 Introduce the last speaker on this panel, my colleague, Dr. Renslow Scherer. Renslow Scherer is Professor of Medicine and Specialist in Infectious Diseases at the University of Chicago. He's also Co-Chair of the Faculty Board of the Posen Center for Human Rights. Dr. Scherer's research focuses on HIV, AIDS prevention and health education programs for orphans and families with HIV in sub-Saharan Africa and across the world. Dr. Scherer has also directed a program to improve medical school and graduate medical education at Wuhan University in China. Today, Dr. Scherer will give a talk entitled, Progress with Reducing Disparities in Global HIV Prevention and Treatment. Please join me in giving a warm welcome to Dr. Scherer. Thank you so much for that generous introduction and I'm really honored to be with this panel and to proceed. My friend and a person I think of as a mentor, Paul Farmer. Looks like we're running out of power. That would be bad. But not me, personally. So, or not yet. I want to talk about actually a theme through this very diverse panel. We've had philosophy in Plato's Republic, we've been in Boston and in Haiti and in India, and talk about the concepts of vulnerability in HIV and then give some specific examples as best I can. Really, I think this is the foundation for this presentation but also for so much of the work that I've been involved with through my career in HIV where I really think understanding the relationship between human rights health and HIV specifically gives you an extraordinarily improved understanding of pathogenesis of the disease but also it's transmission, it's the behavior of the epidemic in the past and currently and maybe more importantly how to succeed with programs to reach people for effective prevention and care and they're really two different types of activities. They're either allowing and enabling the distribution of the scientific benefits that are so remarkable in HIV, so simple access to testing to prevention modalities like the new PrEP pre-exposure prophylaxis or antiretroviral therapy and treatment support or removal, withdrawal, reduction of obstacles to those human rights around the world, that is freedom from stigma and discrimination and other human rights violations. I think our mentor in all of this work is Jonathan Mann and it's not an accident that he began this connection with human rights and health through the lens of HIV during his work throughout the course of his career I want to just take a moment to say just as we heard about from Plato's Republic and I think inherent in the comments both in India and in Haiti that the definition of health we all believe in is not limited to medical care and the treatment of conditions but rather involves societal peace. Adequate shelter and housing, Evan Lyon talked about housing here in Chicago, food, a stable ecosystem, social justice and equity that we're really talking about a very large and broad definition of health and to understand that allows I think for much more credibility in designing HIV prevention and treatment programs and John Mann himself was the one who said that HIV illustrates that individual and population vulnerability to disease, disability and premature death are linked to the status of respect to human rights and I would also include in that just thinking of this Paul Farmer's own characterization of structural violence as being those laws and regulations that in and of themselves present barriers to adequate public health and individual health care and we're fortunate I think worldwide to have at least an agreement on a set of metrics around the sustainable development goals that actually allow for much of this to be recorded, documented and followed in real time like maternal, child health, HIV outcomes, enrollment and antiretroviral therapy, tuberculosis outcomes so ways in which we actually have the development of metrics in public health goals but also in human rights interventions and outcomes. So I'll try to talk about some of the progress and disparities and focus specifically on men who have sex with men and calling them gay men as well but understanding that among those men who have sex with men are some men who consider themselves to be straight heterosexual men but occasionally they have sex with men and that means that we're considering behavior as the critical vehicle not who a person is of their identity but the behavior that can lead to transmissions. The importance I think of recognizing the intersection of those issues is really critical. Is it a battery thing? So think about what's been accomplished in the science of HIV. How extraordinary it is, the time during my career when I was a second year attending at Cook County Hospital was the first patient with HIV in 1982. We've seen the death rate in the United States go up to the top number one cause of death for adults and now is back down to a substantially negligible rate all during our lifetime. I had this graphic up just to remind us that some of the power of the public health interventions have been because of the use of media and images and this very powerful silence equals death and the use of the pink triangle early on in our country captured the imagination of in the first instance the gay community and mobilized them to understand that to not speak up about the problems in access to treatment and prevention was going to lead to death for so many of its members as indeed it did. So I think that's still a powerful way for us to develop some of the themes for health and human rights into this day, the power of the arts and media. So thinking about our progress, there's been an extraordinary decline in the incidence of HIV and mortality that began for the declining incidence 20 years ago and mortality 10 years ago though it's best to understand that HIV is many epidemics within a larger epidemic and even when you get one country reporting very beneficial statistics there are often issues of uncontrolled sub-epidemics within it. The treatment advances in this area are extraordinary and most parts of the world, one pill once a day or twice a day is associated with full virus load suppression and normal life expectancy if treatment is given early enough with good adherence. We have 17 million people treated worldwide, 80% of them are in resource limited settings and yet some of the disparities I'll talk about are in access to those therapies and in our own country the HIV care cascade shows that even though we have the availability of those therapies only 50% or fewer of people are able to access them and have successful antiretroviral therapy and the same is true with all of the advances in HIV prevention modalities such as pre-exposure prophylaxis where there's tremendous disparities in the new rollout of that intervention just to say that's one pill once a day offering people at substantial risk the ability to reduce their risk by better than 90% just by taking one pill once a day. These are the epidemic curves that show on the top the very large increase in the number of people living with HIV but you see gradual decline in the incidence rate overall starting 20 years ago still with much room for improvement and the death rate also beginning to decline about 10 years ago. Oftentimes we don't get a visual and people who don't get a chance to see this may never have seen the extraordinary evolution of the impact of therapy this three and a half year old Thai child this girl showed when before she was treated she had wasting she had thinning here she had a chronic bacterial infection on her lip she had chronic diarrhea she fit the criterion for AIDS wasting disease at the time and just two months after the start of antiretroviral therapy she looks like a changed person and you can see that 18 months later she's made all of her growth milestones and looks wholly different and I'm happy to say last year at the international AIDS meeting this young woman now 25 year old was at the meeting with the individual who presented this case showing what lifelong antiretroviral therapy can do in any part of the world. So I thought I'd try to mention some examples in the regions that you see here in the United States and in China in Eastern and Western Europe and then in Africa and there are so many different vulnerable groups I will just talk a little bit about injection drug users and gay men and then women and mention others as they come up in context. I like this graphic that just shows the key populations on the left of transgender men and women particularly women who are so much more vulnerable and I won't talk about them more except to say as you see in this slide there are organizations of transgender individuals they are actually mobilizing on their own and this is a very important priority I think for advancement of human rights and HIV care and prevention people speaking for themselves and the first principle as a corollary is the importance of engaging and as Evan Lyon said listening to the group that you're trying to reach and talk to what are their needs and how do they understand their issues for transgender women it's quite important for a clinician to know that if you are able to provide their hormonal therapy at the same time you treat their antiretroviral therapy the likelihood of success goes up 30-fold as compared to sending them across town to an endocrinologist or to a specialist for their hormonal therapy. Now that's I think common sensical but it certainly means puts the onus on an HIV clinician to respond to that need. So thinking about people who inject drugs just to go back to this epidemic curve you can see that some of the annual death rates had already changed as early as the mid-1990s but you can see here that in Central Asia and in Eastern Europe continuing rise and if I update that with the most recent information from the European Union you can see a huge difference between the incidents which continues to rise in the non-EU countries as compared to the EU countries. I would say both of these represent important issues because the fact that this line has been steady for the European Union countries also represents a problem. We now have the ability to bend the epidemic curve down but the problem in the Eastern European non-EU countries has largely been an uncontrolled epidemic of injection drug use. And so the kinds of responses that we know are associated with improvements in reducing new infections as well as delivering care are based on harm reduction, the offering of medical care, the use of a medical model for their addiction, access to treatment and therapy and then at the policy level decriminalization of HIV. And this applies also in prisons with the additional element of the need to allow prisoners to receive the very same care and treatment and prevention modalities that are used outside of the prison setting. So let me give you an example of maybe the best, the clearest example of early on in Spain the Spanish authorities decided really in a lot of controversy to provide needle exchange condoms and methadone maintenance to all inmates who were injection drug users. This was very early in the epidemic and this was at a time when they were taking those same steps in the communities in Spain with a successful reduction in overall incidents and you can see here the prevalence of HIV in Spanish prisons fell from 32% down to 7% by the year 2009. Just with the implementation of the strategy of doing the same thing for prisoners that was being done in the community and at the same time you can see an enormous increase in methadone maintenance and the provision of methadone therapy and in the provision of clean syringes in the prison setting. So I think that's a terrific example where Spanish authorities in fact said we will have the same public health intervention that's effective for prisoners in prison as elsewhere. And I'm happy to say this is again just new data from the Spanish government about their progress with hepatitis C which as you know overlaps with those individuals who inject drugs and have HIV. There's a high level of co-infection in Spain. They have now achieved HCV therapy in 75% of all people known to have HIV-HEP-CV co-infection in Spain and are on their way towards eradicating the hepatitis C epidemic because in that case therapy is curative. So I credit the Spanish government with being progressive and using the same treatment for both prisoners and for those injection drug users in the community with tremendous amounts of success. So what about the Ukraine? What can be done in this country actually that does not have that type of a progressive approach where actually prisons are known to be accelerators of tuberculosis, HIV and other sexually transmitted infections? Well in this case this was a community based effort that I'm showing you that was done by an NGO in three cities in Ukraine where they went on the street to talk with the police who were actively finding anyone with needles, syringes or the works the means to cook their drugs and beating them up as a matter of routine before incarcerating them. And this NGO engaged the police and asked them to appreciate, understand what they were doing in terms of the potential for increased transmission of HIV and just with that very low tech intervention, that human rights intervention, they were able to show a decrease in the likelihood of HIV transmission from anywhere to four to nineteen percent in that community. So there are steps that can be taken that are informed by human rights even in the absence of the best therapy. The last example for injection drug users is the extraordinary progress in China where you can see here that the epidemic curves for HIV among MSM are rising rapidly. That's the light blue line, but the injection drug use line is falling steadily because of the massive investment that they made in China in harm reduction for their detainees who are detained for injection drug use. And what they did was to offer needle exchange and or methadone maintenance. It's now the largest program in the world with many, many millions, some thirty-five million people enrolled in these settings and they were able to show dramatic reduction in injection drug use and substantial improvements in employment and in family relations. Now their injection drug use is criminalized and I would say that another step that should be taken is to move towards decriminalization but at least they have taken advantage of the incarceration of those individuals and implemented I think very effective public health interventions on their behalf. So the summary for that portion is that harm reduction effective care decriminalization and access to proven prevention interventions and treatment is highly successful and that's for injection drug users and for prisoners. I think one way to add to that is just the problem with addiction really is still vexing in those countries. It's not that we have taken this and eliminated it but at least they've put it into a manageable context in Scandinavia and in western Europe. I add that because injection drug use is still a source of volatile eruptions of HIV worldwide and that's been true in our country and calls to mind our opioid epidemic at the present time, which for the first time in recorded history has led to an increase in the death rate in the United States. This is a report from rural Indiana, I'm sure many of you are familiar with this, where the use of prescription medications oxymorphone crushed and injected with multiple injections with the average in people who are reported here of nine syringe sharing partners per day and this was in a largely Caucasian poor rural area of southern Indiana and the co-infection rate with hepatitis is 80%. This is an unexpected epidemic that required special legislation by the state legislature in Indiana led by or overseen by our current vice president to actually change the law to allow for needle exchange and methadone maintenance basically for harm reduction in this population. So it's a good example of how volatile still HIV can be in the United States. Another great example is with current workers who are working in the mines in the fracking industry in North Dakota who have lots of free time, lots of money, they're unaccompanied men and there's a great deal of sex work in that area and they're dealing with an HIV outbreak in that part of the world as well. Well if I turn to men who have sex with men, you can see the graphic faintly on the left that shows wherever we look in the world as well as around the world the prevalence of HIV is substantially higher among men who have sex with men. And you can see here organizations certainly historically this was the group that led the response to HIV in the early 1980s in our country and I think sex workers are an important subgroup of this both male and female and it's just important to say that as it was true with transgender women sex workers are organized, are speaking themselves and the one thing they ask for is to be allowed to do their work unencumbered and to be have their health and safety effectively protected by society and by local law and regulation. First problem I think again as is true with injection drug use is homosexual activity is criminalized in 73 countries of the world as you see here and I'm proud to say this is a pep far slide international work that I'll show you actually comes from our own government that is paying for more than half of all of the antiretroviral therapy worldwide, your tax dollars which I think is a fantastic use for our global health diplomacy funding. This clearly is presents an enormous disadvantage and if you think about the consequences of the criminalization it's simply chilling an individual's ability to seek health care, get an antiretroviral therapy to do anything formally with health systems that are run by central governments in which the activity is criminalized. Just to return to the United States if you want to see the disproportion of HIV among MSM in our country you can see that it's highly prevalent among those new infections in people of color who are men who have sex with men disproportionately and down and you can see that still that accounts for 63% that is among men who have sex with men of new infections in the United States and we know that 90% of these new infections comes from one of two sources either a third from people who are not aware that they're HIV positive that means part of any effective national response has to be to accelerate HIV counseling and testing and some of the other sources come from those who are known to have HIV but have fallen out of care who are no longer engaged in our care and I think that's another enormous issue for us to take care of in our thinking about providing effective prevention. This is a view of all HIV in the country by the county map and you can see the extraordinary disproportion in the American south which is very significant and this continuum of care looking at all people in 2009 on the left the 1.1 million people who's been tested, who's ever been seen by a doctor who's retained in care and then on to who's got effective therapy and full virus load control and at the time of this graphic it was only about 30% and more recently this is from 2014 only about half of the people with HIV are known to be on care. The disparity issue is really seen very well in this graphic so you're less likely to be controlled if you're a woman as compared to a man. If you're African American or Hispanic as compared to white, if you're an injection drug user as compared to an MSM or if you're a younger American as compared to older Americans and there are barriers to care for each one of those barriers to understanding what those barriers are and trying to break them down. So it's too big a topic to try to address it once. I think just to think about the south out of Audemura from UNC has spent a lot of time talking about this. What are the challenges to prevention and care in the southern United States that might aggravate the disparities that we've seen in incidents and there's been a lot of discussion about the population that's rural and it's both an urban and rural disease in the United States in the south. We have a poor health infrastructure. Those are largely red states that have not medicaid expanded where there are fewer social supports. There's an inherent distrust of the health care system in the south out of Audemura. There's a lack of adequate federal funding and weaker education system and also policies that are often explicitly anti-immigrant that may also chill an individual's ability to seek health care. I was part of some work at county hospital that showed if we're able to address some of those health disparities for example we find someone who needs bus fare or emergency services. We're also able to improve retention in clinic by 20%. This is now data from a long time ago but that has been held true and this is the kind of service that's funded through the Ryan White Care Act. Other services that were increasingly funding through the care act include prevention and I like this slide talking about combination prevention from Tom coats because it includes prevention and prevention that are still valuable in the use of condoms, circumcision and the use of treatment as prevention which I'll talk about but it includes social justice and human rights on the slide understanding that making accessible testing access to prep and to other prevention modalities and access to treatment is an inherent part of that problem. This is an era where we're talking about prevention and prevention. As you may have seen that the CDC just endorsed that last month undetectable virus load for someone on therapy means they're not able to transmit the virus they are untransmittable. We also know that for those people who are HIV negative treatment works is prevention by pre-exposure prophylaxis. We can reduce the risk of someone acquiring the vaccine. We took this on by doing a large media campaign, the prep for love campaign, you can Google that and see a very large effort targeting black women, targeting young people and members of the gay community, particularly gay men of color with images, with CTA messages, these are some of the things that were posters that were put up on the screen. The idea here is to promote sexual health on the terms of the individuals that we're dealing with, on their priorities, and to take the stigma out of it to encourage healthy sexuality and to let it be understood that either treatment is prevention or pre-exposure prophylaxis allows for that to happen in a safe and protected way. And to offer individuals both HIV and at risk, ongoing engagement in care, STI testing, and treatment if and when HIV occurs. So there's a lot of remedies that have been proposed for the American South, certainly I would argue that we need good medical program nationally and that either stability of the Affordable Care Act or something else is a critical component to that. And I think that what is funded now should continue to be funded and including expanding HIV testing and access to PrEP and expanding treatment as prevention for those who are known to be HIV positive and engaging those individuals in care is an extraordinary priority. I think we've actually seen a lot of progress in this country in many municipal areas. We've seen a lot of progress. We've seen a lot of progress in Denver, Atlanta, places where there's repositories of enlightened proactivity in healthcare for MSM and for those at risk. Those are great examples of model programs where we are seeing more people identified and on treatment and we're seeing rates of infection actually decline for the first time. We've seen a lot of people enable all the others in this country in rural areas in the south. Those folks of color here on the south side of Chicago who to date have not been able to access those therapies reliably or consistently. That's clearly and I would add to that that the opioid epidemic is a tremendous threat to all of us to the world. In resource limited settings in Kenya all of the problems that I've described are present but they're only worse. The HIV prevalence is 40% among gay men in Kenya and 28% among female sex workers and they have criminalization of homosexual activity as an additional barrier. This is what happens when a country in this case Nigeria faces a lot of restrictions on MSM activity. You can see that in purple in every case there's an increase in MSM reporting they fear seeking health care that there's no safe places to go for these individuals that they avoid seeking health care even if they're sick or they've been verbally harassed or blackmailed all because they themselves are MSM. I think that's the definition of an effective HIV response. I think we may lose sight of the fact that so much progress has been made in the last five years in our country including the breakthroughs around gay marriage that really are extraordinarily beneficial in terms of our efforts to control and limit HIV and reduce the spread. The kinds of things that have been seen in this section have been decriminalization, stigma reduction, certainly mentorship for younger people and empowerment. So I've got to finish. I know how much I've seen in the last couple of years. I've seen that in the last couple of years. I've seen that in the last couple of years. How much time do I have? One minute. Yeah. It's too big a topic and I want to apologize to the women and children for not covering this. I think you can get the sense that we've had just tremendous breakthrough in overall in the response to HIV and that the real point of is going all the way back to the slide of making the connection between health and human rights and the response that every program I've been involved in has been improved by making that link, understanding it and using it in the design and implementation of prevention and care programs. Again, I'm honored to have been invited to talk to you all. Thank you very much.