1. Domestic PEPFAR Mohammed Akther MD MPH

2. Accomplishments of PEPFAR Largest commitment in history by any nation to combat a single disease $25 billion Four million individuals in low- and middle-income countries have access to antiretroviral treatment - and more than half of these individuals are supported by the American people through PEPFAR. Compassionate care for more than 10 million people affected by HIV/AIDS – four million orphans and vulnerable children – 240,000 babies to be born HIV-free. Strong partnerships with countries around the world. countries to ensure a sustainable response.

3. Why a domestic PEPFAR? HIV/AIDS is still an emergency – Over 50,000 new infections a year nationally\ – 835 new diagnoses in DC in latest report – Increasing costs, almost $400,000 per patient over the course of their lifetime. The National HIV/AIDS Strategy has laid the groundwork for this step – Pillar four of the Strategy calls for greater efficiency created by synergies, working across silos Lessons learned from PEPFAR may direct next steps for implementation of the National Strategy.

4. Why a domestic PEPFAR? Half of people living with HIV in the US reside in 12 cities Studies have shown that infections in these epicenters are spreading to the rest of the country. Controlling the spread in these 12 cities will help stop the spread through the country

6. What have we learned from PEPFAR that can be applied domestically?. Important features of PEPFAR includes: – coordination of federal agencies – coordination of jurisdictional partner – enhanced funding Similar solutions need to be tried here a home

7. Why the Metro DC – Baltimore corridor needs a domestic PEPFAR The corridor is one social, economic, and epidemiological unit. The disease knows no borders. We need a regional approach to combat HIV and AIDS, to scale up the National Strategy and reach our goals

8. The region The DC metropolitan area includes DC and part of northern Virginia and Maryland. There are 18 jurisdictions (countries) in the region. DC and Baltimore and amalgamating rapidly with the Balt- Wash corridor, a growing active part of the regional economy. The DC metro region is one of the most dynamic in the nation and rapidly changing.

9. Washington Statistical Metropolitan Area (Washington SMA): 22 jurisdictions Washington, D.C. Maryland (five counties) : Calvert County, Charles County, Frederick County, Montgomery County. Prince George's County Virginia (16 counties/cities) * Arlington County * Clarke County * Fairfax County * Fauquier County * Frederick County * Loudoun County * Prince William County * Spotsylvania County * Stafford County * Warren County Independent cities: City of Alexandria, City of Fairfax, City of Falls Church, City of Fredericksburg, City of Manassas, City of Manassas Park West Virginia (1 county): Jefferson County

10. – PEPFAR created an effective mechanism that brought together the many parts of the US federal government to more effectively fight the epidemic. – For example DC has grants from multiple federal agencies and multiple funding cycles, all with their own reporting requirements. – Better coordination and use of existing funds is essential. PEPFAR lessons for domestic effort: Federal coordination

11. PEPFAR lessons for domestic effort: Jurisdictional coordination – PEPFAR encouraged synergies between jurisdictions, with multicounty approaches. – Coordinate between the three jurisdictions (States) and many countries need to begin with: a regional data system Regional planning Regional coordination of service delivery

12. PEPFAR lessons for domestic effort: Enhanced funding – The CDC estimates that a $10 billion investment now will save $66 billion over the long term (savings on very expensive HIV treatment). – Enhanced funding for the region are essential to scale up the National HIV/AIDS Strategy.

13. Domestic PEPFAR in the context of ACA (Affordable Care Act) – Access to care is rapidly being resolved in metropolitan DC. The next step in health reform is improving quality of care and bending the cost curve by redesigning the health care system. – The fragmented, poorly coordinated US health system extends to care for HIV and AIDS. – Domestic PEPFAR will help move in this direction and by working to implement ACA making changes more sustainable.

14. The corridor is ready for a domestic PEPFAR – Domestic PEPFAR was first proposed in an editorial by Nobel laureate Robert Gallo in the Washington Post – The Mayor of DC, Vincent Gray and the Governor of Maryland, O’Malley wrote a letter to the President of the United States calling for a domestic PEPFAR. – COG (Council of Governments) has taken up the issue already.

15. Why start pilot domestic PEPFAR here? – Public health officials in the region have strong working relationships that can be built upon. The region is ready! – Close relations with feds will allow them to more closely monitor the progress to ensure success and gather lessons learned – The corridor will provide experience to the other metropolitan areas in the nation to move.