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Good afternoon and welcome to today's meeting of the Commonwealth Club of California. I'm Jack Cortis, President of Mellen Private Wealth Management of Northern California and the commonwealth club's quarterly chair. It is my pleasure to introduce our distinguished speaker, Ambassador Mark Dybul, US Global AIDS Ambassador, Coordinator. Ambassador Dybul is responsible for implementing President Bush's emergency plan for AIDS relief. Prior to this, he held a position of Deputy US Global AIDS Coordinator. Prior to coming to the coordinator's office, he was the lead for the Department of Health and Human Services for President Bush's International Prevention of Mother and Child HIV initiative. At health and human services, he also served as Assistant Director for Medical Affairs National Institute of Allergies And Infectious Diseases, national institutes of health, as well as Co-Executive Secretary of HHS HIV Therapy Guidelines for Adults and Adolescents. Ambassador Dybul is a captain in the US Public Health Service Commission Core. Ambassador Dybul received his AB and MD from Georgetown University and he completed his residency in internal medicine at the University of Chicago hospital. Please welcome Ambassador Mark Dybul. Good afternoon. Thank you very much Jack for the introduction and for this opportunity to talk about the President's Emergency Plan for AIDS Relief. It's always a special pleasure to return to San Francisco where I worked as a young medical student many years ago with Marcus Koenen at the height of the epidemic more than 15 years ago. I also want to thank Dr. Volberding for participating in today's forum. As I think everyone knows, Paul played an instrumental role in the 1980's as one of the co-founders of the first AIDS designated clinics at San Francisco General Hospital and yesterday I had the privilege of returning to San Francisco General Hospital and touring Ward 86 again and Paul's remained one of the global and domestic leaders in HIV/AIDS from the very beginning. As I think most people know HIV/AIDS is the black death of our time. 39 million people are currently infected. 25 million people have already died and without action, some estimate that more than 70 million will die by the year 2020. That's more than died in all of World War 2. When the history of global health is written, the launch of PEPFAR of the President's Emergency Plan for AIDS Relief, both its size as the largest international health initiative in history dedicated to a single disease, and I think that phrase is alway worth repeating, the largest international health initiative in history dedicated to a single disease. But also it's focused on results, with ambitious goals for prevention, treatment, and care, will be remembered as one of the boldest and most important actions ever. Individuals, communities, and nations are taking control of their lives, and are beginning to turn the tide against HIV/AIDS pandemic and PEPFAR is on track to meet the goals of supporting treatment for 2 million people and in perspective, when the President announced this initiative, only 50,000 people in all of sub-Saharan Africa were receiving treatment, prevention of 7 million new infections, and care for 10 million, including orphans and vulnerable children. As the institute of medicine recently noted in its review, PEPFAR has "demonstrated what many doubted could be done". Through September 30th of last year, the American people supported life saving anti retro viral therapy for 822, 000 people in 15 focus countries, 12 of them in sub-Saharan Africa. And you supported care for 4.5 million people including 2 million orphans and vulnerable children. You supported scale up of the most comprehensive and evidence based prevention program in the world, evidence based behavior change messages for 135 million people of all ages and social strata, including the distribution of 1.3 billion condoms, the development of safe blood systems, and services to prevent transmission of HIV from pregnant women to their children during more than 6 million pregnancies, averting an estimated 101,000 infant infections. All of this has been accomplished through the power of partnerships. The US government and the American people have been privileged to partner with the many local governmental and non-governmental organizations, including faith and community based organizations in the private sector, to achieve these impressive results. 83% of our partners are local organizations and the successes are primarily theirs not ours. It's important to note that PEPFAR is part of a broad and bold development agenda. It does not stand alone. Not since the Marshall Plan, has the world seen such a massive commitment to international development. President Bush with strong bipartisan support, and we're privileged to be in a city with some of the most important bipartisan leaders, Speaker Pelosi, Chairman Lantos, who will be joining later today, Congresswoman Barbara Lee, and with that strong bipartisan support, President Bush has doubled resources for development overall and with his 2008 budget request, will have quadrupled them for Africa, quadrupled. And that doesn't include the massive debt relief, which we've instigated, and doubling of trade with Africa, mechanisms that fuel economic development, the ultimate engine to lift people out of poverty and despair. In many ways, this new era is more ambitious than the Marshall Plan. Unlike the rebuilding of Europe, the American people are building life, liberty, and opportunity where they have never existed in modern times. PEPFAR joins other Presidential initiatives, the millennium challenge corporation, the President's malaria initiative, the African education initiative, the women's justice and empowerment initiative, and others in a renaissance in development. It is a renaissance not only because of the commitment of resources, but because of a radical new philosophy that rejects the failed donor Cyprian reproach and returns to the vision of the Marshall Plan. It is the philosophy rooted in a handshake rather than a handout. It is the philosophy rooted in partnership between people. It is rooted in faith and hope. Hope for and faith in people of the countries in which we are so privileged to work and as importantly hope for and faith in the compassion and generosity of the American people. The Marshall Plan was born of profound compassion and generosity and so have been PEPFAR and the general renaissance and development. President Bush has pursued with bipartisan support an extraordinary effort and as President Bush has often said, most recently this week at the White House event for the inaugural malaria awareness day, to whom much is given, much is required. But in addition to this humanitarian concern, the Marshall Plan recognized that a Europe floundering in destruction and despair was a risk to global peace, freedom and prosperity, and was therefore a risk to the interests of the United States. And so to the continent of Africa and other regions floundering in destruction and despair because of HIV/AIDS and poverty, are global risks to peace, freedom, and prosperity, and so pose a risk to the interests of the United States. The UN general assembly, in its only special session ever dedicated to a disease, the UN security counsel, the US national intelligence counsel, Secretary of State Colin Powell, who knows a bit about peace and security, and many others have stated that HIV/AIDS is a threat to national and international security. General Wald, the former deputy commander of the US/European command, with responsibility for Africa, a four star general, called HIV/AIDS the third greatest threat to our own national security, behind only weapons of mass destruction and terrorism. Now how can an infectious disease be a threat to global and regional peace and security? Well the answer's complicated, but can be captured in terms of short and medium long term risks. One short term risk is clear. The devastating impact of HIV/AIDS is decimating peace keeping forces. 37% of all UN peacekeepers are African, but HIV/AIDS is taking a high toll on African militaries. HIV related deaths have reduced the size of Malawi's armed forces by 40%. 70% of all military deaths in South Africa are due to HIV/AIDS. In a recent effort to field peace keepers, South Africa could not field a single HIV negative battalion. HIV impacts nation's abilities to protect their own citizens and to provide peace keepers for other conflicts, fueling national and regional instability. In addition, the risk of becoming HIV infected has increased significantly among peace keeping troops. HIV prevalence among Nigerian forces, keeping the peace in Sierra Leon, grew from 10% in year one to 15% in year three, which is not surprising. Militaries in service away from home, often engage in risky activity. And so there's a vicious cycle here. HIV/AIDS puts the health and lives of peacekeepers at risk when they're at home, limiting the ability to field an effective force, but when they're deployed, they actually increase the risk of getting HIV for the troops, further impeding in the long term, the ability to field peace keepers. In addition to this immediate impact, in the medium and long term the pandemic is rending socioeconomic fabric of communities, nations, and an entire subcontinent, creating a potential hotbed for instability and a breeding ground for radicalism. The HIV/AIDS pandemic is unique, and this is something I think we need to focus on. Unlike many diseases, it does not mainly attack the oldest, youngest, or weakest. It strikes people in the prime of life. Since the 1990's the largest increase in HIV/AIDS mortality has been among adults aged 20-49, and now accounts for nearly sixty percent of all deaths in sub Saharan Africa in this age group, sixty percent. it is the leading cause of death among this age group. Communities are being hobbled by the disability and loss of consumers and workers at the peak of their productive, reproductive, and care giving years. In the most heavily affected areas, communities are losing a whole generation of parents, teachers, laborers, healthcare workers, peace keepers, and police. The ultimate way to achieve sustainable development is through economic opportunity and that requires a robust business sector. In HIV/AIDS straining corporate budgets, the rising healthcare costs, increased absenteeism, a shrinking work force, lost expertise, high turnover, and reduced productivity. By 2020, UN aids projects that HIV/AIDS will have caused GDP to drop, to drop by more than twenty percent in the hardest hit countries. The World Bank recently warned that while the global economy is expected to more than double over the next twenty five years, Africa is one of the few regions at risk of being left behind. in a cruel irony of the disease, a vicious cycle of economic development threatening peace and security in the medium and long term mirrors the vicious cycle of the immediate impact on peace keeping enforces. Data from Africa, Asia, Eastern Europe demonstrate that it is not the poorest of the poor at greatest risk for HIV/AIDS, but those who have begun to climb the first few rungs of the economic ladder. And so not only does HIV/AIDS limit economic growth, limit gross domestic product growth, but as the economies begin to expand, those participating in the economic advantages could actually be at greater risk of HIV/AIDS infection leading to further impact on economic growth. Now of course the main impact of HIV/AIDS is personal. every person who becomes infected with HIV/AIDS and who dies is a friend, a family member, a colleague, but the ramifications of these many deaths for social structures that keep communities and nations secure, are overwhelming. Parents are dying from HIV/AIDS. Around the world fourteen million children under fifteen have lost one or both parents to HIV/AIDS. And by 2010, that number is expected to exceed twenty million. Educators are dying from HIV/AIDS. Africa has seen an especially high HIV related mortality among teachers and school administrators. In Zambia for instance, the equivalent of two-thirds of each year's newly trained teachers are being lost to HIV/AIDS. How do you educate the next generation, if two-thirds of new teachers die from HIV/AIDS? Many children who have lost parents to HIV are left entirely on their own, leading to an epidemic of orphan headed households and I've had the great fortune to meet with some of these heroes, these young orphans who are running households and taking care of others. But when they drop out of school to fend for themselves and their siblings or for their friends, they lose the potential for economic empowerment that an education can provide and are often alone and desperate. They resort to transactional sex and risk becoming HIV infected themselves, another vicious cycle of this epidemic. I should briefly note that the threat to global health from HIV/AIDS is also there. An ever expanding pool of immunosuppressed people worldwide can both more readily contract and spread disease, including infectious diseases we cannot yet predict. Recently HIV/AIDS seems to be the reason for an outbreak of extensively drug resistant tuberculosis in Southern Africa. This must be of great concern to us all, because XDRTB as its known is literally untreatable. And in this era of globalization, infectious disease has known no boundary. Today it's XDRTB, tomorrow it might be avian influenza, or something even worse. The surest long term strategy for addressing these transnational threats to economic growth, security and public health is to promote health, stability, and economic well being of developing nations, and confronting HIV/AIDS is at the heart of the strategy of the American people. While the focus of PEPFAR is on prevention, treatment, and care of people living with HIV/AIDS, the impact of our programs is not focused on just those and need not be just focused on HIV/AIDS. PEPFAR is central to our efforts to connect the dots to international development. Our programs are increasingly linked to important US initiatives in other areas of health and development, and I'd like to briefly address some of these. Tuberculosis is the number one killer of HIV infected people, and so PEPFAR is heavily engaged in tuberculosis work. With 2007 funding levels, PEPFAR will have tripled resources for tuberculosis programs in just four years. And because of the threat of XDRTB, we're working closely with international partners to establish laboratory systems, infection control measures, and standard programs to prevent, diagnose, and manage both regular tuberculosis and drug resistant tuberculosis. PEPFAR also continues to partner with the President's malaria initiative, in countries targeted by both programs, and in fact in 2008 fifteen countries will be jointly sponsored by the two Presidential initiatives. Earlier this week on malaria awareness day, Mrs. Bush announced the 2.9 million dollar public private partnership involving PEPFAR, the President's malaria initiative, the global business coalition, and the government of Zambia. Together, using the infrastructure developed through PEPFAR, we'll be distributing more than 500,000 long lasting bed nets to approximately 1 million Zambians, using the infrastructure that's already been paid for by PEPFAR to distribute bed nets, reducing the costs of reducing bed nets and saving lives from malaria. As these collaborative efforts illustrate, HIV/AIDS is inextricably tied to threats of public health, thus effective HIV/AIDS programs strengthen health systems overall. As the institute of medicine report noted, capacity is severely limited in the developing world. At least one quarter of PEPFAR's total resources are devoted to capacity building in the public and private health sectors, supporting physical infrastructure, health care systems, and work force development, work force is key. We've supported training or retraining for 1.7 million people, and are working with the world health organization on efforts to expand the available work force through the use of community health workers and other health professionals. In addition PEPFAR is working with host countries to build capacity by establishing transparent and accountable delivery of systems that ensure an uninterruptible supply of high quality, low cost drugs, lab equipment, testing kits, and other essential medical supplies. Earlier this year, we announced the 10 million dollar public private partnership phones for health to strengthen healthcare services and monitoring systems through mobile phone technology. The phones for health network will have applications for more than HIV/TB, and in fact already this year Rwanda is being expanded for malaria and tuberculosis. In all we do, PEPFAR works closely with the local faith and community based organizations, supporting their efforts to grow their capacity, to lead their nation's response to HIV/AIDS. When such organizations expand their capacity in order to meet our fiduciary accountability requirements, they're in a better position to succeed in the future. In these capacity building efforts, this creation of a culture of accountability has spillover effects. When a country upgrades its health care systems and strengthens the work force, it improves overall health care delivery. In a recent study conducted at 30 primary health centers in Rwanda, after six months of offering a full package of HIV care services, 21 of 22 measured non-HIV/AIDS health indicators showed improvement, non - HIV indicators. With regression analysis, 7 were specifically correlated with HIV programs and another 5 were associated with HIV programs, including increased syphilis screening, family planning, and improved antenatal care. As the Institute of Medicine chair, (indiscernible) said PEPFAR is contributing to make health systems stronger. And a trick for the future will be to ensure that as we are expanding programs, and as we are focusing on HIV/AIDS, we are also focusing on sustainability and growing health systems. As I mentioned, one of the things we're doing is increasing accountability. We have a new approach that requires stringent reporting requirements and I know it's often called the burden of reporting, but the burden of reporting is actually a foundational feature of transformational development. Reporting is one of the principle means of creating a culture of accountability that has impact beyond HIV/AIDS. Reporting is used primarily so people can evaluate and improve their programs in an evidence based way. And as the institute of medicine noticed, PEPFAR is a learning organization, and to learn from our successes and from our failures, we will use information collected in these reporting systems. Young people account for over half of all new infections, and an estimated two-thirds of these new infections are among young women. And so as we combat HIV/AIDS, girls and women in developing nations must be targeted and must be engaged. Often women are engaged in power and brutal inequalities and women and girls are often powerless to protect themselves. And so one of the most important focuses of our program is to deal with gender inequality to focus on women's violence, and gender inequality to challenge negative male norms, to expand women's legal rights, and to increase women's access to educational, vocational training and microfinance. Overall, we are strongly committed to meeting the needs of children, and that is an essential part of the PEPFAR program. With our 2007 budget, we will have increased resources for orphans and vulnerable children nearly 8-fold from just 4 years ago. These resources provide shelter, food, school fees, emotional support, legal protection, and other services so orphans and vulnerable children from HIV/AIDS can become happy and healthy children. Even more important than care for children who have already been orphaned, is the work we're doing to prevent children's parents from dying in the first place. The best approach for orphans is preventing them. We've begun to work with international models to develop estimates of the impact of treatment and prevention programs and preventing orphans. But our preliminary estimates suggest that through the first 5 years of PEPFAR, through treatment and prevention, we could have averted more than 14 million orphans. And so our programs not only care for orphans and have increased resources 8-fold to do so, including education and other activities. The greatest impact we will have is on averting 14 million new orphans. A recent study revealed that children who lose a parent to HIV face a 3 times higher risk of death than other children, across all causes even if they are not HIV infected. so clearly preventing orphans is not only good for the child's emotional support, but it's also important to ensure the child's survival and health, and is just another remarkable consequence of the rapid growth of affected HIV/AIDS programs. While our goal is not fully education, we are heavily involved in education programs for orphans and vulnerable children, and importantly we connect with the President's African education initiative so that education is a part of what we do in a connected way. We're also supporting nutrition and safe water programs, not only for children, but for adults because nutrition and safe water are an important part of the overall health of people. Again, these are not the principle responsibilities of focus, but they fit within the general framework of the renaissance in development that has been initiated by the President with strong bipartisan support. The successes that are being achieved now in the fight against HIV/AIDS causes great cause for hope. PEPFAR has made a tremendous start towards meeting our goals and our targets of 2, 7, and 10, and we've done so in a short period of time and in the face of many obstacles. But we must not let success breed complacency. As the Institute of Medicine noted, the US must continue its leadership. PEPFAR is the first quantum leap in America's global leadership on HIV/AIDS. One from which we will not walk away. With this historic crisis, comes a historic opportunity for the United States and for the world; an opportunity for partnership, an opportunity for individuals, communities, and nations to come together to serve one another. In San Francisco, 20 something years ago, in the darkest hour of this city when the poll of HIV/AIDS was over the city, the community came together to care for each other with compassion and generosity. Compassion and generosity and the coming together in adversity is not a characteristic uniquely of Americans. But it is absolutely a part of the character of the American people. And as I close, I'd like to share with you a few words by Secretary of State, George Marshall, in his speech to the graduating class of Harvard in 1947, in which he introduced the framework for the revitalization of Europe that eventually became known as the Marshall Plan. Secretary Marshall said, and I quote, "It is virtually impossible at this distance, merely by reading or listening, or even seeing photographs and motion pictures, to grasp at all the real significance of the situation. And yet the whole world of the future hangs on a proper judgment. It hangs I think to a large extent on the realization of the American people of just what are the dominant factors. What are the sufferings, what is needed, what can best be done, what must be done?" These questions so important in Marshall's era seem equally important in our own as we combat HIV/AIDS. On HIV/AIDS, our nation has come to recognize what must be done, and now we are doing it. As we look at the world today and the devastation of HIV/AIDS, a disease that can kill more than died in World War 2, the impetus for the Marshall plan; we know what must be done. As President Bush said when he launched the emergency plan for aids relief, seldom has history offered a greater opportunity to do so much for so many. Thank you for your commitment to HIV/AIDS, thank you for coming today, and thank you for listening.