations might vary for depending on the population. So what works for Black gay men might be different than what works for Latinas, heterosexual Latinas. So with a new funding that we allocated from the Prevention and Public Health Fund this summer, the biggest chunk went to funding the 12 highest prevalence jurisdictions in the United States that are responsible about 44% of the HIV infections in this country. Now there, this is all about, this first year it's planning and the ideas that like the Race to the Top Initiative in Education, they'll be a more competitive process later. But it's really about testing out and planning for what are the best combinations and as we evaluate them, we'll know what to replicate and scale up. And from this initial phase, we'll be able to learn the lessons from these 12 jurisdictions and scale this up more broadly nationally. And that's just one example, but we think that's sort of like the way of the future is that we do this evaluation and then we scale up these efforts. There's another question here. Hi, I'm Liat Kravchik with the American Bar Association AIDS Coordination Project. HIV criminalization is still based on unscientific evidence at times such as exchange of bodily fluids, including saliva. Is there an attempt to educate the legal community to have medically accurate information in these cases? Well, you know, we talked about in the strategy these HIV criminal laws. And, you know, the way we think about it is that a lot of times I think these laws were enacted in some cases at a different time when we knew less about it. And I think there was an intent to really help the situation, but I think our perspective is not everything, not all these laws on the books are actually helpful. So there's some laws that you know that criminalize spitting and biting by people with HIV. And our view is that it's not really a way that HIV is transmitted. So we're not saying we're pro-spitting and biting, but we're saying you should handle spitting and biting by anybody in the same way without regard to their HIV status, right? There's other more challenging issues regarding consensual sex. But we also know that where these laws existed, they haven't necessarily had the effect they've intended. It sets up this dynamic where it's like, who do you believe, you know? And it's really hard to get around this. But, you know, it also is challenging if our goal is to expand knowledge of serostatus, make people feel safe that they won't be discriminated against, and it's safe for them to disclose, get into medical care, be open about all that. It really sets us back if people are afraid that they can't be open about their HIV status. So we've sort of said to, this is largely state legislators, that you should review these laws and say, look at them, take a fresh look at what we know about best public health practices today and consider if your laws are, you know, consistent with current best public health practices. I think we had another question, Greg. Hi, Greg Smiley from UNA, good afternoon. My question was going back to the strategy itself, and there was a fourth goal that you added, and I believe it was on increasing collaboration amongst agencies or reducing inefficiencies, maybe between CDC and HRSA and some of the others. Were there particular action steps, targets that also went with that goal, and maybe you can talk a little bit about some of the more obvious things that you could see happening? Right, well actually, you know, we gave specific metrics for the other areas, and we didn't in this area. And I was actually open to it and tell you think about what's a good quantifiable way, because a lot of the things we're trying to measure are sort of process measures, and we didn't come up with anything great that's a good way to quantify it. But I think what we have in mind is that there does need to be a greater focus on how these agencies are working together. So, you know, we mentioned our goal about access to care, and we said a key thing is about increasing linkages to care and retention and care. Clearly, CDC has a role in this, HRSA has a role in it, CMS, how can we put them together? So one of the things that we're awaiting the HHS operational plan, but they've already on their blog talked about some of their initial thinking, and one, as I mentioned earlier, that CDC funded work in the 12 highest prevalence jurisdictions. And they want to use that as a model to build on. So this is what CDC is doing. How can we leverage work by HRSA and other agencies in these same highest prevalence communities to learn some things to apply to the rest of the country? And we think that's an appropriate way. You know, in each of these areas, I don't go into all the details, but the presidential memorandum that I referenced, it also directed that, well, I'm responsible for the lead in setting administration policy on HIV. There are a lot of operational and programmatic things that probably aren't most appropriate to have me try to manage from the White House. But the president in this memorandum directed that the Secretary of Health and Human Services would be the lead entity in the federal government for coordination across the federal agencies. And she's designated, delegated that to the Assistant Secretary for Health. And as you may know, Dr. Howard Koh, who is the Assistant Secretary for Health, created a new position of Deputy Assistant Secretary for Infectious Disease. And Dr. Ron Valdiserri, who's a longtime AIDS policy person, has taken this position. And he's been tasked with how can we improve coordination. Now, I know just from our interagency process that led to the development of the strategy, some of these federal partners have told us that they had met more in like three or four months with us than they had in the last 10 years. So that's a start, but some of these challenges are long-term things. So we know that state and local grantees would like to see streamlined grantee reporting requirements. And those are things that are gonna take some time to get to. But I think there's a commitment to getting there. They require rulemaking in some cases. There's lots of complex issues. But I think those are some things. We've asked them, I'm putting the strategy, looking at how can you blend or braid funding? So people say, oh, it's great that you have this new funding announcement, but it's one of 15. And I only have time to write two grants and not 10. And so maybe there's ways that we can pilot some of these approaches and have these agencies work together. But again, even with the best ideas, it's not that these agencies can focus on 50 things all at once. So some of it we need to recognize what are the short-term things we can do right away. Some things like this are really important, but we need to recognize their multi-year efforts. Further questions? Yes, please. Good afternoon, Donna Cruz, AIDS Action. How are you? Quick question on the Medicaid. You've mentioned a couple of times Medicaid Medicare has a lot of, it's taken care of a lot of folks living with HIV, but you're getting your best data from Ryan White programs. How did you get the Medicaid Medicare data for the funding chart that you, the 19 billion PI, and are, when you find the Medicaid Medicare person is all of their healthcare needs in that 19 billion amount. For example, if they were also had diabetes or heart condition, would that be included in that figure for the Medicaid Medicare? Sure, so obviously we have data like that, and that we've had before. So at the aggregate, we get estimates of how many people with HIV we believe are served by Medicaid and Medicare, how much we think the annual spending. But unlike Ryan White where we can get more, we're moving towards more client level data, it's just really hard in this big program that serves 40, 50 million people to get very specific stuff. States report data to the feds, but it's broken out in these broad categories. Are you a person with disability or a low income child? Not all on HIV basis. So we can get some data, but we also know that Medicaid and Medicare also collect lots of other data, and we wanna look at how can we use claims data and other things to just get a better picture of what's going on with people with HIV. Now your question about, does this include all their healthcare needs? And what I would say is if you're a person with HIV in Medicaid and receiving a Medicaid service, with the recognition that not all this is perfect, mistakes are made, I would assume that if they had diabetes that that would be tracked for their spending. But we also know though that in some cases, Ryan White still supplements coverage from other programs. So it's possible that you could be in a state where Ryan White covers a service that's not, is easily covered by Medicaid, for example. That might not be captured there. But on the whole, their total needs within the Medicaid program we think should be included in that spending line. And maybe one last question over here. Hi, I'm Rabita Aziz with the Infectious Diseases Society of America. And I'm wondering if you can comment on HIV funding in the domestic versus global fronts. Right now we're seeing waiting lists for PEPFAR programs in places like Uganda and also waiting lists in Florida. And we have people saying, you know, why should we fund PEPFAR programs when we're having a crisis here at home? So do you see these two, you know, domestic versus global funding is mutually exclusive? Or do you find that increasing funding for global programs is detrimental to domestic funding? Well, you know, thankfully, that's not how we fund our HIV programs. And even, you know, we don't, we don't have a global AIDS budget. So even while in the domestic portfolio, Medicaid and Medicare, they're entitlements. So we don't fight over funding for them. And what we do for funding for AIDS research at NIH versus other research is really independent of what we do for prevention. So there's not always the interchange. We don't make choices. So we could cut in half our PEPFAR funding and there would be no more domestic money for HIV. Right? And I think that's a good thing. But I think what you need to understand is that we're strongly committed to both. That I think President Obama believes that he's doing great things by building on important legacy of President Bush in the PEPFAR program. And I know, you know, most of my job is domestic and, you know, I'm not here to, you know, I can't debate all the statistics, but I think he would say that we've increased our funding for PEPFAR every year and he remains firmly committed to that. Building on the success of PEPFAR, he's launched his global health initiative. Domestically, in tight times, he's prioritized HIV at a time when there's a lot of other needs. But we don't make trade-offs for one or the other. And just to throw in a comment, we were chatting a bit before we came in here to join you all in talking about how both sets of strategies actually in many ways are kind of mutually reinforcing and that, you know, when you read the domestic strategy, if you were to black out the parts of it that indicated it's domestic, a lot of it really sounds like an international strategy. So, you know, I guess I suspect and hope as this all moves forward, there's gonna be a lot of opportunities to reinforce that kind of learning over time. So, before I bring us to a close, let me just do one quick promotional announcement for us here at CSIS, which I should have done when we opened, but on November 22nd at 1.30 in the afternoon, we'll be having the next in our fault line series, debates on the important issues in global health today. It's gonna focus on the question of whether or not, we're going back to the global sphere, countries that are receiving significant amounts of USG HIV AIDS assistance should be bound to the types of policy reforms, be that legal or financial support or other types of reforms and policy changes that will make for more supportive environments for the types of investments the US government is trying to support. So, again, that's on the 22nd at 1.30 in the afternoon, if you'd like to join us, and there'll be more information on our website about who the debaters will be and the exact topic and the resolution to be debated. But just in closing, I would just like to thank you very much for joining us today and to say that this has been an enormously interesting discussion. It's been terrific to hear the scope of what you're trying to achieve, to think a bit about the incredible impacts that could have, but also to realize the complexities involved, not that they're daunting by any stretch of the imagination, but they're serious and they're there, but it certainly sounds like you're equipped and ready to deal with them. So I'm sure that everybody here joins me and wishing you great luck with the strategy and the implementation plan, and we'll hope that we can have you back here in the not too distant future to discuss how things are going. So thanks very much. Please join me in thanking. Thank you. Thank you.