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Barmes Lecture Transcript

December 13, 2011

The President’s Emergency Plan for AIDS Relief (PEPFAR):

Moving from Science to Program to Save Lives

Barmes Lecture

Ambassador Eric Goosby, MD

December 13, 2011

It is an honor to be here today, celebrating the extraordinary life and work of Dr. David Barmes. Thank you to the National Institute of Dental and Craniofacial Research and the Fogarty International Center for the invitation. And of course, I am deeply appreciative of Dr. Francis Collins for his leadership. I would also like to acknowledge my good friends and fellow laborers in the fight against AIDS, Dr. Tony Fauci and Dr. Jack Whitescarver.

Dr. Barmes devoted his life to working to improve public health, and indeed, the common good. And, from what I have read about him, his passion, commitment and tirelessness were so clear to all around him.

In his career at the World Health Organization and at NIH, Dr. Barmes straddled two worlds. He had one foot in the world of science and the investigation of the root causes of oral disease and health, and the other in implementation and questions of how to make widely the benefits of scientific advances such as fluoridation available to all. He emphasized the need for systematic approaches to categorize information, implement cost-effective interventions, and monitor program implementation, including regular surveillance of progress. These tools enabled the world to set goals for public health interventions and to measure progress toward them.

I mention this because many of the concepts that Dr. Barmes helped to develop remain central to the success of public health programs, and especially the program that I am honored to lead, the President’s Emergency Plan for AIDS Relief or PEPFAR. PEPFAR is an interagency US Government program, led by the Department of State and coordinating the efforts of the Department of Health and Human Services family of agencies, the US Agency for International Development, the Department of Defense, Peace Corps, and others. My office’s role is to lead this unified effort on global AIDS in responding to the latest science, epidemic trends, and needs of the people we serve.

Throughout today’s discussion, it is important to remember that PEPFAR was created out of the generosity of the American people, with the leadership of President Bush and a bipartisan Congress. Under President Obama, it has expanded and continues to be an essential expression of our compassion for those at risk or living with HIV in areas of the world less able to support lifesaving services. Congress authorized PEPFAR in 2003, and then reauthorized it in 2008 for five more years until 2013.

In addition to the public health impact of this program, Congress has recognized the health diplomacy benefit of this work. PEPFAR shows the world the heart of the American people, and our desire to work with them in partnership to meet human needs. Actions speak louder than words, and PEPFAR is an example of this truth.

Secretary Clinton has spoken of the importance of development, as well as diplomacy and defense. As part of this development agenda, we’re not only about saving lives today. Improving public health requires creating a lasting, durable improvement in the capacity of our partner countries to address their needs. Providing aid of any type, by itself, does not create that capability. A country’s receipt of foreign assistance funds has not been demonstrated, by itself, to lead to expansion of services to its people, or to grow its economy so that it can better meet human needs. In some cases, in fact, external aid has supplanted financial commitment on the part of the country itself – an unacceptable outcome.

Part of our challenge is thus to ensure that as we move science into programs, we are also supporting the development of capable leadership, good governance, peace and stability, and sensible economic and social policies. Clearly, that increases the degree of difficulty of what we are doing. It often means new ways of doing business, and that kind of change is rarely easy – as we have experienced in PEPFAR. But if we want our impact to last, there really are no short cuts.

As I read about Dr. Barmes, I find that PEPFAR has strong parallels to his career. We are uniquely privileged to sit at the intersection where the worlds of science and implementation combine to produce public health impact. In this work, NIH is a critical partner. So many of the early breakthroughs around the pathophysiology and treatment of HIV, leading up to the advances that continue today, flow from NIH’s scientific mandate.

These advances have been fundamental to the steps PEPFAR has made in rapidly expanding the HIV response in low-income countries with high burdens of HIV disease. This link, between knowledge generation and rapid deployment in the epicenter of the pandemic, makes for a powerful combination.

Today I would like to touch on five aspects of PEPFAR that exemplify this intersection between science and implementation.

I will start with how the US Government has contributed to the science of select interventions that are critical to the HIV response, and has led implementation and developed avenues for expanded impact.

Using these interventions as examples, next I’ll address how we are building on this scientific foundation to work toward an AIDS-free generation, a goal that would have been unthinkable, even several years ago.

Then, in light of our constrained budget environment, I’ll reflect on how PEPFAR is pursuing this ambitious goal through efficiencies and smart investments. At that point, I’ll consider how PEPFAR has opened up the new field of implementation science, taking advantage of our unique position of translator of science to impact, and how we take this to the next level by examining some key questions.

Finally, I’ll describe how we are using the PEPFAR platform to ensure the sustainability of the global effort. This means developing the capacity of health systems and the next generation of

leaders in the heart of the HIV pandemic, to work not only on HIV, but the range of development issues they face.

1. The US government contribution to HIV science and implementation

First, I’d like to talk briefly about three interventions: treatment for HIV infection, interventions for the prevention of mother-to-child transmission, and voluntary medical male circumcision. I’ll describe how PEPFAR has taken them from study results to widespread impact to change the course of the HIV pandemic.

I chose these interventions not because they represent the full spectrum of PEPFAR, but because they are central to the relationship between science and impact through our programs.

Treatment

Let me begin by focusing on treatment. The story of the identification of HIV is one which people in this room are familiar. NIH played a pivotal role in this, and succeeded in a remarkably short period of time -- a feature that has continued to define the fast-moving field of HIV. Your research supported the identification of an initial treatment, zidovudine, which the FDA approved for the treatment of HIV infection in 1987. After years of watching people die without effective intervention, it was monumental to have a treatment that at least delayed the onset of AIDS. One of those people was Ryan White, after whom Congress named the program that I was privileged to help launch to provide resources for the care of HIV-positive people.

In 1992, again after substantial contributions from NIH and investigators, zalcitabine, or ddC was approved, which was paired with zidovudine. The first highly effective ART came in 1994. In my role Office of HIV/AIDS Policy under Secretary Shalala, I was privileged to found the Guideline process in 1995, with Tony Fauci and John Bartlett as the first chairs. Protease inhibitors were then approved and the era of highly active triple combination therapy was launched. Due in large part to the Ryan White Care Act, treatment became the expectation and norm among HIV-positive individuals in the United States and other high-income countries. We now have 27 anti-retroviral drugs and combinations approved for the treatment of HIV disease. We also know how to recognize, diagnose and treat opportunistic infections that are a major cause of morbidity and mortality.

In terms of global implementation, PEPFAR has taken this intervention, once thought to be only possible to deliver in high-income settings, and successfully deployed it in over 30 countries. In 2003, only about 50,000 people in Sub-Saharan Africa were receiving treatment. Today, PEPFAR alone supports 3.9 million on treatment globally, the vast majority of them in Africa. The Obama Administration has increased the number of people directly supported on treatment since taking office by 124 percent.

The effects on individuals receiving treatment are, of course, profound. A Stanford University study demonstrated that over a million deaths were averted in the first 4 years of PEPFAR alone, a number we expect has at least doubled since that time.

In addition to lives saved directly, treatment also reduces vertical transmission, from mother to infant, another benefit I will discuss in more detail shortly. What has been recognized more recently, thanks in large part to the NIH-funded HPTN 052 trial and other important studies, such as Partners in Prevention, are treatment’s effect on sexual transmission. With earlier treatment, 052 demonstrated a 96% reduction in linked HIV transmissions between serodiscordant couples, as shown here. In other words, we’ve added another critical reason to treat people living with HIV.

Many studies have also begun to document the wider societal benefits of treatment. As shown here, a study among tea pluckers in Kenya reported decreases in productivity among HIV-positive individuals before treatment. Following treatment, productivity was regained, as the health and well-being of the individual improved.

Studies have also shown that treatment, by keeping parents alive, has tremendous effects on families -- indeed, for every 1,000 people we support on treatment for one year we avert the orphanhood of 449 children. 449 children - now THAT is another dimension of the concept of treatment as prevention.

It’s also helpful to look at the costs averted by treatment -- for example, the averted lifetime treatment costs of a baby who avoided being infected with HIV due to effective PMTCT, which I will discuss next. Through this lens, the cost per additional life year gained drops to about $150. And when you add to this the productivity gains I mentioned earlier, a recent study of the Global Fund found that the costs of treatment programs, shown below the line, were actually outweighed by the societal economic benefits, shown above the line.

Prevention of Mother-to-Child Transmission (PMTCT)

Turning to mother-to-child transmission, NIH built on the successful development of HIV treatment, leading the use of antiretroviral drugs for the prevention of vertical transmission of HIV. In 1994, the AIDS Clinical Trials Group study 076 found that AZT used during pregnancy and delivery drastically reduces transmission of HIV from mother to child. This finding led to an AZT drug regimen being adopted as an official U.S. guideline within months.

From 1992 to present, vertical transmission in resource-rich countries has plummeted from approximately 25 percent of children born to women living with HIV to less than 1 percent. With the leadership of NIH, this trial has been built upon, and current regimens for pregnant women result in very little transmission, even during extended breastfeeding.

In the global context, I am proud to note PEPFAR has increased its leadership in this effort. In 2011 alone, PEPFAR tested nearly 10 million pregnant women. Of these, more than 660,000 pregnant women were found to be living with HIV, and ARVs for these women allowed more than 200,000 infants to be born HIV-free. These are the highest PMTCT results of any year in PEPFAR's eight-year history.

In June, we launched the Global Plan towards the Elimination of New Pediatric Infections and Keeping Mothers Alive, along with Michel Sidibe, the Executive Director of UNAIDS. The plan has as its central goal to reduce the number of new pediatric infections by 90% by 2015.

First, the plan focuses on national ownership. There are 22 countries which carry 90 percent of the global MTCT burden. All of the countries were an integral part of the team that created this plan -- and this plan reflects their views. Countries must lead the response, with the rest of the world right beside them, supporting their national plans through financial and technical assistance.

Second, the plan calls for unified action and leadership at all levels -- governments, civil society, people living with HIV, faith- and community-based organizations, development partners, the private sector, and others. Everyone has a role to play.

And finally, the plan includes ambitious, but achievable, targets to chart our progress. By stressing the dual principles of shared responsibility and specific accountability, the Plan will help us hold ourselves and each other accountable.

Voluntary Medical Male Circumcision

The focus on Voluntary Medical Male Circumcision grew out of many observational studies showing that, given the propensity of the foreskin to allow for passage of the virus, removal of the foreskin resulted in decreased male acquisition of HIV infection.

Evidence demonstrating the effectiveness of male circumcision in preventing HIV sexual transmission was then released in 2005 from the Orange Farm randomized controlled trial in South Africa. This was followed by results in 2006 from trials in Uganda’s Rakai District and Kisumu in Kenya. All three randomized controlled trials confirmed that male circumcision, performed by well-trained and equipped medical providers, is safe and reduces the risk of heterosexual acquisition of HIV infection among men by as much as 60%. Extended follow-up of participants at up to five years post-trial indicated that the protective effect increased to 68%.

Following the release of the results of the trials, in 2007 WHO and UNAIDS convened an international consultation of stakeholders to review the body of evidence from the three trials and the wealth of earlier ecological and observational studies. The consultation resulted in a firm endorsement of the evidence, and recommended the implementation and scale-up of programs in settings with generalized high-prevalence HIV epidemics and low levels of male circumcision.

In the last few years, PEPFAR has led the global scale-up of male circumcision for prevention. With investments in work to create a conducive policy environment, we have begun to see governments realize that this is one of the most effective ways in which they will reduce new infections among men.

PEPFAR is now supporting male circumcision activities in 14 countries and continues to work side-by-side with countries and other partners in program planning and implementation. Modeling studies predict that the benefits of male circumcision are likely to be large in

populations with high prevalence of primarily heterosexually-driven HIV and low male circumcision. There are numerous countries and regions, particularly in eastern and southern Africa, that fit into this category.

It is estimated that one HIV infection is averted for every five to 15 circumcisions, providing a lifetime benefit, making it a cost-effective intervention. And as HIV prevalence decreases among circumcised men there is an indirect protective effect against HIV for women, women’s uncircumcised male sexual partners, and ultimately the whole population, especially over a ten- to twenty-year time horizon.

PEPFAR has invested over $204 million dollars to date and has supported approximately one million male circumcisions. Putting all the essential components in place takes time and it is important to be sure there is the appropriate balance of demand and supply. Data from Tanzania have shown that such preparation allowed the country to reach the tipping point, and there is a now a great increase in the number of circumcisions being performed. The promise of new circumcision devices could accelerate this scale-up.

2. The vision of an AIDS-free generation

UNAIDS highlighted the potential of these interventions in their Investment Framework model, published earlier this year in the Lancet. They showed that the combination of these high-impact interventions, along with other important supportive interventions to reduce stigma, change behaviors, and raise demand for effective prevention, can result in a major reduction in new infections and a bending of the curve of the HIV epidemic.

The vision of an AIDS-free generation that Secretary Clinton outlined on this very campus last month had these interventions as its core. In her words, ―Now we know beyond a doubt if we take a comprehensive view of our approach to the pandemic, treatment doesn’t take away from prevention. It adds to prevention. So let’s end the old debate over treatment versus prevention and embrace treatment as prevention.‖

In other words, the work of NIH medical officers and other key staff planning and running trials, the courage of patients to face the unknown, with basic laboratory work to develop better targeted drugs, and the commitment of implementers to scaling up in challenging circumstances, have enabled a major policy step by the US Government. We now recognize treatment as a critical element of combination prevention and are working toward the creation of an AIDS-free generation.

This vision, built on our work together, has now received its most important endorsement, by President Obama. On World AIDS Day, at an event including Presidents Clinton and Bush and many others, the President announced ambitious new goals for evidence-based combination prevention. Among these was an increase in our treatment target by 50%, to six million people supported on treatment in the next two years. Recognizing the extraordinary opportunities that exist with the new tools, the President noted that, quote, ―As a matter of policy, we’re now investing in what works.‖

With this set of tools, the global community is now poised to reduce incidence to a level where instead of starting two people on treatment for every three or four new infections, we can reverse that. Indeed, we can reduce the number of newly infected people to below the number newly eligible for treatment each year, as shown in this slide from UNAIDS.

On World AIDS Day, PEPFAR also committed to an additional 4.7 million circumcisions in the next two years, as well as to start 1.5 million women on ARVs to prevent mother-to-child transmission over those two years. Like the treatment goal, these are ambitious targets and represent our contribution to a vigorous global effort.

This is the power of joining science and implementation, and of developing policies based on evidence. As Louis Pasteur so aptly said, ―Science knows no country, because knowledge belongs to humanity, and is the torch which illuminates the world.‖ You are part of that continuum of creating and applying scientific knowledge for the good of the world. And in doing so, you are answering the call to create capacity so that the contributions we make are lasting ones.

3. Making smart investments

As we pursue this goal, we are mindful of the economic context in which we are working. How is PEPFAR accomplishing so much, and able to take advantage of these scientific advances in a relatively level budget environment?

We are doing it through an intentional process of prioritizing smart investments, making our programming more efficient, and leveraging the investments of complementary funding streams, such as the Global Fund and national governments.

Making smart investments is really investing in what works, as the President said. Economists call this ―allocative efficiency‖ -- putting your money into the interventions that will have the biggest impact on outcomes you care about. In our case, those outcomes are human lives saved and reductions in HIV infection in the countries in which we work. We have done this, as I referenced before, through focusing the bulk of our prevention dollars on interventions that have been shown to have the greatest impact.

We are also achieving what economists term, ―technical efficiency.‖ This has taken the form of making our programs less expensive through lowering commodities costs, switching from air to sea and land freight, and through the collection and use of economic and financial data in programming. Through this approach we have lowered the PEPFAR costs of supporting an individual on treatment from nearly $1100 per year to $335 and falling. During my time as Coordinator, PEPFAR has aggressively accelerated the development of costing studies of treatment and other programs, and has funded innovative work examining the cost-effectiveness of service delivery models.

PEPFAR has also pioneered the use of outcome-linked expenditure analysis exercises among prevention, care and treatment partners in several countries. We are working to quickly routinize this activity PEPFAR-wide.

These data are shared with partner governments, and used in decision-analytic and cost-projection modeling sponsored by PEPFAR and other partners to improve national program planning. Better access to updated economic and financial data and indicators will allow for PEPFAR programmers and national governments to better make rapid course corrections to improve planning and effectiveness, and avoid inefficient use of resources.

We also have the potential to achieve better technical efficiency when investing in models of service delivery that are integrated. PEPFAR is one of the key platforms upon which the Obama Administration is building the Global Health Initiative, supporting one-stop clinics offering an array of health services. This means driving down costs, driving up impact, and saving more lives. Through PEPFAR investments, we have put systems of care in place that countries are leveraging to improve their citizens’ overall health.

In addition, through the Global Fund reform process, and the daily efforts of our country teams, we are leveraging our investments through better coordination with the Fund and the elimination of parallel systems. The Fund represents a critical vehicle for other donors to contribute to our shared global responsibility to address this global burden. The United States is the largest contributor to the Fund, and we are now working closely with it to ensure that each dollar achieves maximum benefit as part of a common effort to support our partner nations.

Another focus is what we call country ownership -- working even more closely with the governments and civil society of the countries in a partnership. Part of this discussion is asking countries to assess what complementary resources they can bring to the table. In some cases, they have responded with strong financial commitments, such as the South African government’s impressive recent increases in investments in their HIV program.

Country ownership also takes the form of leadership in prioritization, implementation and accountability at the local level. Through the 21 Partnership Frameworks we have signed with partner countries, we are working to put them in the driver’s seat of their national HIV responses. For HIV as for other development issues, countries must lead their own responses, and we must model our commitment to be supportive partners as they assume increasing responsibility.

4. Expanding implementation science

Our ability to scale these interventions is based on our evaluation framework, which focuses on implementation science and impact evaluation. In the second phase of PEPFAR, characterized by an increased emphasis on sustainability, programs must demonstrate value and impact in order to be prioritized within complex and resource-constrained environments. In this context, there is a greater demand to causally attribute outcomes to programs. Better attribution can be used to inform midcourse corrections in the scale-up of new interventions, or to reevaluate investments in programs for which impact is less clear.

To meet these demands, PEPFAR is adopting an implementation science framework to improve the development and effectiveness of our programs at all levels. As we recently described in an article in JAIDS, implementation science is the study of methods to improve the uptake,

implementation, and translation of research findings into routine and common practices – moving them from bench to bedside.

We used implementation science to evaluate the operational effectiveness of the South African National Program for Prevention of Mother-to-Child Transmission. Investigators explored the survival of HIV-free infants across program sites and identified specific sources of variation such as health system factors -- for example, limited antenatal visits and lack of syphilis screening -- and individual behaviors such as breastfeeding practices. By framing the problem through implementation science, the study revealed opportunities for improving program performance that could be translated into immediate solutions such as, improving quality of care, and infant feeding counseling. In this way, implementation science has proven to be a valuable tool not only to improve program effectiveness, but also to explain what worked, why, and under what circumstances.

We have enjoyed an intensified relationship around science with NIH, and with our other US agencies that are critical to delivering global health care, including CDC and USAID. This has taken numerous forms, including collaboration around rapid expansion of the largest known roll-out of support for implementation science activities.

Together, we have rapidly funded three large implementation science RFAs that have generated many, many excellent proposals that will lead to important questions being answered quickly and with rigor. We have also co-invested with NIH on a targeted RFA for vertical transmission, and with NIDA for one on HIV services for people who inject drugs. It is such a pleasure to work with NIH on these collaborations, given the depth of experience and knowledge of people like Francis Collins, Tony Fauci, Harold Varmus, Roger Glass, Carl Dieffenbach, Lynne Mofenson, Nora Volkov, and Jack Whitescarver, to just name a few.

Perhaps most importantly, we have also recently awarded three groundbreaking grants for trials of combination prevention, using the best available tools of implementation science, scaled to high levels, to allow us to rigorously evaluate the population level effects of combination prevention.

We have also launched a new endeavor we call, ―In-Country Impact Evaluation.‖ Through this process, we have enabled our country teams to use a fraction of their budget to work with academic and local program experts to apply the rigorous methods of impact evaluation to critical programs. Proposals for these evaluations will include the use of counterfactuals and other innovative designs, such as stepped wedge rollouts, and will be intensively reviewed by our review teams, including experts from NIH and CDC. By opening up yet another avenue for rigorous research, we hope to have a burst of public health-relevant data over the next several years that we can use to shape the program to be as impactful as possible in the future.

Once again, it’s important to note that our efforts are part of a larger context that extends to all development activities. The challenge to build an evidence base, evaluate impact, and direct programs accordingly is not limited to HIV or even health programs, but extends to the entire domain of development. At PEPFAR, we see ourselves as part of this larger picture, and are committed to sharing the lessons we’ve learned with our colleagues who work in other areas.

5. Building the capacity to lead

One of the most important pieces of our work is to ensure that we don’t win our battles against the epidemic but lose the larger war to develop the local capacity to lead national health and development responses. Indeed, as part of GHI, PEPFAR has served as the primary engine for building systems that can provide other services. We are moving quickly to leverage the low-hanging fruit, such as ensuring that the supply chains and vehicles delivering HIV commodities are also delivering bed nets and other vital supplies. As we move on, we are exploring the power of our sites to address diseases such as cervical cancer and other chronic diseases that, like HIV, require repeated follow-up, such as tuberculosis, hypertension and diabetes.

I have put into place a number of initiatives borne out of my experience to improve the sustainability of HIV and broader health and development programs. First, we have recognized the centrality of laboratories and trained laboratory specialists to improve the ability of clinicians to deliver quality HIV care and treatment, and for tracking the status of the epidemic through surveillance. Severe shortages of the key personnel we take for granted in the United States have often reduced health systems’ ability to diagnose disease, whether HIV, malaria, tuberculosis or renal disease.

Earlier this year, with CDC and NIH support, we supported the launch of the African Society for Laboratory Medicine, or ASLM. ASLM is a pan-African professional body headquartered in Addis Ababa that will advance the professional laboratory medicine practices, science, systems and networks in Africa. Its activities range from workforce development to technical assistance, with a focus on accreditation and quality management.

With the exception of South Africa, only 8.2% of labs in sub-Saharan Africa are internationally accredited. In order to ensure that the millions of patients in Africa who rely on public labs receive quality services, ASLM is working directly with Ministries of Health, the WHO and other partners to create a more informed and connected cadre of laboratory scientists who work within accredited labs and lab systems.

ASLM is working to connect and inform lab scientists through the creation of a peer-reviewed journal, African Journal of Laboratory Medicine, which launched this month. In addition to increasing the visibility of lab medicine in Africa, the journal serves as a forum for sharing research, training, academic and industry news.

I would also like to highlight two other programs, the Medical Education Partnership Initiative (MEPI) and the Nursing Education Partnership Initiative (NEPI). Launched over the last two years, MEPI and NEPI seek to alleviate Sub-Saharan Africa’s critical shortage of trained healthcare professionals and paraprofessionals, while developing sustainable local capacity to produce skilled doctors, nurses, and midwives for generations to come.

Over the five years of the initiative, MEPI will receive $130 million in funding from PEPFAR and NIH, and administered through the Fogarty International Center and HRSA, to distribute to African institutions in a dozen Sub-Saharan African countries. These funds go towards

developing medical education, investing in innovative technologies, and strengthening educational resources. Funding from this program is also used to support the research capacity of MEPI institutions, and the contributions that African researchers and scholars are making to the larger body of HIV knowledge are invaluable.

In a similar fashion, the nursing initiative provides training and technical support to nursing and midwifery programs throughout Sub-Saharan Africa. NEPI has been launched in three countries—Zambia, Lesotho, and Malawi—that face extreme challenges in meeting the need for trained nurses and midwives, and will soon expand to additional countries. Ministries of Health are key to NEPI’s success, and they have embraced these opportunities to substantially review and prioritize support in developing a strong nursing workforce.

When I talk about doing development differently, these programs focused on laboratories, physicians and nurses are prime examples of what I mean. They build on Africa’s greatest resource of all—its people. They are fostering indigenous capacity to strengthen health systems in a sustainable manner. If we are to make a truly lasting difference in our health and development programs, we must support this kind of work -- across many disciplines.

Future directions

With so much accomplished and so much yet to do, what does the future hold?

In terms of further improving our combination prevention package there is a lot to be hopeful for with continuing research on pre-exposure prophylaxis, microbicides that put women in charge of their protection, and vaccines.

In the meantime, we must expand the impact of our programs by increasing the coverage of our high-impact programs. And we must use the smartest possible strategies to apply our funding as effectively as possible. I would also ask, and am asking our program, ―How much further can we develop true country ownership and capacity to lead?‖ As I’ve noted, this will be every bit as important as the tools we have to implement the HIV response, and I am firmly committed to a further orienting this program toward that goal.

On World AIDS Day, in the New York Times, musician and activist Bono asked how so much had been achieved in the global AIDS response in such a short period of time. His answer? ―America led.‖ America has indeed led, starting with citizens who understand the good that can come with funds that represent a small piece of the national budget. It includes the committed people and organizations that have given mightily of their time and efforts. America will continue to lead, as President Obama and Secretary Clinton have so clearly outlined, but we will and must do it recognizing that to truly be successful, other nations – both donors and partner nations -- must share in this responsibility.

There are formidable challenges, to be sure, but the progress we have made in translating science to impact in order to achieve our collective vision of an AIDS-free generation is heartening. As

Nelson Mandela reminds us, ―It always seems impossible until it’s done.‖ Let’s remember that vision as we continue the long, but winnable fight against HIV and other health and development challenges, using every scientific, public health and political tool we can to help win.

Thank you very much.