Towards an AIDS-Free Generation Women & Girls and HIV in PEPFAR Opening:   Thank you for that gracious introduction. I am pleased to be here today with all of you as we begin what I hope will be a productive three days together. I want to thank Ambassador Gaspard, Counselors General Taylor Ruggles and Erica Barks Ruggles, DCM Virginia Palmer, PEPFAR Coordinator James Maloney and the entire South African PEPFAR Country Team for their incredible hospitality. I know this meeting was delayed, but I am delighted that we’re all here!! My goal for this meeting is to begin a dialogue that continues throughout my tenure as Global AIDS Coordinator….31 months and 19 days…but who is counting?! Ambassador Deborah Birx Global AIDS Coordinator US Department of State September 9, 2014

History of the Epidemic & Response 1 Where We Were:   This morning, I’d like to talk about the history of our response to the epidemic (which we touched on a bit in some of the agency meetings yesterday) and the challenges and opportunities as we move toward an AIDS Free generation…. and then share some thoughts about my vision for PEPFAR. Like some of you in this room, I’ve been on the frontlines of the fight against HIV/AIDS since the early days of the epidemic—when I was treating young soldiers at Walter Reed Army Hospital who had an illness we didn’t have a name for at the time. Being on the frontlines has its highs and lows. In the U.S., we managed our way through the first decade of AIDS without effective treatment as we struggled to contain the spread of the disease in our own communities. After more than a decade of tireless work by scientists, activists and people from all walks of life working together to provide prevention, care and treatment we forged our way to the advent of the lifesaving medicines that changed the course of the disease in America and other countries around the world that could afford the cost of care. At the same time, we were facing the enormity of the AIDS crisis as it raced around the globe and wrought then untold devastation on Africa and much of the developing world. Facing the stark reality of death and despair faced by those in the wake of this disease citizens around the world had to make a choice—the same choice faced by countless individuals and communities before us—to either rally or be overwhelmed. History of the Epidemic & Response Celebrating success and a call to action

Where we were before PEPFAR… 1991 – 2001: Peak of the Pandemic 2001: Nearly 10,000 new HIV infections daily 2002: 50,000 on treatment in sub-Saharan Africa Health systems overwhelmed by the epidemic Life expectancy declines of over 20 years in some countries Loss of working age population – reversing decades of development progress

Delivering an AIDS-Free Generation Unwavering Leadership from Congress Demonstrated Commitment to Ending the AIDS Pandemic 2003 US Leadership Against AIDS, TB, & Malaria Act 2008 Hyde-Lantos Reauthorization of PEPFAR 2013 PEPFAR Stewardship & Accountability Act Delivering an AIDS-Free Generation Accountability Transparency Impact

Trends in New HIV Infections, 1990-2013 PEPFAR Has Saved Millions of Lives New Infections Halved since Peak of Epidemic Trends in New HIV Infections, 1990-2013   But we can’t become complacent now. The road ahead to an AIDS-free generation remains long….. and complicated. And all of you know that because you’re paving the road!

2 Leaving no one behind Women face disproportionally high burden of HIV/AIDS

Key Populations Face a Significantly Higher Risk of Acquiring HIV/AIDS Young women Sex work People who inject drugs Men who have sex with men Transgender Migrants Prisoners Displaced Pregnant women 50+ Disabled African American women Intimate partners Young women in Sub-Saharan Africa are by far the largest group with a disparately high risk of acquiring HIV Source: UNAIDS, 2014

New HIV Infections in Sub-Saharan Africa by Age & Sex, 2013 Disparately High HIV Prevalence among Young Women Compared to Young Men New HIV Infections in Sub-Saharan Africa by Age & Sex, 2013 Source: UNAIDS 2014

HIV Leading Cause of Death among Adolescent Girls in SSA In Eastern and Southern Africa, HIV is the leading cause of death in girls aged 15-19 16.9 Source: Global Burden of Disease 2010

PEPFAR: Improving Outcomes for Women & Girls 3 PEPFAR: Improving Outcomes for Women & Girls

Women & Girls on Lifesaving Treatment

ACT: Accelerating Children’s HIV/AIDS Treatment PEPFAR & CIFF (the Children’s Investment Fund Foundation) launched a public-private partnership to keep Children & Adolescents alive and healthy This $200 million initiative aims to double the number of children on treatment in at least 10 countries in sub-Saharan Africa With this initiative, we could avert an additional 250,000 HIV-related deaths of children under the age of five Additional HIV-related deaths will be averted in the 5-15 year old age group.

800 mothers die attributable to HIV Maternal Deaths & HIV 18% Maternal mortality ratio, 2010 Every day 800 mothers die due to pregnancy & childbirth WHO estimates that 18% of all maternal deaths are attributable to HIV People Living with HIV by Region, 2011 Source: WHO, 2011/2012

PMTCT: HIV Testing for Pregnant Women Over half of HIV+ pregnant women in the world are tested and identified with PEPFAR support 6.9%

PMTCT: Getting Lifesaving ART to HIV+ Pregnant Women to Protect Maternal & Infant Health In 2013, 56% of women received lifelong ART, up from 23% in 2011.

Saving Mothers Giving Life An Innovative Public-Private Partnership SMGL is bringing together key partners… To address the 3 delays that contribute to maternal mortality: Delay in decision to seek care Delay in reaching care Delay in receiving quality health care Approximately half of all women in sub-Saharan Africa deliver at home without skilled care and timely access to emergency services; this puts them and their newborns at increased risk of dying from pregnancy-related complications should they arise.   Saving Mothers, Giving Life focuses on reducing maternal deaths when these emergencies occur, by addressing the three delays: -Delays in deciding to seek appropriate care -Delays in reaching care -Delays in receiving timely, quality care at the facility The partnership works to address these issues in a number of ways: --Raising awareness and mobilizing communities to encourage more women to seek facility births. --Facilitating access to facilities, through enhanced communications, transportation and referral networks. --Improving quality of care through supporting the training of health providers, community midwives and other health workers, by improving facility infrastructure, and by procuring needed supplies.

SMGL Outcomes Evaluation January 9, 2014 SMGL Phase 1 Results: Institutional Maternal Mortality Declined in both Uganda & Zambia - 35% - 35% - 36% - 35% Percentage declines noted are statistically significant

significantly higher risk Pink Ribbon Red Ribbon Public-Private Partnership to Combat HIV & Cervical and Breast Cancers in Africa HIV-infected women have a significantly higher risk of acquiring cervical cancer Cervical cancer – one of most common cancers among women in developing world 275,000 deaths each year >85% global burden in developing countries $85 million over 5 years currently committed Zambia and Botswana are initial PRRR countries Major expansion of “screen and treat” programs Pilot programs for HPV vaccination Training for breast cancer awareness and CBE Founding PRRR members include: PEPFAR The George W. Bush Institute Susan G. Komen for the Cure UNAIDS Multiple private sector partners  

PEPFAR Gender Strategy in the past four years, PEPFAR reached over 114,000 survivors of sexual violence with post-exposure prophylaxis to prevent HIV Increasing gender equity in HIV/AIDS programs and services, including reproductive health services Preventing and responding to gender-based violence Engaging men and boys to address norms and behaviors around masculinity and sexuality Increasing gender-related policies and laws that increase legal protection Increasing gender equitable access to income and productive resources, including education

Mitigation as Prevention: OVC Programs Impacts of social protection on girls’ past-year incidence of transactional sex

Together for Girls A Unique Public-Private Partnership Daniela starts here

Our work is not done. This week alone… Over 3600 children died this week from HIV Over 25,000 adults died this week from HIV Over 4,600 babies were infected with HIV Over 36,500 adults were infected of which more than 7000 were young women

As I reflect on my new role as Global AIDS Coordinator, I am humbled to play my small part in the worldwide effort to bring and end to AIDS as we know it.   I cannot emphasize enough that we are all in this together. That’s why coordination and collaboration is so important. Each and every one of us is doing our part in delivering an AIDS-free generation through impact, transparency and accountability. And each and every one of us is making a difference in the lives of others. That’s a pretty remarkable feat. A feat, which should make us all proud. ……. Again, thank you for all of your hard work and thank you for your continued commitment to PEPFAR’s promise. The next few days will give us an opportunity for open dialogue about how we move forward together—the interagency, donors, multilateral organizations, civil society, people living with and affected by HIV, indigenous organizations, and host-country governments. We all have a critical role to play. The responsibility and success of PEPFAR is dependent on all of us. I look forward to answering your questions.