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On behalf of the conference cochairs, Dr Tim Mastro (CDC) and Dr Vicky Cargill (NIH) I want to extend a warm welcome to this meeting.  As we commence this meeting, I invite each and every one of you to participate, engage and act to advance HIV prevention here in the United States.

Many of us were involved yesterday with World AIDS Day related activities in our communities.  For many, World AIDS Day is a time to reflect on the fact that 26 years and 6 months ago on June 5, 1981, CDC published in the MMWR a report of Pneumocystis pneumonia in five previously healthy young men in Los Angeles, California.  These cases were later recognized as the first reported cases of acquired  immunodeficiency syndrome (AIDS) in the United States.

Since that time, this disease has become one of the greatest public health challenges both nationally and globally.  The recently released UNAIDS/WHO Global estimates show that the epidemic remains substantial, with an estimated 33.2 million people living with HIV globally in 2007.  HIV/AIDS has claimed the lives of more than 22 million persons worldwide, including more than 500,000 persons in the United States.  Despite major advances in prevention and treatment, Americans continue to become infected and lose their lives to AIDS at unacceptable rates.  Today, more than 1 million persons are living with HIV/AIDS in the United States; a quarter of these individuals are unaware of their HIV status, and another quarter are HIV infected, but not in care.

Milestones such as World AIDS Day are not only to commemorate those who we have lost or to highlight many of the challenges faced in the fight against AIDS – it also provides time to reflect on some of the gains that we have made to date.  Today we pause to reflect on the importance of  prevention, and some of the tremendous successes we have had over the past two decades.

Prevention of new cases of HIV infection has been the cornerstone of CDC’s effort to halt the spread of this disease since it was first described.  The agency’s overarching HIVprevention goal is to reduce the number of new HIV infections and to eliminate racial and ethnic disparities by supporting the full range of HIV prevention strategies, including HIV testing and prevention interventions for both persons living with HIV and those at high risk for contracting the virus.

There has been progress in our fight against HIV/AIDS. We have seen dramatic declines in mother-to-child transmission of HIV (from 1650 in 1991 to less than 150 per year); declines in HIV and AIDS cases among injection drug users; declines in risk behavior among youth; and studies repeatedly show that the majority of persons who know that they are HIV-positive take steps to protect their partners and loved ones from acquiring this disease.  CDC’s new recommendations to make voluntary HIV screening a routine part of medical care for all Americans aged 1364 years is a major step forward.  There have been new developments in rapid HIV testing technology, combined with innovative approaches which show promising results (e.g. using social networks to identify unknown positives, and actively linking new positives to care – which will be discussed at this meeting).  We have also improved our ability to monitor the epidemic with new surveillance systems; increased the number of states with confidential named-based HIV reporting; and launched new national behavioral surveillance systems as well as a new monitoring system for HIV infected individuals in care.

But there is still unacceptable and severe impact of this disease, and there is an urgent need to accelerate progress.  HIV remains a significant threat to American’s health, with two groups being most severely affected: MSM of all races and African Americans.  The data are staggering: MSM account for nearly 50% of those people living with HIV and more than half of new HIV diagnoses in 2005.  Overall African Americans, although accounting for just 13.5% of the population, accounted for half of all HIV diagnoses (49% in 33 states) and nearly half of people living with HIV (47% in 2005).  The rate of HIV diagnosis among blacks is nearly nine times higher than the rate among whites.  While the impact is not as severe among Latinos, Hispanics are also disproportionately affected by HIV, with a rate of diagnosis roughly three and a half times that of whites.  While advances in treatment have greatly improved the lives of thousands of HIV-infected Americans, HIV remains a serious and fatal disease – in 2005, over 16,000 Americans with AIDS died.

So in summary, we have seen important signs of progress, but HIV/AIDS among our families and our communities remains unacceptable and severe.  We know that proven interventions exist, but too many people at risk are not being reached (e.g. Just over 20% of MSM report receiving interventions we know to be most effective). As a nation we must continue to invest in prevention, especially for MSM.  We must do more, faster and more efficiently.  We need to reach critical mass with our prevention efforts and go beyond what we have done to date.  This conference and our efforts cannot be just about “business as usual”.

At this conference, you have our commitment to strengthen our engagement with people and community leaders affected by HIV/AIDS; to strengthen collaboration and integration of HIV prevention across federal agencies; and to expand the search for solutions.

For this 2007 Conference we have incorporated a number of new developments to meet these commitments including:

• Ensuring each Track has dedicated sessions on the impact of HIV/AIDS among ethnic communities and sexual minorities, with particular attention to AA, Hispanic/Latino, and MSM.
• Expanding outreach to Hispanic/Latino communities by developing conference materials and Internet resources in Spanish, for the first time.
• Expanding engagement with researchers and community members of minority communities through dedicated forums with CDC and our Advisory Committee leaders to reflect upon the state of the HIV,STD and Hepatitis epidemics.
• Expanding tracks which focus on the synergies between science and program, but with a particular emphasis on moving from knowledge to action.
• Highlighting our commitment to structural interventions for HIV/AIDS prevention through the establishment of a new Track (G) on Program Collaboration and Service Integration.
• Talking about new opportunities for advancing and integrating HIV prevention within domestic TB, STD and Hepatitis prevention Programs.
• And bringing together HHS leaders from: HRSA, SAMHSA, IHS, NIH and CDC to talk about how to intensify Federal collaboration to promote HIV prevention and increase joint programming and research in order to enhance HIV prevention efforts.

• Data will be presented on the impact of routine HIV testing.
• Data will be presented exploring trends towards earlier diagnosis of HIV among MSM and factors that contribute to the severe impact of HIV among AA MSM.
• Data will be presented on new effective interventions planned for national dissemination in 2008

We have also launched a Heightened National Response to the HIV/AIDS Crisis among African Americans.  This initiative aims to expand the reach of prevention services; increase opportunities for diagnosing and treating HIV; develop new effective prevention interventions; and mobilize broader community action.

As we reflect upon our efforts to accelerate progress and expand access to HIV prevention, I know many of you will want to know the status of one of the most exciting developments in the area of surveillance and strategic information in the fight against HIV/AIDS.  Recent reports have highlighted the fact that CDC is developing new estimates of HIV incidence for the United States.  We are excited about these estimates, which will provide the clearest picture to date of HIV infections in the United States.  The estimates are based on the first national system for directly measuring new HIV infections, made possible by new technology that can distinguish recent from longstanding infections.

The estimates are currently being peer-reviewed prior to acceptance and publication in a scientific journal. We anticipate releasing these data as soon as they are publicly available. Given the enormous importance of these data for the nation’s prevention efforts, this expert peer review is important to ensure that the methodology and conclusions are accurate.  I look forward to speaking in greater detail about the new data once they are finalized and published.

We are also committed to increasing the number and scope of effective HIV prevention interventions.  I am delighted to report that CDC has made substantial progress in this area.  On Friday, the Updated Compendium of Evidence-Based HIV Prevention Interventions went live on the CDC Web site.  This update uses more rigorous criteria for evaluating the evidence of efficacy for individual and small group-level interventions.  This update brings the number of interventions from the 24 identified in the original Compendium to a total of 49 that meet new best-evidence or promising evidence criteria.  A special session will be held on Tuesday morning to provide more information and answer your questions about this update.

CDC is also working to identify new criteria for studies evaluating community-level and structural interventions.  In addition, we are working to increase the availability of intervention materials and trainings to you and your organizations.  CDC is working to expand the use of 8 new scientifically proven  nterventions for a range of populations at risk including AA women and adolescents, Latino IDUs, incarcerated men, heterosexual AA and Latino couples.  This is in addition to the more than a dozen programs already in use.  At the same time we still need innovative approaches for key risk groups including AA MSM – CDC is testing a number of innovating behavioral interventions with this group; and to address immediate needs we are supporting the adaptation of scientifically proven programs (e.g. POL for AA MSM) as well as testing promising biomedical approaches.

Finally, we are reconfirming our commitment to addressing societal issues which continue to drive HIV transmission in the US today.  For the individual this includes age, presence of other STIs, circumcision status, nutritional status, immunogenetic factors, type of exposure, and, most critically, having sex with an infected partner.  Within partnerships, this includes type of partnership and societal contexts (e.g. social norms and expectations, gender roles).  And both individuals and partners are part of larger sexual networks.  Thus, the likelihood of an individual acquiring HIV is dramatically affected by the prevalence of infection among their partners and within the larger sexual network.  This is likely to be a major contributor to the high rates of HIV among Black MSM in the USA today.

Data also suggest that demographic, epidemiological, social, and political contexts directly influence the structure and dynamics of sexual networks and, in turn, are influenced by them. Population composition, rates of fertility and mortality, and patterns and levels of migration and urbanization are key demographic influences on HIV/AIDS.  Other factors relevant to HIV transmission include the availability and cost of prevention services, legislation, and law enforcement, and the role of the media in creating or reinforcing social norms.  Societal and religious attitudes and tolerance towards marginalized or socially disadvantaged populations may impact the delivery and implementation of effective evidence-based interventions. While there are no easy answers for addressing these societal-level influences, it is vitally important that practitioners take into account these wider contexts.

Now more than ever, CDC is committed to working on solutions to structural issues in partnership with governmental and nongovernmental partners.  Racism, homophobia, stigma, and discrimination are some of society’s most difficult and longstanding challenges and many have argued that they go beyond the scope of any single agency or sector, and certainly cannot be resolved overnight.  However, I firmly believe that change begins from within.  Therefore we must begin within our agencies to articulate a shared vision for tackling these issues.

As we think about these societal determinants of HIV transmission, you will hear much about structural interventions at this meeting.  Structural interventions refer to public health interventions that promote health by altering the structural context within which health is produced and reproduced.

CDC is involved in a number of activities across agency lines to address the societal factors, and it is my commitment that we will continue to collaborate across Federal agencies to facilitate integrated, comprehensive approaches to HIV prevention. For example:

• CDC is partnering with NIH to look at how networks and access to care may influence infection.
• With HUD to study how unstable housing affects adherence to medications, health, and risk behavior among persons living with HIV.
• And increasing our joint consultations with NIH, HRSA, SAMHSA and IHS to talk about structural/socio-cultural research and programmatic efforts needed.

Twenty-six years, and six months into this epidemic.  On the day after World AIDS Day 2007, let us begin this conference by reflecting and remembering those who we love and those whom we have loved and lost. So much has passed, so much has been achieved; yet the challenges seem so daunting.

To the scientists in the room – I want to thank you for your work; for your dogged persistence in tackling the tough questions; for your creativity in the face of numerous challenges and difficulties in undertaking studies to benefit communities in the US and around the world.

To our program and policy colleagues in the room whether working in State, Local Health Departments and NGOs, or Other Federal Agencies – thank you for your leadership; your persistence to continue the fight; your thoughtfulness and mindfulness in getting services and policies to those in greatest need.

To our community partners thank you for persevering when the road seems incredibly rough, lonely, endless and thankless.  Know that the lives of many today, and those who have past, depend upon you and your leadership, commitment and strength.

Thank you all for your leadership and commitment to HIV prevention. I will end as I began, by laying down the challenge for you all to use this meeting to engage, interact, mobilize and act.

Thank you very much.